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Treatment Goals, Assessment, and Evaluation Practices in Rape Crisis Centers

Rachael Voth Schrag; Tonya Edmond

Abstract

Counselors in Rape Crisis Centers (RCCs) provide crucial services to survivors of sexual

violence. However, little is known about RCCs, including the treatment goals and assessment

strategies of counselors. Counselors in all Texas RCCs (N=83) were invited to participate in a

web-based survey. Participants were asked to indicate which treatment goals they frequently

identified and assessed, as well as their usual assessment techniques. Counselors endorsed

treatment goals around self-esteem, empowerment, and relational functioning, along with trauma

and mental health. Fewer counselors endorsed goals around drugs/alcohol, or school/work/sexual

functioning. Counselors in urban settings were more likely to endorse goals related to mental

health. Gaps were noted between counselors’ goals and how often outcomes are assessed.

Increasing the use of assessments in practice could promote the provision of effective services

and increase access to funding.

Key Words: Sexual Assault, Victim Services, Counseling, Clinical Measurement

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Background

Practitioners in Rape Crisis Centers (RCCs) provide crucial services to survivors of

sexual violence, including crisis intervention, advocacy, and individual and group counseling

(Macy, Rizo, Johns, & Ermentrout, 2013; Ullman & Townsend, 2007). Assistance provided by

RCCs is unique, in that it includes “safety, protection, and trauma services that…are not offered

by most other health, human, and legal service providers” (Macy et al., 2013, p. 1041). Survivors

frequently suffer secondary victimization during interactions with judicial, medical and law

enforcement personnel, inhibiting them from seeking services (Maier, 2008). In the face of these

risks, survivors of sexual violence rate RCCs as the most helpful in the aftermath of an assault,

with those accessing RCC services reporting significantly less distress than others (Campbell,

Wasco, Ahrens, Sefl, & Barnes, 2001). RCCs help survivors cope with and heal from sexual

violence and its resultant trauma (Macy et al., 2013).

Strong evidence supports that utilizing standardized assessments of outcomes can

enhance treatment planning, implementation, and evaluation of counseling services (Mazefsky &

White, 2013). Benefits include better targeting of interventions, improved service delivery,

improved outcomes, and increased funding (Dennison, 2002). However, the treatment goals or

accompanying assessment techniques of RCC practitioners are unknown. This study seeks to

identify counselors’ treatment goals and assessment approaches. It also examines any differences

by agency location or counselor educational attainment.

The Rape Crisis Center Service Sector

Nearly 1,100 RCCs operate within the United States, but the RCC service sector has been

described as a “black box,” as there is a general understanding of the goals, aims, and values of

RCCs, but little knowledge of the inner workings of agencies (Macy, Giattina, Sangster, Crosby,

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& Montijo, 2009). RCCs serve adult and child survivors who have experienced a wide range of

types of sexual violence, including rape, sexual assault, incest, child sexual abuse, and sexual

harassment perpetrated by strangers, acquaintances, and intimate partners (Shaw & Campbell,

2011). Typical RCC services include crisis intervention, hospital & legal advocacy and support,

individual and group counseling, and case management services (Shaw & Campbell, 2011).

The de-centralized, grassroots nature of the service sector has led to considerable

variation in the structure, delivery, and services from agency to agency (Macy et al., 2013; Shaw

& Campbell, 2011). The work of Macy and colleagues (2013) highlights differences in service

delivery practices between RCC providers in urban and rural areas. They find that rural

practitioners emphasize flexibility and the provision of holistic services and the need to break

down as many barriers to access as possible (Macy et al., 2013).

Trauma Treatment for Sexual Assault Survivors

The consequences of sexual violence for adult and child survivors are well documented.

