Psychology

Problem Background
In our time, the world has witnessed numerous human rights violations and the most scandalous is violence against women. This is primarily caused by discrimination which denies women of equal opportunities with men in all aspects of life. General Recommendation 19 issued by the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) made it very clear that violence is a form of discrimination (Dauer, 2006).

Indigenous women in the US are the most represented victims of brutal sexual violence. The likelihood that Native American or Alaska Native women are raped or sexually assaulted is more than twice that of any other women in the US. Interviews by Amnesty International (2008) are testaments on the ubiquity of sexual violence among Native Americans. Although rape is in itself an act of violence, evidence suggests that indigenous women sustain additional violence in the hands of their perpetrators, mostly non-Native. Logistic regression analysis by Yuan et al. (2006) revealed that history of childhood maltreatment, alcohol dependence, and marital status were significant predictors of sexual abuse among Native American women.

Sexual violence against Native American women can be traced back in history at the infamous Trail of Tears and the Long Walk. Rape is said to be a very powerful tool of conquest and intimidation (Weaver, 2009). Most of societys discriminatory attitudes towards Native American are still existent in present-day American society and culture which have increased the rates of violence against them and helped protect attackers from due process of law. There are in existence treaties, the US Constitution and federal law that establish the political and legal framework between tribal nations that are federally recognized numbering to more than 550 and the federal government. These Indian tribes that have achieved federal recognition are autonomous under US law therefore they can exercise jurisdiction over their citizens and land and maintain intergovernmental ties with each other and the US government.  It is the mandate of the federal government to exercise legal means to protect the rights and well-being of Native American peoples (Amnesty International, 2008).

Mostly investigators consider these racist incidents as stressors resulting in psychophysiological disease while only a few conceptualize these as forms of trauma.  In 2002, Walters and Simoni (as cited in Bryant-Davis  Ocampo, 2005) pointed out that racism  is unresolved trauma among Native American women which leads to post-traumatic stress disorder and depression. Carter, Lo, Milliora, Sanchez-Hucles, Villena-Mata, and Wyatt also adopted this paradigm.  This clinical construct can potentially be utilized in treating disorders that have adversely affect victims of these abuses. Therefore it is necessary to assess the level of severity of the incident first when investigating the traumatizing impact of these experiences. Lo et al. (2001) and Woodard (2001) as cited in Bryant-Davis and Ocampo (2005) identified racism as a significant predictor of PTSD in other racial backgrounds particularly Asian and African Americans. 

Survivors experiencing PTSD manifest these symptoms intense fear, helplessness, or horror re-experiencing the traumatic incident avoidance or numbing and increased arousal after a traumatic event. In contrast to non-traumatic stress, traumatic stress requires restructuring because the individual is constantly haunted by fear and experiences destabilization (McFarlane  Girolama, 1996 as cited in Bryant-Davis  Ocampo, 2005). Heckman, Cropsey and Olds-Davis (2007) cited that while there are no empirically well-established PTSD treatments, there are probably efficacious treatments which include exposure treatment, stress inoculation training, eye movement desensitization retraining (EMDR), stress management, and pharmacological treatments with antidepressants.

There are two salient parameters psychologists should consider when treating PTSD- anger and guilt for several reasons. Pretreatment anger has been shown to be associated with poor outcome based on studies by Foa et al. (1995), Taylor et al. (2001) Cahill et al. (2003), Taylor (2003), van Minnen, Arntz, and Keijsers (2002) (as cited in Stapleton, Taylor,  Asmundson, 2006). Likewise Pitman et al. (as cited in Stapleton, Taylor,  Asmundson, 2006) found that anger or guilt elevated during the course of prolonged exposure therapy. Moreover, no difference in general symptom reduction was detected among various PTSD treatments (Taylor, 2004 van Etten  Taylor, 1998 as cited in Stapleton, Taylor,  Asmundson, 2006) when compared to EMDR or selective serotonin reuptake inhibitors. However, these three treatments were better than supportive therapy, benzodiazepines, tricyclic antidepressants, and hypnosis.

