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THE COUNSELING
10.1177/0011000002250638
Westefeld,
Heckman-Stone
PSYCHOLOGIST
/ CRISIS INTERVENTION
/ March 2003
ARTICLE
PROFESSIONAL FORUM
The Integrated Problem-Solving
Model of Crisis Intervention:
Overview and Application
John S. Westefeld
The University of Iowa
Carolyn Heckman-Stone
Iowa State University
Crisis intervention is a role that fits exceedingly well with counseling psychologists’
interests and skills. This article provides an overview of a new crisis intervention model,
the Integrated Problem-Solving Model (IPSM), and demonstrates its application to a
specific crisis, sexual assault. It is hoped that this article will encourage counseling psychologists to become more involved in crisis intervention itself as well as in research and
training in this important area.
Recently, significant crisis events (e.g., sexual assaults, school shootings,
terrorist attacks, and other violent crimes) have received major media attention. This has led, among other things, to an increased interest in this topic as
a subspecialty among human service providers (James & Gilliland, 2001). In
addition, it appears that we live in an increasingly fast-paced and technological society in which individuals may be less connected with family and other
positive influences than in the past (Pitcher & Poland, 1992). Mental health
professionals need to be prepared to help society cope with such crises, and
counseling psychologists are particularly well suited for this type of intervention. Coping with life transitions, a major focus of counseling psychology
throughout its history, sometimes involves the successful negotiation of crises (Brown & Lent, 2000). Counseling psychologists are particularly skilled
in promoting self-enhancement among relatively healthy individuals, which
is often the case in crisis situations. In addition, crisis intervention matches
well with counseling psychologists’ skills at implementing brief, problemsolving, developmental, educational, and self-empowering intervention
approaches.
Relatively few articles have been published in The Counseling Psychologist concerning crisis intervention and the role of the counseling psycholoCorrespondence concerning this article should be addressed to John S. Westefeld, Counseling Psychology, 361 Lindquist Center, The University of Iowa, Iowa City, IA 52242;
e-mail: john-westefeld@uiowa.edu.
THE COUNSELING PSYCHOLOGIST, Vol. 31 No. 2, March 2003 221-239
DOI: 10.1177/0011000002250638
© 2003 by the Division of Counseling Psychology.
221
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THE COUNSELING PSYCHOLOGIST / March 2003
gist. Indeed, we believe that the field of counseling psychology has not historically seen itself as working extensively in this area. Interestingly, in
1979—more than 20 years ago—Baldwin published an excellent manuscript
in The Counseling Psychologist, wherein he reviewed crisis theory, discussed
types of crises, and described his own stage model of crisis intervention.
Baldwin’s model consisted of the following major steps: catharsis/assessment, focusing/contracting, intervention/resolution, and termination/integration. Since 1979, however, there has been little in this journal explicitly
dealing with the topic of generic crisis intervention per se as a major role of
counseling psychologists. A review of the articles written concerning the last
major counseling psychology conference (the Georgia conference)
(Weissberg et al., 1988) yields few indications that crisis intervention per se
has been an explicit major area of concern for the field of counseling psychology. However, it should be noted that in our view, things are changing. At the
Fourth National Conference for Counseling Psychology (the Houston conference), a large number of work/social action groups addressed a wide spectrum of social issues, many of which relate to crisis intervention. In addition,
it is important to note that The Counseling Psychologist recently published a
major contribution on suicide (Westefeld et al., 2000), which is obviously a
crisis-laden phenomenon. Because we believe that crisis intervention is an
emerging and important area for counseling psychologists, we present this
article in an effort to augment the current knowledge base in this area. Rather
than review the numerous existing crisis intervention models (e.g., Baldwin,
1979; James & Gilliland, 2001; Roberts, 1991), this article presents the
authors’ Integrated Problem-Solving Model (IPSM) of crisis intervention,
which is based on many of the principles of the specialty of counseling psychology as a profession. We then present an exemplar of how this model may
be used in a specific type of crisis that counseling psychologists may encounter: sexual assault.
