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Psychological disorder and moral harm : conceptions of the victims of rape Shea, Shannon Anne 1996

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PSYCHOLOGICAL DISORDER AND MORAL HARM: CONCEPTIONS OF THE VICTIMS OF RAPE by SHANNON ANNE SHEA B.A., Eastern Washington University, 1993 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Philosophy We accept t h i s thesis as conforming to the. requ^r^d standard THE UNIVERSITY OF BRITISH COLUMBIA August 1996 ® Shannon Anne Shea, 1996 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of !olumbia The University of British C l i  Vancouver, Canada Date Z 4 DE-6 (2/88) Abstract This essay examines two perspectives from which to consider rape victims. The f i r s t perspective i s adopted by psychologists and other professionals who treat rape victims. The second perspective i s a moral framework that draws on fundamental Kantian insights into moral agency. Chapter One o f f e r s the t h e o r e t i c a l basis of the f i r s t framework. P a r t i c u l a r attention i s paid to the diagnosis of rape victims as su f f e r i n g from a s p e c i f i c disorder, rape trauma syndrome. Chapter Two further elaborates t h i s framework. It considers the connection between rape trauma syndrome and an o f f i c i a l mental disorder, posttraumatic stress disorder. I note some stresses induced i n the notion of disorder by t h i s assimilation. I also o f f e r concerns about seeing both rape victims and r a p i s t s as su f f e r i n g from mental disorders. Chapter Three draws on the philosophical l i t e r a t u r e , e s p e c i a l l y the work of Peter Strawson and other Kantian moral philosophers, as well as my own experiences as an advocate i n a rape c r i s i s center, to o f f e r an alternative perspective. This framework asks us to see rape victims not as su f f e r i n g a p a r t i c u l a r sort of mental disorder, but as needing to recover t h e i r sense of moral agency and worth i n response to h o r r i f i c e v i l . TABLE OF CONTENTS Abstract i i Table of Contents i i i Acknowledgement i v Dedication v Introduction 1 Chapter One Rape C r i s i s Theory 5 Rape Trauma Syndrome 12 C r i s i s Theory 16 The Needs Identified, Treatment and Recovery 2 3 Endnotes to Chapter One 33 Chapter Two The Psychological Account of Rape: Elaborations and Concerns 35 Rape Trauma Syndrome and Mental Disorder 3 5 C l i n i c i a n s and the Rapist 43 Conclusion 51 Endnotes to Chapter Two 6 0 Chapter Three An Alternative Framework: Rape and Moral Harm 61 Strawson 66 An Application 74 An Alternative Framework 81 Autonomy and Respect 87 Autonomy and U n i v e r s a l i z a b i l i t y 95 Conclusion 97 Endnotes to Chapter Three 104 Bibliography 106 i i i Acknowledgement I must begin by thanking the Spokane Sexual Assault Center of Spokane, Washington, where I worked as an advocate for victims of sexual assault from August 1993 to August 1994. There I learned to be much more than an advocate: I was encouraged to pursue my research e f f o r t s , as well as to develop new ways of a s s i s t i n g the many women, children and men who were i n contact with the Center. I would also l i k e to thank Stephanie Holt for showing me what i t means to treat a human being as a person. I am grateful to Professor Earl Winkler, who took on the task of reading t h i s essay. Throughout my time at U.B.C. he has been a source of l i v e l y encouragement and good f a i t h i n my work. My largest debt of gratitude i s owed to Alan Richardson. He was w i l l i n g to take on t h i s project with enthusiasm and understanding. I can scarcely imagine what might have come of i t without his steady guidance. Through him I have come to understand much more of what i t i s to be a philosopher. i v This essay i s dedicated to the memory of Terence S. Shea, S.J. v Introduction Rape i s to women as lynching was to blacks: the ultimate physical threat by which a l l men keep a l l women i n a state of psychological intimidation (Susan Brownmiller found i n Hilberman, 1976, p. 6) . Rape i s an act of aggression i n which the vict i m i s denied her self-determination. It i s an act of violence which, i f not act u a l l y followed by beatings or murder, nevertheless always c a r r i e s with i t the threat of death. And f i n a l l y , rape i s a form of mass terrorism, for the victims of rape are chosen indiscriminately but the propagandists for male supremacy broadcast that i t i s women who cause rape by being unchaste or i n the wrong place at the wrong time- i n essence, by behaving as though they were free (Susan G r i f f i n found i n Hilberman, 1976, p. 6, emphasis added). When one comes across such poignant statements as these, one feels that i t has f i n a l l y come to be known that rape i s one of the ultimate human horrors. Those who work in a i d of rape victims speak eloquently and touchingly about the s u f f e r i n g of those they treat. The language used i s often f i l l e d with terms philosophers regard as the moral notions regarding human beings and humanity i n general. The papers, lectures, and books written by professionals involved i n the research and treatment of rape victims use terms which are very much moral terms: trust, autonomy, dignity, self-respect, g u i l t , shame, anger, and degradation are among the terms used. But there i s something d i s t i n c t l y d i f f e r e n t about these terms when one finds them i n the theories used to treat rape victims. They seem to lack the thick moral content that i s to be found when they are used 1 by moral p h i l o s o p h e r s . The d i f f e r e n c e i s that they have undergone a r e d u c t i o n of s o r t s , a r e d u c t i o n to t h e i r usefulness f o r p s y c h o l o g i c a l purposes. The p r o j e c t of the f i r s t chapter i s to expose the meaning behind the moral terms used by those who are t r e a t i n g , i n one way or another, the v i c t i m s of rape. There i s a great deal of ground to cover i n chapter one. I have s p l i t i t i n t o three s e c t i o n s . I w i l l begin the f i r s t s e c t i o n by e x p l i c a t i n g rape trauma syndrome. This w i l l l e a d to an e x p l o r a t i o n of general c r i s i s theory and rape c r i s i s theory. Then, I w i l l look at how c r i s i s theory forms the b a s i s f o r the treatment of and recovery c r i t e r i a f o r v i c t i m s of rape. Psychology and medicine have taken on a very s c i e n t i f i c approach to d e a l i n g w i t h human s u b j e c t s . 1 Yet the t o p i c at hand i s laden w i t h moral i s s u e s . In the second chapter I take a step back to see a l a r g e r p i c t u r e . I w i l l demonstrate a connection between rape trauma syndrome and mental d i s o r d e r . I t turns out that one can draw the s t a r t l i n g c o n c l u s i o n that a l l rape v i c t i m s are bound to s u f f e r from a diagnosable mental d i s o r d e r . In order b e t t e r to understand what i t might mean to diagnose a rape v i c t i m w i t h a mental d i s o r d e r I then t u r n to look at the d e f i n i t i o n s f o r the terms used i n making a diagnosis of t h i s k i n d . Then, I w i l l conclude chapter two by p u l l i n g together the threads of the var i o u s t h e o r i e s and treatments to show the reader what psychology sees i n a person and how i t perceives that i t can best help those i n psychological d i s t r e s s . The case w i l l be put forward that the standards for diagnosis, treatment and recovery may not be s u f f i c i e n t to help victims recover from t h i s very p a r t i c u l a r kind of harm. In fact, the claim I make i s that they may be doing further harm to rape victims. F i n a l l y , i n chapter three I propose an alternative framework for thinking about and aiding victims of rape. Rape victims turn to the moral aspects of having been raped; these are aspects that the c l i n i c a l framework i s i l l equipped to handle. After considering the problems which come up when using a s t r i c t l y c l i n i c a l approach i n treating rape victims I w i l l examine alternative moral frameworks which might better accommodate the issues raised by victims of rape. Then, i n the f i n a l sections of chapter three, I argue that the best moral framework to take up i n aid of rape victims i s a Kantian moral perspective. A robustly moral perspective i s most able to help rape victims regain the sense of t h e i r own humanity which they seem to have l o s t . 3 Endnote to the Introduction 1. In t h i s work I w i l l be discussing the theories of s o c i a l s c i e n t i s t s of many st r i p e s . Those that I have researched for t h i s work are predominately North American psychologists who worked i n t h i s century. The tenor of most of what the c l i n i c i a n s , researchers and theorists are doing i s psychologistic. Thus, I have elected to use the term "psychology" as a very general term meant to include those whom I have studied. I do not mean to include here the whole of psychology. It w i l l be demonstrated that the choice of the term i s appropriate on the following pages. 4 Chapter One Rape C r i s i s Theory The experience of rape and i t s aftermath i s c l e a r l y one of the worst possible experiences any person could have. 1 The victim's l i f e i s threatened, she i s degraded and vi o l a t e d i n an exceptionally personal way. In the aftermath she must f i n d ways of dealing with the incident, of carrying on i n the face of an experience that tends to destroy one's sense of how l i f e can and should go. The vic t i m i s subject to both physical and emotional (or psychological) harm. The long term e f f e c t s of t h i s event can reach into every aspect of her l i f e . The event of a rape i n a person's l i f e w i l l often a l t e r her l i f e permanently. It i s profoundly moving to l i s t e n to the testimonies of women who have undergone the h o r r i f i c experience of being raped. Every rape i s d i f f e r e n t and every vi c t i m i s an ind i v i d u a l , and yet there i s a stunning s i m i l a r i t y i n the report of what they think and f e e l i n the days, weeks, months and even years a f t e r the rape. What follows i s a series of quotes which are taken from many rape victims. The time span of the quotes begins with an interview done some days a f t e r a rape and continues through to some years a f t e r a rape. ° Since the night of the rape, I haven't f e l t much except anxious (Koss, 1991, p.49). 5 o A l l I f e l t was te r r o r and pain ... I couldn't even cry (McCombie, 1980, p. 169). ° It's the worst thing I have ever gone through. I wouldn't wish i t on my worst enemy (McCombie, 1980, p.158). ° Why did t h i s have to happen to me? (McCombie, 1980, 159). o It takes away a l l security (Koss, 1991, p.42) . o Now I sleep with a hockey s t i c k and f e e l as though my previous sense of confidence has been replaced with an overwhelming f e e l i n g of helplessness (Koss, 1991, p. 65). o I [feel] d i f f e r e n t from other people (Koss, 1991, p. 68). o I'm scared I ' l l never be the same (McCombie, 1980, p.159). When reading the l i t e r a t u r e on rape and i t s e f f e c t s on the v i c t i m i t becomes clear that there i s a common experience of horror and degradation. Fear, anxiety, i s o l a t i o n and pain (both psychological and physical) are prevalent amongst victims during and a f t e r the rape. In addition, the victims are struck by the inexplicable nature of the event. They cannot understand why i t happened to them. Research reveals that victims of unexpected traumatic events (such as rape or terrorism) need to have an explanation for the occurrence, something that can j u s t i f y the event. With rape victims i t i s often the case that they w i l l f i n d f a u l t with themselves rather than leave the question unanswered.2 6 In l i g h t of the recognition of the devastating e f f e c t s of rape, researchers i n the s o c i a l sciences, medicine, psychology and psychiatry have set out to explain rape and i t s e f f e c t on victims. They look at r a p i s t s and at rape victims to see why i t happens, who i t happens to, how i t ef f e c t s them, and perhaps eventually, how to prevent i t from happening. As mentioned before, i f the question of why i t happened has an answer, then i t w i l l be possible for victims, with the help of the c l i n i c i a n s , to make sense of the experience. Making sense of the experience seems to mean that the victim knows and understands why i t was that she was raped and that t h i s 'knowledge' helps her to recover from the event. Because of the criminal aspect of rape, researchers tend to have more access to the victims of rape than to the perpetrators of rape. There are very few convictions on rape charges, and even fewer charges made i n r e l a t i o n to the number of victims claiming to have been raped. It i s highly u n l i k e l y that there w i l l ever be people coming into therapy or research labs as r a p i s t s unless they are compelled to do so by the law. Thus, a large body of information has developed about victims of rape but there i s comparatively l i t t l e information regarding the r a p i s t s . 3 The most i n f l u e n t i a l research has been done by Ann Wolbert Burgess, a professor of nursing (and subsequently the Chairperson of the Rape Control and Advisory Committee for the U.S. 7 Department of Health, Education and Welfare) and Linda Lytle Holmstrom, a professor of sociology. In 1972 Burgess and Holmstrom began a victim counselling program at the Boston City Hospital i n cooperation with the emergency unit s t a f f . It was an e f f o r t to observe, describe, understand, and treat the e f f e c t s of rape on the victim. Their project was to interview and o f f e r a kind of c r i s i s intervention to victims of sexual assault at the f i r s t possible time a f t e r a vic t i m has been raped. This turns out, i n many cases, to be the emergency room of the l o c a l h o s p i t a l . Based on t h e i r research and practice i n the f i r s t year they published Rape: Victims of C r i s i s which according to Anne Hargreaves i n her preface to the book, "communicates basic p r i n c i p l e s of technique" for treating rape victims (Hargreaves i n Burgess and Holmstrom, 1974, p. v i i ) . Their work resulted i n many changes for hospitals and s o c i a l service agencies dealing with rape victims throughout North America. The research done at that time i s the cornerstone of rape c r i s i s theory and intervention techniques implemented today. Before I launch into my analysis a few technical points must be made here i n order for there to be c l a r i t y of reference throughout t h i s work. For the sake of brevity and, I hope, c l a r i t y I have chosen to use the term ' c l i n i c i a n ' to ref e r to the doctors, nurses, p s y c h i a t r i s t s , psychologists and s o c i o l o g i s t s who treat rape victims. I w i l l l i m i t the scope of t h i s term to the people who are 8 regarded i n the f i e l d as professionals with a kind of expertise that i s suited to the needs of the rape victim. There are also non-professional individuals trained to "stand up for" the rape victim. The term "advocate" i s used to i d e n t i f y the individuals of t h i s group. Standing up for the vi c t i m simply means that advocates provide support to the vi c t i m by giving her information, by t e l l i n g her what to expect at d i f f e r e n t stages of her experience, and by being there as l i t e r a l l y a shoulder to cry on i f need be. An advocate i s usually present at the hospital when the vic t i m f i r s t comes i n , can accompany the victim to pol i c e interviews, meetings with lawyers, court appearances, and so on. In short, whatever in t e r a c t i o n the vi c t i m may have with others as a d i r e c t r e s u l t of having been raped i s an int e r a c t i o n that may, at the victim's d i s c r e t i o n , be attended by the advocate. For the most part advocates are trained volunteers associated with a rape c r i s i s center. Social workers tend to f i t into t h e i r own category. This i s due, at least i n part, to the fact that they play a role only when the victim i s i n need of the p a r t i c u l a r kinds of care that a s o c i a l worker has access to ( i . e . welfare and other forms of public assistance). " C l i n i c s " w i l l designate the places where a rape v i c t i m goes for various forms of health treatment. (Treatment i s yet another ambiguous term; i t s various meanings w i l l be worked out i n the course of this chapter.) Obviously there are some crossovers between 9 what treatment i n hospital i s and what treatment i s i n a c l i n i c for psychological treatment. But there are also vast differences. The common ground i s more i n the conceptual framework used to treat victims of rape than i t i s i n the d e t a i l s of implementation of the conceptual framework. A very general framework i s used by Burgess and Holmstrom, as well as by the larger c l i n i c a l community today. Burgess and Holmstrom are said to have used a biopsychosocial approach i n conducting t h e i r research. 4 The biopsychosocial approach i s an attempt to overcome perceived d i f f i c u l t i e s i n the dominant antecedent approach to medically treating people, the biomedical approach. 5 In Health Psychology: Biopsychosocial Interactions, Edward Sarafino explains tliat biomedicine bases i t s treatment and diagnosis schemes on the assumption that " a l l diseases or physical disorders can be explained by disturbances i n physiological processes, which res u l t from injury, biochemical imbalances, b a c t e r i a l or v i r a l i n f e c t i o n and the l i k e . . . " (Sarafino, 1994, p.9). It "assumes that disease i s an a f f l i c t i o n of the body and i s separate from the psychological and s o c i a l processes of the mind" (Sarafino, 1994, p.9). According to the proponents of the biopsychosocial model t h i s model does not regard the subject as a person; personality and l i f e s t y l e are not thought to be relevant to any possible l i n e of diagnosis or treatment. For the most part the psycho-social s i t u a t i o n of the person 10 i s viewed as a kind of impediment to understanding what i s happening to or i n the body. Here we see the mind-body d i s t i n c t i o n i n a very l i t e r a l way. The patient i s not thought to know enough to be able to contribute i n a relevant way to discovering the cause or cure to his ailment. More and more often we are hearing that t h i s i s a f a u l t y model because of i t s intentional neglect of the person suffering. It has come to be believed that a person's ' l i f e s t y l e ' , that i s t h e i r "everyday pattern of behavior", plays a s i g n i f i c a n t role i n understanding health and i l l n e s s (Sarafino, 1994, p.10). The biopsychosocial approach to health and i l l n e s s takes into account "... that health and i l l n e s s r e s u l t from the interplay of b i o l o g i c a l , psychological and s o c i a l forces" (Sarafino, 1994, p.15). To a great extent the biopsychosocial approach to health and i l l n e s s looks at each person as a system. A system i s seen as a "dynamic e n t i t y consisting of components that are continuously i n t e r r e l a t e d " (Sarafino, 1994, p. 17). In t h i s way i t remains very much within the framework of medicine and mechanism. There are thought to be three basic systems to consider for each person: the b i o l o g i c a l organism including genetic makeup, c e l l s , organs, etc.; the psychological system composed of the l i f e s t y l e and personality of the person; and the s o c i a l system where one's relationships to others are considered. The psychological system i s also includes behavioral and mental processes, the 11 l a s t being divided into three subsystems: cognition, emotion and motivation. The s o c i a l system encompasses family and friends, community, and society i n general. When assessing a prospective patient for treatment needs of whatever kind, a c l i n i c i a n w i l l attempt to f i n d out how a l l of these factors (or systems) play into the l i f e of that i n d i v i d u a l . By i d e n t i f y i n g which systems are 'functioning' and which are not the c l i n i c i a n i s better able to determine the needs of her patient. For example, does a patient have headaches because she has bumped her head? Or, as i s more common, i s there some aspect of her " l i f e s t y l e " (stress, caffeine, lack of sleep, too much sleep, etc.) that might bring about headaches? Using the biopsychosocial approach, the patient i s assessed for her l e v e l of functioning i n a l l three of the general systems mentioned above. This i s thought to be a more e f f e c t i v e way of treating people when they are i l l and e s p e c i a l l y for preventing i l l n e s s i n the future. Rape Trauma Syndrome Burgess and Holmstrom i d e n t i f i e d the c l u s t e r of "symptoms" displayed by rape victims as "Rape Trauma Syndrome". There are three sub-components of t h i s syndrome, A) Rape trauma, B) Compounded reaction and C) S i l e n t reaction. Rape trauma (A) has two categories; i t i s characterized i n i t i a l l y by either a controlled or an 12 expressed emotional reaction to the event of the rape which develops into two phases -- the acute or disorganization phase and the long term, or reorganization phase. The i n i t i a l categorization for v i c t i m reaction, expressed or controlled, allows for the fact that many victims appear to be very much i n control of themselves. Some c l i n i c i a n s might go so far as to say that victims sometimes appear to be unaffected by the event; t h i s may cast doubt for some people on whether or not a rape has occurred at a l l . It turns out that victims are frequently i n a kind of shock or are su f f e r i n g from utter exhaustion; they may not, for whatever reason, show a reaction. This by no means should be construed as evidence of an undisturbed person. The compound reaction (B) includes rape trauma and i s "compounded" by factors outside of the "rape event" such as p r i o r psychological or physical problems, alcohol or drug use, and stressors such as relationship, work, academic, or f i n a n c i a l hardship. 