Survivors experience a range from minimal symptomology to serious and life-long mental and

physical health consequences (Olafson, 2011; Putnam, 2003). Negative long-term impacts

include increased rates of depression, posttraumatic stress disorder, and anxiety disorders

(Regehr, Alaggia, Dennis, Pitts, & Saini, 2013). Survivors also face higher rates of substance

use disorders, physical health challenges, self-blame, and difficulties with functioning (Regehr et

al., 2013). For children, the consequences of sexual violence include psychological

symptomology, impaired daily functioning in childhood and adulthood, and changes in self

image and perceptions of the world (Olafson, 2011). Survivors of sexual violence are also at an

increased risk of revictimization, emphasizing the need for intervention to address the negative

impacts of sexual violence and disrupt abusive cycles (Olafson, 2011). The serious impacts of

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sexual violence are clear. However, the ways in which counselors in RCCs conceptualize their

goals when working with survivors, their processes for assessing survivors’ needs, and for

evaluating the effectiveness of their work, is unknown.

Impact of Setting on Service Delivery

There is strong evidence that geographic setting plays a major role in the delivery of effective

social services. Previous work demonstrates that the majority of services for victims of all kinds

are situated in an urban context, and few studies have been published that take rurality into

account when examining sexual assault programs (Logan, Evans, Stevenson, & Jordan, 2005;

Van Hightower & Gorton, 2002). Yet rural survivors of sexual assault face many challenges that

their urban counterparts do not, partly stemming from challenges in accessing services (Lewis,

2003; Macy, et al., 2013). Areas with smaller populations have a lower tax base to publicly fund

such services, and a lack of transportation and isolation also complicate service delivery

(Stommes & Brown, 2002). Further, mental health services are rare in rural areas (Randall &

Vance, 2005). Survivors of sexual assault who are at risk for developing PTSD may not receive

the treatment they need from traditional mental health centers, making any services provided by

rape crisis centers that much more critical. RCCs in rural areas also employ fewer practitioners

who possess the advanced degrees that are often associated with counseling tasks, even as they

seek to provide such services, potentially creating additional barriers to service delivery

(Edmond, Lawrence, & Voth Schrag, 2016; Edmond & Voth Schrag, 2017). Despite the unique

characteristics and challenges associated with service delivery in rural areas, few studies to date

have specifically examined any potential service differences between rural and urban RCCs or

among RCC providers with different levels of education (Lewis, 2003).

Treatment Planning and Assessment

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Accurate assessment is a key step in the provision of effective services, and is critical in

treatment planning. It informs the practitioner and service recipient’s case conceptualization,

understanding of specific needs, and decision making around intervention and treatment choices

(Mazefsky & White, 2013). It can identify potential roadblocks before they arise, and serve as a

basis for making choices regarding the use of resources (Sellborn, Marion, & Bagby, 2013).

Assessment can also inform treatment planning by challenging a practitioner’s clinical

impressions and encouraging attention in areas of need (Sellborn, et al., 2013). The use of

assessments can help counselors make evidence-based treatment recommendations and identify

key areas for work, which is especially critical when treatment may be time-limited due to

financial or other constraints (Mazefsky & White, 2013). Further, evidence suggests that mental

health service recipients feel positively about participating in assessment, and find the

assessment process helpful (Lyon et al., 2016).

The use of standardized assessments, which are developed based on research and

evidence and made publically available, support treatment through providing evidence for

needed adjustments to enhance the efficacy of services (McLeod, Jensen-Doss, & Ollendick,

2013). Assessment is critical to monitoring client outcomes and program effectiveness. Using

standardized assessments can document successes and point to areas for improvement across

clinicians and program areas, as well as provide information for planning (Sellborn, et al., 2013).

Assessment techniques vary across settings and disciplines, from clinical impressions and

single case evaluations to agency wide efforts in collaboration with researchers. While important

in developing a holistic understanding of the client, ‘clinical impressions’ (i.e. the providers

sense of the clients’ needs and diagnoses based on conversation or unstructured interviews) have

been documented to result in less accurate diagnosis and provision of less relevant treatment

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(Wilson, Sherritt, Gates, & Knight, 2004). Comparatively, the use of standardized measures to

assess specific domains has been identified as an important method for enhancing the quality of

treatment (Berkman & Marimaldi, 2001). Berkman & Maramaldi (2001) identified a number of

important criteria to consider when evaluating standardized measures for treatment outcomes for

use in practice: (1) conceptual link: the extent to which there is a logical connection between the

assessment, intervention, and outcome to be measured, (2) potential for change: extent to which

the intervention is likely to create change in the outcome being assessed over the chosen time

period, (3) reliability and validity: evidence for minimal measurement error and efficacy in

detecting change, (4) cultural competence: extent to which the assessment strategy is appropriate

for the cultural context of the survivors served by the agency, (5) practicality: the extent to which

the strategy is relatively easy to implement in a busy practice environment.