For the purposes of this article, the term crisis is defined as a relatively and
usually brief reaction of severe distress in response to a typically unexpected
event or series of events that can lead to extreme and severe disequilibrium,
growth, or both, depending on the effectiveness of the crisis management
strategies employed. This definition draws on the work of James and Gilliland
(2001), Pitcher and Poland (1992), Roberts (1991, 1995), and a variety of
others. It emphasizes the unexpected and time-limited nature of a crisis (e.g.,
sudden death of a child), the subjective perception of the situation as overwhelming to the resources available, and the experience of disequilibrium or
disorganization among several areas of functioning (i.e., affective, cognitive,
behavioral). In addition, it emphasizes that the short- and long-term consequences of a crisis can involve deterioration, growth, or some combination of
the two, depending on the nature of the crisis intervention utilized. In fact, the
Westefeld, Heckman-Stone / CRISIS INTERVENTION
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ancient Greek term for crisis came from two root words meaning “decision”
and “turning point,” and the Chinese ideograph for crisis combines two symbols representing “danger” and “opportunity” (Roberts, 1995).
BRIEF SUMMARY OF EXISTING
CRISIS INTERVENTION WORK
The mental health literature concerning crisis intervention work is obviously very extensive and includes such diverse writings as Erikson’s (1950)
stage model of normal developmental crises, recommendations based on
World War II experiences with combat fatigue (Roberts, 1995), and reactions
to bereavement after a major fire at the Coconut Grove nightclub in Boston
(Lindemann, 1944). A flurry of crisis intervention work after the deinstitutionalization of many mentally ill individuals by the Community Mental
Health Centers Act of 1963 led to an upsurge in research and the increased
popularity of using paraprofessionals and crisis hotlines in the 1970s and
1980s. Currently, financial strains on the healthcare system are leading to
greater accountability and briefer treatment approaches than previously used
(Pitcher & Poland, 1992).
Numerous crisis intervention models have been developed during the past
decade. To cite just two of many examples, Roberts’s (1991) model and
James and Gilliland’s (2001) six-step model can be used by professional
human service providers and laypersons alike. Roberts’s excellent model is
based on facilitating positive change via a somewhat time-limited and goaldirected approach (Roberts, 1991, 1995). The highly regarded model by
James and Gilliland (2001), as they stated, is based on assessing, listening,
and acting, and “the entire six-step process is carried out under an umbrella of
assessment” (p. 33). James and Gilliland also provided an excellent discussion concerning many other crisis intervention theories/models. Extensive
data-based empirical research examining crisis intervention models, however, appears to be lacking; as such, we propose the IPSM as a model that
lends itself to such research because the IPSM is a graduated approach, draws
on cognitive-behavioral approaches, and has a multicultural perspective. We
hope that this model will be sufficiently user-friendly to encourage researchers and clinicians alike to increase their participation in crisis intervention
research and practice.
The authors’ model—the IPSM—involves 10 stages and is designed to
provide step-by-step detail in responding to a crisis from beginning to
postcrisis. As a point of contrast, Roberts’s (1991) model has seven steps and
James and Gilliland’s (2001) model has six steps. The IPSM also draws on
several of the models to which we earlier alluded. We believe that the IPSM
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does have several advantages over some previous models in that it is very
detailed in terms of exploring and implementing options and plans, places
emphasis on immediately and explicitly establishing and maintaining rapport, and in particular is based on a framework that focuses on cultural context and empowerment. We feel that the notion of empowerment is especially
critical to our model and is consistent with the philosophy of counseling psychology, that is, a focus on the existing assets that clients can utilize to continue to grow and develop. Moreover, our model is distinct from some others
in that we feel that evaluating outcome is an important part of any therapeutic
intervention, and we explicitly identify this as a very critical step in our
model. Finally, as counseling psychologists, we decided to frame the intervention explicitly in positive terms by including “set goals” rather than to
“define the problem” as in some previous models. For these reasons, we feel
that our model updates and advances the literature.
OVERVIEW OF THE IPSM
The IPSM is a wide-ranging integration of several different perspectives,
including the crisis-intervention (e.g., Baldwin, 1979; James & Gilliland,
2001; Pitcher & Poland, 1992; Roberts, 1991, 1995) and trauma-theory
(Herman, 1997) literatures, the cognitive-behavioral problem-solving
approach developed by D’Zurilla and colleagues (D’Zurilla, 1986; D’Zurilla &
Goldfried, 1971; D’Zurilla & Mashcka, 1988; D’Zurilla & Nezu, 1982;
D’Zurilla & Sheedy, 1991), narrative and solution-focused therapies
(Greene, Lee, Trask, & Rheinscheld, 2000; Semmler & Williams, 2000), and
multicultural counseling (Sue & Sue, 1990). The perspectives incorporated
into the IPSM framework are described as follows.