6 It i s not necessary to show any p a r t i c u l a r or s p e c i f i a b l e behavior i n order to be c l a s s i f i e d as s u f f e r i n g from compounded rape trauma. In addition, there are women who do not report that they have been raped. It i s considered to be a given by a l l form of research done on rape that more than half of the rapes perpetrated go unreported by the victim. Category (C), the s i l e n t reaction, i s designed to capture that set of victims who undergo a rape and subsequently rape trauma 13 syndrome, but elect for whatever reason(s) not to t e l l anyone that they have been raped. Burgess and Holmstrom regard t h i s group of women as more l i k e l y to s u f f e r long term compounded aff e c t s of rape trauma. As a r e s u l t of t h e i r silence they do not receive the kinds of attention thought by c l i n i c i a n s to be needed i n order to foster the reorganization and recovery phases of rape trauma syndrome. Below i s a chart that b r i e f l y sets out the symptoms of a person su f f e r i n g from rape trauma syndrome. This chart i s taken from the previously mentioned C l a s s i f i c a t i o n of Nursing Diagnoses (Kim, et a l . , 1980, p.393). In t h i s book rape trauma syndrome i s o f f i c i a l l y recognized as a diagnosis which nurses can make. Rape trauma syndrome has an o f f i c i a l diagnostic number and even a s u b c l a s s i f i c a t i o n i n d i c a t i n g the person's pot e n t i a l for violence. 7 29.148 Rape Trauma Syndrome .149 Violence, p o t e n t i a l for A. Rape Trauma Defining Characteristics of the Acute Phase: Emotional reactions: anger, embarrassment, fear of physical violence and death, humiliation, revenge, self-blame. Multiple physical symptoms: ga s t r o i n t e s t i n a l i r r i t a b i l i t y , genitourinary discomfort, muscle tension, sleep pattern disturbance. Defining Characteristics of the Long-term phase: Changes i n l i f e s t y l e (changes i n residence, dealing with r e p e t i t i v e nightmares and phobias; seeking family support; seeking s o c i a l network support). 14 B. Compound Reaction A l l defining c h a r a c t e r i s t i c s l i s t e d under rape trauma. Reactivated symptoms of such previous conditions, i . e . , physical i l l n e s s , p s y c h i a t r i c i l l n e s s . Reliance on alcohol and/or drugs. C. S i l e n t Reaction The defining c h a r a c t e r i s t i c s of the s i l e n t reaction: Abrupt change i n relationships with men; increase i n nightmares; increasing anxiety during interview, i . e . , blocking of associations, long periods of silence, minor stuttering, physical d i s t r e s s . Marked changes i n sexual behavior; no v e r b a l i z a t i o n of the occurrence of rape; sudden onset of phobic reactions (Kim, et a l . , 1980, p.393) . It i s an i n t e r e s t i n g fact about rape trauma syndrome that every possible reaction i s considered a symptom of rape trauma syndrome - including the cuts and bruises, muscle tension, and headaches which are some of the physical traumata that r e s u l t from rape. A v i c t i m i s l i k e l y to be anxious, angry, depressed, even shocked. Or she may not show any sense of disruption at a l l and may even seem quite normal. According to the diagnostic c r i t e r i a , a l l of these things are, nevertheless, signs of the acute/disorganization phase of rape trauma syndrome setting i n . What the c l i n i c i a n s are saying, i n e f f e c t , i s that i f one i s raped one w i l l necessarily s u f f e r from rape trauma syndrome. Any reaction to rape i s regarded as evidence of rape trauma syndrome. Rape trauma syndrome i s a diagnosable mental disorder. Thus i f one i s raped, then, necessarily, one w i l l s uffer from a mental disorder. Rape trauma syndrome allows 15 for any kind of reaction, thus one can be reacting "normally" but only from within the parameters of the syndrome. In the face of t h i s necessity, c l i n i c i a n s claim that to suffer rape trauma syndrome i s to experience a kind of break down constituted by the "disorganization" or "disruption of l i f e s t y l e " for the victim. For c l i n i c i a n s , organization and the resuming of one's previous l i f e s t y l e are the signs of recovery from the syndrome. In general i t i s thought that humans order t h e i r l i v e s based on various events and situations that confront them. We are supposed to develop in c e r t a i n ways at ce r t a i n times. At any point i n a person's l i f e he or she may be confronted with any number and kinds of c r i s e s . Rape i s a c r i s i s because i t seriously disorganizes and disrupts the victim's l i f e s t y l e . The theory of c r i s i s informs the deep background for both rape trauma syndrome i t s e l f and treatment of those su f f e r i n g from rape trauma. In the next section I turn to examine the theories of human l i f e c r i s e s . Then we can move on to consider the treatment and recovery of the rape v i c t i m i n more d e t a i l . C r i s i s Theory There are several key elements of assessment for Burgess and Holmstrom. In the basic treatment, intervention 16 and assessment of a rape vi c t i m i s concerned with her physical well being, her psychological needs and her s o c i a l support system. Part of what defines the assessment i s the reliance upon established c r i s i s theory. Burgess and Holmstrom ground t h e i r treatment and research of rape victims i n research done on c r i s i s theory. At the time, the work of Erik Erikson (1950) was the primary body of research on human developmental c r i s i s . A general theory of human c r i s i s had not been formulated. However, much of what they took from Erikson continues to serve as the basis of c r i s i s theory and, s p e c i f i c a l l y , rape c r i s i s theory today. A c r i s i s i s "a c r u c i a l s i t u a t i o n which, i n turn, causes a disequilibrium to an individual's l i f e s t y l e " (Burgess and Holmstrom, 1974, p. 300). The theory of c r i s i s i s a predi c t i v e and explanatory tool designed to allow c l i n i c i a n s to short c i r c u i t a c r i s i s reaction. C r i s i s theory contends that there are two kinds of cr i s e s a person may have, int e r n a l or external. The response to rape i s seen as a response to an i d e n t i f i a b l e externally imposed c r i s i s i n the victim's l i f e . Rape victims are supposed to experience a c r i s i s which causes a di s i n t e g r a t i o n of l i f e s t y l e and a potent i a l stoppage i n ego qu a l i t y development. In an e f f o r t to understand how rape victims are viewed and subsequently treated by c l i n i c i a n s I want to explain how rape c r i s i s theory i s constructed. It i s important to see how the c l i n i c i a n s go about i d e n t i f y i n g what i s important 17 for the treatment of rape victims. It w i l l t e l l us about how human beings are understood today by the predominant i n s t i t u t i o n s t r e a t i n g victims of sexual assault. As Burgess and Holmstrom are to the bedrock of the research done on rape victims, Erik Erikson i s to North American human developmental psychology -- the foundation of c r i s i s theory. 1 w i l l begin by o u t l i n i n g the developmental c r i s i s theory of Erik Erikson from his book Childhood and Society (Erikson, 1950, pp. 67-92 and 219-234). According to Burgess and Holmstrom the notion of intern a l c r i s e s i s taken from Erikson's "developmental cr i s e s of the l i f e cycle" (Burgess and Holmstrom, 1979, p. 2 04). Developmental c r i s e s are considered normal and expectable, even predictable events or phases i n every person's l i f e . The way that they are described by Burgess and Holmstrom presents them as situations where there i s a task that must be completed for the c r i s i s to be overcome. There are opposing ego q u a l i t i e s which one must choose between. Each c r i s i s i s set within a p a r t i c u l a r age range, so that by a ce r t a i n age one w i l l normally be expected to have mastered c e r t a i n tasks and incorporated them into her way of coping i n l i f e . The rape c r i s i s , which i s external, i s said to "interact" with the developmental tasks that the vict i m i s currently engaged i n . This i n t e r a c t i o n of the two kinds of c r i s e s determines the meaning that the rape w i l l have for the p a r t i c u l a r victim. 18 The sexual assault takes on s p e c i f i c meaning to victims according to t h e i r stage of development i n the l i f e cycle. The counsellor needs to look at the developmental point of the vic t i m and t r y to understand what the attack means to the vic t i m at that age (Burgess and Holmstrom, 1974, p. 112) . There are eight developmental c r i s e s , Erikson c a l l s them "The Eight Stages of Man" (Erikson, 1950, p.219). In these stages a c r i s i s occurs wherein the i n d i v i d u a l must struggle to a t t a i n some ego qu a l i t y necessary to getting on in l i f e . Thus the c r i s e s are set up as contests between two or more ego q u a l i t i e s . Within each stage i s a task that must be accomplished i n order to resolve the c o n f l i c t . Each phase i d e n t i f i e s ego q u a l i t i e s - one of which i s the sign of a successful c o n f l i c t resolution. In the l i s t below I have underlined the ego q u a l i t y which i s to be achieved i n the c r i s i s struggle. In parentheses next to each stage I have written the developmental "zones and modes and modalities" of the respective c o n f l i c t s , and a rough estimate of the age at which each stage occurs. The "Eight Stages of Man" are, i n chronological order: basic trust versus mistrust (oral-sensory, infancy); autonomy versus shame and doubt (muscular-anal, 2-3); i n i t i a t i v e versus g u i l t (locomotor-ge n i t a l , 4-7); industry versus i n f e r i o r i t y (latency, 8-12); i d e n t i t y versus role confusion (puberty and adolescence, 13-19); intimacy versus i s o l a t i o n (young adulthood, 20-29); generativity versus stagnation (adulthood, 30-49); and ego i n t e g r i t y versus despair (maturity, 50+). According to Erikson, i f one f a i l s to integrate one i n f a n t i l e stage or 19 another i t can lead to neurotic mental disorders l a t e r i n l i f e (Erikson, 1950, p. 57). What follows i s a b r i e f explanation of the tasks involved i n each of the eight stages and a b r i e f description of how each of these corresponds to the rape c r i s i s . 8 Stage I Basic Trust vs. Mistrust (infancy) Task: "To form establishment of enduring patterns for the sol u t i o n of the nuclear c o n f l i c t of basic trust versus basic mistrust i n mere existence i s the f i r s t task of the ego" (Erikson, 1950, p.226). Rape c r i s i s Issue: The v i c t i m may f a i l to acquire trust as her p r e v a i l i n g ego q u a l i t y . 9 Stage II Autonomy vs. Shame and Doubt (2-3) Task: To gain control of the eliminative functions. To learn to stand on one's own feet while s t i l l under the protection of those one learned to trust i n Stage I. Stage III I n i t i a t i v e vs. G u i l t (4-7) Task: The c h i l d i s to "gradually develop a sense of parental r e s p o n s i b i l i t y , where he can gain some insight into the i n s t i t u t i o n s , functions and roles which w i l l permit his responsible p a r t i c i p a t i o n " (Erikson, 1950, p.226). Rape c r i s i s issue: At t h i s stage a c h i l d i s concerned with notions of right and wrong. Usually a v i c t i m at t h i s age grasps the notion that what was done to her should not have happened, that people are not allowed to do t h i s to children. Stage IV Industry vs. I n f e r i o r i t y (8-12) Task: "He can become an eager and absorbed unit of a productive s i t u a t i o n " "To bring a productive s i t u a t i o n to completion i n an aim which gradually supersedes the whims and wishes of his autonomous organism ... the work p r i n c i p l e (Ives Henrick) teaches him the pleasure of work completion by steady attention and persevering diligence" (Erikson, 1950, p. 227). 20 Rape c r i s i s issue: The c h i l d begins to be aware of rape as a sexual act, and as such, i t i s embarrassing. It i s frequently confused with any or a l l other intimate acts (He may wonder i f rape i s what his parents do or i f k i s s i n g i s rape.) Stage V Identity vs. Role D i f f u s i o n (13-19) Task: Childhood ends here, youth begins. "The sense of ego i d e n t i t y then, i s the accrued confidence that the inner sameness and continuity are matched by the sameness and continuity of one's meaning for others, as evidenced by the tangible promise of a 'career'" (Erikson, 1950, p. 228) . Rape c r i s i s issue: An adolescent i s not i n c l i n e d to talk to or confide i n adults. She may be concerned about the p o s s i b i l i t y of pregnancy. It i s thought that t h i s i s one of the largest groups of rape victims who do not report that they have been raped. Stage VI Intimacy and Isolation (20-29) Task: To "face the fear of ego loss i n situations which can c a l l for self-abandon: i n orgasms and sexual unions, i n close friendships and i n physical combat, i n experiences of i n s p i r a t i o n by teachers and of i n t u i t i o n from the recesses of the s e l f " (Erikson, 1950, p. 229) . Rape c r i s i s issue: The young adult i s concerned with the p o s s i b i l i t y of pregnancy and with maintaining her established intimate rel a t i o n s h i p . She tends to be more tal k a t i v e with c l i n i c i a n s , perhaps seeking advice on how to t e l l other people and to take a course of action with regard to the p o t e n t i a l for pregnancy and disease. Stage VII Generativity vs. Stagnation (30-49) Task: "Generativity i s p r i m a r i l y the interest i n establishing and guiding the next generation or whatever i n a given case may become the absorbing object of parental kind of r e s p o n s i b i l i t y " (Erikson, 1950, p. 231) . Rape c r i s i s issue: The adult v i c t i m i s concerned with how the rape w i l l a f f e c t others i n her family or support network. She w i l l be concerned with how t h i s may change her l i f e s t y l e , i t may c a l l into question issues of sexuality (a diminished desire, e t c . . ) The adult v i c t i m i s also concerned about possible pregnancy and disease. 21 Stage VIII Ego Integrity vs. Despair (50+) Task: " ... [T]he ego's accrued assurance of i t s p r o c l i v i t y for order and meaning" i s a sign of one's entrance into Stage VIII. "The possessor of i n t e g r i t y i s ready to defend the dignity of his own l i f e s t y l e against a l l physical and economic threats." He i s the possessor of " ... emotional integration which permits p a r t i c i p a t i o n by fellowship as well as acceptance of the r e s p o n s i b i l i t y of leadership" (Erikson, 1950, pp. 232-3). Rape c r i s i s issue: The mature or older adult i s usually more concerned with her physical safety , she may be more strongly affected by a fear of having nearly died. She i s also concerned with how to t e l l her family (her children and grandchildren). Having d e t a i l e d the general theories of i n t e r n a l , developmental c r i s e s which are ordinary and expected stages of a person's l i f e I now to move on to look at what Burgess and Holmstrom define as an external c r i s i s . Rape i s a c r i s i s which i s externally imposed. This externally imposed c r i s i s can set o f f a new i n t e r n a l c r i s i s . (In the next section I address t h i s issue by looking at d i f f e r e n t treatment models.) Burgess and Holmstrom consider two kinds of external c r i s e s : s i t u a t i o n a l and v i c t i m c r i s e s (Burgess and Holmstrom, 1974, p. 110). S i t u a t i o n a l c r i s e s a r i s e from events or situations that "from the point of view of the person affected" are unexpected and unpredictable (Burgess and Holmstrom, 1974, p.110). The lack of preparedness for the event can increase the potential for a c r i s i s reaction because one i s at a loss for how to handle the new and unexpected event. This i n turn brings about a "psychological disequilibrium" (Burgess and Holmstrom, 1979, p. I l l ) . The following are events that might cause or at 22 l e a s t precede a s i t u a t i o n a l c r i s i s : death (being unexpectedly widowed), b i r t h (a new s i b l i n g o r perhaps a c h i l d born w i t h a s e r i o u s b i r t h d e f e c t ) , g e t t i n g married, and b e g i n n i n g s c h o o l f o r the f i r s t time. V i c t i m c r i s e s are those where "the i n d i v i d u a l f a c e s and overwhelmingly hazardous s i t u a t i o n and i n which the i n d i v i d u a l may be p h y s i c a l l y [and]/or p s y c h o l o g i c a l l y i n j u r e d , traumatized, d e s t r o y e d or s a c r i f i c e d " (Burgess and Holmstrom, 1974, p . I l l ) . The causes o r precedents can be of human d e s i g n or environmental. Among the human designed c a u s a l f a c t o r s are war, r i o t s , murder, rape and t o r t u r e . Environmental causes are events such as earthquakes, f l o o d s , and o t h e r v e r y dangerous, sudden and v i o l e n t forms of n a t u r a l d i s a s t e r . Rape, of course, c o n s t i t u t e s a v i c t i m c r i s i s . I t has an e f f e c t on the v i c t i m t h a t i s not u n l i k e the e f f e c t war has on s o l d i e r s . I t can be u t t e r l y d e b i l i t a t i n g . L a t e r i n t h i s chapter I w i l l demonstrate t h a t these two groups of people are understood to have a good d e a l i n common. The Needs I d e n t i f i e d , Treatment and Recovery In a s s e s s i n g the k i n d of treatment thought t o be warranted f o r v i c t i m s of rape we must r e t u r n t o the p e r c e i v e d needs of the v i c t i m s . Then we w i l l proceed t o the way th a t these needs form the k i n d of treatment a person 23 might receive. From there we can take a closer look at what constitutes a recovery from the event of a rape i n one's l i f e . ' The needs i d e n t i f i e d by Burgess and Holmstrom are f i r s t touched upon i n the developmental c r i s i s theory. A b r i e f reminder of the rape c r i s i s issues associated with each l e v e l of development may be i n order here. For the very young victims (infancy to age 3) trust i s the issue. For children ages 4-7, notions of right and wrong are present. For children 8-12, they perceive that the event can be construed as sexual and, as such, as embarrassing. Once the rape v i c t i m enters adolescence the concerns begin to cohere around a p a r t i c u l a r set of issues: pregnancy, sexually transmitted disease, and the stigma attached to rape victims. Within the age groups 13-19, 20-29, 30-49 and 50+ the concern i s how to t e l l a ce r t a i n group of people. For teens the concern i s with t a l k i n g to parents; with young adults the concern i s to t a l k to one's s i g n i f i c a n t other and family; i n maturity the concern turns p a r t i a l l y around, one must now decide whether and how to t e l l c hildren and partners. F i n a l l y , i n late maturity there i s the concern for t e l l i n g one's adult children and perhaps also one's grandchildren. Late maturity also c a r r i e s an increased concern with physical harm, as one i s more f r a g i l e i n these years than i n the teen to adulthood years. It seems to be the case that these are the concerns addressed most quickly 24 for victims. Most of the issues involved for teens through the oldest victims tend to be resolved within the f i r s t few days following the rape. Thus, they constitute the acute c r i s i s intervention. As time passes, victims suffer i n the ways s p e c i f i e d i n the acute phase of rape trauma syndrome. These are less s t r i c t l y physical a f t e r e f f e c t s and tend to be more focused on the psychological and s o c i a l aspects of the event. This i s when the disorganization of a victim's l i f e becomes apparent. A v i c t i m may lose her appetite, sleep badly or not at a l l , s u f f e r from headaches, mood swings, anxiousness and the l i k e for quite a long time. Most r a p i s t s threaten t h e i r victims with death or torture immediately i f they do not cooperate, and l a t e r , i f they t e l l anyone. Thus, i t i s not unusual for the victim to f e e l that she i s not safe anywhere. Often she w i l l change her phone number, stay with friends or family and/or move to a new place. These changes, brought about by the victim, are seen as a move from the acute phase to the long-term phase of rape trauma syndrome. It i s thought that these changes are signs that the v i c t i m i s re-establishing herself, her l i f e - s t y l e (which, you w i l l r e c a l l , i s said to have been interrupted and disorganized); she i s on the path to recovery. The way that a c l i n i c i a n may encourage a victim on her path to recovery i s by using various psychological theories which 25 are thought to put to r e s t the issues that a r i s e during the acute phase of rape trauma syndrome. There are s e v e r a l models of treatment i n v o l v e d , some run concurrent w i t h one another, others are taken up at d i f f e r e n t phases of recovery, some come up only i n p a r t i c u l a r cases. I w i l l address each as i t would come up c h r o n o l o g i c a l l y i n the treatment of the v i c t i m , beginning w i t h the medical model. Medical treatment i s very s t r a i g h t f o r w a r d i n that i t i s concerned p r i m a r i l y w i t h the p h y s i c a l harm done to the v i c t i m and the p o s s i b l e a f t e r e f f e c t s that t h i s w i l l have f o r the v i c t i m . The medical treatment e n t a i l s g a t h e r i n g evidence f o r a p o s s i b l e p r o s e c u t i o n i f the a s s a i l a n t i s caught and t r i e d , medication f o r p o s s i b l e pregnancy and s e x u a l l y t r a n s m i t t e d diseases, and assessment of the p s y c h o l o g i c a l a f f e c t s of the event. For the most p a r t the medical model i s concerned to ensure the p h y s i c a l w e l l - b e i n g of the v i c t i m . The s o c i a l network model i s the next aspect of treatment. The p o i n t here i s to determine the extent to which the v i c t i m has a supportive s o c i a l network. A c l i n i c i a n or advocate t r i e s to assess the number and l o c a t i o n of p o s s i b l e f r i e n d s and f a m i l y that the v i c t i m may r e l y upon f o r support i n the immediate aftermath of the rape. I t i s thought that the stronger the s o c i a l network of the v i c t i m the more l i k e l y she i s to begin to recover. 