While the literature provides guidance on best practices for assessment, little is known

regarding the treatment goals and assessment approaches of RCCs. This inhibits our ability to

evaluate services provided, and could be a barrier in the effective implementation of

interventions. Expanding our knowledge can help practitioners as they seek to improve services

and demonstrate effectiveness to funders. Thus, this study sought to identify the treatment goals,

assessment and evaluation strategies of practitioners providing counseling services in RCCs, by

answering these questions: (1) What do practitioners working in RCCs see as the commonly

desired outcomes (treatment goals) of counseling services? (2) What outcomes are routinely

assessed for prior to providing services? (3) What outcomes do practitioners routinely assess for

using standardized measures? (4) What methods do the agencies use to assess the effectiveness

of their counseling programs? (5) Are there differences in these assessment practices based on

provider education level or agency setting (urban/rural location)?

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Methods

Participants

A quantitative, cross-sectional, web-based survey of counselors from RCCs in Texas was

conducted over the summer of 2013. Practitioners were asked to participate if their job

descriptions included on-going individual or group counseling tasks. Responding counselors (n

= 76) were predominately female (95%), on average 39 years old with three years of experience

at their current agency and 8 years of experience in this field of practice (see table 1). The

majority identified as social workers and counselors, although many of those without an

advanced degree identified more with their job title (‘advocate,’ ‘counselor,’ etc.) than a

profession (n = 13, 17%). Slightly over half of the counselors (54%) had a Masters or PhD

degree, 22% had a Bachelor’s Degree, and 24% had less than a Bachelor’s Degree. Nearly 60%

worked at agencies in urban or suburban settings, while 40% worked in rural areas.

Approximately 70% of respondents reported that the assessment process used in their agency is

standard across all staff that provide individual or group counseling. <insert table 1>

Materials

Based on the available literature and in consultation with experts in the field, a set of

potential treatment goals and evaluation strategies were identified. These measures were

developed for the current study based on feedback gathered from agency leaders, RCC

counselors, Texas Association Against Sexual Assault (TAASA) staff, and a review of previous

studies of RCCs and domestic violence service agencies (e.g., Edmond, 2004; Macy et al., 2009).

The final checklist of thirteen potential treatment goals (see table 2) spanned three primary

domains- mental health (addressing trauma, PTSD, depression, anxiety, substance use, and

stigma/shame), daily functioning (general, relational, work/school, and sexual functioning), and

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self-esteem/ empowerment (assertiveness, self-esteem/confidence, and empowerment). From this

list, practitioners were asked to identify which treatment goals they commonly pursue with

survivors in counseling. They were then asked to identify which of these areas they routinely

include in their pre-treatment assessment, and which are routinely assessed using standardized

measures. Finally, 10 potential forms of assessment were identified. These were: clinical

impressions, client satisfaction survey, assessment only before treatment with agency scales,

assessment before and after treatment with agency scales, assessment after treatment with agency

scales, assessment before treatment with standardized scales, assessment before and after with

standardized scales, assessment after treatment with standardized scales, and collaboration with a

university researcher (see table 3). Respondents were asked to indicate which of these forms of

assessment were used in their agencies. Because the study seeks to capture the perceptions of

counselors, no definition of what constitutes a ‘standardized measure’ was provided. As such,

providers may have interpreted the meaning of standardized to indicate ‘consistent.’

Procedure

In close collaboration with the Texas Association Against Sexual Assault (TAASA), the

state coalition of RCCs, a comprehensive list of all Texas RCCs was developed (N = 83). With

TAASA’s endorsement, direct practitioners from all 83 agencies were invited to participate

through postal and e-mail. Agency directors were asked forward the web-survey link to staff

members. Participants were given a $20 gift card as an incentive. Pre-approval for study

procedures was obtained from the Institutional Review Board of the sponsoring university.