The IPSM is consistent with current trauma theory in that it begins with a
focus on safety, stabilization, and self-care; moves to processing the traumatic event; and finally, encourages integration of this material into everyday
life (Herman, 1997). Some earlier approaches to trauma treatment involved
primarily psychodynamic processing of the traumatic material to the exclusion of the other two stages. This may have left clients somewhat defenseless
and incapacitated, albeit insightful and in touch with emotions, yet unable to
function in the outside world. Therefore, we prefer a graduated approach to
dealing with trauma: first enhancing coping skills and safety, then processing
traumatic material, and finally, generalizing this foundation to broader life
arenas (Herman, 1997). This more recent approach would also seem to be
more consistent with multicultural perspectives in which diverse clientele are
empowered to identify and utilize existing strengths and who seem to appre-
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ciate practical strategies for coping with everyday life (Sue & Sue, 1990).
The IPSM differs from some previous crisis-intervention models because it
also provides opportunities for processing traumatic material or at least for
goals to be set along these lines for future reference. It is interesting that
despite their relevance and similarities to one another, the crisis-intervention
and trauma-theory literatures have not been well integrated yet.
The IPSM draws heavily from cognitive-behavioral approaches, which
seem to be the most popular and have the most empirical support for use in
crisis counseling (Dattilio & Freeman, 1994; Muran & DiGuiseppe, 1994).
Cognitive-behavioral approaches are appropriate for crisis intervention
because they are active, directive, structured, often time limited, and psychoeducational in nature (Dattilio & Freeman, 1994). Clients in crisis can benefit
from this type of approach because crises are often time limited, clients may
be in such a state of disorganization that they may need a firm guiding hand,
and they may benefit from education because the experience may be unlike
anything they have ever experienced before. Problem-solving approaches in
particular may lend themselves to crisis situations in that they are structured,
efficient, concrete, and directive, yet flexible (Spiegler & Guevremont,
1993). Clients from underrepresented groups may especially appreciate the
structured, directive, and present-focused qualities (Sue & Sue, 1990) of the
IPSM. As Sue and Sue (1990) pointed out, many minorities and immigrants
may be more familiar and comfortable with medical as opposed to psychological treatment and therefore expect immediate and concrete solutions to
their problems provided by authoritative “experts.”
As counseling psychologists, we are also particularly influenced by
solution-focused models (Greene et al., 2000) that emphasize the existing
strengths and resources of clients in improving their own situations. This
approach has clients identify what strategies have worked well in the past and
encourages clients to increasingly employ the strategies in the future; thus,
the approach focuses on solutions rather than problems. Solution-focused
models are well suited to crisis intervention situations because clients are
encouraged to draw on all available resources and implement concrete solutions. Again, such characteristics also provide a good match for diverse clientele. Therefore, in the IPSM, we have clients frame the events as much as possible in a positive light. For example, we designate a step to set goals as
opposed to identify the problem as is done in some other crisis intervention
models, and we use the term survivor as opposed to victim with people who
have experienced sexual assault.
Similarly, we utilize aspects of narrative therapy (Semmler & Williams,
2000) to help clients empower themselves and increase their sense of control
by developing their own adaptive accounts of the traumatic events and their
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THE COUNSELING PSYCHOLOGIST / March 2003
outcomes. This can be accomplished by helping clients understand the meanings that they have created of historical events and then by assisting clients in
reconstructing a new “story” (Kelley, 1998). A common narrative technique
is to help clients view the problem as external but the solution as internal to
them. For example, women who have been sexually assaulted often blame
themselves for the rape. A narrative approach can help survivors appropriately place blame on the perpetrators and can help women see that the way
they can fight back is to progress in their recovery. By emphasizing the strategies that clients have used to cope with and survive a situation, narrative clinicians might help clients “restory” the crisis event. Clients would also likely
be encouraged to develop an audience—social support—with roles to play in
their new, more adaptive life story. As we mentioned previously, such positive and empowering approaches are appropriate for multicultural clientele
and, in the case of narrative therapy, may even help such clients progress
along the stages of cultural identity by moving from self-deprecation to selfappreciation (Helms, 1994).