26 Thus, the c l i n i c i a n or advocate t r i e s to see that the victim i s i n contact with someone she can r e l y upon f o r support before she leaves the h o s p i t a l . Part of the s o c i a l network i s the victim's work, school, and s o c i a l a c t i v i t i e s . The s o c i a l network model i s concerned to get the vi c t i m back to l i v i n g her l i f e as i t was before she was raped. It i s , of course, encouraged i n such a way that the vi c t i m i s empowered to make her own decisions about when to do something and what to do. So long as she begins to pursue a c t i v i t i e s and interactions with other people the s o c i a l network model i s considered to be e f f e c t i v e l y helping the vic t i m to recover. The next model of treatment i s c a l l e d the Behavioral Model. Its primary focus i s on "desensitizing the person to the behavior that r e s u l t s from the rape experience -s p e c i f i c a l l y , the phobic reactions". The thought here i s that "mental health problems or d i s t r e s s [are] unacceptable or noneffective behavior[s] .... " Phobic reactions are seen as "behavior learned i n a maladaptive way" (Burgess and Holmstrom, 1974, p.228). 1 0 The implementation of t h i s model of treatment i s designed to diminish the negative reactions to the rape, such as fear, anxiety and stress. Moreover, the behavioral model seeks to ... i n f l a t e her [the victim's] own self-esteem and self-confidence i n dealing with the world again. The vi c t i m then has the pote n t i a l to reach her previous l e v e l of functioning or of strengthening 27 her c a p a b i l i t i e s to f e e l secure again (Burgess and Holmstrom, 1974, p.228). The process of desensitization i s aimed at helping the vict i m gain a kind of control over her memories of the rape. The further aim i s to get the victim not to f e e l the feelings associated with the rape. She w i l l ( i t i s hoped) be able to r e c a l l the event i n a more dispassionate manner thus having "psychological control over the memory" which " s t r i p s i t of i t s power to di s t r e s s the vic t i m over and over" (Burgess and Holmstrom, 1974, p.228). It seems that the goal here i s to "s e t t l e the issue" so to speak. The s e t t l i n g seems to consist i n returning to one's p r i o r l i f e s t y l e . If rape i s considered a disruption of l i f e s t y l e leading to disorganization of the l i f e s t y l e , then to reorganize or at least put i t back into place constitutes a recovery, or at least a s e t t l i n g of the event into the past that no longer confronts the victim. The l a s t model i s c a l l e d the Psychological Model. It i s a model of treatment involving the b e l i e f that "...there i s a reason or meaning to the problem a person experiences" (Burgess and Holmstrom, 1974, p.230). This model uses the developmental stage theory as part of i t s basis, and personality theory f i l l s i n the rest of the story and treatment. Under t h i s model a c l i n i c i a n assesses the way that the vic t i m "...handled maturational or developmental phases of l i f e " (Burgess and Holmstrom, 1974, p.230). This i s done because i t i s thought that traumas such as rape make 28 see, they turn out to be something that one might c a l l basic human needs. But as further interpreted by Burgess and Holmstrom they begin to look a b i t d i f f e r e n t . The need to be cared about, when i t i s a strongly f e l t need p r i o r to the rape, may cause the v i c t i m to s u f f e r more acutely from the kinds of r e j e c t i o n that many rape victims are subjected to, too often by the people they most need to f e e l loved by. It i s not at a l l unusual for family members, spouse, boyfriend or friends of a rape vi c t i m to react to the event i n an unsupportive, sometimes even h o s t i l e or accusatory way. This i n turn leads the v i c t i m to f e e l that she i s somehow i n f e r i o r or unworthy of the affections of those she loves and respects. She may begin to think that she could be blamed for having been raped to the degree that she a c t u a l l y deserved to be raped. The need to be i n control i s interpreted by Burgess and Holmstrom i n the following way. The person who needs to be i n control needs to be i n control of herself, her emotions. More s p e c i f i c a l l y she i s the type of person who needs to be seen as good and loving rather than angry, hateful or destructive. Being emotionally out of control i s equated with being bad. Thus, when t h i s v i c t i m becomes angry she views herself as bad and out of control; she i s thus unable to f e e l what some construe as the appropriate emotions for the circumstances. She too i s l i k e l y to f a l l into s e l f -blame and self-doubt concerning the part she may have played 30 a person p a r t i c u l a r l y vulnerable to the p i t f a l l s of a poorly resolved ego q u a l i t y . That i s , i f one was never able to e s t a b l i s h the trust necessary i n Erikson's stage 1, then one w i l l be faced with many d i f f i c u l t i e s with trust now as a res u l t of the rape. 1 1 Personality theory holds that one can explain aspects of the rape event i n terms of the victim's personality. Her personality i s thought to dictate the d e t a i l s of her l i f e s t yle i n such a way that once the c l i n i c i a n s understand her personality they w i l l understand her l i f e s t y l e which i s i n turn supposed to inform the conditions of the rape and her reaction to i t . The questions asked within t h i s model run along the following l i n e s : why was the victim at the p a r t i c u l a r location, what i s her chosen l i f e - s t y l e , and more generally how does her personality dictate the choices she makes?12 There are three "dynamic" issues i n personality theory. When any one of these issues i s threatened i n some way "...one's self-esteem i s also lowered which i n turn brings on a psychological or c r i s i s reaction" (Burgess and Holmstrom, 1974, p. 230). The three dynamic issues are a r t i c u l a t e d by Burgess and Holmstrom as they r e l a t e to the rape c r i s i s . For us i t i s important to see how they make use of t h i s theory i n order better to assess the c r i t e r i a for treatment and recovery of a rape victim. In a nutshell the issues are as follows: the need to be cared about; the need to be i n control; and the need to achieve. As you can 29 i n the rape -- that i s , she begins to believe that i t was her f a u l t that she was raped and that she could or should have prevented i t . Her po s i t i v e self-evaluation depends upon her a b i l i t y to deny negative emotions ( i . e . anger and hate) and to believe that there was nothing she could or should have done to prevent the rape from happening. The need to achieve i s seen to be the need for superiority, strength, and security. This person w i l l have to f i g h t o f f feelings of weakness and in s e c u r i t y a f t e r having been raped. The feelings e l i c i t e d by the event of a rape are less centered on how t h i s a f f e c t s her r e l a t i o n to others or her feelings of moral i n t e g r i t y . She i s i n c l i n e d to f e e l a kind of defeat and powerlessness i n d i c a t i v e of a competitive person who has l o s t at something -- i n t h i s case she l o s t her power to control and protect herself, thus lowering her perceived status as an achiever (and as a human being). The recovery of a victim from a rape i s supposed to be shown through her move back into her previous l i f e s t y l e i n such a way that i t i s clear to the vic t i m and to her counsellor that she i s not denying the event or i t s e f f e c t on her. This i s demonstrated i n part by the victim's testimony that the memory of the event i s no longer traumatic and that she has control over when she thinks about the event. She i s able to "psychologically l e t go of the pain, fear and memory and feels a degree of calm within 31 herself to go about the business of l i v i n g again" (Burgess and Holmstrom, 1974, p. 234). She moves from being a victim to being a survivor. 32 Endnotes to Chapter One 1. In t h i s paper I have elected to ref e r to rape victims i n the feminine rather than the masculine. This i s not to be read as claiming that males are not raped or sexually-assaulted. When i t w i l l not be confusing, I w i l l incorporate reference i n the masculine i n order to s t r i k e a balance of reference between male and female o v e r a l l . Moreover, as an advocate I spoke to women nearly a l l of the time and f i n d that i t would be inappropriate to incorporate gender neutral language into a paper about rape victims. I am i n c l i n e d to think that gender neutral language makes a mockery of the countless women who have been raped and assaulted. 2. Throughout t h i s document I w i l l return to t h i s issue. I believe i t i s a very important aspect i n determining what must be done to help rape victims. 3. At the end of chapter two I w i l l b r i e f l y examine some aspects of the early research by c l i n i c a l a u t h o rities on men deemed to be sexually dangerous. 4. According to the C l a s s i f i c a t i o n of Nursing Diagnoses --Proceedings of the Third and Fourth National Conferences by Mi Ja Kim, et a l , they "collected biopsychosocial data" during the counselling sessions for rape victims (Kim et a l , 1980, pp. 305-6). 5. Burgess and Holmstrom do not claim overtly that t h i s i s what they are doing. But given the kinds of things that they stress i n assessing victims and seeking ways of f a c i l i t a t i n g recovery i t seems both acceptable and sensible r e t r o a c t i v e l y to claim that t h i s i s the approach that they took i n t h e i r research of rape victims. 6. The term 'stressors' i s psychological jargon f or those aspects of l i f e that can and do cause stress i n one's l i f e . They have i n mind troubled relationships, tensions at work, pressure to perform at school or elsewhere, and any other thing that i s l i k e l y to cause stress i n an i n d i v i d u a l . 7. However, i t i s not found i n the more widely known medical manuals such as the Diagnostic and S t a t i s t i c a l Manuals, the Merck Manual, or the ICD-10. In section II of t h i s chapter I w i l l return to t h i s i n order to o f f e r an explanation for the absence of rape trauma syndrome from these diagnostic manuals. 8. Burgess and Holmstrom think that the victim's age determines the type of c r i s i s and concerns that she w i l l have. One may have d i f f i c u l t y resolving the autonomy vs. shame and doubt c o n f l i c t i f one i s molested or raped at the age when 33 t h i s i s the c o n f l i c t at hand ( i . e . 2-3 years of age) . But that a victim, at age 23, may be troubled by the thought that the rape constitutes a v i o l a t i o n to her autonomy i s presumably not what they would i d e n t i f y as a c r i s i s r elated issue. (That i s , i t i s not an issue related to the c r i s i s caused by the rape.) 9. Burgess and Holmstrom lump stage one and two together such that . between infancy and age three there i s a cert a i n uniformity to the concerns and issues involved for the victim. 10. I f i n d i t necessary here to quote somewhat extensively. I want to allow Burgess and Holmstrom to speak for themselves. When I turn to the analysis of what they have said i t w i l l make more sense to the reader i f he has seen what they said i n the f i r s t place. 11. Of course, t h i s makes sense on one l e v e l . But, i t seems that anyone would have- a d i f f i c u l t i e s with trust a f t e r having been raped. Does t h i s e n t a i l that a l l rape victims who suffer a compounded c r i s i s involving an i n a b i l i t y to e s t a b l i s h t r u s t i n g relationships f a i l e d to resolve the stage I ego c r i s i s ? 12. The terms used by the c l i n i c i a n s here, e s p e c i a l l y the notion of chosen l i f e s t y l e , intimate that they presume that how and where victims l i v e i s l a r g e l y a matter of choice. This i s , at best, doubtful i n the case of many of the women most at r i s k of rape: the poor and uneducated. (This remark was prompted by comments made by E a r l Winkler on a p r i o r draft. ) 34 Chapter Two The Psychological Account of Rape: Elaborations and Concerns With the framework of rape c r i s i s theory now i n place, we can now step back and look more generally at how t h i s framework asks us to conceive rape victims. In t h i s chapter we w i l l look at some of the claims about both rape victims and ra p i s t s to which t h i s framework i s committed. These claims, i t w i l l be argued, both show stresses within the framework of rape c r i s i s theory and stand rather at odds with the victims' own conceptions of themselves. This w i l l prepare us f o r the alte r n a t i v e framework offered i n Chapter Three. Rape Trauma Syndrome and Mental Disorder On the psychological model rape victims are considered to experience a kind of traumatic shock beginning with the r e a l i z a t i o n that they are about to be deeply harmed and possibly k i l l e d f o r reasons they cannot discover. The trauma continues through a long process of recovering from the event. In the Merck Manual of Diagnosis and Therapy, published by the Merck Research Laboratories, rape trauma syndrome has not been acknowledged as such but the rape vi c t i m i s considered to have suffered an extremely s t r e s s f u l 35 psychological trauma (Merck, 1992, pp. 1832-30). Under the heading "Medical Examination of the Rape Victim" one finds the following i n s t r u c t i o n : "Patients should be viewed as undergoing a post traumatic stress disorder that t y p i c a l l y has an acute phase l a s t i n g a few days to a few weeks, followed by a long-term process of reorganization and recovery" (Merck, 1992, pp. 1832-3, emphasis added). As mentioned before, rape trauma syndrome i t s e l f i s not even mentioned i n the diagnostic manuals, except f o r the C l a s s i f i c a t i o n of Nursing Diagnoses manual. In 1980, rape trauma syndrome appears to have been completely subsumed under the larger disorder "Posttraumatic Stress Disorder" by the American Psychiatric Association i n Diagnostic and S t a t i s t i c a l Manual -- III (henceforth, DSM-III). Posttraumatic stress disorder i s most commonly thought of as the disorder suffered by war veterans. The disorder i s , however, much more broadly defined than that. In accordance with the general diagnostic thrust of the American Psychiatric Association, i t i s characterized by c e r t a i n kinds of behavior or symptoms of the group of people who are diagnosed with i t . The most important factor i n those who s u f f e r from posttraumatic stress disorder i s that they a l l undergo the experience of a "...traumatic event that i s generally outside the range of usual human experience" (APA, DSM-III, 1980, p.236). It i s thought that anyone i n the s i t u a t i o n would be greatly distressed and i t 36 must be outside the range of such events as bereavement, i l l n e s s , business l o s s e s and so on. The c h a r a c t e r i s t i c symptom f o r s u f f e r e r s i s an i n a b i l i t y to c o n t r o l the r e c a l l of the traumatic event. 1 For demonstrative purposes, I w i l l l i s t below the most recent c r i t e r i a f o r the diagnosis of posttraumatic s t r e s s d i s o r d e r 2 : D i a g n o s t i c c r i t e r i a f o r 309.81 Post traumatic s t r e s s d i s o r d e r A. The person has been exposed to a traumatic event i n which both of the f o l l o w i n g were present: (1) the person experienced, witnessed, or was confronted w i t h an event or events that i n v o l v e d a c t u a l or threatened death or ser i o u s i n j u r y , or a t h r e a t t o the p h y s i c a l i n t e g r i t y of s e l f or others (2) the person's response i n v o l v e d intense f e a r , h e l p l e s s n e s s , or h o r r o r . * B. The traumatic event i s p e r s i s t e n t l y reexperienced i n one (or more) of the f o l l o w i n g ways : (1) r e c u r r e n t and i n t r u s i v e d i s t r e s s i n g r e c o l l e c t i o n s of the event, i n c l u d i n g images, thoughts, or perceptions.* (2) recurrent d i s t r e s s i n g dreams of the event.* (3) a c t i n g or f e e l i n g as i f the traumatic event were r e c u r r i n g (includes a sense of r e l i v i n g the experience, i l l u s i o n s , h a l l u c i n a t i o n s , and d i s s o c i a t i v e flashback episodes, i n c l u d i n g those that occur on awakening or when i n t o x i c a t e d ) . * (4) intense p s y c h o l o g i c a l d i s t r e s s at exposure to i n t e r n a l or e x t e r n a l cues that symbolize or resemble an aspect of the traumatic event. (5) p h y s i o l o g i c a l r e a c t i v i t y on exposure to i n t e r n a l or e x t e r n a l cues that symbolize or resemble an aspect of the traumatic event. 37 C. Persistent avoidance of s t i m u l i associated with the trauma and numbing of general responsiveness (not present before the trauma) , as indicated by-three (or more) of the following: (1) e f f o r t s to avoid thoughts, feelings, or conversations associated with the trauma (2) e f f o r t s to avoid a c t i v i t i e s , places, or people that arouse r e c o l l e c t i o n s of the trauma (3) i n a b i l i t y to r e c a l l an important aspect of the trauma (4) markedly diminished inte r e s t or p a r t i c i p a t i o n i n s i g n i f i c a n t a c t i v i t i e s (5) f e e l i n g of detachment or estrangement from others (6) r e s t r i c t e d range of a f f e c t (e.g. unable to have loving feelings) (7) sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal l i f e span) D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) d i f f i c u l t y f a l l i n g or staying asleep (2) i r r i t a b i l i t y or outbursts of anger (3) d i f f i c u l t y concentrating (4) hypervigilance (5) exaggerated s t a r t l e response E. Duration of the disturbance (symptoms i n C r i t e r i a B, C, and D) i s more than 1 month. F. The disturbance causes c l i n i c a l l y s i g n i f i c a n t d i s t r e s s or impairment i n s o c i a l , occupational, or other important areas of functioning. specify i f : Acute: i f duration of symptoms i s less than 3 months Chronic: i f duration of symptoms i s 3 months or more specify i f : With Delayed Onset: i f onset of symptoms i s at least 6 months af t e r the stressor (APA, DSM-IV, 1994, pp. 424-9). So, rape trauma syndrome i s never acknowledged as a separate disease entity, but a dir e c t comparison between 38 rape trauma syndrome and posttraumatic stress disorder makes clear that rape victims are l i k e l y candidates for t h i s mental disorder. There i s also the diagnostic category "Acute stress disorder (308.3)" for those that s u f f e r s i m i l a r symptoms for 1 month or less. It i s only i f one's symptoms continue for more than one month that one i s upgraded to an o f f i c i a l case of posttraumatic stress disorder. There i s , c l e a r l y , a firm connection between posttraumatic stress disorder and rape trauma syndrome even though they emerged as o f f i c i a l diagnoses for d i f f e r e n t groups of p r a c t i t i o n e r s i n d i f f e r e n t publications. Though neither group mentions the other disorder, both disorders were o f f i c i a l l y acknowledged i n 1980. They f i t together due to the obvious s i m i l a r i t i e s i n the e f f e c t s that war has on veterans and that rape has on victims. Posttraumatic stress disorder emphasizes the lack of control one has over one's memory r e c a l l and one's moods. Generally, those with posttraumatic stress disorder are not managing t h e i r l i v e s according to the norms of t h e i r culture. They are disorderly i n c e r t a i n ways which they are not able to control ( i . e . angry outbursts, joblessness, homelessness, addiction to any number of l e g a l and i l l e g a l drugs). Rape victims exhibit s i m i l a r i n a b i l i t y to cope and to function normally. 