Aggression and Violent Behavior 46 (2019) 15–24

Contents lists available at ScienceDirect

Aggression and Violent Behavior

journal homepage: www.elsevier.com/locate/aggviobeh

A systematic literature review of early posttraumatic interventions for T

victims of violent crime
⁎
Stéphane Guaya, , Dominic Beaulieu-Prévostb, Josette Sadera, André Marchandc
a
School of Criminology, Université de Montréal, C.P. 6128, Succ. Centre-ville, Montréal, Québec H3C 3J7, Canada
b
Department of Sexology, Université de Québec à Montréal, C.P. 8888, Succ. Centre-ville, Montréal, Québec H3C 3P8, Canada
c
Department of Psychology, Université de Québec à Montréal, C.P. 8888 Succ. Centre-ville, Montréal, Québec H3C 3P8, Canada

A R T I C LE I N FO A B S T R A C T

Keywords: Criminal acts are the most common traumatic events to which the general population is exposed. Developing
Posttraumatic stress disorder clinical guidelines for preventing posttraumatic stress disorder (PTSD) among victims of violent crime would
Early interventions help to reduce the mental health costs related to these events. The goal of the current article was to system-
Victims atically review published studies on the efficacy of early interventions for victims of violent crime. Of the twelve
Violent crime
selected studies, six evaluated the efficacy of cognitive behavioral therapy (CBT), four evaluated psychological
Review
Cognitive behavioral therapy
debriefing (PD) and two evaluated another type of intervention (i.e., video). Our review found modest and
Psychological debriefing inconsistent effects of active early interventions. CBT appeared to be the most promising early intervention when
compared to an assessment condition or a progressive relaxation group, but relatively equivalent to supportive
counselling. No proof of efficacy was found for PD compared to other interventions or a control group. A psy-
choeducational video for rape victims appeared to help a subgroup of victims. The assessment conditions and PD
led to similar reductions in posttraumatic symptoms, while CBT had a greater impact. Further research is needed
in order to develop early interventions to prevent PTSD, improve quality of life, and reduce healthcare costs.

Criminal acts are the most common traumatic events to which the
general population is exposed (Breslau et al., 1998). In the United
States, there were an estimated 386.3 violent crimes per 100,000 in
2016, which include homicide, rape, robbery and physical assault (U.S.
Department of Justice, 2017). Although violent crime rates have gen-
erally declined over the past 20 years, these acts remain extremely
costly on both societal and individual levels.
Research consistently shows that criminal victimization leads to
negative mental health outcomes such as depression, complicated grief,
anxiety and substance abuse disorders, as well as acute stress disorder
(ASD) and posttraumatic stress disorder (PTSD; Green & Roberts, 2008).
Both ASD and PTSD are disorders that emerge following exposure to an
actual or threatened death, serious injury, or sexual violation and in-
clude similar symptoms such as intrusion related to the traumatic event,
avoidance, alterations in arousal and reactivity, and negative changes
in mood (American Psychiatric Association, 2013). Studies on the
consequences of violent crime estimate that between 17% and 82% of
victims will develop ASD within the month following the incident
(Armour, Elklit, & Shevlin, 2013; Boccellari et al., 2007; Brewin,
Andrews, Rose, & Kirk, 1999; Elklit, 2002; Elklit & Brink, 2004; Harb,
2006; Kleim & Ehlers, 2008; Möller, Bäckström, Söndergaard, &
Helström, 2014), with this type of traumatic event generating the
highest prevalence rates for this disorder (American Psychiatric
Association, 2013). Among victims of violent crime (VVC) with ASD, up
to 89% may develop PTSD six months following the event (Elklit &
Brink, 2004). A number of studies have found that the lifetime pre-
valence of PTSD is significantly higher among VVC (17.8% to 38.5%)
than among victims of other traumatic events (6.8% to 9.4%; Brewin
et al., 1999; Green & Roberts, 2008; Kilpatrick & Acierno, 2003), and
this is particularly true for women (Tolin & Foa, 2006).
1. Specificities of criminal victimization
Several specificities of criminal victimization may lead to the ex-
acerbation of posttraumatic symptomatology. These factors include
experiencing a threat to one's life or physical integrity, physical injury,
completed rape or intentional harm, exposure to grotesque sights, and
the violent or sudden death of a loved one (Bisson & Shepherd, 1995).
In addition, VVC may be stigmatized by their relatives and friends and
may even become targets of victim blaming (O'Hara, 2012). Evidence
from studies with sexual assault survivors are in relative agreement that
negative social reactions such as victim blaming are associated with

⁎
Corresponding author.
E-mail address: stephane.guay@umontreal.ca (S. Guay).