Analysis included descriptive statistics and chi-square analysis for differences between

groups. Some missing data occurred due to question non-response. These missing data were

treated in an available-case analysis fashion. The number of included cases is provided for each

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item in Tables 1-3. The final sample for analysis included 76 counselors from 47 of the 83

agencies, with 57% of all Texas RCCs represented. Forty-seven percent of rural RCCs had at

least one counselor responding, while 61% of urban agencies had a participating counselor.

Results

Commonly Desired Service Outcomes

The most frequently endorsed treatment goals were enhancing self-esteem, confidence

(99%), and a sense of empowerment (94%); improving relational functioning (93%); decreasing

general trauma symptoms (91%); and symptoms of anxiety (90%), depression (87%), and PTSD

(86%). <insert table 2>

Routinely Assessed Service Outcomes

Practitioners most frequently endorsed assessing for mental health, with 85.5% assessing

survivors’ general trauma symptoms, followed by depression (81%), anxiety (78%) and PTSD

(68%). Self-esteem (73.9%) and empowerment (63.8%) were assessed at rates that were similar

to the mental health concerns. Even though less than half of the respondents identified reducing

drug/alcohol abuse as a treatment goal, it was assessed by 56.5%of them. Respondents reported

lower rates of assessment for feelings of stigma/shame (53.6%) and assertiveness (44.9%) even

though these were highly endorsed treatment goals. Seventy-eight percent of respondents

reported assessing general functioning, with fewer assessing specific areas of functioning:

relational (65%), school/work (49%) and sexual (42%).

Use of Standardized Measures

Use of standardized measures for assessment was low across all domains, ranging from

10% for sexual functioning to a high of 38.6% for depression (see Table 2). Practitioners most

frequently used standardized measures to assess mental health: Depression (38.6%), general

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trauma symptoms (37.1%), anxiety (35.7%), PTSD (34.3%), and drugs/alcohol abuse (21.3%).

Use of standardized measures for functioning or empowerment outcomes was uncommon.

Methods for Evaluating Effectiveness

Practitioners reported using a variety of methods to evaluate the effectiveness of their

work (see Table 3). The highest level of endorsement was for client satisfaction surveys

(84.3%), followed by clinical impressions (41.4%) and assessment before and after treatment

with agency developed scales (38.6%). Fewer than one in four use standardized scales before

and after treatment (24.3%). Client focus groups are employed by 15.7% of these agencies, and a

small number of agencies (n = 6; 8.6%) collaborate with university researchers to evaluate

program effectiveness. <insert table 3>

Differences by Rurality and Education

There were a few statistically significant differences in treatment goals or assessment

strategies between urban and rural practitioners. Practitioners in urban settings were significantly

more likely to endorse reduction of anxiety as a treatment goal, χ2 (1, N = 69) = 6.1, p < .05.

Urban practitioners were also more likely to endorse reduction of PTSD (92.5% vs 75.9%) and

enhancement of sexual functioning (65% vs 44.8%) as treatment goals. These may reflect

clinically significant differences, however neither were statistically significant. Practitioners in

rural settings indicated a higher use of “standardized measures only before treatment,” χ2 (1, N =

70) = 4.4, p < .05), and for assessment “before and after treatment,” χ2 (1, N = 70) = 5.01, p <

.05. Several differences between practitioners were observed based on level of education.

Practitioners with an advanced degree and those without any degree were significantly more

likely to select “reduce general trauma,” χ2 (2, N = 69) = 9.1, p < .05, and “reduce PTSD,” χ2 (2,

N = 69) = 6.6, p < .05 as treatment goals. Non-degreed practitioners were also more likely to

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identify reducing abuse of alcohol and drugs as a goal than those with more education, χ2 (2, N =

69) = 6.7, p < .05. In terms of pretreatment assessment, non-degreed practitioners were more

likely to assess for self-esteem/confidence (93.8%), χ2 (2, N = 69) = 7.37, p < .05. In addition,

they were more likely than their peers with college degrees to assess general functioning in their

clients using a standardized measure (47.1% vs 14.3% and 12.8%), χ2 (1, N = 70) = 8.8, p < .05.