39 Thus, as we have shown i n Chapter One above, given the way that rape trauma syndrome i s defined, one need only be raped i n order to suffer from i t . Therefore, since rape trauma syndrome i s considered a type of posttraumatic stress disorder (or acute stress disorder), a rape v i c t i m i s taken to be necessarily s u f f e r i n g from a mental disorder as soon as she begins to react to the traumatic event of the rape. The notions of mental disease, i l l n e s s , and disorder are a b i t vague even within the language of psychiatry. It has been d i f f i c u l t to locate the p a r t i c u l a r meaning of these terms. However, a look at attempts to define these terms reveals that rape trauma syndrome only problematically f i t s within the general notion of mental disorder. This fact reveals a tension i n c l i n i c a l thought that proves to be i n s t r u c t i v e . In P s y c h i a t r i c Diagnosis: A Biopsychosocial Approach, Jess Amchin, quoted the DSM-III-R as defining a disorder as follows: In DSM-III-R each of the mental disorders i s conceptualized as a c l i n i c a l l y s i g n i f i c a n t behavioral or psychological syndrome or pattern that occurs i n a person and that i s associated with present d i s t r e s s (a p a i n f u l symptom) or d i s a b i l i t y (impairment i n one or more important areas of functioning) or with a s i g n i f i c a n t l y increased r i s k of s u f f e r i n g death, pain, d i s a b i l i t y , or an important loss of freedom. In addition, t h i s syndrome or pattern must not be merely an expectable response to a p a r t i c u l a r event, e.g. the death of a loved one. Whatever i t s o r i g i n a l cause, i t must currently be considered a manifestation of a behavioral, psychological, or b i o l o g i c a l dysfunction i n the person. Neither deviant behavior, e.g. p o l i t i c a l , 40 r e l i g i o u s , or sexual, nor c o n f l i c t s that are p r i m a r i l y between the i n d i v i d u a l and society are mental disorders unless the deviance or c o n f l i c t i s a symptom of a dysfunction i n the person as described above... (Amchin, 1991, p.53, emphasis added). The disorders we are concerned with here, posttraumatic stress disorder and rape trauma syndrome, were considered anxiety disorders i n DSM-III. Quoting again from Amchin, anxiety i s defined as the f e e l i n g of "apprehension, tension, [and] uneasiness that stems from the a n t i c i p a t i o n of danger, which may be i n t e r n a l or external" (Amchin, 1991, p. 112). Anxiety disorders, according to ICD-10 C l a s s i f i c a t i o n of Mental and Behavioral Disorders, published by the World Health Organization (WHO), are to be regarded as "maladaptive responses to severe or continued stress, i n that they i n t e r f e r e with successful coping mechanisms and thus lead to problems i n s o c i a l functioning" (WHO, 1992, pp. 145-6). In 1980 the disorders which are now regarded as anxiety disorders were regarded as "neuroses". There was, however, a conscious s h i f t from DSM-III to DSM-III-R i n the conceptual framework. The "neurotic-psychotic" d i s t i n c t i o n was dropped i n favor of more phenomenologically descriptive c r i t e r i a for mental disorders. (Perhaps cre d i t can also be given to an increasing amount of p o l i t i c a l pressure from advocacy groups on the one hand and insurance companies on the other hand.) In The New Language of Psychiatry: Learning and Using DSM-III, Ronald Levy, says of posttraumatic stress disorder that i t describes the 41 "...untoward reactions of some individuals a f t e r undergoing extreme stress" (Levy, 1982, p. 203, emphasis added). There i s a tension here i n ps y c h i a t r i c thought about those su f f e r i n g from rape trauma and posttraumatic stress. Those who suffer from these disorders have experienced something beyond the bounds of ordinary human experience that i s thought l i k e l y to induce s i g n i f i c a n t stress reactions. In some sense, not reacting might be considered (and i s considered i n the case of rape trauma syndrome and posttraumatic stress disorder) p o t e n t i a l l y more harmful to the vi c t i m than manifesting a stress or anxiety disorder right away. So, psychological reaction to the point of dysfunction i s considered the norm i n the case of extremely s t r e s s f u l events such as rape, torture, war, and some natural disasters. But, according to the d e f i n i t i o n of disorder above, the behavior of the person "...must not be merely an expectable response to a p a r t i c u l a r event..." In the case of people with rape trauma syndrome or posttraumatic stress disorder the response i s , i n an important sense, normal but the cause of the response i s not within the bounds of ordinary human experience. Right off the bat, then, we have a tension here. Obviously these are people i n need of help. They have l i t t l e i f any control over t h e i r memory and for many i t i s as i f they have no control over t h e i r own minds. The d e f i n i t i o n of posttraumatic stress disorder s p e c i f i e s that 42 the trauma cannot be an experience most of us w i l l have undergone. Thus, there i s a t e r r i b l e sense of i s o l a t i o n for those who do have these experiences. One does not talk about such things i f one feels that one w i l l be misunderstood or i f the l i s t e n e r might underestimate the importance and traumatic nature of the s i t u a t i o n . Naturally, these aspects of trauma drive a person to a kind of adaptation that may not f i t well with the standard expectations of the rest of society. It seems that they do become disordered i n a way from the experience and perhaps from the ongoing recurrence of the trauma within them. But th i s seems quite d i f f e r e n t from the person who, within ordinary circumstances (i . e . , circumstances not punctuated with extreme trauma), i s unable to cope and becomes seriously disordered and dysfunctional. Rape trauma and posttraumatic stress both have p r e c i p i t a t i n g causes, which are extreme. Most mental disorders do not. Or at least, one need not know the cause i n order to diagnose a person with most o f f i c i a l DSM mental disorders. There i s no obvious way to resolve t h i s tension while remaining within the c l i n i c a l framework. The clear place to begin would be to t r y to make out a d i s t i n c t i o n between expectable reactions to expectable or normal events i n human l i f e (for example, the death of a parent) and expectable reactions to abnormal and extreme events (for example, rape and war). It i s not at a l l cle a r that t h i s can be done, 43 however. "Abnormal" here cannot simply be understood as "unusual" or "unexpectable". It i s not within the s p i r i t of the psychological approach to claim, for example, that rape trauma syndrome would cease to exist i n so c i e t i e s where rape was an expectable event i n the l i f e of women. Indeed, ps y c h i a t r i c l i t e r a t u r e (such as Folnegovic-Smalc, 1994) on the rape of women i n the c i v i l war i n Bosnia-Herzegovina uses the language of posttraumatic stress disorder i n a si t u a t i o n of widespread and systematic rape. The best attempts to understand "abnormal" i n t h i s context seem to be notions such as " h o r r i f i c " or "inhuman" but these notions don't seem to be explicable i n straight-forwardly psychological ways. The fact that rape trauma syndrome f i t s into posttraumatic stress disorder indicates something only problematically resolvable. The i n e v i t a b i l i t y of rape trauma syndrome i n response to the rape event seems to indicate that the c l i n i c i a n s want to be able to say that rape victims are harmed severely i n a l l cases. They want to acknowledge and emphasize the severity of these kinds of trauma. War, torture and rape must be seen i n l i g h t of what they almost necessarily do to those who experience them. The h o r r i b l e nature of the trauma event must be acknowledged in some way. Within the c l i n i c a l framework, the way to do thi s i s to claim that the harm done i s so severe as to cause a mental disorder. This i s the obvious way within the 44 framework to acknowledge the u n i v e r s a l l y harmful nature of extreme trauma. Any reaction to h o r r i f i c events can, then, be seen as normal because a l l who suffer such events are disordered. The pathologization of victims and, thus, normal reactions to abnormal and hideous traumatic events, i s the way that c l i n i c i a n s t y p i c a l l y understand the universal harm of rape and other severe traumas. The problem i s that the disorders (rape trauma syndrome and posttraumatic stress syndrome), which are by d e f i n i t i o n the sum of predictable and inevitable reactions to such traumas, do not f i t the d e f i n i t i o n of disorders given by the APA. Disorder seems i l l - f i t t e d to the work i t i s asked to do i n cases of extremely traumatic events -- expected responses to unexpected events are not part of the standard d e f i n i t i o n of mental disorder. In chapter one I mentioned that some research has been done by c l i n i c i a n s on r a p i s t s . Before I continue the analysis of the implications of the c l i n i c a l framework I want to turn b r i e f l y to examine what the c l i n i c i a n s have learned about r a p i s t s . C l i n i c i a n s and the Rapist In the same way that c l i n i c i a n s are regarded as having expert knowledge of rape victims, they have come to be regarded as the experts on criminal behavior. 3 They claim 45 to have a body of knowledge about ra p i s t s , as they do other kinds of criminals. That i s , they have spent time researching, interviewing and observing r a p i s t s and from these e f f o r t s i t i s thought that a ce r t a i n expert knowledge has come about. Although I am primarily concerned with the treatment of rape victims, i t i s helpful to see what the c l i n i c i a n s have to say about those who commit rape. As mentioned before, research subjects of t h i s kind are hard to come by because they are criminals. Most of the research done i s on the rap i s t s who are caught and convicted of t h i s crime; t h i s may skew the sample quite a b i t . Before going into the res u l t s of the study of rap i s t s I w i l l introduce t y p i c a l circumstances under which c l i n i c i a n s have access to them. The Massachusetts Correctional I n s t i t u t i o n at Bridgewater was founded i n 1959 for the observation, evaluation, treatment and r e h a b i l i t a t i o n of "sexually dangerous" in d i v i d u a l s . The subjects were evaluated to determine whether they should be committed to the center for treatment. If the subject was judged to be treatable he was then committed for an i n d e f i n i t e period of time, meaning u n t i l he was considered by the c l i n i c i a n s to be less l i k e l y to commit sexually dangerous acts. The following information i s taken from an a r t i c l e about t h i s f a c i l i t y , "The Psychology of Rapists", written by Murray Cohen, et a l (Cohen, et a l . 1971, pp. 307-27). 4 6 Studies show that there are three basic kinds of rapi s t , each i s distinguished according to the aim the rapi s t seeks. These aims are a) aggressive aim, b) sexual aim, and c) aggression d i f f u s i o n aim.4 Each category i s composed of descriptive q u a l i t i e s of character, personality, developmental a b i l i t i e s i n behavior, relationships, work and other a c t i v i t i e s of day to day l i f e . It i s i n t e r e s t i n g to note that each kind of ra p i s t i s thought to have a defective development of one or more of the Eriksonian ego q u a l i t i e s . At the time that the a r t i c l e was published the c l i n i c i a n s guardedly compared each category with a p a r t i c u l a r diagnosis found i n the DSM-II. The DSM disorders did not include the p r o c l i v i t y towards s o c i a l l y unacceptable sexual behavior. I suspect that i f one were to consult the more recent DSM-IV one would f i n d that there are more d e s c r i p t i v e l y accurate diagnoses that assimilate both the DSM-II personality disorders and the symptomatic behavior such as sexual assault. The aggressive aim rap i s t i s vio l e n t and angry when he rapes, his aim i s to v i o l a t e and to hurt his vic t i m severely. He rapes t o t a l strangers chosen randomly, usually a f t e r an a l t e r c a t i o n with a person he i s i n a rel a t i o n s h i p with. He i s b a s i c a l l y regarded as normal i n his day to day l i f e , except for his quick temper and vio l e n t outbursts. He works regularly and well, he i s manly and responsible, and he hates things that affront his sense of manhood. The 47 problems l i e i n his underdeveloped ego q u a l i t i e s of i d e n t i t y and intimacy. The c l i n i c i a n s regard his behavior as symptomatic of poorly resolved homosexual tendencies which he represses as best he can. The opposing q u a l i t i e s to id e n t i t y and intimacy are role d i f f u s i o n and i s o l a t i o n . The related DSM-II disorder i s the "explosive personality disorder" which f a i l s to capture his focused aggression toward women, but holds adequately enough (Cohen, et a l . , 1971, p.326). The sexual aim rapist i s perhaps the most stereotypical or popularly understood kind of r a p i s t . This r a p i s t seeks out a woman, usually a stranger, but not at random as with the aggressive aim ra p i s t . He i s sexually aroused and thinks, or at least hopes, that his victim w i l l f i n d him pleasing. In general, the sexual aim rap i s t i s not gratuitously v i o l e n t ; he does harm only to get what he wants. C l i n i c i a n s f i n d that the sexual aim rap i s t i s a f f l i c t e d by g u i l t and shame. He i s said to be both s o c i a l l y and sexually impotent i n d a i l y l i f e , as well as when he attacks his victims. G u i l t and shame are the opposing ego q u a l i t i e s to autonomy and i n i t i a t i v e . The sexual aim ra p i s t i s also thought to be struggling with homosexual impulses, but his reactions are less v i o l e n t than the aggressive aim r a p i s t . Nonetheless his raping i s symptomatic of someone tr y i n g to f i n d intimacy which he has f a i l e d to f i n d using the s o c i a l l y sanctioned practices. The 48 DSM-II disorder most c l o s e l y f i t t i n g the sexual aim r a p i s t i s "inadequate personality disorder", which f a i l s to accommodate the extent of the perversity of t h i s type of r a p i s t , but o v e r a l l describes his personality structure adequately (Cohen at a l . , 1971, p. 326). The sex aggression-diffusion r a p i s t i s concerned to e l i c i t aggressive behavior from his victim. There i s no sexual e x c i t a t i o n without violence for him. C l i n i c i a n s observe that there i s a " s a d i s t i c component" to t h i s type of r a p i s t . According to Burgess and Holmstrom t h i s person w i l l also show a history of nonsexual, a n t i s o c i a l behavior, an absence of stable relationships, [a] lack of concern for others, d i f f i c u l t y i n t o l e r a t i n g f r u s t r a t i o n , poor ego controls, [and] absence of psychic discomfort over t h e i r behavior... (Burgess and Holmstrom, 1974, p.29). His personality development "reveals an absence of the latency period" which i s the stage when one i s supposed to resolve the c o n f l i c t between industry and i n f e r i o r i t y . It i s not e n t i r e l y clear i f the c l i n i c i a n s mean to say that the personality development arrests at t h i s point or i f i t simply skipped over t h i s stage. Given that Erikson understood each stage to be successive upon the l a s t i t i s l i k e l y that the c l i n i c i a n s mean that the sex aggression-d i f f u s i o n r a p i s t developed the undesirable ego q u a l i t i e s from t h i s point forward. This idea i s supported by the symptoms that c l i n i c i a n s point to. His behavior i s impulsive and he i s cruel to those who are weaker than he 49 i s . C l i n i c i a n s are i n c l i n e d to view t h i s type of ra p i s t as psychotic and su f f e r i n g from the DSM-II " a n t i s o c i a l personality disorder". There i s one other category of ra p i s t mentioned by Burgess and Holmstrom, but i s not discussed i n any depth by Cohen et a l . . The impulse ra p i s t does not set out to rape but w i l l do so i f the opportunity arises. According to Burgess and Holmstrom "various researchers ... consider t h i s rape an expression of predatory disorder" (Burgess and Holmstrom, 1974, p.32). The aim of the impulse r a p i s t i s d i f f i c u l t to gauge, he i s usually engaged i n some other criminal a c t i v i t y f i r s t . Some compare t h i s person to one who i s with a conquering army, raping and p i l l a g i n g go hand i n hand. I w i l l not go further into t h i s aspect of c l i n i c a l study. I want merely to point out the s i m i l a r i t y of framework used to view r a p i s t s and t h e i r victims. Both groups of people are regarded as suf f e r i n g from psychological problems of one kind or another. The c l i n i c i a n s have found a way to say that rape i s abnormal by making both rape and the reaction to i t expressions of mental disorder. In laymen's terms, a l l of these people are sick. The r a p i s t s are sick. They express the symptoms of t h e i r sickness by raping, which i n turn makes t h e i r victims sick. 50 Conclusion The c l i n i c i a n s want to know why the victims of rape and other traumas become disordered in d i v i d u a l s . In psychology the answers and explanations l i e i n the vocabulary of medicine and s o c i a l science. The people who rape, murder and torment are not normal. Not being normal translates into being sick. The sickness that these deviants have i s s o c i a l only i n so far as the expression of symptoms affe c t others, hence the term a n t i - s o c i a l . The c l i n i c i a n s are looking for explanations that show that these people are sick i n the same way that a person with cancer i s sick. That i s , they seek the causes which show that the deviant has l i t t l e or no control over his behavior. As a consequence, when a victim needs to know why she, of a l l the people i n the world, was chosen to be tormented, the answer i s simple; "the person who did t h i s to you i s sick". Thus the vi c t i m i s able to know that she i s a victim, she had no r e s p o n s i b i l i t y for the perpetrators actions, she was chosen because the ra p i s t i s sick. In the same sense the r a p i s t ' s "sickness" also diminishes his r e s p o n s i b i l i t y . As I draw t h i s chapter to a close, I want to d i r e c t attention to the thread that holds c r i s i s theory and the various treatment theories together. They are used to treat people who have been raped, but are also applied to people seeking psychological treatment generally. The connecting 51 thread i s an instrumentalist view that c l i n i c i a n s have of the human subject. We are, on t h i s view, complex systems ordered toward various functions. The language of psychology and medicine i s about function, order, organization, integration and productivity. Yet, as we have seen, autonomy, shame, g u i l t , i n t e g r i t y , anger, self-respect or self-esteem, victimhood, and trust are a l l also part of the language of psychology. The framework of instrumentalism within psychology requires a consequentialist view of harm. An action i s wrong i f i t causes harm. The harm of rape i s apparent. Victims of rape manifest both physical and psychological traumata as a d i r e c t r e s u l t of the rape. Treatment based on a diagnosis of rape trauma syndrome i s designed to be helpful to a l l victims of rape. But once one goes beyond the 'normal' set of reactions (i.e. symptoms of rape trauma; sleep disturbance, mood swings, moving, etc.), one i s then suf f e r i n g a compounded reaction which puts her into a category where she i s abnormal because she i s reacting badly or i n a maladaptive way. The harm that c l i n i c i a n s see i s the disordering, the disorganization, and the cessation of normal functioning i n the psychological, physical and s o c i a l systems. Once a rape victim i s back to her previous l e v e l of functioning i n these areas she i s considered to be a recovered survivor of rape. The bad e f f e c t s have been reversed. To be a survivor i s to 52 able to manage both one's