https://doi.org/10.1016/j.avb.2019.01.004
Received 18 January 2018; Received in revised form 5 December 2018; Accepted 14 January 2019
Available online 15 January 2019
1359-1789/ Crown Copyright © 2019 Published by Elsevier Ltd. All rights reserved.
S. Guay et al.
increased posttraumatic stress (Ullman, 2010). Furthermore, help
seeking behaviors may be more limited than that of victims of other
types of events, mainly due to the interpersonal aspect of the trauma
and its impact on trust. Such aspects may also limit the ability of re-
latives and friends to provide assistance. People close to the victim may
present with strong emotional reactions (e.g., helplessness, anger, un-
certainty towards others) as well, which can prevent them from pro-
viding adequate support. This is particularly important to consider, as
several empirical studies and etiological models of PTSD indicate that
social support is both a significant risk and protective factor for the
onset and maintenance of PTSD (Guay, Billette, & Marchand, 2006).
Another specificity of criminal victimization is the involvement re-
quired of the victim in the judicial process. In addition to the psycho-
social consequences of the event itself, victims of crime can experience
secondary victimization due to negatively perceived interactions with
law enforcement and the criminal justice system (Green & Roberts,
2008). Indeed, the unique challenges that exist for victims of crime,
such as legal investigations, hearings, trials, and the uncertain nature of
the criminal justice process and outcomes, may generate additional
stress for the victim. Furthermore, these procedures can impede upon
both the victim's recovery process and the interventions intended to
prevent psychological difficulties, as the judicial process may drag on
for months or even years and delay the opportunity to put the trauma to
rest (Green & Roberts, 2008). In particular, the criminal justice process
can negatively influence the victim's causal attributions, perceived
control, perceived social support, and coping related to the event
(MacLeod & Paton, 1999). Moreover, rates of PTSD appear to be higher
among victims who report crimes to the criminal justice system than
among those who do not (Green & Roberts, 2008).
Finally, VVC may be reluctant to formally disclose their victimiza-
tion and to engage in therapeutic interventions. Jaycox, Marshall, and
Schell (2004) assessed mental health service utilization among a sample
of men hospitalized for an injury following community violence and
found that, although 34% of the sample was experiencing elevated le-
vels of PTSD symptoms at a 12-month follow-up, only 15% reported
seeking services from a mental health professional. Similarly, it has
been estimated that only 9% of Canadian VVC seek help from com-
munity resources (Brazeau & Brzozowski, 2008). Yet, seeking and uti-
lizing mental health services may be crucial for the reduction of distress
and the prevention of long-term psychological sequelae in VVC.
2. Early interventions
The early aftermath of violent victimization may offer a critical
period for determining risk or resilience for the victim. Early responses
can impact upon the prolongation or mitigation of distress caused by
the traumatic event (Dworkin & Schumacher, 2016). The two most
common forms of early psychotherapeutic interventions following
traumatic events intended to reduce distress among victims are psy-
chological debriefing (PD) and cognitive behavioral therapy (CBT). PD
is a brief, swift intervention (between 24 and 72 h after the trauma),
generally consisting of a single meeting offered regardless of the level of
distress or symptoms. The objective of this intervention, which may be
offered to individuals or groups, is to normalize psychological reactions
following the event and to encourage the expression of emotions related
to the trauma (Bisson, McFarlane, Rose, Ruzek, & Watson, 2009). On
the other hand, early CBT is offered on an individual basis and usually
ranges from five to 12 weekly sessions. This type of intervention in-
volves a variety of trauma-focused strategies, including psychoeduca-
tion, stress management training, cognitive restructuring and exposure
therapy, all intended to be collaborative, action-oriented and experi-
ential (Litz & Bryant, 2009). Although studies have generally concluded
that CBT leads to a reduction of posttraumatic symptom severity while
PD does not (Forneris et al., 2013; International Society for Traumatic
Stress Studies, 2009), their relative effectiveness specifically among
VVC has yet to be evaluated.
16
Aggression and Violent Behavior 46 (2019) 15–24
3. Objective
The objective of the current paper is to systematically review the
efficacy of early psychotherapeutic interventions aiming to reduce
posttraumatic and related symptoms experienced by victims following a
violent crime. Although a past review examined interventions seeking
to prevent PTSD in the aftermath of several types of trauma (e.g., as-
saults, medical events, motor vehicle accidents, combat-related events;
Forneris et al., 2013), criminal victimization appears to merit exclusive
investigation due to the multiple specificities that may exacerbate its
psychological impact. The current review also expands upon that of
Dworkin and Schumacher (2016) by looking beyond the early experi-
ences of sexual assault survivors and examining other forms of violent
victimization as well. Considering the important distress often experi-
enced by VVC, it is urgent to establish the levels of efficacy of known
structured interventions with this population. Identifying the most ef-
fective interventions across the literature may serve to develop clinical
guidelines for the prevention or attenuation of posttraumatic stress
among VVC, to help reduce mental and overall health costs, and to
improve service utilization.
4. Methods
4.1. Data sources and searches
A systematic review of trials investigating the efficacy of early
psychotherapeutic interventions for VVC was conducted. The general
methods and selection criteria were based on different sources
(Chambless & Hollon, 1998; Kornør et al., 2008; Zaza et al., 2000).
First, four major electronic databases (Medline, Embase, Pilot and
PsyInfo) were searched for studies corresponding to our selection cri-
teria. Second, the reference sections of the identified studies and re-
views were scanned for additional relevant studies satisfying the cri-
teria. The following search terms were used in appropriate
combinations: intervention, crisis intervention, psychotherapy, de-
briefing, early intervention, posttraumatic stress disorder, acute stress
disorder, crime, victim, rape, robbery, domestic violence, and assault.
No limits were placed with regards to the year of publication and efforts
were made to retrieve unpublished data.
4.2. Selection criteria
Studies were included if they met the following criteria: 1) The
study involved direct VVC, aged 15 or over, defined as anyone who
suffered an actual or attempted physical or sexual assault, or robbery;
2) The aim of the intervention under study was to help victims recover
from the negative psychological effects of criminal victimization; 3)
When other types of trauma were also investigated, the data for VVC
were analysed and reported separately; 4) The intervention was pro-
vided less than three months after the crime; 5) At least one continuous
measure of a posttraumatic outcome (i.e., ASD or PTSD symptoms) was
reported; 6) The study involved a comparison between at least two
groups with at least two assessment points; 7) The experimental design
was either a randomized controlled trial, a quasi-experimental design or
a cohort study.
One hundred and sixty-eight studies were identified in the elec-
tronic databases. Two reviewers with a Ph.D. in psychology evaluated
the eligibility of the retrieved studies separately. According to the se-
lection criteria previously mentioned, twelve studies were retained (see
Fig. 1 for inclusion process). Their characteristics are presented in
Table 1. In addition, the quality of the included studies was evaluated
using a revised version of the Graphical Appraisal Tool for Epidemio-
logical Studies (GATE), as tailored by the National Institute for Health
and Care Excellence (NICE) to be more suitable for public health in-
terventions (NICE, 2012). The evaluation tool is comprised of five
sections evaluating the study population, the method of allocation to
S. Guay et al.
Fig. 1. Flowchart of study inclusion process.
study groups, the assessment and reporting of outcomes, the analyses,
as well as a summary of internal and external validity. With the removal
of two items specifically pertaining to United Kingdom practices, our
quality assessment tool yields a possible total score of 25 (see Table 1).
4.3. Data extraction and data synthesis
Between- and within-group effect sizes (ES) were calculated to ob-
tain a quantitative estimate for comparison between the different early
interventions. All ES computations were conducted by a coauthor on
this study (JS) and verified by an experienced biostatistician. The be-
tween-group ES were calculated for each psychosocial measure at the 6-
month follow-up. For studies without a 6-month follow-up, the ES were
calculated with data from the last follow-up available. Cohen's d was
first extracted or calculated for all studies that presented means and
standard deviations for each group. The formulae used for the between-
group ES were the following:
d = (M1 − M2)/s pooled (1)
s pooled = √ [(s12 + s22)/2] (2)
where d is Cohen's d, spooled is the pooled standard deviation, M1/M2
and s12/s22 are, respectively, the mean and variance of groups 1 and 2.
The within-group ES were calculated with values from the first as-
sessment and from the 6-month follow-up or the last follow-up avail-
able. Cohen's d could not be used, as the assumption of homogeneity of
variance cannot be held in a repeated-measures design when treatment
is expected to appreciably change the variability among cases from pre-
test to post-test. Thus, Glass's Δ was used instead, for which the de-
nominator is the standard deviation from the pre-test condition
(spretest), i.e. the variability in the sample before treatment (Kline,
2004). The formula used for the within-group ES was the following:
Δ = (M1 − M2)/s pretest (3)
All Cohen's d and Glass's Δ were converted in r in order to facilitate
the interpretation. A value of 0.1 was interpreted as a small ES, 0.3 as
medium, and 0.5 as large. The formulae used to convert the ES in-
dicators were the following:
r = d/ √ (d2 + 4) (4)
r = Δ/ √ (Δ2 + 4) (5)
To estimate and compare PTSD symptom reduction following dif-
ferent early interventions, standardized mean ES (change scores) were
calculated using random-effect meta-analyses. The 95% confidence
17
Aggression and Violent Behavior 46 (2019) 15–24
interval of these ES are also presented. Standardized mean ES were
computed only for CBT, PD, and assessment conditions due to an in-
sufficient number of studies on other types of interventions for the
calculations to be meaningful. Out of the six studies testing CBT,
standardized mean ES could not be estimated for two studies (Andre,
Lelord, Legeron, Reignier, & Delattre, 1997 [no standard deviations
provided]; Rothbaum et al., 2012 [insufficient pre-treatment informa-
tion]), while one study provided two measures of PTSD symptom re-
duction towards the calculation (Foa, Zoellner, & Feeny, 2006). Of the
four studies with a PD condition, one presented two measures of PTSD
symptom reduction (Rose, Brewin, Andrews, & Kirk, 1999), another
reported on two outcome measures for two separate PD conditions
(Richards, 2001), while another was excluded from the analyses due to
insufficient information regarding pre-treatment scores (Campfield &
Hills, 2001). Two studies with an assessment condition were also dis-
carded due to incomplete information (Andre et al., 1997; Rothbaum
et al., 2012). Parametric estimations were calculated for completers as
the intent-to-treat results were rarely presented, both for the post-
treatment and for the follow-up assessments. For studies with multiple
follow-up assessments, the one closest to 6-month was chosen, as it was
the most frequent possibility. Unless otherwise specified, all statistical
tests were done with an alpha of 0.05.
5. Results
Table 2 summarizes the findings extracted from the twelve included
studies. Six assessed the efficacy of CBT, four assessed a PD intervention
and two examined another type of intervention. All interventions were
either delivered by a therapist (individually or in groups) or through
self-help media such as videos. Nine studies included a control group.
5.1. Efficacy of cognitive-behavioral therapy (CBT)
Six studies evaluated CBT or its components, such as exposure and
cognitive restructuring (Andre et al., 1997; Echeburua, de Corral,
Sarasua, & Zubizarreta, 1996; Foa et al., 2006; Foa, Hearst-Ikeda, &
Perry, 1995; Nixon, 2012; Rothbaum et al., 2012).
Four studies combined victims of physical and sexual assault (Foa
et al., 1995; Foa et al., 2006; Nixon, 2012; Rothbaum et al., 2012). In
two studies conducted by Foa and colleagues, CBT was delivered to
female victims of physical and sexual assault and consisted of four
weekly 2-hour sessions that included one or more of the following
procedures: education about normal reactions to assault, breathing/
relaxation training, imaginal exposure, in vivo exposure, and cognitive
restructuring (Foa et al., 1995; Foa et al., 2006). The results of the first
 Table 1
Characteristics of reviewed studies.
Study Study design; Mean response Treatment duration; Sample; Mean age and SD Primary outcome measure Study quality
S. Guay et al.