Differences were also found in treatment outcome assessment strategies. Practitioners with

advanced degrees were more likely to use clinical impressions as an assessment strategy (59%)

than those with less education, χ2 (1, N = 70) = 11.2, p<.01, but less likely to assess only after

treatment with scales developed ‘in house’ at the agency, χ2 (2, N = 69) = 6.9, p<.05.

Discussion

RCCs are dedicated to meeting the needs of survivors of violence, and counselors in

these agencies report substantial agreement regarding their goals and aims. They are engaged in

work to empower survivors, improve mental health, and enhance daily functioning. These

common aims, which are clearly aligned with the empirically documented needs of survivors,

can be a primary point for organizing and continuing to develop and expand this vital but often

under resourced sector. Based on this observed alignment, in order to support RCCs in doing

their important work in often under resourced settings, the authors of the current study used

Berkman & Marimaldi’s (2001) criteria to identify a number of assessment measures that could

fit within RCC system constraints and help meet the needs of survivors, practitioners, and

funders. These measures meet Berkman & Marimaldi’s (2001) criteria for acceptable

standardized assessment tools in that they are (1) logically connected to the treatment domains

most frequently endorsed by counselors in RCCs (2) capable of capturing change over time (3)

psychometrically validated (4) Previously used in a range of populations (although individual

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agencies should always review measures to ensure cultural competence with their specific

setting) and (5) practical, in that they are generally low-cost or free, short, and easy to

administer. Administrators and practitioners in this sector should consider incorporating such

assessments to promote positive client outcomes and meet the expectations of a wide variety of

groups providing funding and oversight. <insert table 4>

Importantly, few differences in treatment goals were seen by agency setting. Given

considerable health disparities in access to treatment between urban and rural settings, the fact

that agencies reported similar goals and strategies should be seen as a positive sign for the RCC

sector in Texas (Singh & Siahpush, 2014). Despite organizational, philosophical or service

differences observed in other studies (Lewis, 2003), the treatment goals, and assessment

strategies of urban and rural providers in Texas seem to be very similar. This could be due to the

leadership of a robust state collation (TAASA), which puts considerable emphasis on and

resources into supporting the wide diversity of agencies in Texas. Indeed a major strength of the

current study was the support and assistance of TAASA leadership and staff in the development

and implementation, demonstrating their on-going commitment to supporting and building the

service sector in the state.

A number of significant differences in treatment goals and assessment strategies were

observed between providers with differing levels of education. An unexpected finding was the

way in which goals, as well as assessment practices were most aligned between practitioners

with advanced degrees and those without any degrees. These two groups of practitioners were

more likely to endorse mental health related treatment goals than practitioners with bachelor’s

degrees. Comparatively, providers with advanced degrees were less likely to assess for self-

confidence and less likely to assess general functioning with standardized measures. This may

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be related to the fact that undergraduate programs tend to train practitioners for generalist

practice skills such as case management and advocacy, which involves more of a focus on

ameliorating problems with daily functioning and building self-confidence and personal self-

efficacy. Comparatively, graduate social work and psychology programs train practitioners to be

specialists in assessing and treating mental health related problems. Neither of these possible

explanations though accounts for the similarities in assessment practices between those

counselors without any college degrees and those with advanced degrees. Perhaps in the absence

of having a degree those counselors are compensating by more proactively seeking resources to

support their work rather than relying solely on their educational training. Given the number of

non-degreed counselors observed, and their wide range of treatment goals for survivors, state

coalitions and others providing on-going technical assistance to RCCs should consider ways to

resource this important group of practitioners. Interestingly, fewer counselors endorsed

addressing substance abuse issues as a goal than endorsed screening for them. It could be that

agencies are more likely to refer out for substance treatment, so counselors may screen and refer

rather than feel capable of treating substance issues themselves.