reactions to and memories of the rape to the point that they no longer i n t e r f e r e with one's l i f e . The instrumentalism stems from two things, the heavy and barely acknowledged reliance of much psychological theory on Erik Erikson's "Eight Stages of Man" and the deeper framework which sees human beings as mechanical, functional systems. Only when we f a i l to function within the norms of our society i s something wrong enough to be concerned with i t . North American Psychology and medicine i n general have become highly scientized. They no longer seek to work within the murky regions of the moral and humane. There are not enough 'facts' i n t h i s realm. Morality, the soul, and humanity have been exchanged for cognitive function, biochemistry, s o c i a l systems and prozac. The words commonly construed as moral (or at least value laden) i n the theories on the preceding pages are hollow s h e l l s by comparison to the f u l l y moral use of these words. Autonomy has become an ego q u a l i t y one acquires i n the face of shame and doubt. It i s the c h i l d ' s quest to learn to control his eliminative functions that brings up the p o s s i b i l i t y of autonomy i n a person. Shame i s a result of f a i l i n g to l i v e up to the expectations of those one tru s t s . Doubt comes with finding oneself less worthy by v i r t u e of f a i l u r e . Thus, i t i s 53 possible to be undeserving of, or even to f a i l to be i n possession of autonomy. The l i s t of required ego q u a l i t i e s i s impressive and in s t r u c t i v e when t r y i n g to understand why c l i n i c i a n s might question emotional reactions to rape. If one i s f e e l i n g suddenly unable to continue i n her previous l i f e due to deep fear of both the ra p i s t and other people's reactions to her having been raped, then she i s having a compounded reaction based i n a poorly resolved ego c o n f l i c t . Rather than a j u s t i f i e d fear based on the c u l t u r a l norms surrounding rape and the fact that many rap i s t s are never prosecuted, she i s displaying a f a u l t i n her personality structure (seen by c l i n i c i a n s as the source of the s e l f and of one's p o s i t i v e s e l f - e v a l u a t i o n ) . Emotions frequently referred to as moral emotions --anger, g u i l t , shame, indignation, and outrage -- are treated as further signs of a maladaptive personality on the part of the victim. She may be asked why she i s angry or why she feels that she should have or could have done something to prevent the rape. The answers to these questions are thought to be found i n the victim's past, that i s i n the personality structure and developmental stage of the person, not i n the actual trauma experienced during and af t e r the rape. A person who has been raped has been victimized. No one wants to question t h i s . The kind of victimhood assigned 54 to one who has been raped varies across the relevant f i e l d s . Legally speaking, one i s a victim of a vi o l e n t crime. This applies to one's le g a l status, the person's l e g a l rights have been v i o l a t e d . Rape causes physical harm, so one i s a vic t i m of violence done to the body. Rape also causes harm to the psyche; a person who has been raped may see herself as e s s e n t i a l l y a victim. This brand of victimhood i s an i d e n t i t y of sorts that one who has been raped may adopt. By adopting the language of disorder, disorganization, abnormality, lack of control and dysfunction, c l i n i c i a n s encourage a rape v i c t i m to adopt the stance of a person defined as a v i c t i m (as opposed to a person who has been victimized). In Rewriting the Soul: Multiple Personality and the Sciences of Memory, Ian Hacking c a l l s t h i s the looping e f f e c t of human kinds (that i s , kinds of humans we might be). He argues that we tend to behave i n ways that are expected of us, e s p e c i a l l y i f the expectation arises from an authority we respect such as a physician or therapist. People c l a s s i f i e d i n a c e r t a i n way tend to conform to or grow into the ways that they are described; but they also evolve i n t h e i r own ways, so that the c l a s s i f i c a t i o n s and descriptions have to be constantly revised (Hacking, 1995, p.21). 5 The treatment offered by c l i n i c i a n s and the framework which informs the treatment i s designed to get a person to function i n a cert a i n way. In order to excuse and to a l t e r her behavior, c l i n i c i a n s ask the rape vi c t i m to see herself 55 from within the stance of victimhood. This i s true because her behavior i s deviant from the norm. As deviant, i t i s seen as undesirable or dysfunctional. But, i f the deviance i s caused by a trauma such as rape, then she i s a vi c t i m and, as such, her behavior i s excused from some of the standards of normalcy. Thus, the rape v i c t i m takes on the id e n t i t y of a victim i n order to explain herself and to excuse herself from the standards applied to non-victims. But she must remain a vic t i m for as long as she i s affected by the event of the rape. Given that most rape victims do not f e e l that they w i l l ever return to being t h e i r former selves, they appear to be stuck, helpless i n the vic t i m stance. After years of feminist c r i t i q u e , psychology has come up with a move out of the vic t i m stance. It i s the move from vi c t i m to survivor. As a survivor she i s s t i l l able to acknowledge herself, and be acknowledged as, a person who was a vic t i m and who may not be the way she was before she was raped. But she does not remain i n the state where she i s unable to function i n everyday l i f e . Thus, one i s s t i l l affected, and sees herself as changed permanently, but she w i l l survive and carry on. The looping e f f e c t of human kinds re s u l t s i n people changing t h e i r way of being (for good or e v i l ) . As "constructed knowledge loops i n upon people's moral l i v e s , [it] changes t h e i r sense of s e l f -worth, reorganizes and reevaluates the soul" (Hacking, 1995, 56 p. 6 8 ) . It c e r t a i n l y seems to be true that psychological victimhood and survival have the e f f e c t of changing the rape victim's conception of h e r s e l f . 6 The move to pathologize normal (or at least reasonable) reactions to extraordinary trauma seems l i k e a p o t e n t i a l l y harmful move. There are d e t a i l s i n the d e f i n i t i o n s and testimonies of the victims of posttraumatic stress disorder and rape trauma syndrome that lead me to think that these symptoms s i g n i f y more than psychological dysfunction. The harm done seems to a f f e c t more than basic human functioning. It i s said by a l l the manuals that posttraumatic stress disorder i s more severe i n those who suffered at the hands of other human beings - that i s , i f the trauma was of human design and implementation. So the question I want to ask i s t h i s , are these people sick or has t h e i r humanity been deeply injured? Either way, at t h i s time i n our society they are going to wind up seeing an expert i n psychological disorders. But perhaps the approach that the c l i n i c i a n takes i s not the one that i s most b e n e f i c i a l to the v i c t i m of severe trauma. It w i l l be said that the v i c t i m i s mentally disordered, sick, disorganized, managing or functioning badly, a l l i n the course of acknowledging her suffering. As a r e s u l t , victims of trauma must take on a kind of r e s p o n s i b i l i t y that works against them. They have f a i l e d to cope with a traumatic event. The question that needs to be asked i s why did they f a i l to cope? It was not 57 for lack of coping s k i l l s i n normal l i f e . It i s more that the horror of the experience has l e f t them without any explanation of why i t happened. There are no good reasons; or, rather, there are no j u s t i f i c a t i o n s for the hideous things that have been done to veterans of wars and to rape victims. In war and rape, the message sent i s that one i s not regarded as a fellow human being; one wouldn't do t h i s to one's fellows. It i s inhuman treatment aimed at destroying one's personhood or humanity. And i t works, i n so f a r as i t places the person i n a p o s i t i o n where the world i n which trusted f a l l s apart. With a medicalized framework the c l i n i c i a n s take the question of why a person has been victimized to be a request for an empirical explanation. In essence, i t i s a question of the nature of the r a p i s t ' s disorder. S i m i l a r l y , i f the vic t i m asks how she i s to l i v e with t h i s event, she receives an answer that i s aimed at getting her back to a c e r t a i n p r i o r l e v e l of functioning. But i n my experience as an advocate these questions are asked less with a c u r i o s i t y about explanations or prognoses and more with an eye toward possible j u s t i f i c a t i o n s . When a person has been victimized by her or his fellow human beings those who t r y to help must be doubly careful not to revictimize the person. In the following chapter I turn to another way of thinking about these events and the reactions of the people to whom they happen. I w i l l begin by examining the notion 58 of psychological victimhood and compare i t to other ways of thinking about being a victim. Then I take up the question put forward by rape victims: When a vi c t i m of rape asks why she was raped and how she ought to react, what i s she asking? The psycho-social-medicalized answer has been examined i n t h i s chapter. I w i l l propose another framework for thinking about what a vi c t i m of rape i s asking. 59 Endnotes to Chapter Two 1. For an ill u m i n a t i n g discussion of the r e l a t i o n between posttraumatic stress disorder and memory see Ian Hacking (1995) . 2. In the places marked with a '*' there i s a note that s p e c i f i e s the symptoms a c h i l d might exhibit i f she i s suf f e r i n g from t h i s disorder. In an attempt to be b r i e f I have omitted these notes. 3. In the introduction to t h i s chapter I explained the catch-a l l term " c l i n i c i a n s " to apply to the people researching, tre a t i n g and ( i t i s hoped) curing rape victims. I w i l l now change the scope of the term s l i g h t l y i n order to accommodate a somewhat d i f f e r e n t group of people researching, tr e a t i n g and curing criminals. In t h i s case the term i s meant to re f e r to p s y c h i a t r i s t s , behavioral and s o c i a l s c i e n t i s t s , s o c i o l o g i s t s , psychologists, and criminologists. I want to stress that the use of the term i s i n no way meant to re f e r to any s p e c i f i c person i n any these f i e l d s . It i s important that the scope of the term also be l i m i t e d to those professionals concerned with these two groups of people. I do not wish to be seen as c r i t i q u i n g the whole of any of these d i s c i p l i n e s . 4. Burgess and Holmstrom have found that these categories accurately correspond to the descriptions, given by victims, of the way they perceive the behavior and intentions of the r a p i s t (Burgess and Holmstrom, 1974, p.22). 5. This might be why rape victims have come to be known as sufferers of posttraumatic stress syndrome rather than rape trauma syndrome. 6. I w i l l return to t h i s i n greater d e t a i l i n Chapter Three. 60 Chapter Three An Alternative Framework: Rape and Moral Harm Chapter two concluded with a preliminary examination of the p o s i t i o n a rape victim finds herself i n when she undergoes the treatment suggested v i a rape c r i s i s theory. On the following pages I take up alte r n a t i v e frameworks for tre a t i n g persons and t h e i r needs. One of the central issues, perhaps the central issue, for a rape vi c t i m i s the question of why th i s event happened to her. Many people are unable to come to terms with an event which they cannot explain to themselves. The c l i n i c a l approach can serve the purpose of providing a explanation, and, perhaps, an excuse. Rape communicates contempt, malevolence and utter disregard for the victim; these are very d i f f i c u l t attitudes to come to terms with. Rape i s the acting out of the symptoms of a disordered i n d i v i d u a l , according to c l i n i c i a n s . The vict i m i s an object of the rapi s t ' s actions. This may explain why the perpetrator allowed himself to behave i n such a way: he has tendencies to behave i n unsanctioned ways. Perhaps he convinces that women i n short s k i r t s want to be raped, or that drunken women deserve to be raped, or simply that women are there for whatever purposes he may have. Explanations of t h i s sort are not intended to provide j u s t i f i c a t i o n , but i t i s thought that they provide an account of the ra p i s t ' s behavior. But i s an explanation of t h i s sort what a rape 61 v i c t i m needs? Suppose a contributing cause for the rape was some unintended cue from the victim, then the answer suggests that the vi c t i m could have done something to prevent herself from being the person the perpetrator chose to attack. Rape victims are offered medical explanations of the r a p i s t ; they are also given medical explanations for the reactions they experience as a res u l t of having been raped. The medical explanations sta r t with rape c r i s i s theory which, not unreasonably, t r i e s to prevent rape victims from seeing themselves as responsible for causing the rape. It also attempts to keep the rape victims from developing a f u l l blown c r i s i s i n l i f e s t y l e and functioning. Granting vic t i m status to a rape victim may seem l i k e the helpful thing to do given that one needs an excuse to behave i n ways o r d i n a r i l y considered abnormal i n some way. If there i s no sign of physical harm then psychological harm i s the only explanation available that legitimates behavior which does not conform to the norms of our society. But by v i r t u e of imposing t h i s framework onto rape victims, c l i n i c i a n s have c l a s s i f i e d both rapists and t h e i r victims as psychologically abnormal people. From chapter one we know that a l l rape victims are ipso facto thought to suffer from rape trauma syndrome. Then i n chapter two rape trauma syndrome was determined to be a mental disorder by virt u e of i t s connection to posttraumatic 62 stress disorder. In the conclusion to chapter two I referred to the looping e f f e c t of human kinds. Rape trauma syndrome has created a new class of people, or a new way of being a person by redescribing rape victims under the description of a mental disorder. Rape victims have become psychological victims i n so far as they see themselves and are seen as victims. B a s i c a l l y , rape victims have become a special sub-class of a larger class of human victims. I have misgivings about placing rape victims into a stance where they are viewed by others, and see themselves, as psychological victims. It i s one thing to say that I have been the v i c t i m of a crime. In t h i s case I mean that some harm has been done to me, some harmful event has occurred i n my l i f e . This has no extension to my i d e n t i t y i n general. It i s more a statement about my circumstances or perhaps the experiences of my l i f e , than a statement about who I am. However, rape c r i s i s theory asks us to consider that when a person says, "I am a victim," she i s t e l l i n g you something about herself; she i s t e l l i n g you she suffers from a mental disorder. It also asks the v i c t i m to consider herself i n t h i s way. The designation communicates something about how she may think, f e e l and behave, as well as how you should think, f e e l and behave i n r e l a t i o n to her The difference i s that of the two stances: one i s about an event that occurred which v i o l a t e d t h i s person i n some way, the person has been victimized -- t h i s i s victimhood per se 63 The other simply, and poignantly states that the speaker i s a victim, that an event has changed her status i n the world from ordinary person to vic t i m -- t h i s i s psychological victimhood. "Victimhood" i s a term, l i k e many others i n t h i s work, which has taken on so many meanings that i t i s hard to know just what i s implied i n any one case. I have used the term repeatedly when r e f e r r i n g to those who have been raped. In some cases i t i s simply a l a b e l . Certainly i t makes sense to r e f e r to those who have been raped as victims of rape. The act i s harmful i n so many ways that there i s l i t t l e i f any surface ambiguity. However, when we begin to look at the connotations of the term i t looks less and less l i k e a good thing to c a l l oneself or to use as a way of l a b e l l i n g for therapeutic purposes. The kind of account and associations we have about victimhood and related moral terms can make a difference between helping a rape vi c t i m and further harming her. In th i s chapter I w i l l examine t h i s difference by looking at the alt e r n a t i v e stances that can be taken up by c l i n i c i a n s , rape victims, and society i n general. F i r s t , I want to look at what happens when one adopts the psychological victim stance. In my discussion I w i l l make use of Peter Strawson's essay "Freedom and Resentment" (1962). In t h i s essay he gives an account of two stances people tend to take up when dealing with t h e i r fellow human 64 beings. Then, i n the second section, I r e l y upon my experience as an advocate for victims of sexual assault to tal k about what victims of rape are going through. I w i l l o f f e r an example of what helped the rape victims during the i n i t i a l stages of dealing with the trauma of having been raped. It turns out that my p r a c t i c a l experience points to the importance of a moral stance when t a l k i n g to and a s s i s t i n g the victims of rape. I found that the harm the victims were f e e l i n g seemed to go beyond the bounds of the standard c l i n i c a l framework. In the t h i r d section of t h i s chapter I turn to examine d i f f e r e n t moral frameworks from which to view and treat those who have been raped. I suggest that, of the standard moral theories, rights based morality and Kantian morality are the most plausible theories to take up when thinking about the needs of rape victims. Ultimately, I f i n d that Kantian morality best illuminates the issues and helps i n thinking about the moral nature of rape. I put forward the claim that rape victims must f i r s t be treated as persons rather than as victims. In conclusion, I put forward a proposal to use a robustly moral stance which prevents the vic t i m from f a l l i n g prey to the t y p i c a l p l i g h t s and assumptions made about rape and protects her from seeing herself as a vic t i m rather than as a moral agent who has been victimized. With the framework of moral agency i n place, moral personhood ceases to be some far off abstraction and becomes something of genuine human value. 65 Strawson Peter Strawson (1962) claims there are two important stances we take up i n situations where moral sentiments are l i k e l y to a r i s e . There are some people we excuse due to exceptional circumstances as not f u l l y responsible for t h e i r actions. Though we may resent t h e i r behavior, we do not f e e l they deserve to be treated as having transgressed any moral boundaries. A common example i s the way we regard the behavior of children. Another example i s of a person who has been victimized per se. We do not hold her morally responsible for the event or for her reaction to i t (within c e r t a i n boundaries). We tend to excuse her odd behavior for a while and hope that t h i s person w i l l soon recover from the trauma. However, we do not expect to assume t h i s stance with eith e r children or victims permanently. These people are s t i l l members of the moral community though they receive the temporary benefits of being excused from certain, though not a l l , of the standards held for a l l members of the community. These are everyday people who f i n d themselves i n very extraordinary circumstances that are taken to be a temporary state of a f f a i r s . 1 The standard notion of victimhood per se and commonsense seem to indicate that t h i s i s the correct stance for rape victims. The vi c t i m may maintain f u l l standing as a responsible member of the 66 community while being given the understanding and patience needed to come to grips with her experience. 