Intervention (n) time and range Follow-up duration % female; (years) (out of 25)
Violent crime

Andre, Lelord, Légeron, RCT; 14 days CBT: 1 to 6 one-hour sessions (mean = 2,3), Standard 132 bus drivers; 35.2 (not reported) Impact of Events Scale 17
Reignier, & Delattre CBT (65), Standard care (67) (no range) care: no information % not reported;
(1997) 6 months Physical assault
Campfield and Hills RCT; Immediate: 5.08 h Immediate and delayed: 1 session lasted one to 2 h 77 non-physically Immediate PD: 22.6 Posttraumatic Stress 18
(2001) Immediate PD (36), Delayed PD (no range) injured victims; (3.4), Delayed PD: Diagnostic Scale
(41) Delayed: 62.29 h 55%; 23.0 (3.6)
(no range) Robbery (at place of
employment)
Echeburua, Corral, RCT; 5 weeks CBT and PMR: 5 one-hour sessions; 20 victims with PTSD; 22 (6.9) Scale of Severity of 17
Sarasua, & CBT (10), PMR (10) (4–13 weeks) 12 months 100%; Posttraumatic Stress
Zubizarreta Sexual assault Disorder Symptoms
(1996)
Foa et al. (1995) Quasi-experimental; 12.2 days CBT: 4 two-hour sessions, AC: 5 90-minute sessions 20 victims with PTSD CBT: 33.7 (11.5), AC: Posttraumatic Stress 16
CBT (10), AC (10) (no range) over 12 weeks +1 session at 5.5 months; except duration 31.3 (8.5) Disorder Symptom Scale –
5.5 months criterion; Interview
100%;
Physical and sexual
assault
Foa et al. (2006) RCT; 20.5 days CBT, AC and SC: 4 weekly 2-hour sessions; 90 victims with PTSD 33.7 (11.1) Posttraumatic Stress 23
CBT (31), AC (31), SC (29) (2–46 days) 12 months except duration Disorder Symptom Scale –
criterion; Interview;
100%; Posttraumatic Stress
Physical and sexual Disorder Symptom Scale –