Although practitioners’ goals are clearly in line with the needs of survivors as explicated

in the literature, standardized assessment of treatment outcomes is uncommon. There are

substantial gaps between identified treatment goals and the use of standardized assessment tools,

which may hinder the assessment of both the specific treatment needs of a client and the

effectiveness of their treatment. In addition, it limits the ability of agencies to evaluate the

effectiveness of their client services. This creates a potential funding vulnerability for RCCs in a

competitive nonprofit environment where funders are increasingly expecting agencies to

demonstrate impact through positive service outcomes (Bliss, 2007). The adoption of

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standardized assessment tools, such as those outlined in Table 4, could help practitioners more

accurately identify the constellation of symptoms for each survivor. This would in turn inform

the treatment plan and help guide the selection of the interventions most needed. The use of the

same standardized assessments after treatment would help the client and the practitioner see the

impact of their work, which could be an empowering experience for survivors. If each counselor

in the agency employed standardized measures with all of their clients, the agency would be able

to more accurately evaluate the effectiveness of their counseling services and demonstrate to

funders the importance of their services.

RCC practitioners operate in challenging environments with many constraints.

Consequently, it may not be feasible, even with free or low cost instruments, to use standardized

measures for each identified treatment goal. Practitioners are most often using standardized

measures is in the assessment of mental health symptoms, which are often debilitating for

survivors, and where treatment approaches such as CBT and EMDR already incorporate

standardized assessments (Foa, Keane, Friedmna, & Cohen, 2005). This should be viewed

positively, as RCC counselors are prioritizing the formal assessment of critically important

symptoms. However, service to survivors could be improved with such assessments occurring

with greater frequency, across all education levels, and in all RCCs.

Limitations

The study has a number of limitations. Data are from a small sample of providers in a single

state, and all work at agencies that are members of the state coalition against sexual assault.

There are smaller numbers of practitioner’s with no degree (24%) and Bachelors’ degrees (22%)

than advanced degrees, which may influence the findings. Given the moderate response rate,

there may be systematic differences between responding and non-responding agencies (such as

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shared computer use or other electronic access issues) that jeopardize the generalizability of

findings. Additionally, “Standardized” was not defined, so it is possible that practitioners have

different interpretations of standardization and that some of the variation in use of standardized

measures by educational attainment is an artifact of these differences. There is a risk of social

desirability, which could lead to respondents over-endorsing goals and assessment techniques.

Similarly, as agency contracts are often tied to working towards certain treatment goals or using

certain techniques for evaluation, some items may have been over-endorsed by counselors

concerned about agency funding.

Implications

Sexual violence creates range of consequences, and counselors in RCCs are striving to reduce

symptoms and enhance empowerment and functioning of survivors. RCC practitioners need

access to free or low cost standardized measures that are easy to administer and score in order to

assess the broad constellation of trauma symptoms that survivors have and to enhance the

accuracy of assessments, treatment planning, intervention selection and monitoring of treatment

outcomes. Where measures are lacking, work should focus on development of tools to assess

key domains identified by counselors as central to their work. For example, a clinically useful

tool for assessing change in survivors’ perceptions of stigma and shame related to sexual

violence could be an important contribution for RCCs. Expanding the use of such tools in RCCs

could improve the effectiveness of assessment and treatment for survivors of sexual violence and

provide stronger data to assess effectiveness. This could help the field address funding needs by

better meeting the reporting expectations of a wide array of potential funders, including

foundations, private donors, and federal and state agencies. <insert table 4>

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21

Table 1 Demographic data for participating RCC practitioners (n=76) Variable Frequency (%) Rural (%/N)

31 (40.8)

Urban (%/N)

45 (59.2)

Professional Discipline

Social Work 26 (34.2) 7 (22.6) 19 (42.2)

Criminal Justice 1 (1.3) 0 (0.0) 1 (2.2)

Psychology 6 (7.9) 3 (9.7) 3 (6.7)

Counseling 23 (30.3) 8 (25.8) 15 (33.3)

Divinity/Theology 2 (2.6) 2 (6.5) 0 (0.0)

Education 3 (4.0) 2 (6.5) 1 (2.2)

Job Titlea 13 (17.1) 7 (22.6) 6 (13.33)

Other 2 (2.6) 2 (6.45) 0 (0.0)

Female 71 (94.7) 31 (100.0) 40 (90.9)

Educational Attainment

Less than Bachelor’s degree 18 (23.7) 13 (41.9) 5 (11.1)

Bachelor’s Degree 17 (22.4) 7 (22.6) 10 (22.2)

Advanced Degree 41 (54.0) 11 (35.5) 30 (66.7)

Agency assessment

process is standardized

48 (69.6) 18 (62.1) 30 (75.0)

Mean (SD) Range Rural

(Mean/SD)

Urban

(Mean/SD)

Age 39.5 (12.1) 23-65 41.8 (2.5) 38.0 (1.6)

Years of Experience 7.8 (6.8) 0-28 6.6 (1.0) 8.6 (1.0)

Agency Tenure 3.0 (3.5) 0-18 3.8 (.8) 3.0 (.6) a13 respondents indicated a job title such as ‘advocate’ as their professional discipline.