2 There are other people, though, who are somehow abnormal. It i s not merely an event or circumstance of t h e i r l i v e s but that they are somehow d i f f e r e n t from the rest of us; the people are extraordinary rather than the s i t u a t i o n they are i n . We do not i n general hold t h i s group responsible for t h e i r actions i n spite of the fact that they may offend against the bounds of the moral community. These people are not subject to the ordinary standards of society. In some cases t h i s may be important for the object of t h i s stance. Perhaps she cannot measure up due to a lower i n t e l l i g e n c e or a less robust sanity than i s expected of a f u l l member of the community. This i s not to say that they are not members, rather that they are not f u l l members of the community. Nor are they ever expected to achieve t h i s status. Strawson c a l l s t h i s the objective stance: To adopt the objective attitude to another human being i s to see him, perhaps, as an object of s o c i a l p o l i c y ; as a subject for what, i n a wide range of sense, might be c a l l e d treatment; as something to be taken account, perhaps precautionary account, of; to be managed or handled or cured or trained; perhaps simply to be avoided (Strawson, 1962, p. 194). The v i c t i m stance recommended by c r i s i s theory and psychology i n general takes up objective attitudes toward rape victims by v i r t u e of the fact that victims are categorized as mentally disordered. The objective stance permits us to step back and i n some sense withhold our moral 67 attitudes. This stance does not carry any of the standard attitudes towards the subject (e.g., resentment, anger, gratitude). It i s a d i r e c t r e s u l t of the framework that the c l i n i c i a n s use to evaluate and treat rape victims that makes t h i s the stance that c l i n i c i a n s adopt with t h e i r subjects. Rape victims are placed into the realm of those i n need of treatment and reordering to the exclusion of other human needs. In short, a psychological v i c t i m i s no longer a f u l l y fledged member of the moral community.3 An al t e r n a t i v e stance i s the Participant stance where we are engaged with others and able to argue, reason and negotiate with them. There i s at least the presumption that we are p a r t i c i p a t i n g i n some kind of reasoned exchange with another person. In t h i s case sympathy, empathy and other re c i p r o c a l sentiments are possible and appropriate. We view each other as equally p a r t i c i p a t i n g i n a r e l a t i o n s h i p . I talked about ordinary people i n extraordinary circumstances above. The participant stance includes these people by v i r t u e of the fact that they r e t a i n the fundamental aspects of t h i s stance even during the time when we excuse them from many the day to day standards. There i s a fundamental opposition between the stances. On one end of the spectrum we have the objective stance where we f e e l no moral reactive attitudes at a l l . At f i r s t t h i s seems l i k e the right stance to occupy i n viewing the victim. She ought not be the recipient of any more 68 resentment, blame or anger. C l i n i c i a n s use expert knowledge and facts as a guide to t h e i r reaction to those viewed objectively. You w i l l r e c a l l that the Merck Manual recommends that c l i n i c i a n s view the rape vi c t i m as "undergoing a posttraumatic stress disorder". Any and a l l reactions to the trauma w i l l prove to the c l i n i c i a n that the vic t i m i s i n need of treatment. The c l i n i c i a n i s there to treat and study the subject, not to pass judgment on her. But as mentioned above, the objective stance r e s t r i c t s our attitudes and sentiments. Fellow f e e l i n g i s not appropriate when one adopts objective attitudes for another person. At the other end of the spectrum we f i n d that our "humanity" (participation) i s what guides our reactions to the persons and situations that c a l l f o r t h moral reactive attitudes (Strawson, 1962, p.194). 4 The objective stance places the c l i n i c i a n i n the p o s i t i o n where he may not f e e l indignation on behalf of his c l i e n t . He i s to remain "objective". To take up the objective stance i s to o b j e c t i f y and even dehumanize the subject. What I am t r y i n g to draw out here i s the d i s t i n c t i o n made when one s h i f t s from viewing others as one of us to viewing someone as a object, for the purposes of treatment, a c q u i s i t i o n of expert c l i n i c a l knowledge, or whatever. This s h i f t removes the subject's humanity. It i s important to see the implications of turning responsible moral agents who have been victimized 69 more or less e n t i r e l y into victims of disease and disorder. As victims they are incapable of explaining or claiming control over t h e i r behavior. Their state has control over them. This i s not a helpful way to treat victims of rape. A rape victim's sense of s e l f and place i n the community has been deeply v i o l a t e d . She has l o s t her cle a r sense of her human (moral) standing. By eliminating or diminishing her p a r t i c i p a t o r y status as a responsible member of the community, the c l i n i c i a n s also take away the basic ground for moral agency. Without these basic human q u a l i t i e s i t becomes exceptionally d i f f i c u l t for a vic t i m of rape to recover what she has lo s t i n the trauma. When a rape victim faces the utter contempt that rape expresses she may f i n d herself f e e l i n g gravely distressed. Even i n situations where some event seems u t t e r l y random we fi n d ourselves wanting to know what the ra p i s t meant to communicate by his action. Strawson, drawing on another commonplace, points out how much i t matters to us, whether the actions of other people -- and p a r t i c u l a r l y of some other people -- r e f l e c t attitudes towards us of goodwill, a f f e c t i o n , or esteem on the one hand or contempt, indifference, or malevolence on the other (Strawson, 1962, p.191). I think that t h i s i s the reason we are so concerned to f i n d out why ra p i s t s rape. If we f i n d a way to think that they have treated t h e i r victims wrongly, then we are able to compensate for the violence done to us by them by regarding t h e i r contempt and malevolence as unfounded. So, t h i s may 70 explain why we must know why. The question now remains, i s the answer provided by c l i n i c i a n s the most hel p f u l answer? Strawson gives an account of the attitudes we adopt with regard to people i n a v a r i e t y of situations (Strawson, 1962, pp. 190-99). If we believe that we are the b e n e f i c i a r i e s of someone's kind intentions we f e e l gratitude. When someone does some small harm, say stepping on someone's toes, we f e e l r e s e n t f u l . If he apologizes, claiming i t was an accident, we forgive and forget. However, when someone causes another person harm, for no reason other than his contempt for the other person, we r i g h t f u l l y f e e l resentment. Under t h i s analysis, a rape vic t i m may appropriately f e e l extreme resentment toward the r a p i s t . In addition, other members of her moral community may f e e l indignant on the victim's behalf. The perpetrator has offended both the victim and the community with his callous attitude and hateful treatment of others. But there i s a c o n f l i c t here between the participant stance and the stance occupied by c l i n i c i a n s , the objective stance. The participant stance reveals an unfortunate byproduct of psychological victimhood. The c l i n i c i a n s must hold that rape constitutes a double v i c t i m i z a t i o n . Someone who i s raped i s the v i c t i m of a mentally disordered person and t h i s event causes her to be the victim of a mental disorder. The therapy model used employs the t a c t i c of teaching her that she i s i n no way responsible for having been raped. This i s 71 surely r i g h t . But she i s also taught that the anger, shame or g u i l t she might f e e l as a r e s u l t of the rape are symptoms of her disorder. Such emotions s i g n i f y a flaw i n her personality development (rather than understandable reactions to the harm done to the v i c t i m as seen from the participant stance). Thus, she i s f i r s t a v i c t i m of a sick person toward whom resentment might be inappropriate (he, too, i s to be considered from the objective stance) and then a v i c t i m because her natural reaction s i g n i f i e s a c r i s i s and disorder i n her personality structure. There i s , i n other words, something wrong with her. She must now come to view herself from the objective stance. There i s no question but that c l i n i c i a n s want to help rape victims. Certainly the work and research that has been done has had s i g n i f i c a n t impact on the way we think about rape and i t s e f f e c t s on.victims. Drawing attention to the seriousness of the harm i s a help. C u l t u r a l l y speaking, tolerance for persons who rape has gone down. People have begun to question the common assumptions about rape. The most reprehensible assumption i s that i f a woman i s raped, then she must have done something to deserve i t . This i s not to say that t h i s kind of thinking has disappeared. But the research has been able to e s t a b l i s h that those who are raped are quite often severely harmed i n one way or another and that r a p i s t s are possessed of views and personality structures which society finds i n t o l e r a b l e . 72 Given the s c i e n t i f i c / i n s t r u m e n t a l framework the harm must be empirically v e r i f i a b l e and c l i n i c a l l y s i g n i f i c a n t . The conception they have of persons i n general forces them to see a natural reaction to a h o r r i f i c event as a malfunctioning which leads to mental disorder. The c l i n i c i a n s have developed a method of sorts for restoring rape victims to t h e i r previous l e v e l of functioning. As a person with a disorder, a rape vi c t i m has a special status which r e l i e v e s her of c e r t a i n r e s p o n s i b i l i t i e s that most of us have. Rape trauma syndrome i s an explanatory tool as well as a tool for i d e n t i f y i n g victims. It explains what a v i c t i m does when she has been raped. It also t e l l s us how to spot a rape victim. What i t does not do i s acknowledge the wrong of the rape i t s e l f . It seems as i f one could say that rape i s both a sign of and a cause of a disorder i n the same way that high fat diets s i g n i f y the p o s s i b i l i t y of and the cause of heart disease. The question one must ask i s how i s i t helpful to me i f I have been raped to be t o l d that I now suffer from a mental disorder (as does the rapist)? It i s as i f what the c l i n i c i a n s are saying i s that rape trauma syndrome i s the one harm done by rape. Surely t h i s can't be r i g h t . In the next section I turn to see how these theories f i t with the r e a l i t i e s of rape and i t s a f t e r e f f e c t s for victims. In my work as an advocate I have had many conversations with victims of rape. Frequently these 73 conversations took us beyond the framework of rape c r i s i s theory. This happened as a r e s u l t of the questions the victims were asking and the answers they were finding. It i s hoped that t h i s section w i l l help to c l a r i f y what the rape victims think and f e e l as they undergo the process of adjusting to the horrors of having been raped. An Application The work of Burgess and Holmstrom functioned as a textbook of sorts for t r a i n i n g advocates. Thus, I went into the work looking for the symptoms of rape trauma syndrome. But perhaps because of my lack of t r a i n i n g as a c l i n i c i a n I had not l o s t contact with the natural d i s p o s i t i o n toward p a r t i c i p a t o r y interactions with the people I wanted to help. Let me begin by t e l l i n g you what I found to be true as I worked with victims of rape. It i s true that rape victims are t y p i c a l l y i n shock and that they are often behaving abnormally by ordinary standards. They cry, shake, chain smoke, lash out angrily, stare at the walls, refuse to talk, or t a l k incessantly. This l i s t could go on forever. When the rape victims talked, they frequently expressed concerns for t h e i r safety or the safety of t h e i r children. By the standards of Burgess and Holmstrom t h i s was a rape c r i s i s issue. Frequently I spent time making sure that the v i c t i m was i n 74 fact safe. There i s l i t t l e else that matters to a person i f she f e e l s that she i s i n danger. Basic needs come f i r s t i n advocacy work. C r i s i s intervention at t h i s l e v e l takes very l i t t l e expert knowledge. One must be sure that there i s a place for her to go and that her children are safe. It helps to f i n d out i f the v i c t i m has anyone she can r e l y upon for support i n the immediate future. A l l of t h i s must come f i r s t . A person's mind must be at ease about the immediate future before she w i l l begin to turn to thinking about what has happened and how she w i l l be affected by i t . But once t h i s has happened, that i s , once a vi c t i m begins to turn a c r i t i c a l eye on the event, and usually upon herself, an advocate's work r e a l l y begins. The c r i t i c a l eye of the victim i s looking for explanations for what has happened to her. She may f e e l shame, doubt and g u i l t immediately. Her feelings are generally a sure sign that she believes that she somehow caused the rape. Perhaps she had been drinking, or perhaps she even f l i r t e d with the r a p i s t the l a s t time she saw him. Or maybe she i s merely acquainted with him from work or school. More often than not the victim and the r a p i s t have some minimal acquaintance. The c l i n i c i a n takes these thoughts and feelings of shame, doubt and g u i l t to be aspects of rape trauma syndrome. As mentioned above rape victims i n e v i t a b l y ask why they were raped. It seems that there are many ways of 75 understanding and answering t h i s question. As discussed above, the c l i n i c a l framework takes the question .to be one of accounting for the motives and actions of the r a p i s t . The c l i n i c i a n s endeavor to explain what motivates a r a p i s t . In part the motive can be detected i n hearing the account of a r a p i s t ' s behavior from the victim. In other words, i f the victi m perceived the attacker as angry with a vi o l e n t hatred of her, then t h i s w i l l reveal that her attacker was an anger r a p i s t . According to c l i n i c i a n s the men who rape women have strong a n t i s o c i a l and destructive b e l i e f s and attitudes towards women. Most of t h e i r negative emotional reactions manifest i n violence towards whatever distresses them, i n thi s case i t i s women. B a s i c a l l y men rape women because they hate women. C l i n i c i a n s then need to f i n d out why the rapi s t s have t h i s attitude. C l i n i c i a n s acknowledge the u n d e s i r a b i l i t y of rape and of the b e l i e f s and attitudes that contribute to the event of a man raping. However, i t often seemed to be true that the rape victims were asking for more than information and explanations of the psychological makeup and health of the ra p i s t . There are events i n human l i f e that lead us to ask how something could have happened and whether there i s any way i t could possibly be j u s t i f i e d or made sense of. Rape i s one of those events. The harm done to a person who i s raped expands beyond the physical and the functional aspects of the i n d i v i d u a l . Rape also constitutes a moral harm, i t 76 c a l l s into question the victim's very humanity. When a rape vic t i m asks why she was raped she i s asking about how someone could possibly have done t h i s to her. There are issues of desert and j u s t i f i a b i l i t y implied i n t h i s kind of question. Causal explanations can and do lead to victims blaming themselves for having been raped. When I took the rape victims' question to be about the moral aspects of what had been done to them i t proved to be helpful i n finding a way out of the victim stance for the victim. According to c l i n i c i a n s , part of being i n shock i s a disordered thought process. One of my duties was to help a rape v i c t i m think c l e a r l y i f she was w i l l i n g to l e t me help. It i s important to short c i r c u i t any tendency she might have to blame herself for the rape. I often had conversations about the thoughts and feelings of the rape victims with regard to rape i n general and more s p e c i f i c a l l y i n r e l a t i o n to having been the vic t i m of a rape. Many victims do f e e l that they could deserve to have been raped. I t r i e d to examine the grounds for t h i s b e l i e f with rape victims to see i f the vic t i m r e a l l y believed that she deserved to be raped. 5 When a rape victim blamed herself for having been raped I asked her to think about whether or not i t i s possible or permissible to consider someone she knows as deserving of such inhumane treatment. As the quotes i n chapter one point out (pp. 4-5), t h i s i s something that most rape victims 77 would not wish on t h e i r worst enemy. I f i n d that looking at the event of the rape as i f i t happened to someone else helps the v i c t i m to see things more c l e a r l y . She i s more i n c l i n e d to adopt a p a r t i c i p a t o r y stance when thinking about others. So, I take the victim's experience and ask her to think about i t as having happened to someone else - a loved one, perhaps a s i s t e r or a f r i e n d . Once the v i c t i m has begun to think about the rape i n a s l i g h t l y abstracted fashion I ask her to review the event with me. Let us c a l l t h i s chosen person ' J i l l ' and the r a p i s t 'Jack' for the sake of s i m p l i c i t y . Here i s an example of what I might ask a victim: J i l l met Jack at a party, just the way you did. J i l l was t i p s y and she did hope that Jack would ask her out for next weekend. She might have even f l i r t e d with him a b i t . When Jack offered to walk J i l l home, she accepted. But instead of walking J i l l home, Jack raped J i l l i n a secluded spot along the way and then l e f t her there. Did J i l l deserve to be raped? If the rape v i c t i m answers no I move on to check over the p a r t i c u l a r d e t a i l s that make the v i c t i m think that she might have done something to deserve to be raped. Thus, we w i l l go over d e t a i l s about her a t t i r e , her marital status, the locks on her door, and so on u n t i l we run out of the things she may have been at " f a u l t " over. The basic question i s t h i s , "could J i l l deserve to be raped for any reason at a l l ? " When we come to the point where the rape v i c t i m thinks that her loved one could not possible deserve to be raped under the very circumstances under which she was 78 raped, I change the loved one for anyone. That i s , I ask i f th i s i s something that any other person could deserve? Some w i l l say that they think r a p i s t s deserve to be raped, but rap i s t s are the only group of people that rape victims have ever picked out i n my presence as deserving of rape. Usually, the rape victim w i l l say that she does not think that anyone else could deserve to be raped. From t h i s point i t i s a matter of pointing out that she, the victim, i s a person. She i s a person i n the same way that a l l of those people undeserving of rape are persons; thus she does not deserve to be raped either. No circumstance can a l t e r the fact that she did not and could not deserve to be raped. As a person she i s deserving of a certain kind of treatment. She deserves to be treated with the respect due any person. Her humanity and dig n i t y have been assaulted. To a l l of t h i s she can now reply that the rapi s t i s wrong and that she i s a person undeserving of t h i s kind of treatment. When she regards herself i n t h i s way she begins to see the requirements of self-respect as well. Self-respect w i l l minimally require that she not regard herself as deserving of treatment that she would deem inhumane, and thus impermissible, for any person to receive. When t h i s process goes well, the vic t i m r e a l i z e s that rape cannot be j u s t i f i e d under any circumstances. She also comes to r e a l i z e that the c l i n i c a l explanations for the ra p i s t ' s 79 actions, and for her feelings as well, are explanations and not j u s t i f i c a t i o n s . In t h i s process, the rape victim engages i n a discourse involving moral reasoning with regard to others; she takes up the participant stance. The vi c t i m shows that she cares about the issue and that she regards herself as a moral agent when thinking about others when she discusses them. This action presupposes moral agency and status and i t exhibits these q u a l i t i e s . As the vic t i m i s able to discuss the relevant considerations for J i l l , she comes to see that she too i s within the group of people who must be seen as moral agents by the very fact that she i s questioning and reasoning as a moral agent. A point I must make i s that what counts as success for me i s quite d i f f e r e n t from the kind of success aimed at i n rape c r i s i s theory. I aim to show a rape v i c t i m that the best way out of victimhood i s to reassert her moral personhood. This i s not to say that I think that t h i s w i l l prevent the rape vi c t i m from developing a c r i s i s of some sort. I do intend to maintain that i t i s only as a moral agent that the rape vi c t i m w i l l f i n d the most robust way of combating the harm done by the r a p i s t . She w i l l not be rendered merely an object of treatment and p i t y , and she w i l l be bolstered by the fact that no act of contempt can take away her humanity. 