To reiterate, it should be clear that the frameworks used to form the foundation of the IPSM are all consistent with the philosophy of counseling psychology in terms of empowering people to draw on their inherent strengths,
resources, and coping skills. Other potential benefits of the IPSM are that it is
a specific, clear, detailed, and step-by-step method that comprehensively
integrates previous models using an empowerment framework. We feel that
for these reasons the IPSM could be easily utilized by counseling psychologist clinicians and researchers alike. However, the IPSM would also be flexible enough to accommodate various types of crisis situations. The following
is a description of the stages involved in the IPSM (see Table 1).
1. Establish and Maintain Rapport
As in all therapeutic encounters, rapport building is a crucial first step in
effective intervention. This may be all the more true in crisis situations due to
client distress, vulnerability, distrust, and fragility. Relationship building
includes all of the standard tools that a counseling psychologist would utilize
in other therapeutic situations, although the crisis situation involves a compressed time frame. These tools include basic attending and listening skills,
empathy, reflection of affect, encouragement, support, and instillation of
hope (Ivey & Ivey, 1999). Rapport building can foster a thorough and accurate assessment of client safety and form the background for other subsequent stages. Special attention should be paid to contextual or sociocultural
factors that may influence the way in which a client copes with the crisis situation. For example, extra efforts may need to be taken in building rapport
Westefeld, Heckman-Stone / CRISIS INTERVENTION
TABLE 1:
227
Westefeld and Heckman-Stone Model
1. Establish and maintain rapport.
2. Ensure safety.
3. Assess client and begin processing trauma.
4. Set goals.
5. Generate options.
6. Evaluate options.
7. Select plan.
8. Implement plan.
9. Evaluate outcome.
10. Follow-up.
when intervening with a person of color who may feel a “cultural mistrust”
(Sue & Sue, 1990) of traditional mental health and other social support agencies. Kiselica (1998) reminded us that we may also have to be ready to use a
wide variety of strategies in helping clients from diverse cultures. Clearly, a
key here is empathy throughout this stage and, in fact, throughout the entire
model. In 1959, Rogers described empathy as the ability to access another’s
view/feelings as if the helper were the helpee but without taking on the
helpee’s emotional state. In crisis response, it seems to us that this is especially crucial in that true empathy, as discussed by Rogers (1959), provides an
opportunity for assistance while at the same time reducing the chance of
burnout on the part of the helper.
2. Ensure Safety
Ensuring safety should be an early intervention and remain a focus
throughout the entire crisis response period. Clients need to be assessed as to
their level of safety in terms of overall physical environment and physical
health, self-destructiveness, harm toward others, and/or harm by others
toward them, depending on the nature of the crisis. If safety is of concern, this
takes priority over other issues in terms of problem solving and implementing
plans for resolution. Suicide, in particular, may be an initial and/or continuing safety concern. See Westefeld et al. (2000) for some specific guidelines
related to suicide.
3. Assess Client and Begin Processing Trauma
In addition to safety issues, other areas for assessment include circumstances of the crisis event, past and current coping abilities, social support
and other practical resources, related developmental and historical events, as
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well as psychological distress and basic functioning. Quantitative measures
can be used, although crisis situations typically limit time and available
resources. Due to the frequently limited time frame of crisis intervention,
processing of traumatic material and assessment of the client often need to
occur simultaneously. However, if more time is needed for cognitive and
emotional processing, this can be identified as a potential goal to be explored
during the following stages.
4. Set Goals
Based on the assessment of the client, problems can be defined and goals
set. As counseling psychologists, we feel it is important to reframe negative
problems into positive goals, and this is a key aspect of our model. Sample
solution-focused goals are improving self-care, developing coping skills or
resources, processing and managing emotions and cognitions, and improving relationships. These goals should allow clients to increase their sense of
control over constructing the current narrative of the traumatic experience,
for example, by externalizing the problem yet internalizing the solution
(Greene et al., 2000). This also may be framed as growth through dealing
with adversity.
5. Generate Options
This step involves the client and counseling psychologist working
together in thinking creatively to generate a variety of potential actions to
achieve the stated goals. The particular focus is on adaptive techniques that
the client is already employing and those that would continue to shape a
desirable narrative.
6. Evaluate Options
Here, the client and counseling psychologist discuss the advantages and
disadvantages of each option depending on desirability, feasibility, available
resources, and so forth.
7. Select Plan
Based on the evaluation of options, the client and counseling psychologist
now collaboratively decide on a plan of action, which frequently has multiple
components and steps. Developing a plan in a crisis situation may involve a
more directive approach than in other clinical situations because the client
may be quite disorganized and/or time is often a critical issue.
