Victims of violent crime experience extreme emotional distress, which is particularly intense for those who suffer serious physical injuries that require hospitalization. Unfortunately, most victims leave the hospital without receiving any services to reduce this distress or any information about crime victim compensation programs to which they may be entitled. Moreover, many victims do not participate in the judicial process because such participation would exacerbate the emotional problems they are experiencing and because they know little about it. This lack of criminal justice system knowledge may further contribute to victims’ emotional problems, particularly if they are called on to participate in the process (e.g., testify in court). Thus, after experiencing interpersonal violence, and even after sustaining physical injury, many victims receive no information about crime victim compensation programs, suffer enduring emotional distress, and avoid court participation. Services that will have the maximum impact on reducing victim suffering and increasing knowledge about crime victim compensation and the criminal justice system are needed.
Violence remains an unavoidable facet of human experience. Virtually no one escapes at least vicarious exposure to severe interpersonal conflict, and more than 10 percent of the population endures direct aggression in the form of simple, aggravated, or domestic assault at some point in their lives (Resnick et al., 1993). Indeed, in 2000, National Crime Victimization Survey estimates approximated 6,475,000 violent crimes against citizens (Bureau of Justice Statistics, 2001). Fully 60 percent of violent crimes are not reported to police. Moreover, data indicate that repeated victimization characterizes a significant subgroup that could benefit from risk reduction or crime prevention strategies. Tangible effects of physical assault are far-reaching and devastating. The U.S. Department of Justice reports that annual violent crime results in at least 2.2 million known injuries, requiring more than 700,000 days of hospitalization (Harlow, 1989; see also Conway et al., 1995). It is, therefore, not surprising that violence is considered both a social and public-health emergency in the United States and other countries (Koop, 1992; Novello, 1992). The overt economic and medical difficulties that victims endure often come with less visible, albeit equally significant, psychological and emotional complications. These include extreme levels of anxiety, depression, substance abuse, and impaired interpersonal and vocational functioning (Kessler et al., 1995; Kilpatrick et al., 1987; Resnick et al., 1993).
Effects of Criminal Violence
Across studies, physical assault is either the most common, or among the most common forms of trauma experienced in the general population (Breslau, Davis, and Andreski, 1991; Kessler et al., 1995; Resnick et al., 1993). Several aspects of victimization are strongly related to subsequent development and/or exacerbation of emotional distress. Indeed, the risk of posttraumatic emotional problems is greatest for individuals who reported that during the trauma they feared they would be seriously injured or would die, or who actually were injured (Green, 1990; Kilpatrick et al., 1989; Resnick et al., 1993; Wirtz and Harrell, 1987). Of the assault victims who believed that their lives were threatened and who suffered physical injuries, 30.8 percent developed posttraumatic stress disorder (PTSD), compared to 20.6 percent of those who believed their lives were threatened and 25 percent of those who were injured but did not believe their lives were threatened (Kilpatrick et al., 1989). A more recent investigation of 251 victims of violent crime also found that victims who were seriously injured, who feared that they would be seriously injured, and who believed their lives were threatened were more likely to suffer from PTSD (Freedy et al., 1994). Because perceived threat of serious injury and actual injury are both risk factors for posttraumatic emotional distress, it is important to identify which forms of trauma are associated with an event. Along these lines, Resnick and colleagues (1993) demonstrated that the threat of injury or actual injury were most often observed in physical assault victims (90.8 percent), followed by rape victims (67.9 percent). Further, 61.1 percent of physical assault victims and 36.7 percent of rape victims reported both perceived threat of injury and actual injury.
These findings are hardly surprising when considering that most assailants plan to inflict pain and injury during physical assault. Specific emotional problems that follow an assault include PTSD, depression, substance abuse, and panic disorders. According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), a diagnosis of PTSD is assigned only when an individual is exposed to a traumatic event that presents both of the following: actual or threatened death or serious injury to oneself or others, and intense fear, helplessness, or horror. Obviously, physical assault meets these criteria. Data regarding the course of PTSD for rape victims have been obtained, and, given the comparability of outcomes related to physical and sexual assault, it is reasonable to assume that similar proportions of seriously physically assaulted victims will suffer from the disorder over time. Rothbaum and colleagues (1992) found that fully 90 percent of rape victims met symptom criteria for PTSD within 2 weeks of being raped, and about 50 percent continued to meet criteria 3 months later. Moreover, Kilpatrick and colleagues (1987) showed that PTSD was present 17 years after the assault in 16.5 percent of cases. Overall, about 50 percent of those who meet the criteria for PTSD recover within 2 years, while almost 33 percent do not experience full remission of symptoms, even after several years (Kessler et al., 1995).