80 S t r i c t l y speaking, the c l i n i c a l framework does not accommodate the moral questions asked by rape victims. The fact that they do not address t h i s aspect of the event with the v i c t i m leads to the continued diminution of the sense of humanity that a rape victim has. As she takes her role as a psychological v i c t i m she w i l l be less and less able to see herself as a moral agent. An Alternative Framework The psychological approach leads a v i c t i m further into the v i c t i m stance i n order to show her that she i s not responsible for causing the rape; moreover, i t renders understandable any reaction she may have. But her reaction can only be seen as a manifestation of a mental disorder. The c l i n i c i a n s want to restore a victim to proper functioning by moving her from vi c t i m to survivor. This i s done by " i n f l a t i n g her self-esteem". An analogy that has always occurred to me when thinking about t h i s i s the following. When a vase i s broken i t can be glued together again. In i t s restored state i t w i l l function as before. But i t w i l l be less valuable, less a t t r a c t i v e and more f r a g i l e than i t was p r i o r to the break. It seems to me that t h i s i s what the psychological victim: to survivor strategy does with persons who have been raped. By rendering t h e i r treatment value neutral c l i n i c i a n s have diminished by the 81 a b i l i t y of the rape v i c t i m to see herself as a whole person with worth regardless of what happens to her. I have been using the term "victimhood per se" as a term that acknowledges the moral nature of victimhood. At t h i s point I want take on more e x p l i c i t terminology by adopting the term moral victimhood as a stronger version of victimhood per se. I take moral victimhood to be d i f f e r e n t from psychological victimhood i n several ways. F i r s t i t i s d i f f e r e n t because the harm done need not be empirically v e r i f i a b l e by an expert i n how humans work. Moral harm may be assessed by looking at what the assailant did to the victim. Rape attacks the humanity of the victim; she has been the object of contempt. Rape i s said to be a crime of violence, not of sex. But there i s no denying that the nature of rape lends i t s e l f to very complicated thoughts and emotions that occur with human intimacy. As Onora O'Neill (1989, p. 120) argues, intimacy i s the human rel a t i o n s h i p with the greatest capacity for treating others as persons as well as the greatest capacity for v i o l a t i n g the humanity of another person. Shame, doubt and g u i l t are common emotions for victims of vi o l e n t crimes i n general. Rape victims continue to f e e l these emotions long a f t e r the event, sometimes many years go by with l i t t l e or no improvement i n the rape victim's outlook (Koss, 1991, p. 60-70). Sometimes, as i n the case of those who thoroughly adopt the psychological v i c t i m stance, these emotions become part of 82 t h e i r i d e n t i t y . Such a person feels shame and g u i l t for having been raped; i t has changed her i n some very important way. Her doubt may l i e i n her i n a b i l i t y to know whether or not she behaved i n the right way during the rape. A second way that moral victimhood d i f f e r s from psychological victimhood i s that moral victimhood acknowledges that rape attacks the victim's moral personhood. Moral personhood has to do with humanity rather than with proper function. Another important difference i s that with moral victimhood one has the backing of the moral community and the assurance that rape i s u n j u s t i f i a b l e . This, of course, lends her the sense of her humanity i n common with others which i s a potent p o s i t i v e factor for those who have been treated as i f they have no claims to being treated as persons. In what follows I propose a more formalized al t e r n a t i v e to the c l i n i c a l approach based on my experience as an advocate. To see the rape v i c t i m right from the st a r t as having been morally harmed allows her to maintain her i n t e g r i t y as a person. Those who are diagnosed with mental disorders lose a degree of something ess e n t i a l to that i n t e g r i t y . Depending upon the way we view human beings t h i s i s something that w i l l vary greatly. From a moral stance those who are mentally disordered at least lose t h e i r status as f u l l y p a r t i c i p a t i n g members of a moral community. Part of what they lose i s t h e i r voice because they have l o s t 83 t h e i r status as reasonable agents and so t h e i r deepest concerns may not be taken very seriously. Rape confronts the vic t i m with treatment that denies her status as a member of the moral community. It c e r t a i n l y does not constitute t r e a t i n g the vic t i m as a human being deserving of respect. Rather she i s treated as less than human and a good deal more than her rights are vi o l a t e d . As an advocate I found that rape victims l o s t sight of t h e i r moral personhood. They came into the emergency room looking for an explanation (which when going the biopsychosocial route doubles as an excuse because when ra p i s t s are viewed obj e c t i v e l y they are excused from membership i n the moral community) for what had happened to them. When faced with the senselessness of rape the vic t i m often looks to herself to see i f there i s anything about her that would make a person think that t h i s i s the way she should be or wanted to be treated. In c l i n i c a l research, theory and treatment one does not see the assertion that moral harm has been done. But surely the c l i n i c i a n s are tr y i n g to f i n d a way to say that rape i s wrong and should not happen. By s h i f t i n g to a moral framework we are able to say that rape i s simply wrong i n i t s e l f . There i s a way to see the act as wrong regardless of i t s e f f e c t s . That i s to see i t as morally wrong. To regard i t as morally wrong i s to say that i t i s impermissible i n any circumstances and that there i s never a 84 j u s t i f i c a t i o n for the act. It i s not to say that there are no explanations for why ra p i s t s rape, or why they choose the people that they do. Certainly, there do seem to be explanations of t h i s sort. If a rape v i c t i m i s offered the opportunity to see that what was done to her was wrong regardless of the circumstances, including the amount and kind of harm done, she may be able to avoid the descent into the stance of psychological victimhood. Why i s that? Because to assert the absolute wrongness of rape i s to say that there are ce r t a i n things that people cannot ever do to each other for any reason. Thus, the rape vi c t i m maintains her status as a f u l l moral agent i n the moral community. She i s able to adopt the appropriate moral attitudes to someone who morally harms another person. She i s also able to receive from her fellow moral agents the benefit of t h e i r moral indignation on her behalf. This kind of community builds a bond that brings a vi c t i m into the f o l d of the community rather than separating her with the status of a mentally disordered person. The mentally disordered garner our pi t y , our fear, and our p a t e r n a l i s t i c a f f e c t i o n . 6 They do not enjoy participant status i n the moral community because they are unable (for whatever reasons) to be f u l l y p a r t i c i p a t i n g . When one thinks about human action without the c l i n i c a l framework one i s able morally to condemn the behavior of those who commit crimes against humanity. 85 P a r t i c i p a n t s t a t u s enables a person t o f e e l a f u l l range of moral sentiments and a t t i t u d e s which are a p p r o p r i a t e t o those who have both r e s p o n s i b i l i t i e s and r i g h t s as moral agents. Those who are not ab l e t o adopt t h i s stance may have these same sentiments and a t t i t u d e s but these w i l l be regarded as s i g n s o f a problem i n the p e r s o n a l i t y s t r u c t u r e or coping mechanisms of the person. M o r a l i t y has been cut out of psychology perhaps because c l i n i c i a n s take themselves t o be s t u d y i n g how humans work, not r i g h t and wrong. But i t seems t h a t sometimes we don't 'work' because some deep moral wrong has been done t o us. But t h i s i s not the i s s u e f o r psychology. The i s s u e i s t o get the s u b j e c t to f u n c t i o n again i n a s a t i s f a c t o r y way. The problem of course i s that a v i c t i m of rape has been t r e a t e d as though she were not a person ( i n any m o r a l l y p a r t i c i p a t o r y and s i g n i f i c a n t sense). She w i l l need h e l p i n r e s t o r i n g h e r s e l f t o the p o s i t i o n of f u l l moral agent. That i s where t h i s a l t e r n a t i v e way of h e l p i n g a rape v i c t i m comes i n t o p l a y . We must help the v i c t i m t o see t h a t she i s a human being. Humanity c a r r i e s w i t h i t powerful moral s t a t u s which she can r e l y upon as a source of s t r e n g t h and s e l f -assurance at a time when she has been t r e a t e d as unworthy of b a s i c human r e s p e c t and d i g n i t y . The source of t h i s humanity i s Kantian autonomy. I t i s f r e q u e n t l y argued that Kantian autonomy i s a metaphysical n o t i o n r e q u i r i n g copious amounts of complicated argument t o j u s t i f y . But i t tu r n s 86 out that t h i s i s the framework that best illuminates our moral practices, at least i n cases l i k e these. 7 I have chosen Kantian autonomy because i t i s a moral stance that asserts that there are c e r t a i n fundamentally valuable q u a l i t i e s shared by a l l human beings. Autonomy i s the ground of our humanity. Our basic moral and l e g a l rights as human beings stem from t h i s autonomy. Autonomy and Respect I have stated above that I am sure that c l i n i c i a n s are tr y i n g to do something b e n e f i c i a l for rape victims. Although they want to say that rape should not happen, they do not want to say that i t i s morally wrong. They want to leave the moralizing out of t h e i r interactions with people. But i t i s p r e c i s e l y the concerns raised i n chapters one and two, the profound e f f e c t s of rape on the victim, which form the basis of c l i n i c a l research, that show that rape i s a moral issue that must be regarded as such. Rape victims continue to ask for moral reasons. Even i n a disordered state a rape vi c t i m i s morally reasoning and t r y i n g to understand what has happened to her. 8 Considered from the point of view of psychology and medicine a victim's autonomy, self-respect, and i n t e g r i t y are matters of ego development at best. Those using personality theory and Eriksonian developmental theory w i l l 87 hold that i f a victim suffers from feelings of shame, g u i l t and doubt she i s exhibiting the signs of an i n t e r n a l developmental c r i s i s . According to Erikson, a poorly-developed ego q u a l i t y can i n fact lead to neurotic dysfunction l a t e r i n l i f e (Erikson, 1950, p. 57). Undoubtedly the event of a rape i n one's l i f e i s l e g i t i m a t e l y regarded as a c r i s i s . The question i s how we ought to regard the c r i s i s . Is rape a p r e c i p i t a t i n g event to a c r i s i s or i s i t a c r i s i s i n i t s e l f ? Like the notion o victimhood i t i s possible for c r i s i s to be located within the person, as with psychological victimhood, or a c r i s i s can be an event that happens to a person, as with moral victimhood. By adopting a moral stance the v i c t i m i s s t i l l seen as an autonomous moral agent and the c r i s i s i s an external event. As such, the c r i s i s may have an influence on her l i f e but i t does not render her a d i f f e r e n t kind of person. Psychological autonomy i s not something which everyone has i n equal proportion. The Eriksonian autonomy i s very narrow i n scope; there i s a more general version i n use within psychology. Psychological autonomy i s taken to be a kind of psychological maturity which some humans have and some do not. It i s an empirically d i s c e r n i b l e q u a l i t y involving a c e r t a i n type of independence of judgment. For some psychologists i t also involves emotional independence from others. S e l f - r e l i a n c e and security i n one's s e l f -88 esteem are some of the hallmarks of psychological autonomy. If one i s w i l l i n g to l i s t e n to other viewpoints, and to think c a r e f u l l y by weighing options before acting t h i s too i s a sign of psychological autonomy.9 Thomas H i l l (1992) points out that t h i s version of autonomy functions as both a descriptive category and as a normative i d e a l . It i s a way of assessing people and of encouraging them to develop i n a s o c i a l l y sanctioned manner. By making autonomy into an ideal of character i t marks as superior those who exhibit highly developed autonomy.10 Recall that for Erik Erikson autonomy i s an ego q u a l i t y to be achieved. The c h i l d i s charged with the task of developing s e l f - c o n t r o l i n order to deflect the pot e n t i a l shame and doubt which might come about i f he f a i l s . The autonomy of rape c r i s i s theory i s based i n Eriksonian autonomy. On the other hand, "Kantian autonomy i s treated as "an 'idea' of reason, attributed on a p r i o r i grounds to a l l r a t i o n a l w i l l s " ( H i l l , 1992, pp. 78-9). This autonomy i s a t r a i t of a l l people and serves as the ground for the respect due to a l l human beings. From the moral point of view autonomy ca r r i e s a great deal of si g n i f i c a n c e . To be possessed of autonomy one must merely be capable of reasoning. Rape victims continue to reason. The q u a l i t y or correctness of t h e i r reasoning i s not s t r i c t l y speaking a 89 c o n s i d e r a t i o n f o r e x h i b i t i n g autonomy. Kantian autonomy i s an a p r i o r i a t t r i b u t e of a l l r a t i o n a l b eings. 1 1 One need not behave mor a l l y i n order to be autonomous. A Kantian would say that the knowingly immoral simply f a i l to behave i n accordance w i t h t h e i r autonomy. Perhaps a b e t t e r way of p u t t i n g i t i s to say that they f a i l to expres t h e i r autonomy. A c t i o n according to maxims i s autonomous reg a r d l e s s of whether the maxims are c o n s i s t e n t w i t h the c a t e g o r i c a l imperative. One can choose to behave i n accordance w i t h such maxims. To f l o u t the moral law i n t h i way i s to behave immorally p r e c i s e l y because one could have fol l o w e d i t . Autonomy grants a st a t u s i n the moral world that has l i t t l e or nothing to do w i t h s e l f - c o n t r o l and independence per se. These are more a c c u r a t e l y described a q u a l i t i e s that can develop out of one's autonomous nature. U n l i k e ' p s y c h o l o g i c a l autonomy, Kantian autonomy i s e x p l i c i t l y concerned w i t h moral o b l i g a t i o n s and moral r i g h t s . These i n t u r n make up the u n i v e r s a l c o n d i t i o n of moral agency f o r a l l human beings. Only autonomous moral agents are under moral o b l i g a t i o n s . An autonomous agent i s one who e x h i b i t s "minimal r a t i o n a l i t y " , i . e . , can reason and be reasoned w i t h ( r e c a l l Strawson's p a r t i c i p a n t stance) As such she i s a member of a moral community w i t h i n which she enjoys both the b e n e f i t s and the r e s p o n s i b i l i t i e s of moral agency. 90 Onora O'Neill writes a compelling c r i t i q u e of the non-Kantian autonomy i n her a r t i c l e "Action, anthropology and autonomy": Autonomy as now commonly construed ... may have l i t t l e of no i n t r i n s i c connection with conceptions of the good, the right or the r a t i o n a l . No doubt autonomy, so construed, may have instrumental importance as an e f f i c i e n t means to human happiness ... but t h i s i s a contingent matter. In many situations t h i s sort of autonomy w i l l cost rather than constitute our happiness, and i t s connection with morality i s often obscure (O'Neill, 1989, p.75). If autonomy i s simply a matter of independence from something or s e l f - c o n t r o l then our happiness may be contingent upon things we frequently have l i t t l e influence over. There are many circumstances i n l i f e where we are i n fact dependent upon others. If autonomy i s the means to happiness but i s so e a s i l y l o s t then we may be condemned to unhappiness rather e a s i l y . Rape i s c e r t a i n l y an event i n which the vi c t i m loses her control over her l i f e and becomes dependent upon others for assistance and understanding. Her psychological autonomy has been l o s t . S t r i c t l y Kantian autonomy, on the other hand, i s i n t r i n s i c to a l l people and constitutes at least some portion of our humanity. This autonomy i s not l o s t by the rape victim. Another use of the term "autonomy" comes up i n t a l k of human r i g h t s . It i s often tempting to see autonomy as a ri g h t . As a right we can demand that people not v i o l a t e i t . But people do v i o l a t e each other's r i g h t s ; thus, autonomy so construed i s also something one can lose. Moreover, even 91 b a s i c r i g h t s can be o v e r r u l e d by those who enforce the r i g h t s . Thus, i f autonomy i s a r i g h t and .an agent behaves i n o p p o s i t i o n to the standards f o r the bearers of t h i s r i g h t , she could l o s e her autonomy (or never gai n i t i n the f i r s t p l a c e ) . On t h i s account a person could wind up not being considered autonomous. Without autonomy she i s f r e e of r e s p o n s i b i l i t y and we are fr e e of our o b l i g a t i o n s to her I f someone i s undeserving of our respect then we are permitted to t r e a t her i n any way that we see f i t . At f i r s t , t h i s may seem benevolent: we may "know b e t t e r " than the non-autonomous agent or determine that she i s not moral l y f i t at a l l . C l i n i c i a n s , as experts on human f u n c t i o n i n g , are thought to be the a u t h o r i t i e s i n t h i s area Subjects are expected to defer to the expert knowledge of the c l i n i c i a n s . 1 2 Kantian autonomy i s not something people have a r i g h t to i n the same way that we have r i g h t s to l i b e r t y or su f f r a g e . I t i s a property which i s the b a s i s of moral r i g h t s but i s not i t s e l f a r i g h t . A r i g h t that autonomy grants i s perhaps the r i g h t to s e l f - d e t e r m i n a t i o n . But someone who i s not capable of s e l f - d e t e r m i n a t i o n i s not, by v i r t u e of t h i s i n a b i l i t y , a non-autonomous agent. For example, a slave may be unable to d i r e c t h i s l i f e c o n s i s t e n t l y w i t h h i s choices; he i s by a l l e x t e r n a l standards not s e l f - d e t e r m i n i n g . But, he s t i l l has autonomy i n the Kantian sense as i t i s a q u a l i t y guaranteed a p r i o r i 92 of a l l persons. It i s part of what i t i s to be human regardless of one's l o t i n l i f e . It i s of course true that one w i l l have less opportunity to behave i n accordance with t h i s inherent q u a l i t y i f one i s a slave, but t h i s does not take that q u a l i t y away. The same i s true for a rape victim, her humanity and dignity have been assaulted but she i s no less an autonomous moral agent as a re s u l t of being raped than she was before the incident. For psychology to neglect a victim's moral agency i s to grant c l i n i c i a n s permission to view victims merely as subjects for treatment. This i s also what the ra p i s t has done to the victim; he has denied her status as a moral agent. Their intentions are opposed, but benevolence and malevolence may both lead to domination and indifference to the persons affected. What we must do i s regard the vic t i m as possessed of autonomy, which means that we respect her as a human being rather than treat her as a victim. This i s not to say that she has not been victimized, nor that she i s undeserving of our sympathies for the traumatic experience she has had. Rather the point i s that she i s a person who has been victimized. She i s not now changed into a di f f e r e n t type of person, a victim. To treat a person who has been victimized with respect as a moral agent i s quite d i f f e r e n t from the requirements of treatment for a psychological victim. 93 As there i s a vast conceptual difference between Kantian and psychological autonomy, so to there i s a difference between Kantian and psychological respect. In psychology, respect takes on a less morally robust character. To be the object of respect i s to be held i n esteem. The esteem i s granted on the basis of c e r t a i n c h a r a c t e r i s t i c s attributed to the person. The ch a r a c t e r i s t i c s have l i t t l e i f anything to do with moral personhood. They are general q u a l i t i e s of excellence, talents, etc. For example, we a l l admire and hold i n high esteem a fabulous chef. She maintains standards of q u a l i t y that repeatedly regale us with gastronomic delights. The esteem i s based on our assessment of her q u a l i t i e s as a chef. Should she f a i l to be such a chef, we would f i n d no basis for holding her i n so high a position, unless we also f e l t that she had some other aspect worthy of value. As a subject of such respect, a person i s judged according to what she does and how well she does i t . A person's worthiness i s constituted by attributes involving factors e x t r i n s i c to her. The psychological concept of s e l f i s so deeply connected to function and productivity that when there i s a f a i l u r e of function there may be l i t t l e or nothing l e f t that i s considered valuable or worthy of respect. Victims of c r i s i s , therefore, may have nothing l e f t to value but t h e i r f a i l u r e . 