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8. Implement Plan
During this step, the components of the action plan are carried out. The
counseling psychologist should ensure that the client has sufficient preparation and support for this step, which may require taking on the role of advocate, particularly if members of certain oppressed groups plan to interact with
traditional social services agencies with which they may lack experience or
have had negative experiences. However, the client should have as much control over selection and implementation of the plan as possible.
9. Evaluate Outcome
During this stage, it is important to elicit and process feedback from the
client about the plan, how it is working, how the client feels about it, and so
forth, in case the plan needs modification. This step can help the client to
identify how the client has grown (again, a key principle from counseling
psychology), how the narrative has changed, and what has been learned from
the crisis experience for future reference. If preintervention measures have
been used, corresponding postintervention measures can be administered.
10. Follow-Up
Follow-up can occur with the original counseling psychologist or with a
referral source such as other therapists, physicians, community organizations, religious and other support groups, traditional healers, and so forth.
Regardless, the client should have future appointments scheduled after the
initial crisis to help ensure that the client follows through with the plan, that it
continues to be beneficial, and that new skills become integrated into the client’s everyday narrative. The entire crisis intervention process may take only
one extended session or several sessions during days or weeks, depending
on the nature of the crisis and the functioning level of the client. Extended
follow-up is crucial and is another key aspect of our model.
APPLICATION OF THE IPSM TO SEXUAL ASSAULT
Because sexual assault is such an important societal issue and an issue
with which many counseling psychologists may deal, we now present an
overview of the phenomenon of sexual assault and the application of the
IPSM to its intervention. We hope that applying our model to one very important example of a crisis will help to operationalize the model. “Sexual assault
is the fastest growing, most frequently committed and most underreported
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THE COUNSELING PSYCHOLOGIST / March 2003
violent crime” (Dunn & Gilchrist, 1993, p. 359) and “is a highly traumatic
event from which many victims never completely recover” (Resick &
Mechanic, 1995, p. 97). It can result in posttraumatic stress disorder (PTSD),
depression, problems with self-esteem, anger and hostility, somatic symptoms, and difficulties in relationships including sexual dysfunction. Approximately a quarter of untreated sexual assault survivors report normal functioning 1 year after the assault, but many report continuing problems for 1 year or
more (Gilbert, 1994).
Sexual assault crisis intervention generally corresponds to the three stages
of recovery from rape or “rape trauma syndrome,” first described by Burgess
and Holmstrom in 1974. These stages are (a) acute disorganization, (b) denial
and avoidance, and (c) help seeking and working through. Crisis intervention
for sexual assault usually occurs during the acute disorganization phase, but
crises can occur during the other phases as well. The goals of rape crisis counseling are to “reduce the victim’s emotional distress, enhance her coping
strategies, and prevent the development of more serious psychopathology”
(Calhoun & Atkeson, 1991, p. 39). The use of the IPSM specifically with the
population of sexual assault survivors is now described.
1. Establish and maintain rapport. Due to the brief and urgent nature of
rape crisis counseling, it must be more active, directive, and supportive than
other modes (Calhoun & Atkeson, 1991). Crisis workers should exhibit the
following characteristics as well as behaviors: warmth and calmness,
patience, availability but not intrusiveness or control, acceptance and understanding, empathy and concern, effective listening skills, trustworthiness,
and encouragement of appropriate referrals and support seeking. The messages the survivor should hear are “I’m sorry this happened to you,” “You are
safe now,” and “This wasn’t your fault” (Kitchen, 1991, 35); and “I know you
handled the situation right because you’re alive” (Dunn & Gilchrist, 1993,
p. 364). These messages and statements may be particularly important for
members of certain oppressed and stigmatized groups to receive to alter their
preexisting and potentially self-depreciating narratives.
2. Ensure safety. Safety must be assessed/addressed in terms of client selfdestructiveness or suicidality and potential situations in which the victim
may come in contact with the perpetrator. Common coping mechanisms
include self-mutilation, eating disorders, substance abuse, and promiscuity
and other types of risk-taking behaviors. Ensuring safety is a critical step in
which clients must be assessed and empowered to develop effective safety
plans and/or contracts, which may be incorporated into subsequent stages.
Resources should be identified for potential use by the survivor.
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3. Assess client and begin processing trauma. Identifying the stage of
recovery from rape trauma syndrome is important in guiding treatment interventions (Daane, 1991; Petretic-Jackson & Jackson, 1990). The crisis intervention strategies presented here are structured with these stages in mind.