18
assault Self-Report
Marchand et al. (2006) RCT; 7.93 days 2 one-hour sessions at a week interval; 75 victims; Female: 22.4 (7.3) Impact of Events Scale 17
PD (33), AC (42) (no range) 90–110 days posttest 52% Male: 21.2 (6.1)
Armed robbery
Miller et al. (2015) RCT; < 72 h 1 session (9-minute video); 164 victims; 28.8 (10.5) Posttraumatic Stress 20
Video group (79), (no further details) 2 months 100%; Disorder Symptom Scale –
Standard care (85) Sexual assault Self-Report
Nixon (2012) RCT; Within 4 weeks CPT and SC: 6 weekly 90-minute sessions; 30 victims with ASD; CPT: 40.6 (13.2), SC: Posttraumatic Stress 20
CPT (17), SC (13) (no further details) 6 months 47%; 40.7 (10.3) Diagnostic Scale
Physical and sexual
assault
Resnick et al. (2007) RCT; < 72 h 1 session (17-minute video); 140 victims; Video group: 25.2 Posttraumatic Stress 22
Video group (68), Standard care (no further details) 6 months 100%; (9.7), Control group: Disorder Symptom Scale –
(72) Sexual assault 25.8 (10.3) Self-Report
Richards (2001) Cohort study; 3 days CISD: 1 group session (1.5–2 h), CISM: 4 sessions of 524 victims; CISD: 31.4 (8.33) Impact of Events Scale; 18
CISD (225), CISM (299) (no range) pre-raid training +1 group session (1.5–2 h) + 1 CISD: 91.8%, CISM: CISM: 32.5 (9.6) Posttraumatic Stress
individual session (0.5–1 h) 1 month post event; 88%; Disorder Symptom Scale –
12 months Armed robbery Self-Report
Rose et al. (1999) RCT; 21 days Psychoeducation: 1 30-minute session, 157 victims; 35 (13) Posttraumatic Stress 21
Psychoeducation (52), (9–31 days) PD + Psychoeducation: 1 one-hour session, 25%; Disorder Symptom Scale –
PD + Psychoeducation (54), AC AC: no information; Physical and sexual Self-Report;
(51) 11 months assault Impact of Events Scale
Rothbaum et al. (2012) RCT; 11.79 h Exposure: 3 one-hour sessions, AC: 3 assessments; 84 victims; Exposure: 30.17 Posttraumatic Stress 17
Exposure (47), (no range) 3 months 65% (including other (12.08), Disorder Symptom Scale –
AC (37) traumas); AC: 32.78 (11.12) Interview
Physical and sexual
assault

Note. SD = standard deviation; RCT = randomized controlled trial; CBT = cognitive behavioral therapy; AC = assessment condition; PD = psychological debriefing; CISD = critical incident stress debriefing;
CISM = critical incident stress management.
Aggression and Violent Behavior 46 (2019) 15–24
 Table 2
Key findings in reviewed studies.
Study Study groups Assessment Primary outcomes Secondary outcomes
S. Guay et al.

(n) times
Measures Within group Between group Summary of findings Measures Within group ES Between Summary of findings
ES ES group ES

Andre, Lelord, Légeron, CBT (65); Pretest; IES N/A N/A CBT = AC HADS N/A N/A CBT > AC
Reignier, & AC (67) 6 months (Total score) (Anxiety)
Delattre IES CBT > AC HADS CBT = AC
(1997) (Intrusion) (Depression)
IES CBT = AC EPI CBT = AC
(Avoidance) (Extraversion)
EPI CBT < AC
(Neuroticism)
BSAS CBT < AC
(Sociotropy)
BSAS CBT = AC
(Autonomy)
Campfield and Hills Immediate PD Immediately PDS N/A 0.78 Immediate > Delayed PD – – – –
(2001) (36); posttest; (Number of
Delayed PD 2 days; symptoms)
(41) 4 days; PDS N/A 0.79
2 weeks (Severity of
symptoms)
Echeburua, Corral, CBT (10); Pretest; SSPSDS 0.87 (CBT) 0.51 CBT = PMR (posttest, 1, 3, MFS-III 0.28 (CBT) 0.05 CBT = PMR
Sarasua, & PMR (10) Posttest; (Intensity) 0.85 (PMR) 6 months); 0.71 (PMR)
Zubizarreta 1 month; SSPSDS 0.87 (CBT) 0.26 CBT > PMR (12 months) STAI 0.88 (CBT) 0.10
(1996) 3 months; (Reliving) 0.92 (PMR) 0.89 (PMR)

19
6 months; SSPSDS 0.81 (CBT) 0.35 BDI 0.68 (CBT) 0.10
12 months (Avoidance) 0.81 (PMR) 0.55 (PMR)
SSPSDS 0.85 (CBT) 0.34 Scale of 0.92 (CBT) 0.00
(Arousal) 0.81 (PMR) Adaptation 0.84 (PMR)
Foa et al. (1995) CBT (10); 3 weeks post PSS-I 0.89 (CBT) 0.33 CBT > AC (2 months); BDI 0.73 (CBT) 0.51 CBT = AC
AC (10) assault; (Total Score) 0.88 (AC) CBT = AC (5.5 months) 0.53 (AC) (2 months);
Posttest PSS-I 0.82 (CBT) 0.38 CBT > AC (5.5 months)
(2 months); (Avoidance) 0.82 (AC)
5.5 months PSS-I 0.85 (CBT) 0.15
(Arousal) 0.85 (AC)
PSS-I 0.88 (CBT) 0.43 CBT > AC (2 months);
(Reliving) 0.75 (AC) CBT > AC (5.5 months)
Foa et al. (2006) CBT (31); Pretest; PSS-I 0.80 (CBT) 0.04 CBT = AC; BDI 0.50 (CBT) 0.11 CBT = AC;
AC (31); Posttest; 0.85 (AC) (AC - CBT) CBT = SC 0.63 (AC) (AC - CBT) CBT = SC
SC (29) 2 months; 0.83 (SC) 0.02 0.46 (SC) 0.14
3 months; (AC - SC) (AC - SC)
6 months; PSS-SR 0.76 (CBT) 0.02 CBT = AC; BAI 0.67 (CBT) 0.07
9 months; 0.76 (AC) (AC - CBT) CBT = SC except CBT > SC 0.58 (AC) (AC - CBT)
12 months 0.63 (SC) 0.07 PTSD severity 0.42 (SC) 0.16
(AC - SC) (AC - SC)
Marchand et al. (2006) PD (33); Pretest; IES 0.48 (PD) 0.21 PD = AC – – – –
AC (42) 30–40 days 0.45 (AC)
posttest;
90–110 days
(continued on next page)
Aggression and Violent Behavior 46 (2019) 15–24
 Table 2 (continued)