22

Table 2 Frequency of practitioner reported treatment goals, assessment of domains pre-treatment, and assessment of domains with standardized measure (n=69)

Treatment Goals Total Sample

No BA Degree

BA Degree

Advanced Degree

Rural Urban Assessed Pre-Treatment

Assessed: Stand. Measure

N % N % N % N % N % N % N % N %

Trauma Symptoms 63 91.3 16 100 10 71.4 37 94.9* 25 86.2 38 95.0 59 85.5 26 37.1

PTSD Symptoms 59 85.5 15 93.8 9 64.3 35 89.7* 22 75.9 37 92.5 47 68.1 24 34.3

Depression Symptoms 60 87.0 16 100 10 71.4 34 87.2 25 86.2 35 87.5 56 81.2 27 38.6

Anxiety Symptoms 62 90.0 14 87.5 12 85.7 36 92.3 23 79.3 39 97.5* 54 78.3 25 35.7

Abuse of Drugs/Alcohol 33 47.8 11 68.8 3 21.4 19 48.7* 14 48.3 19 47.5 39 56.5 15 21.3

Stigma/Shame 62 90.0 15 93.8 12 85.7 35 89.7 26 89.7 36 90.0 37 53.6 10 14.3

General Functioning 59 85.5 14 87.5 11 78.6 34 87.2 27 93.1 32 80.0 54 78.3 15 21.4

Relational Functioning 64 92.8 15 93.8 13 92.9 36 92.3 26 89.7 38 95.0 45 65.2 10 14.3

Work/School Functioning 53 76.8 15 93.8 10 71.4 28 71.8 24 82.8 29 72.5 34 49.3 9 12.9

Sexual Functioning 39 56.5 9 56.3 6 42.9 24 61.5 13 44.8 26 65.0 29 42.0 7 10.0

Assertiveness 56 81.2 14 87.5 11 78.6 31 79.5 22 75.9 34 85.0 31 44.9 8 11.4

Self-Esteem/Confidence 68 98.6 16 100 14 100 38 97.4 29 100 39 97.5 51 73.9 15 21.4

Empowerment 65 94.2 15 93.8 13 92.9 37 94.9 27 93.1 38 95.0 44 63.8 14 20.3 *p<.05 Chi-Square tests for difference in frequency of endorsing specific treatment goals between urban/rural agencies, or education level of providers (no BA/BA/Advanced)

23

Table 3 Differences in frequency of use for assessment techniques (n=70)

Assessment Technique

Total Sample

No BA Degree

BA Degree

Advanced Degree

Rural Urban

N % N % N % N % N % N % Clinical Impressions 29 41.4 3 17.7 3 21.4 23 59.0** 10 34.5 19 46.3

Client Satisfaction Survey 59 84.3 13 76.5 12 85.7 34 87.2 24 82.8 35 85.4

Client Focus Groups 11 15.7 4 23.5 2 14.3 5 12.8 5 17.2 6 14.6

Assessment only before tx with agency developed scales 3 4.3 1 5.9 1 7.1 1 2.6 2 6.9 1 2.4

Assessment before and after tx with agency scales 27 38.6 8 47.1 4 28.6 15 38.5 10 34.5 17 41.5

Assessment only after tx with agency developed scales 4 5.7 3 17.7 1 7.1 0 0.0* 3 10.3 1 2.4

Assessment only before tx with standardized scales 3 4.3 2 11.8 1 7.1 0 0.0 3 10.3 0 0.0*

Assessment before and after tx with standardized scales 17 24.3 5 29.4 2 14.3 10 25.6 11 37.9 6 14.6*

