Home > Public Resources > Trauma Blog > 2017 - July > Developmental Traumatology Incapacitated Sexual Assault (ISA) on College Campuses: Emerging Spaces f Developmental Traumatology Incapacitated Sexual Assault (ISA) on College Campuses: Emerging Spaces for Clinical Intervention July 31, 2017 Incapacitated Sexual Assault on College Campuses With several universities in the United States currently undergoing Title IX investigations (Fedina, Holmes, & Backes, 2016; Sutton, 2016), campus responses to preventing campus sexual violence and investigating sexual assault are increasingly under scrutiny (Sabina & Ho, 2014). The challenge facing university administrators, staff, and mental health clinicians alike is that drinking alcohol on college campuses is a normative practice for many students, but also a potential predictor of sexual violence and other adverse outcomes. The annual incidence of rape (non-consensual intercourse) among college women has been estimated at 5 percent, five times higher than the rate observed among non-college women (Kilpatrick, Resnick, Ruggierio, Conoscenti, & McCauley, 2007). Carey and colleagues (2015) reported that 15 percent of female students reported incapacitated rape (attempted or completed) during the first year of college and 26 percent had experienced incapacitated rape (attempted or completed) by the start of the second year. Incapacitated sexual assault (ISA) has also been referred to in the literature as “substance-involved assault” (Relyea & Ullman, 2016), and further distinction is made between whether drug or alcohol consumption was voluntary or involuntary (e.g., the use of sedatives or “date-rape” drugs). One of the central struggles for universities is to determine when intoxicated sex becomes sexual assault – or in other words, how much alcohol must be consumed to determine if an individual is “too drunk to have sex.” Additionally, sexual misconduct policies vary across universities in how they address the role of alcohol and drugs as it relates to sexual violence and the clarity they provide in how decisions on sexual assault cases are made when it is not clear that a victim was “incapacitated.” The need for clear guidelines around this issue is an area that college communities continue to struggle with, leaving a sometimes ambiguous space for clinicians to use their best judgment about how to navigate this concern therapeutically. Consent and Alcohol Use Universities across the United States are facing increasing pressure to address the problem of sexual assault, revise their policies, and are attempting to more clearly define the issue of consensual vs. nonconsensual sexual contact (Muehlenhard, Humphreys, Jokowski, & Peterson, 2016). On college campuses, counseling centers may be one of the only or few offices where a student can receive confidential services and are increasingly having to educate clients about consent and the role of alcohol use. The issue of consent has been an especially controversial topic when alcohol is consumed. Additionally, the role of “alcohol expectancies” (p. 461) where men may perceive women as having more sexual intent when under the influence (Abbey, Zawacki, & Buck, 2005) has gained momentum in the literature. Furthermore, intoxication is shown to inhibit attentional capacities towards identifying cues of sexual risk (Davis, Stoner, Norris, George, & Masters, 2009). These complexities, combined with the developmental and social norms of young adults, can further impact the ways in which consent is communicated and verbalized. Campus interventions and programming that promote consent are working to be more intentional about addressing alcohol consumption in conjunction with consent negotiation. Simple messages of receiving consent in general do not address how to assess someone's ability to provide consent when they have consumed alcohol or other drugs (Benson, 2007). In a study by Joskowski and Weirsma (2015), it was found that alcohol consumption prior to sexual activity was associated with fewer feelings of safety and comfort in relation to readiness for sex. Similarly, recent alcohol expectancies were associated with more use of physical and direct nonverbal behaviors. However, this was not found for students who did not report drinking prior to their most recent sexual activity. Importantly, those participants who did not engage in drinking prior to sexual activity experienced increased levels of safety and comfort in regards to sexual activity but also engaged in more direct behaviors to initiate and communicate consent. Examining more clearly the relationship between consent expression and alcohol consumption is an area of growing focus in the literature. Revictimization Risk and Self-Blame Several studies have examined the role of revictimization among college students, as many matriculating students report a prior exposure to an assault or traumatic event (Carey et al., 2015; Parks, Hsieh, Taggart, & Bradizza, 2014). However, some studies find that reduction of drinking does not fully account for reduced revictimization risk among women with previous histories of incapacitated sexual assault (Clinton-Sherrod, Morgan-Lopez, Brown, McMillen, & Cowell, 2011). In a longitudinal study of 1,012 adult sexual assault survivors (Ullman & Relyea, 2016), the effects of victim drinking on posttraumatic stress disorder (PTSD), as well as the mediating role of self-blame attributions were examined. They found that victims who were drinking before their assault experienced less PTSD symptoms and more self-blame than those who were not. While drinking was overall related to less PTSD; it was also associated with increased PTSD symptoms via self-blame attributions. Internalization of blame after an assault can be an important cognitive and emotional response to assault, which further suggests that examining only the direct relationship between victim drinking and PTSD might provide a somewhat incomplete picture of post-assault sequelae. In a cross-sectional study, data from 340 college sexual assault victims who drank alcohol prior to assault found that those who reported