Study Study groups Assessment Primary outcomes Secondary outcomes

S. Guay et al.

(n) times
Measures Within group Between group Summary of findings Measures Within group ES Between Summary of findings
ES ES group ES

Miller et al. (2015) Video group Pretest; PSS-SR 0.10 0.35 (No Video > Standard (2 weeks); STAI 0.44 N/A Video > Standard (2 weeks,
(79), 2 weeks posttest; (Video, no history of Video = Standard (2 months), (State) (Video, no prior 2 months), regardless of rape
Standard care 2 months prior rape) rape) no history of rape rape) history
(85) 0.22 0.62
(Video, prior (Video, prior
rape) rape)
0.38 0.48
(Standard, no (Standard, no
prior rape) prior rape)
0.20 0.20
(Standard, (Standard, prior
prior rape) rape)
Nixon (2012) CPT (17) Pretest; PDS 0.77 (CPT, 0.32 (posttest) CPT > SC (posttest, 6 months) BDI 0.61 (CPT, 0.22 CPT > SC (posttest, 6 months)
SC (13) Posttest; posttest) N/A posttest) (posttest)
6 months 0.75 (CPT, (6 months) 0.49 (CPT, N/A
6 months) 6 months) (6 months)
0.59 (SC, 0.47 (SC,
posttest) posttest)
N/A (SC, N/A (SC,
6 months) 6 months)
Resnick et al. (2007) Video group Pretest; PSS-SR N/A 0.07 (History Video > Standard (6 weeks); BDI N/A 0.27 (History Video > Standard (6 weeks,
(68); 6 weeks posttest; of rape) Video = Standard (6 months) of rape) 6 months)
Standard care 6 months BAI 0.38 (Video) 0.10 (History Video > Standard (6 weeks);

20
(72) 0.30 (Standard), of rape) Video = Standard (6 months)
History of rape
Richards (2001) CISD (225); Pretest; IES 0.66 (CISD) 0.15 N/A GHQ-28 0.48 (CISD) 0.07 CISD = CISM
CISM (299) 1 month; (Intrusion) 0.67 (CISM) 0.45 (CISM)
3 months; IES 0.54 (CISD) 0.13 N/A
6 months; (Avoidance) 0.58 (CISM)
12 months IES 0.65 (CISD) 0.15 CIDS < CISM
(Total) 0.67 (CISM)
PSS-SR 0.53 (CISD) 0.12 CIDS < CISM
0.51 (CISM)
Rose et al. (1999) Education (E) Pretest; PSS-SR 0.11 (PD + E) 0.09 (E – AC) PD + E = E = AC BDI N/A 0.18 (E – AC) PD + E = E = AC
(52); 6 months; 0.19 (E) 0.03 (PD + E – 0.07 (PD + E
PD + E (54); 11 months 0.10 (AC) AC) – AC)
AC (51) IES 0.23 (PD + E) 0.17 (E - AC)
0.19 (E) 0.09 (PD + E –
0.12 (AC) AC)
Rothbaum et al. (2012) Exposure (47); Pretest; PSS-I N/A 0.33 (Post) Exposure > AC (Post, – – – –
AC (37) Posttest (Sexual) 0.25 3 months)
(1 month); (3 months)
3 months PSS-I N/A 0.07 (Post) Exposure = AC (Post,
(Physical) 0.05 3 months)
(3 months)