Assessment only after tx with standardized scales 4 5.7 2 11.8 2 14.3 0 0.0 3 10.3 1 2.4

Collaboration with university researcher 6 8.6 1 5.9 2 14.3 3 7.7 3 10.3 3 7.3

*p<.05 **p<.01 Chi-Square tests for difference in use of assessment methods between urban/rural agencies, or education level of providers (no BA/BA/Advanced)

24

Table 4 Measurement tools that could be used to assess frequently endorsed treatment goals

Measurement Instruments for Adult Survivors

Domain Instrument Purpose Cost

Time to

Administer Available:

Empower-

ment

Empowerment Scale (Rogers,

Chamberlin, Ellison, & Crean,

1997)

Scale to measure empowerment as defined by

consumers of mental health services

Contact the

author

28 items, 10-15

minutes

Contact the author for

rights

Empower-

ment

Measure of Victim

Empowerment Related to Safety

(Goodman et al., 2015)

Self-report scale aimed at assessing

empowerment related to safety from abuse

(Intimate Partner Violence specific)

Published in

Psychology

of Violence 13 items

Published in Psychology

of Violence

Self-Esteem Rosenburg Self-Esteem Scale

(Rosenburg, 1965) A self-report measure of feelings of self-worth. Free

10 items

completed in 5-

10 minutes

http://www.socy.umd.edu/q

uick-links/rosenberg-self-

esteem-scale

Functioning

Quality of Well-Being Scale

(Kaplan, Ganiats, and Sieber,

1996)

A self-report measure of functioning. While

some domains may be inappropriate to an RCC,

subscales from the QWB-SA could be useful.

Free to

nonprofits 10-15 minutes

https://hoap.ucsd.edu/qw

b-info/#

PTSD PTSD Checklist for DSM-V

(Weathers et al., 2013)

Self report measure for PTSD screening and

making provisional diagnosis Free

20 items, 5-10

minutes www.ptsd.va.gov

Anxiety

Acute Stress Disorder Structured

Interview (ASDI) (Bryant et al,

1998)

A clinician administered interview based on

DSM-IV criteria for Acute Stress Disorder,

including dissociative symptoms

Free for

members of

ISTSS

19 items

completed in 5-

10 minutes

http://www.istss.

org

25

Depression Patient Health Questioner (PHQ)

(Kreonke & Spitzer, 2002)

Self-report measure of severity of depression

symptoms. Can also be used for diagnosis using

DSM-IV criteria. Free

9 items

completed in 5-

10 minutes. Phqscreeners.com

Measurement Instruments for Children/Adolescents

Domain Instrument Purpose Cost

Time to

Administer Available At:

Empowerm

ent

Self-Efficacy Questionnaire

for Children (SEQ-C) (Muris,

2001)

Self report measure of three domains of self-

efficacy (academic, emtoinoal, social)

Designed for youth 14-18 years of age Free

24 items, 10-

15 minutes

http://drjenna.net/wp-

content/uploads/2013/0

7/self-

efficacy_questionnaire.

pdf

Self-Esteem

&

Functioning

KINDL (Ravens-Sieberer &

Bullinger, 1998)

Self and parent report, including wellbeing,

self-esteem, and functioning. Versions exist

for children aged 4-17.

Free to

non-profits

24 items in 10-

15 minutes

http://www.kindl.org/e

nglish/information/

PTSD

Clinician-Administered PTSD

Scale for Children (Nader et

al., 1996)

Clinician administered scale for youths aged

8-18 assessing the frequency and intensity of

DSM-IV PTSD symptoms Free

33 items in 10-

30 minutes

http://www.ptsd.va.gov

/professional/assessme

nt/child/caps-ca.asp

Anxiety

Screen for Childhood Anxiety

Related Emotional Disorders

(Birmaher et al., 1999)

Child and parent self-report instrument for

anxiety disorders, including GAD, separation

anxiety, panic disorder, and social phobias. Free

41 items

completed in

10 minutes

http://www.psychiatry.

pitt.edu/research/tools-

research/

Depression

CESD/Children (Weissman et

al., 1980)

Self-report inventory for depression

symptomology. Children ages 6-17. Free

20 items/5

minutes

http://www.brightfuture

s.org/mentalhealth/