Effects of Emotional Distress
During victimization, individuals experience extreme fear, anxiety, dread, and aversive physiological arousal. Immediately following victimization, they may experience additional symptoms of depression and panic as outlined above. These negative emotional responses become associated with salient triggers present in the environment during the attack (e.g., perpetrator race and build, location, weapon) which then elicit emotional distress in the future. Thus, a victim’s exposure to reminders of the violent crime, such as those present during participation in criminal justice system proceedings, triggers an anxiety response. To reduce or eliminate the extreme discomfort of this anxiety response, individuals will avoid these triggers. Because avoiding these triggers temporarily diminishes emotional distress, the individual is likely to continue avoiding them and any likelihood that the victim will participate in the criminal justice system process may be decreased. More important, however, the triggers retain their power to produce fear, and victims experience emotional distress indefinitely.
In addition to triggering emotional problems such as anxiety, fear, and depression, the criminal justice system may also seem confusing and intimidating to many victims of crime. Either of these factors alone may discourage victims from actively participating in the criminal justice system; combined, they are likely to severely curtail victim participation.
What Can Be Done
Victims’ lack of knowledge about the criminal justice system, including its processes and the potential benefits of participating in them, must be addressed. However, educational campaigns delivered through mass media presentations are exceedingly expensive “one-shot” attempts that increase knowledge very little. Victims need individualized education, which must be developed at low cost and delivered consistently and in standard format to ensure its quality.
This report describes a standardized service that can be delivered individually to crime victims at very little cost. We have carefully scripted and filmed a DVD (Best, Resnick, and Acierno, 1999) to address the needs and knowledge deficits of physically injured crime victims. The DVD addresses concerns raised in the previous section by increasing crime victims’ knowledge about, and familiarity with, the criminal justice system, its relevance to their case, and the benefits of participation, such as crime victims’ compensation programs. It also includes information about PTSD and ways to cope with its symptoms. Finally, the content is delivered in a manner that is neither threatening nor embarrassing to crime victims. The following sections describe our efforts to this end. In short, we used knowledge gained from our development of a video-based intervention for rape victims (Resnick et al., 1999) to develop a standardized DVD intervention for physically injured crime victims.
Description of the DVD
The DVD is a 12-minute color DVD for use with any seriously injured crime victim, regardless of the type of victimization or injury. The DVD, which is based on a model created by Resnick and colleagues (1999) for use with sexual assault victims in an emergency department, consists of two major components, each with several subcomponents. The overall goals are to educate victims about the criminal justice system and to help them reduce the emotional distress they experience.
The first component of the DVD includes general information about the criminal justice system and the crime victim compensation program. It includes definitions of terms frequently used in criminal justice (e.g., indictment, victim impact statements); a discussion of victim notification rights and other victims’ rights, such as the right to be present at bond hearings and to comment on plea bargains; and a description of the crime victim compensation program and how to access it.
The second component focuses on common psychological reactions to victimization and strategies for reducing the distress of these reactions. It describes common victim reactions to crime such as feelings of depression, fear, and anxiety; the tendency to avoid people or places that remind the victim of the crime; and the potential for increasing use of alcohol and/or other substances. It explains the potential development of these difficulties and offers strategies for reducing distress and effectively dealing with these feelings.
The visual presentation that accompanies the verbal information on the DVD includes multiple scenes with actors demonstrating the following situations: patients receiving medical care, health care providers treating patients, patients and providers in a physical therapy setting, outpatient care scenes, and crime victim compensation program coordinators helping patient victims fill out paperwork. Images that are frequently associated with the criminal justice system are also featured, such as law enforcement officers, police stations, and bond hearings and other courtroom scenes. Finally, the DVD features multiple scenes of patient victims engaging in positive behaviors that help reduce emotional distress and are associated with healthy outcomes, such as keeping outpatient medical appointments, returning to an acceptable level of previctimization daily routine, spending time with friends while avoiding overuse of alcohol, and seeking out professional mental health services. Throughout the DVD, graphic overlays summarize the major points with written text.
A multicolored, trifold brochure that accompanies the DVD summarizes its main points and contains several screen shots from the DVD to remind the viewer of the points it illustrates.