being impaired or incapacitated felt a greater sense of stigma and self-blame than those who were not (Littleton, Grills-Taquechel, & Axsom, 2009). In turn, self-blame is related to more psychological distress and risk of revictimization (Breitenbecher, 2006; Miller, Markman, & Handley, 2007), and self-blame attributions can mediate the effect of negative social reactions on problem drinking (Sigurvinsdottir & Ullman, 2015). Spaces for Intervention Consent education and dialogue. Mental health clinicians must work together with campus programming initiatives on consent so that assessment and perception of risk when under the influence of alcohol can be integrated into campus dialogue and education around consent. Education about consent must also be considered as a part of trauma-informed care among clinicians in college counseling centers. While this may not have been a significant aspect of focus in traditional psychology training programs, clinicians are increasingly finding the need to expand their clinical roles by being educators and consultants for the larger community they serve. Talking with campus partners about substance use can be an uncomfortable discussion for many, and the emphasis on the relationship between treating clinicians and non-clinical service providers on campus becomes increasingly important in being able to bring innovative strategies to the table around the issue of consent and alcohol use (Novotney, 2014). Alcohol education and risk awareness. Current standards of clinical practice can be enhanced when clinicians can talk about the impact of alcohol and intoxication not just with sexual assault survivors, but also with students accused of sexual assault and sexually active students who seek out health services on campus. Efforts to educate students about alcohol expectancies may be a non-blaming way in which to get the attention of students who consume alcohol or other drugs. This is an emerging area in need of further research and development as the current programs educating college students have not been empirically validated and lack efficacy in terms of positive outcomes for these students (Walters, Bennett, & Noto, 2000; Chisolm, Manganello, Kelleher, & Marshal 2014). Additionally, formal sanctions are often the primary way in which universities address alcohol use and misuse. Clinicians can expand their consultative roles to collaborate with alcohol and drug offices that deliver sanctions to students on how the issue of excessive alcohol consumption is discussed with students and the role of minimizing judgment when having these conversations. Additionally, knowledge about alcohol-free events on campus, risk reduction programs, information about actual and perceived alcohol use on campuses, and online assessment and screening tools on alcohol use can be important information for clinicians to stay updated with and share this knowledge with their clients as well as with the larger campus community. A framework of intersectionality and revictimization risk. Addressing the intersections of sexual violence and alcohol use as it relates to consent, the cultural landscape of college life, and institutional policies, remains a challenging issue (Coulter et al., 2017). Protocol-based trauma treatments are not always easy to implement on college campuses, yet there is a large need for trauma exposed students to be integrated back into university life in order to be able to actively engage with their environment and continue to thrive. Cultural competence/sensitivity among clinicians working in college settings should participate in trainings that address the interconnections between gender, race, class, and social rank as it relates to campus culture and norms around drinking practices and expectations (Nash, 2008). Separation of these issues from trauma-focused treatments might fail to address key components of how victimization occurs and is maintained within a college setting. To expand on this idea, a proposed ecological framework of revictimization (Grauerholz, 2000; Relyea & Ullman, 2016) provides a broader cultural context within which revictimization occurs. This model is particularly significant for providers within college settings to understand due to the complex interplay between survivor histories and experiences, their interactions with the “campus culture,” and their transition into young adulthood. This leads to also understanding how the social structures and systems addressed the victimization in previous assaults as well as when the revictimization occurred. For instance, because drinking behaviors are likely to occur more than once, vulnerability of students to further assaults remains a concern. Conclusion As drinking behavior is often a cultural norm for many college students, it is important to find ways of addressing problem drinking without expressing shame or judgement and for clinicians to examine their own biases and attitudes about college drinking and how that could potentially impact their work with survivors of sexual assault. Although providers know the cultural norm of college drinking to be risky, clinicians are constantly navigating a fragile balance of increasing risk awareness for their students while also communicating empathy and respect. It can be important to inform students when there is risk in the types of behaviors and situations they may be engaging in and pursuing versus seeing risk in all situations that involve alcohol or that are normative for campus culture. About the Authors Divya Kannan, PhD, is an Assistant Professor of Clinical Psychiatry at the Vanderbilt University Medical Center and the lead psychologist for the trauma team at the Vanderbilt University Psychological & Counseling Center. Her research has focused on the investigation of factors that impact psychotherapy and psychotherapy training, and she has a strong interest in working with survivors of sexual assault and complex trauma. Meredith Kalies, PsyD, is a Postdoctoral Fellow at the Vanderbilt University Psychological and Counseling Center. 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