The initial, acute phase of recovery from rape involves somatic, emotional,
and cognitive disorganization and lasts for a few days to several weeks or
months. Victims experience feelings of shock, helplessness, fear,
hypervigilance, guilt, shame, intrusive recollections, and exhaustion. The
behavioral response varies widely among victims and has been characterized
as either expressed or controlled. The expressed response refers to anxious,
angry, fearful, tense, and restless reactions, whereas controlled tends to
involve masked emotions and a calm, composed, and subdued appearance.
Of course, responses may vary along cultural and numerous other dimensions as well. Assessment may reveal that the client is in the acute phase of
recovery and not yet prepared to participate in the more in-depth processing
of the trauma that may occur in later stages of recovery. However, potential
goals to be addressed in the following intervention stages may be (a) to process the trauma at the intensity level that the client can tolerate at any given
time, and (b) to construct the trauma into a narrative that is more adaptive and
empowering than the existing one. The narrative approach may be especially
helpful for women with histories of prior traumatic experiences in that it can
help them acknowledge and develop the courage and strength that helped
them survive in the past (Draucker, 1998).
“Triage (rapid assessment and prioritizing of needs) is necessary to determine what type of intervention is appropriate and whether some approaches
are contraindicated” (Resick & Mechanic, 1995, p. 101). Risk of decompensation, suicide, self-harm, or lack of sufficient coping resources must be
assessed and the client stabilized before intensive techniques such as exposure are utilized. Assessment of immediate presenting problem, daily functioning, the specific nature of the assault, reactions to the event and coping
skills utilized, available social support, premorbid adjustment, interpersonal
relationships, and previous traumatic experiences is necessary to determine
the severity of the crisis and plan for treatment.
The effect of the assault on the individual and the length of recovery
depend on many factors, including
age, race/ethnicity, family background, cultural and religious mores, community attitudes, type of abuse experienced, length of time and intensity of
victimization, attitudes about sex roles, attitudes of family and support persons following disclosure/discovery of the abuse, and effects of policy or legal
proceedings following disclosure/discovery of the abuse. (Williams &
Holmes, 1981, as cited in Gilliland & James, 1997, pp. 224-225)
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Certain types of clients who may on occasion require alternative crisis intervention approaches are children, incest survivors, victims of gang rape, racial
or ethnic minorities, men, people with disabilities, suicidal clients, gay men,
lesbians, and so forth. For example, the mental health concerns of some male
sexual assault survivors may be somewhat different from those of some
female survivors in that the former may face a different type of prejudice and
stigmatization and use different coping skills to deal with and express emotions such as anger, shame, and helplessness (Evans, 1990). Likewise, African Americans and other racial/ethnic minorities’ care may sometimes be
affected by stereotypes about their sexuality and personalities, and in some
cases minority women may be reluctant to “betray” members of their communities if the perpetrators also happen to be members of the same minority
group (McNair & Neville, 1996). Similar discriminatory attitudes and
assumptions may prevent gay and lesbian assault survivors from obtaining
the unique care that they need (Orzek, 1989). A solution-focused framework
could help the client identify current coping skills yet expand these to become
a more flexible and comprehensive repertoire and therefore a more adaptive
narrative.
4 and 5. Set goals and generate options. Sexual assault may result in a
series of crises from the assault itself to reporting the attack, appearing in
court, and resolving intimate relationships (Pruett & Brown, 1990). The
counseling psychologist
must help the victim deal with the following issues during the acute phase: 1)
medical attention, 2) legal matters and police contacts, 3) notification of family
or friends, 4) current practical concern, 5) clarification of factual information,
6) emotional responses, and 7) psychiatric consultation. (Fox & Scherl, 1972,
p. 38)
Again, these situations may be exacerbated because of cultural issues such as
a lack of experience or previous unsatisfactory experiences with various
agencies (Sue & Sue, 1990), and these factors must be taken into account
when developing and implementing the action plan.
6 and 7. Evaluate options and select plan. Control is a major issue of concern for rape survivors. They have experienced an extreme loss of control and
need “to be reassured that that loss of control is neither total nor permanent”
(Gilliland & James, 1997, p. 239) while being given as many choices as possible in their recovery, such as whom to tell and where to stay. In this way, clients can restory their traumatic narrative into one in which they have more
power and control and thus facilitate their long-term recovery. The reasons
for seeking medical attention and what to expect during the examination
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should be presented (