Note. ES = effect size, presented as an r-value; CBT = cognitive behavioral therapy; AC = assessment condition; SC = supportive counselling; CPT = cognitive processing therapy; PMR = progressive muscular re-
laxation; CISD = critical incident stress debriefing; CISM = critical incident stress management; PSS-I = posttraumatic stress disorder scale – interview; PSS-SR = posttraumatic stress disorder scale – self-report;
PDS = posttraumatic stress diagnostic scale; SSPSDS = scale of severity of posttraumatic stress disorder symptoms; IES = impact of events scale; BDI = Beck depression inventory; BAI = Beck anxiety inventory;
STAI = state-trait anxiety inventory; MFS = Modified Fear Survey; HADS = hospital anxiety and depression scale; EPI = Eysenck personality inventory; BSAS = Beck sociotropy-autonomy scale; GHQ = general health
questionnaire; < less effective than; > more effective than; = as effective.
Aggression and Violent Behavior 46 (2019) 15–24
S. Guay et al.
study indicated that, at post-treatment, CBT was associated with sig-
nificantly more improvement on posttraumatic and depression symp-
tomatology than an assessment condition (Foa et al., 1995). At the 5.5-
month follow-up assessment, however, these differences persisted only
for the ‘reexperiencing’ symptoms. The second study (Foa et al., 2006)
compared CBT to supportive counselling (in this case, active listening)
as well as an assessment condition up to 12 months following the in-
terventions. No significant differences were found between CBT and the
other conditions on the majority of primary and secondary outcomes at
most follow-up assessments. The only exception was for self-reported
PTSD severity immediately following the intervention, with partici-
pants in the CBT condition showing significantly greater improvement.
The study conducted by Nixon (2012) compared the efficacy of cogni-
tive processing therapy (CPT) to supportive counselling at post-treat-
ment and at a 6-month follow-up. CPT protocol consisted of six weekly
sessions of 90 min including psychoeducation, cognitive restructuring,
imaginal exposure, and relapse prevention. Supportive counselling
consisted of psychoeducation, monitoring thoughts and emotions in a
diary, problem-solving skills, discussion of current life stressors, and
nondirective support. As the same therapists were involved in both
conditions, they were not blind to treatment assignment. The results
indicated that both interventions were successful in reducing PTSD and
depressive symptoms as well as negative cognitions at post-treatment
and follow-up with no statistical difference between the two. However,
within and between-group effect sizes and the proportion of partici-
pants not meeting PTSD criteria favoured CPT over supportive coun-
selling for all measures. For intent-to-treat analyses, CPT showed a
greater reduction in PTSD symptoms (i.e., d = 2.55 and 2.26) as well as
in depression symptoms (i.e., d = 1.48 and 1.12) from baseline to post-
test and at a 6-month follow-up compared to supportive counselling
(i.e., d = 1.41 and 1.43 for PTSD and 0.71 for depression).
The last study conducted among victims of physical and sexual as-
sault (Rothbaum et al., 2012) compared CBT exposure strategies to an
assessment condition at posttreatment (i.e., one month) and at a 3-
month follow-up in the emergency department. The exposure inter-
vention consisted of three weekly 60-minute sessions of psychoeduca-
tion, self-care activities and modified prolonged exposure including
imaginal and in vivo exposure and exposure homework exercises. Re-
sults indicated that exposure strategies produced a greater reduction of
posttraumatic symptoms compared to the assessment condition at
posttreatment and at the 3-month follow-up, but only for victims of
sexual assault. No difference was found for victims of physical assault.
Next, one study exclusively examined victims of sexual assault
(Echeburua et al., 1996). The CBT protocol consisted of five sessions
and included: (1) an explanation of the normal reactions to sexual as-
sault and the process of acquisition and maintenance of fears, (2)
modification of negative thoughts associated with rape, (3) strategies
such as progressive muscular relaxation, thought-stopping, cognitive
distractions, and gradual exposure. The CBT results were compared to
those of a progressive muscular relaxation (PMR) group. Both treat-
ments were carried out by the same clinical psychologist who was
therefore not blind to treatment assignment. Notably, the CBT group
displayed posttraumatic symptoms of lesser severity than the PMR
group at the 12-month follow-up assessment. However, no statistically
significant differences were found regarding secondary outcomes (i.e.,
depression, anxiety, social functioning).
Finally, one study exclusively examined victims of physical assault
(Andre et al., 1997). One hundred and thirty-two bus drivers who had
been physically attacked were randomly assigned to one of two groups:
the standard care group, which consisted of the usual medical-social
care offered by the bus company, and the treatment group, which in-
cluded the same medical-social care in addition to one to six CBT ses-
sions with a psychiatrist. Four CBT strategies were utilized according to
the needs and capacities of the participant: imaginal exposure, sys-
tematic desensitization, social skills training, and cognitive re-
structuring. Results revealed that, for the primary outcome of PTSD
21
Aggression and Violent Behavior 46 (2019) 15–24
symptom severity, only intrusion symptoms were significantly more
reduced in the CBT condition than in the control group. In terms of
secondary outcomes, the authors noted a greater reduction of anxiety
symptoms in the CBT group, while participants in the control group
demonstrated greater improvement on neuroticism and sociotropy
scores.
Overall, these studies suggest a relative advantage of CBT over other
conditions. On primary posttraumatic outcomes, the examination of
between-group ES available in five of the six studies revealed that,
compared to the control groups, CBT components had a medium to
large effect in four studies (Echeburua et al., 1996; Foa et al., 1995;
Nixon, 2012; Rothbaum et al., 2012) and a small effect in one study
(Foa et al., 2006). However, it should be noted that sample sizes were
relatively small when large effects were found. Regarding secondary
outcomes, a large effect was found for depression symptoms in two
studies at post-test (Foa et al., 1995; Nixon, 2012). Lesser effects on
most of the secondary outcomes were found in two other studies
(Echeburua et al., 1996; Foa et al., 2006). The calculation of ES was not
possible for the study by Andre et al. (1997) due to the absence of
standard deviations in the reported results. Results pertaining to ES are
presented in Table 2.
5.2. Efficacy of psychological debriefing (PD)
Four studies evaluated the efficacy of PD with VVC (Campfield &
Hills, 2001; Marchand et al., 2006; Richards, 2001; Rose et al., 1999;
see Table 1). The Critical Incident Stress Debriefing (CISD: Mitchell,
1983) protocol or an adapted form of this debriefing procedure was
used in all four studies.
Two randomized controlled trials assessing the efficacy of PD in
comparison to control groups revealed no significant differences be-
tween study conditions (Marchand et al., 2006; Rose et al., 1999). In-
deed, Rose et al. (1999), who compared psychoeducation, psychoedu-
cation coupled with PD, and an assessment condition within a sample of
victims of physical and sexual assault, found no significant differences
between the PD group and the two other conditions with regards to the
improvement of posttraumatic and depression symptoms. Similarly,
Marchand et al. (2006) concluded that PD did not impart greater re-