1 3 However, when one can conceive of oneself as i n t r i n s i c a l l y a moral agent (but, of 94 course, with other external attributes such as being a chef or mechanic, then one's worth i s not so linked to the fluctuations and unexpected events of l i f e . A f a i l u r e at something i s not a motive to cease regarding oneself as a person worthy of one's own or others' esteem. It can be a serious matter - but i t should not c a l l into question one's sense of personhood. Autonomy and U n i v e r s a l i z a b i l i t y I have claimed that the Kantian moral perspective i s the best way of thinking about rape victims and t h e i r concerns. We can also illuminate aspects of the Kantian moral philosophy by thinking about rape victims. It i s frequently argued that the connection between autonomy and the categorical imperative i s very d i f f i c u l t to see. But I have found that the p r i n c i p l e of u n i v e r s a l i z a b i l i t y comes up natu r a l l y as a part of the discourse with victims of rape as they think about the implications of what has been done to them. Let me return to the conversations I had with rape vi c t i m i n order to demonstrate t h i s . I n i t i a l l y I found that rape victims suffered from feelings of shame, doubt and g u i l t . They feared that they were somehow responsible for the rape. At the same time these women were w i l l i n g and able to assert that no other person could deserve to be raped. What I found was an 95 i n s t a b i l i t y i n the victim's sense of her moral standing. She knew that i t made sense to hold c e r t a i n moral standards for others, but she did not firml y believe that the same standards applied to herself. In a sense she regarded herself as d i f f e r e n t from everyone else, seemingly by vi r t u e of having been raped. Thus when I engaged a rape v i c t i m i n a moral discourse about others she was quite able to see that the rape was morally wrong. But i t was not u n t i l I asked her what exempted her from these standards that she began to see that she could consider herself as having been morally v i o l a t e d by an impermissible and inhumane act. Her sense of the humanity of others and her willingness to act as a p a r t i c i p a t o r y member of the community were r e a d i l y accessible i n conversation. So why did she think that she, but no other (potential) victim, could be deserve to be raped or be blameworthy for having been raped? The missing l i n k was her sense of her own humanity. Thus, a l l I had to do was show her own place as part of the moral community to her and to engage her i n thinking that her humanity was no less valuable than any other person's. It should be made clear that I did not go into the emergency room planning to apply the u n i v e r s a l i z a b i l i t y p r i n c i p l e to the s i t u a t i o n . This i s simply the kind of reasoning that proved most able to guide the rape v i c t i m back into her sense of humanity. The universal q u a l i t y of the s i t u a t i o n , that i s that rape i s always wrong, removed 96 the i n t r i n s i c a l l y personal interest of the victim. By thinking of herself i n a s l i g h t l y abstracted fashion she was able to generalized back to herself that which she held for a l l other people -- i n t h i s case that rape i s wrong i n and of i t s e l f ; no causal story can change that. Perhaps t h i s i s what Kant had i n mind when he was thinking about the facts of moral reasoning. The process I have described was something that came about quite naturally. It seems to be true that t h i s simply i s the way that we think about c e r t a i n aspects of human moral l i f e . It c e r t a i n l y seems to l i n k autonomy and the moral law i n a way that i s not laden with the burdens of metaphysical doubts offered constantly by those who do seem to have forgotten what i t i s "actually l i k e to be involved i n ordinary i n t e r -personal relationships, ranging from the most intimate to the most casual" (Strawson, 1962, p.192). Conclusion I have from time to time referred to the consequentialist nature of the framework adopted i n psychology; l e t us return to t h i s subject. Within psychology the obvious way to say that something ought not to happen i s to say that i t causes either physical or psychological harm that impairs functioning. The 97 consequences of other's actions must not i n t e r f e r e with the proper functioning of human beings. When a person i s thought to be a complex ordered system which either functions properly or not, then a sign of harm i s when the system i s not functioning. Once one i s functioning again then the harm has been removed. L i f e can go on as before. If one does not malfunction, one i s considered to be unharmed. Human beings, however, are much more than so many systems functioning i n some way or other. Functioning i s a rather minimal requirement for human l i v i n g ; s u r v i v a l i s an even lower standard. The notion of f l o u r i s h i n g i s absent from the psychological l i t e r a t u r e I have read. When a person i s harmed to the point where she "disorders" we must look more c a r e f u l l y at what i s happening. Why does she suddenly f e e l that her whole l i f e has just crumbled i n on i t s foundation? As mentioned above, victims of extreme human designed and executed trauma want to know why one of t h e i r fellow human beings would t r y to destroy them. When someone or something i s t r y i n g to destroy you, you want to know what you could have done to deserve destruction. The notion of desert i s of course t i e d i n with morality. I suspect that one "disorders" p r e c i s e l y because the harm i s a moral harm that cuts to the core of a person. Someone has set out de l i b e r a t e l y to treat you as something unworthy of basic human respect and dignity. A 98 consequentialist framework may, however, allow that there may be a time when harm to an ind i v i d u a l w i l l achieve a j u s t i f i e d end. 1 4 Also, considered c l i n i c a l l y , i f a person can recover from the attempt at destruction then the harm done can be taken less seriously. But surely we want to be in a p o s i t i o n to say that intentional destruction of human beings by other human beings i s legit i m a t e l y regarded as morally wrong. The a p r i o r i autonomy of persons grounds requirements for respecting ourselves and one another. This i n turn grounds the legitimacy of reactive moral attitudes i n situations where t h i s respect i s vio l a t e d . Once autonomy i s an a p r i o r i a t t r i b u t e of a l l persons we have open to us a f u l l range of rights and r e s p o n s i b i l i t i e s to ourselves and others. This simply cannot happen i f autonomy i s something earned or learned that can be absent or taken away from some. We cannot assert moral r e s p o n s i b i l i t y without some ground for the rights we claim as human beings. If we view victims i n t h i s way perhaps we can make more sense of the notion of regarding a rape v i c t i m as a moral agent. As a moral agent, a rape vi c t i m continues to be an autonomous r a t i o n a l being. As such she i s the bearer of human di g n i t y and moral r i g h t s . The moral rights e s t a b l i s h that rape i s wrong because as a vic t i m of rape she has been treated as something other than a moral agent. But she i s a moral agent. By virtue of her agency she i s able to f e e l 99 reactive moral attitudes such as resentment for the treatment and anger she suffered at the hands of the r a p i s t . In addition we may f e e l indignation on her behalf. To be sure, her grave moral s i t u a t i o n leads to diminished capacities and she i s i n need of ce r t a i n kinds of assistance. It does not mean that we should think of her nonmorally by adopting the objective stance. By regarding rape as a moral wrong the vic t i m i s able to maintain her agency while compensating for the harm done; she need not regard herself as a p a r t i c u l a r and disordered type of in d i v i d u a l , a rape trauma sufferer, i n order to regard herself as having been victimized. I suggest that a rape vi c t i m needs assistance that reestablishes her sense of being a human being i n the moral sense. There i s no doubt that c e r t a i n kinds of events --rape and torture, for example -- c a l l into question the victim's sense of humanity. In ordinary l i f e we form b e l i e f s and ideals based on notions of how human beings ought to treat each other. We are moral beings and we do organize our l i v e s according to basic assumptions and expectations about what i s and i s not permissible. This i s not to say that we think that h o r r i b l e things w i l l not happen. It i s more accurately seen as an assumption that c e r t a i n things should not happen and that when they do, some kind of moral reaction w i l l be appropriate. We behave as i f we have at least some confidence that others w i l l not do 100 these things to us. When a person does suffe r at the hands of a fellow human being i t brings into question those basic assumptions. One asks oneself, "why me?"; we search for reasons for such horrors. T y p i c a l l y we can f i n d a cause, but we should not make the mistake of equating a cause with a j u s t i f i c a t i o n . It would make no sense to look for j u s t i f i c a t i o n when a hurricane destroys a v i l l a g e . However, as human beings possessed of reason and autonomy, i t i s incumbent upon us to ask the question, "what could possibly make t h i s j u s t i f y t h i s act?" If there i s no j u s t i f i c a t i o n then i t i s an immoral act, and hence wrong. A r a p i s t ' s reasons for raping may be s o c i a l l y conditioned or even determined; c l i n i c i a n s may even f i n d some category of person that he f i t s into. But they are do not assert that the rapi s t has committed a moral wrong. To say that i t i s morally wrong would necessitate the p o s s i b i l i t y of holding a rapi s t responsible for his actions regardless of why he behaves as he does. A current c l i n i c a l trend i s to argue that people who behave i n a n t i - s o c i a l ways, which tend to be criminal ways as well, are i n need of p s y c h i a t r i c treatment (broadly construed) and not punishment. The a n t i - s o c i a l behavior i s not under the control of the person acting, thus i t i s thought to be cruel to hold him responsible for his actions. I argue, however, that t r e a t i n g people as human beings f i r s t and subjects of psychological theory, disease, 101 disorder, and/or as victims second i s a more help f u l way to aid them. When a person i s harmed i n the way that rape victims are harmed she needs a robust foundation to r e b u i l d her b e l i e f s and ideals upon. The rape v i c t i m has been morally harmed and t h i s i s the reason she i s so overcome by the "symptoms" of rape trauma syndrome. If we f a i l to say that the harm i s moral then we are only able to e s t a b l i s h that the event was wrong i f i t i s p h y s i c a l l y or psychologically harmful. The v e r i f i c a t i o n of the harm can be asserted i n various ways, i f i t i s prosecutable (which i s very rare) or i f there i s s u f f i c i e n t psychological and physical harm to sustain a claim that the v i c t i m i s i n fact a victim, then harm has been done. It seems to me that the l a s t thing we want to do to a person i n so f r a g i l e a state i s to condemn her to view herself as a victim. This version of victimhood i s more about who the person i s than about what has happened to her. So, rather than being a person who has been victimized gravely, she i s a victim, a disordered i n d i v i d u a l . Victims move from being victims to being survivors. But what does i t mean to think of oneself as a v i c t i m or as a survivor? These terms are only helpful when they are understood to be moral concepts rather than functional or dysfunctional states of the human organism. The move from psychological v i c t i m to survivor i s not as morally helpful a move as adopting a framework that retains the rape victim's status as a moral agent throughout 102 her ordeal. If one i s a moral agent, one has ce r t a i n c h a r a c t e r i s t i c s , rights and strengths to r e l y on that a psychological v i c t i m i s not perceived to have. If c l i n i c i a n s were to reinstate a more morally robust terminology into t h e i r treatment, rape victims would not have to remain i n a stance that sets them morally apart f the rest of society. 103 Endnotes to Chapter Three 1. Children may be regarded somewhat d i f f e r e n t l y i n that the circumstance i s t h e i r very immaturity, but that too i s regarded as temporary. 2. I have used the term "we" to re f e r to the general moral community. This i s not a p a r t i c u l a r group, such as the c l i n i c i a n s of chapter one, but a group which composes a community or society i n very general terms. 3. I should stress that Strawson (1962, p. 190) pointed out that he was going to be trade i n c e r t a i n dichotomies and generalizations, which he refers to as commonplaces, for the sake of being able to t a l k about how we tend to behave and f e e l i n r e l a t i o n to other people i n our i n t e r a c t i o n with them. I w i l l follow him on t h i s point. He has an eminently more graceful way of putting t h i s than I when he says, the object of these commonplaces i s to t r y to keep before our minds something i t i s easy to forget when we are engaged i n philosophy, e s p e c i a l l y i n our cool, contemporary st y l e , v i z . what i t i s a c t u a l l y l i k e to be involved i n ordinary inter-personal relationships, ranging from the most intimate to the most casual" (1962, p.192) . 4. The term "humanity" i n t h i s context i s taken from Strawson. Strawson i s not t r y i n g to give an account of humanity outside of the terms used to describe the commonplace notion of the participant stance. The essence of his project claims that there i s no account of humanity that can be given i n non-moral terms. I follow him i n t h i s i n as much as I f i n d t h i s way of thinking about humanity to agree with my experiences of both the "intimate and the casual inter-personal r e l a t i o n s h i p s " . 5. In what follows I have been careful to generalize to the point that no i n d i v i d u a l that I ever worked with can be i d e n t i f i e d . The d e t a i l s that I give are merely there to help the reader to appreciate the kinds of thoughts and feelings that a rape vi c t i m might experience. 6. Which i s not to say that I think that t h i s i s a good thing. At t h i s point though, I have merely adopted Strawson's method of sta t i n g "the facts as we know them." 7. This i s not to deny that there are metaphysical concerns for Kantian autonomy, i t i s more the case that these are not my concern i n t h i s essay. 104 8. Admittedly she may be reasoning badly, but from the Kantian point of view i f she i s capable of reasoning at a l l we are morally obligated to treat her as a moral agent possessed of reason and autonomy. 9. For a very thorough investigation of the many d i f f e r e n t connotations of autonomy, dignity, self-respect and so on see D i l l o n (1995) and also Christman (1989) . 10. See Lawrence Kohlberg's work on moral development. For a contrasting view of t h i s brand of autonomy see G i l l i g a n (1982) . 11. My ideas about Kantian ethics are informed by the scholarship of Thomas E. H i l l , J r . (1991; 1992) and Onora O'Neill (1989). This i s not to say that what follows i s an e x p l i c a t i o n of t h e i r work. Rather, I take myself to be i n agreement with them about the basic notions of Kantian autonomy and respect for persons. They may not be i n agreement with me with regard to how I apply these notions i n the case of rape. 12. Thinking of autonomy as a right granted or withheld also permits the i n s t i t u t i o n of slavery; slaves did not count as persons at a l l . Thus, they were not even candidates for moral agency. 13. It's no wonder people are said to suff e r i d e n t i t y c r i s e s . If one's worth i s bound up i n nothing but n o n - i n t r i n s i c q u a l i t i e s what i s there that cannot be lost? 14. When there i s a war on i t i s the custom of each country to v i l i f y the enemy as something lower than a mere animal. The enemy i s a monster that wants nothing more than your destruction, and i t wants that for no good reason. But when we meet t h i s monster, i t i s nothing more than another human being who i s equally surprised to see that we are human beings. It i s only by dehumanizing that i t becomes a simple matter of destroying the enemy. 105 Bibliography Amchin, Jess, M.D. Psychiatric Diagnosis - A Biopsychosocial Approach Using DSM-III-R. American Psychiatric Press, Inc., 1991. American Psychiatric Association. Diagnostic and S t a t i s t i c a l Manual of Mental Disorders (Third E d i t i o n ) , Washington D.C.: American Psychiatric Association, 1980. . Quick Reference to Diagnostic C r i t e r i a From DSM-III. Washington D.C.: American Psychiatric Association, 1980 . . DSM-III-R - Diagnostic and S t a t i s t i c a l Manual of Mental Disorders (Third E d i t i o n - Revised), Washington D.C.: American Psychiatric Association, 1987. . Diagnostic C r i t e r i a From DSM-III-R. Washington D.C.: American Psychiatric Association, 1987. . DSM-IV - Diagnostic and S t a t i s t i c a l Manual of Mental Disorders (Fourth E d i t i o n ) , Washington D.C.: American Psychi a t r i c Association, 1994. Brownmiller, Susan. Against Our W i l l : Men, Women and Rape. Simon and Schuster, New York, 1975. Burgess, Ann Wolbert, R.N., D.N.Sc., and Lynda Lyt l e Holmstrom, Ph.D. Rape: Victims of C r i s i s . Robert Brady Company, Prentice H a l l Publishers, 1974. . Rape: C r i s i s and Recovery. Robert Brady Company, Prentice H a l l Publishers, 1979. Christman, John, editor. The Inner C i t a d e l : Essays on Individual Autonomy. Oxford University Press, 1989. Cohen, Murray L., Ralph Garofalo, Richard Boucher, and Theoharis Seghorn. "The Psychology of Rapists", Seminars i n Psychiatry, v o l . 3, no. 3, August 1971, pp. 307-327. D i l l o n , Robin S., editor. Dignity, Character and Self-Respect. Routledge, 1995. Erikson, E r i k H. Childhood and Society. W.W. Norton and Company, Inc., 1950. 106 Folnegovic-Smalc, Vera. "Psychiatric Aspects of the Rapes i n the War against the Republics of Croatia and Bosnia-Herzegovina ." In Mass Rape: The War against Women i n Bosnia-Herzegovina. Edited by Alexandra Stiglmayer. University of Nebraska Press, 1994. G i l l i g a n , Carol. In a Different Voice. Harvard University Press, 1982. Hacking, Ian. Rewriting the Soul - Multiple Personality and the Sciences of Memory. Princeton University Press, 1995 . Hilberman, Elaine, M.D. The Rape Victim. American Psychiatric Association, Basic Books, Inc., Publishers, 1976 . H i l l , Thomas E. Autonomy and Self-Respect. Cambridge University Press, 1991. . "The Kantian Conception of Autonomy." In Dignity and P r a c t i c a l Reason In Kant's Moral Theory. Cornell University Press, 1992, pp. 76-96. Kim, Mi Ja, R.N., Ph.D., F.A.A.N. and Ferry Ann Moritz, R.N., M.Ed., M.S., editors. C l a s s i f i c a t i o n of Nursing Diagnoses - Proceedings of the Third and Fourth National Conferences. McGraw-Hill Book Co., 1982. Koss, Mary P and Mary R. Harvey. The Rape Victim - C l i n i c a l and Community Interventions, 2nd e d i t i o n . Sage Library of Social Research; v. 185, Sage Publications, Inc., 1991. Levy, Ronald, M.D. The New Language of Psychiatry - Learning and Using DSM-III. L i t t l e , Brown and Company, 1982. McCombie, Sharon L., editor. The Rape C r i s i s Intervention Handbook - A Guide for Victim Care. Plenum Press, 1980. Merck Research Laboratories. The Merck Manual of Diagnosis and Therapy. Robert Berkow, e d i t o r - i n - c h i e f , 1992. M i l l s , Patrick, Ed.D., ed. and comp. Rape Intervention Resource Manual. Charles C Thomas, Publisher, I l l i n o i s , 1977 . O'Neill, Onora. "Between Consenting Adults." In Constructions of Reason:Explorations of Kant's P r a c t i c a l Philosophy. Cambridge University Press, 1989, pp. 105-125. 107 . "Action, Anthropology and Automomy." In Constructions of Reason:Explorations of Kant's P r a c t i c a l Philosophy. Cambridge University Press, 1989, pp. 66-77. Sarafino, Edward. Health Psychology: Biopsychosocial Interactions, 2nd Edition. Wiley Publishers, New York, 1994. Strawson, P.F.. "Freedom and Resentment." Proceedings of the B r i t i s h Academy, Volume XLVIII. Oxford University Press, 1962, pp. 187-211. World Health Organization. ICD-10 - The ICD-10 C l a s s i f i c a t i o n of Mental and Behavioral Disorders -C l i n i c a l Descriptions and Guidelines. Geneva: World Health Organization, 1992. 108 

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