duction of posttraumatic symptoms in comparison to an assessment
condition among victims of armed robbery. A third randomized con-
trolled trial (Campfield & Hills, 2001) investigated the importance of
the timing of PD by comparing immediate (< 10 h) and delayed
(> 48 h) CISD. Results indicated that PD reduced the number and se-
verity of posttraumatic symptoms more effectively in the group that
received immediate intervention.
As part of a quasi-experimental cohort study, Richards (2001)
compared CISD to Critical Incident Stress Management (CISM), an in-
tegrated program including pre-trauma training, CISD, and individual
follow-up. Participants were victims of armed robberies working in a
major financial services company in the UK. In the CISM condition, pre-
trauma training was conducted in groups with all employees working in
customer facing environments. Staff was shown videos of real and en-
acted robberies along with procedural instructions and anxiety man-
agement coping strategies. CISD within the CISM condition was iden-
tical to that delivered in the CISD-only group, consisting of a structured
group meeting with all employees working in a raided branch and
closely following Mitchell's model. Employees in the CISM group also
received an individual follow-up session one month after the robbery,
structured around a cognitive-behavioral/ problem-focused model of
intervention. Richards (2001) found CISM to be superior to CISD on
certain measures of posttraumatic symptoms, although the two groups
improved equally on the secondary outcome of general mental health.
Overall, studies among VVC conclude that PD does not significantly
differ from comparison or control groups on both primary and sec-
ondary outcomes. CISM may be superior to CISD and immediate in-
tervention may be more effective than delayed PD, but more research is
S. Guay et al.
needed to confirm these results.
5.3. Other intervention
The last two studies meeting the selection criteria investigated an-
other form of intervention. First, Resnick et al. (2007) evaluated the
effect of a video intended to decrease PTSD and other mental health
problems among victims of sexual assault. The 17-minute video was
presented prior to a forensic medical examination conducted within
72 h post-assault and included a description of the examination, psy-
choeducation on possible reactions to rape, and information on how to
avoid high-risk cues (instructions for self-directed graded in vivo ex-
posure exercises, method to recognize and terminate inappropriate
avoidance, and strategies to improve mood by increasing and/or
maintaining positive activities). Victims who watched the video were
compared to victims who received standard services, which involved a
forensic examination performed by a nurse and a physician trained in
post-rape medical examinations. A rape crisis counsellor was also
available during the examination. The authors hypothesized that prior
rape would be a moderator of the impact of the intervention. Indeed, at
the 6-week assessment, the results revealed that, among women who
had been previously raped, the video intervention was associated with
lower scores on PTSD measures and depressive symptoms than the
standard services condition. At 6 months, depression scores were also
lower among victims with prior rape history in the video condition.
However, among women without a prior history of rape, PTSD and
general anxiety symptoms were more frequent at the 6-week assess-
ment in the video condition than in the standard services condition.
However, these negative effects were small in magnitude and were only
observed at the shorter-term assessment. For depression symptoms, no
significant differences were observed. In contrast, Miller, Cranston,
Davis, Newman, and Resnick (2015), who presented a 9-minute version
of the video (i.e., including only the psychoeducation component) to
female rape survivors, found that women without a prior history of rape
who saw the video displayed greater posttraumatic symptom reduction
in comparison to the control group after 2 weeks, although no such
effect was found for those with a prior rape history. No effect was un-
covered at the 2-month assessment.
5.4. Calculation of the standardized mean effect size per type of
intervention
The standardized mean ES for PTSD symptom reduction was cal-
culated for the two main types of early intervention (i.e., CBT and PD)
and for the main control condition (i.e., assessment condition). As
shown in Table 3, two main patterns emerge from these parametric
estimations. First, PTSD symptom reduction at post-treatment and at
follow-up is very similar. Second, PTSD symptom reduction for the
assessment condition and the PD condition is quite similar while that of
CBT stands out as superior. The confidence intervals of the differences
confirm that the symptom reduction following CBT is statistically larger
than that of PD. These results suggest a superiority of CBT over PD in
Table 3
Standardized mean effect sizes (change scores) for PTSD symptom reduction following an early intervention using random-effect meta-analyses and fail-safe N
statistics.
Intervention Post-treatment (d) N Fail-safe N
(95% CI)
CBT 2.23 (1.80, 2.66) 5 182
PD 0.88 (0.55, 1.20) 7 972
AC 1.23 (0.41, 2.06) 6 149
CBT – PD 1.35 (0.81, 1.89)
CBT - AC 1.00 (0.40, 1.60)
PD - AC −0.35 (−0.88, 0.18)
Note. CBT = cognitive behavioral therapy; PD = psychological debriefing; AC = assessment condition; CI = confidence interval.
22
Aggression and Violent Behavior 46 (2019) 15–24
the context of early intervention for VVC.
6. Discussion
The goal of the present study was to systematically review published
studies examining the efficacy of early psychotherapeutic interventions
for VVC. Overall, our review found modest and inconsistent effects in
terms of the reduction of posttraumatic and related symptoms. CBT and
CPT appeared to be the most promising interventions when compared
to an assessment condition or a progressive relaxation group, but were
relatively equivalent to supportive counselling. No proof of efficacy was
found for PD when compared to other interventions or a control group,
although delayed PD and CISM appeared to be superior to early PD and
CISD, respectively. A psychoeducational video for rape victims ap-
peared to help a subgroup of participants, although results were
somewhat contradictory.
The calculation of the standardized mean ES per type of interven-
tion suggests a superiority of CBT over PD in a context of early inter-
vention for VVC. This finding is in line with reviews on early inter-
ventions for other types of trauma among adult populations (Bisson,
2003a, 2003b; Bryant, 2007; Ehlers & Clark, 2003; Forneris et al., 2013;
Kornør et al., 2008; Rose et al., 1999; Rose, Bisson, & Wessely, 2003;
van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). Generally,
these reviews conclude that (1) PD is not effective for preventing PTSD
and may even be harmful for some victims, and (2) early and brief CBT
interventions are promising. For example, Rose et al. (2003) found that
PD might increase the risk of PTSD and depression, with no evidence
supporting the provision of PD for trauma victims. As for CBT, an article
reviewing studies on rape treatment outcomes, including early and late
treatment studies, highlighted that CBT and prolonged exposure were
the most empirically supported strategies, although an important pro-
portion of victims (11% to 47%) still had a PTSD diagnosis after
treatment (Vickerman & Margolin, 2009). Early and brief cognitive-
behavioral intervention has also been shown to be effective with motor
vehicle accident victims (Bryant et al., 2008; Sijbrandij et al., 2007) and
promising with mixed trauma samples (Forneris et al., 2013; Sijbrandij
et al., 2007). This suggests that it may be useful to pursue the devel-
opment and enhancement of early CBT for VVC.
Many factors may potentially contribute to the mitigated results
regarding the efficacy of early interventions for VVC. First, as pre-
viously mentioned, VVC present with a distinctive profile: they report
more intense psychological reactions and more aggravated social mal-
adjustment than victims of other types of traumatic events (Shepherd,
Qureshi, Preston, & Levers, 1990; Zinzow & Jackson, 2009). Studies
have also suggested that survivors of interpersonal violence exhibit the
highest levels of global attributions and post-traumatic stress symptoms
(Zinzow & Jackson, 2009), with the association between sexual assault
and post-traumatic stress being especially strong and consistent across
the literature (Dworkin, Menon, Bystrynski, & Allen, 2017). Since
greater symptom severity is a well-known predictor of poorer treatment
outcomes (Karatzias et al., 2007), VVC may be at a disadvantage.
Second, motivation to participate in a treatment study and commitment
Follow-up (d) N Fail-safe N
(95% CI)
2.40 (1.84, 2.96) 5 172
1.01 (0.61, 1.40) 7 889
1.55 (0.47, 2.64) 6 169
1.39 (0.70, 2.08)
0.85 (−0.37, 2.07)
−0.54 (−1.69, 0.61)
S. Guay et al.
to the treatment procedures are two important factors to consider, as
studies have reported higher proportions of drop-outs and non-re-
sponders among assault victims (Scholes, Turpin, & Mason, 2007). The
greater reluctance of VVC to seek and to remain in treatment may be
partly explained by the reactions of their social network following
victimization. While some studies indicate that VVC generally report
being well supported by family or friends (Elklit, 2002), others suggest
a drop in overall satisfaction regarding social support (Elklit & Brink,
2004). Sexual assault survivors appear especially vulnerable to negative
reactions from their social network, such as stigmatization and victim
blaming (O'Hara, 2012; Ullman, 2010), which could prolong the ex-
perience of trauma and bring about secondary victimization (Dworkin
& Schumacher, 2016). Yet, the presence of both psychological and so-
cial resources appears to facilitate the use of mental health services
(Billette, Guay, & Marchand, 2008; Norris, Kaniasty, & Scheer, 1990).
6.1. Applicability of the findings
Clinicians and researchers should interpret the present fındings
cautiously, given the limited number of studies that met review criteria.
The parametric estimations presented in this paper should be regarded
as mainly descriptive and inferences should be drawn with caution.
Nevertheless, these likely represent the best estimates that can be
drawn from the current literature (see Table 3 for fail-safe N estimates;
Rosenthal, 1979).
Confounding variables may have influenced the reported efficacy of
interventions. For example, differences in follow-up periods and dura-
tion of treatment may have potentially affected the results. However, no
statistically significant difference was found for the weighted average
time to follow-up, which varied between 3 and 6 months. In contrast,
the weighted average number of hours of intervention was statistically
different between the conditions. On average, CBT lasted a total of 6 h,
PD 1.6 h and the assessment condition 5.75 h, when the information
was available. Thus, it is possible that the longer duration of treatment
bolstered the impact of CBT. Finally, it is noteworthy that the instru-
ments used to assess posttraumatic symptoms varied between studies
(e.g., PTSD Symptom Scale, Impact of Events Scale, Posttraumatic
Stress Diagnostic Scale), which may have influenced the results.
Finally, there were important methodological differences between
the studies. Three out of twelve did not use a control group (Campfield
& Hills, 2001; Echeburua et al., 1996; Richards, 2001) and participants
had to have an ASD or PTSD diagnosis in some of the studies (mainly in
those evaluating CBT interventions) while others did not have this re-
quirement. In addition, a number of included studies utilized the IES as
the main measure of post-traumatic reactions (Andre et al., 1997;
Marchand et al., 2006; Richards, 2001; Rose et al., 1999). Although this
measure is widely used in research on PTSD and contains two subscales
measuring intrusion and avoidance in reaction to a specific incident, it
does not assess all PTSD criteria. Finally, there appeared to be an over-
representation of women. Indeed, a female proportion over 88% was
found in six out of the twelve studies, mainly because the samples
consisted of rape victims, which is statistically more frequent for
women.
6.2. Limitations
The conclusions of this systematic review should be interpreted in
light of certain limitations. First, a limited number of studies were in-
cluded, pointing to the need for more recent research. Second, although
interventions were generally offered early after the event, the delay
varied between a few hours and 3 months. Comparisons between these
interventions should therefore be made with caution. Third, none of the
studies reported sex or gender comparisons, although there may be
differences in adaptation following a criminal event (Green & Diaz,
2008). It was also not possible to determine whether some studies in-
cluded victims of intimate partner violence, which may differentially
23
Aggression and Violent Behavior 46 (2019) 15–24
affect symptoms and recovery depending on gender (Carbone-López,
Kruttschnitt, & MacMillan, 2006; Williams & Frieze, 2005). Fourth,
psychosocial outcomes varied from one study to another, but more
often than not, the range of measures was narrow in scope. Only five
out of the twelve studies examined other psychological outcomes such
as depression and anxiety in addition to assessing PTSD symptoms.
Moreover, only two studies investigated individual functioning fol-
lowing the event (e.g., work, social life, family relationships, leisure
activities, household, etc.), while only one assessed personality factors.
Fifth, although including formal tests for moderators would have been
ideal, these analyses would not have been sufficiently reliable given the
limited and heterogeneous data at hand. Finally, only four studies ex-
amined intent-to-treat data.
6.3. Conclusions
Developing and evaluating early interventions for VVC is an im-
portant clinical challenge because of the psychosocial impact of vio-
lence and the frequent reluctance of VVC to seek help. Although judicial
procedures and contact with formal responders may influence the
psychological adaptation of victims and their ability to be involved in a
therapeutic process, the impact of these events has been understudied
and is not considered in early intervention programs. Future studies
should therefore assess for the influence of judicial procedures and
other formal contacts (e.g., with the police, rape crisis centers, emer-
gency medical services) on the recovery of VVC. Furthermore, as social
support is considered to be a moderator for the onset of PTSD, future
studies should take this variable into account in the evaluation of early
interventions. Moreover, potential sex and gender differences should be
examined. Finally, in addition to the severity of symptoms (e.g., PTSD,
anxiety, depression), other important variables regarding the effec-
tiveness of interventions, such as quality of life, sleep, wellbeing, and
social functioning, should be considered.
Acknowledgement
The writing of this paper was supported by a salary grant from the
Fonds de la recherche en Santé du Québec, Canada (#10201) and by a
grant from the Canadian Institutes of Health Research (CIHR; #MOP-
87391).
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