Presently there is limited literature on the application of certain PTSD therapies on Native American rape survivors so that case management will be clearly understood. Therefore this justifies the proposed study. 

Purpose of the study
This proposed study will determine the effectiveness of PTSD treatments on selected samples. In studying the effectiveness of selected PTSD treatments on trait- and trauma-related anger and guilt, the research will investigate whether or not the effect of the interventions differed from pre-treatment severity of anger or guilt.

Research Questions
The study is designed to ascertain the effectiveness of PTSD treatments. In order to do this, the following will be the specific objectives

What is the psychosocial profile of the survivors in terms of age, civil status, highest educational attainment, employment, and history of violence

2. What are the pre- and post-treatment trait- and trauma-related anger and guilt among the rape survivors

3. Is there a significant difference in both trait and trauma-related anger and guilt after undergoing PTSD treatments

Hypothesis
The null hypothesis will be tested at alpha of 0.05 posits that there is no significant difference in the levels of trait- and trauma-related anger and guilt of Native American rape survivors before and after the interventions.

Rationale and significance of the study
It is hoped that this study will contribute in generating data on the subject of PTSD among Native American rape survivors and possible treatments that could be recommended. Moreover, the findings, if well disseminated, will be helpful in policy formulation which is aimed at improving the victims well-being and recovery. Furthermore it has important implications in theory and practice for researchers and practitioners in psychology and counseling. 

Limitations
Participants for this study will be Native American women who can voluntarily report their rape experience. These subjects may not be representative of all recorded rape cases involving Native American women. Due to stigma, lack of awareness, or nature of the crime, many cases are unreported. In truth, the difficulty the researcher is anticipating is uncertainty on the survivors ability to describe and label what is happening to her. Even if they can describe the experience to themselves, their willingness to accept what is happening differs from each other. With this, the researcher will ask the aid of therapists to make the survivors feel at ease. The demographic factors to be described will include age, civil status, highest educational attainment, employment, and history of violence. The independent variable will be the treatments namely prolonged exposure, eye movement sensitization, and relaxation training. The dependent variable will be trait- and trauma-related anger and guilt.

II. Literature Review
Theoretical Framework
The Cognitive-Behavioral Theory will be the theoretical basis of this study. The theory implies that cognition has an important role in modifying behavior. Specifically, cognitions or thought processes impact behaviors thus having negative thoughts or beliefs would be difficult in creating a positive behavioral change. Interventions patterned after this theory combine both cognitive and behavioral approaches in solving a variety of behavioral and psychological problems.  Through education and enforcement of positive experiences, the clients irrationality will be changed dramatically enabling the person to actively cope. Thus, by altering or shifting the way of thinking of clients, they are able to more clearly think about their choices as well as their behaviors. Another significant theory is the emotional processing theory proposed by Foa and Kozak (1986). According to this theory, encounter of pathological fear structures evokes feelings of trepidation. These fear structures are harmless stimuli associated with the conceptualization that the world is a dangerous and inhospitable place. Treatment is successful when these fear structures become emotionally processed in such a way that exposure to stimuli will not elicit fear.

Anger and guilt in rape victims
Taylor (2006) mentioned two types of beliefs that are associated with anger. The first points out that the survivor is wronged by others. Survivors might be heard saying They had no right to do this to me or Others should be punished for what theyve done. These are associated with or predict severity of experienced PTSD symptoms. The second however are referred to as metacognitions which by definition are beliefs about the value of dwelling on angry thoughts. These enable survivors to understand, prepare for, and cope with distressful and threatening instances and justify aggression towards their attackers (Others are not likely to take advantage of me if I have been dwelling on my angry thoughts, Dwelling on what happened prevents me from blaming myself). There are occasions when survivors entertain negative metacognitive beliefs which are concerned with the detrimental emotional impact of anger on the overall functioning of the individual socially and occupationally (My anger builds up, last longer, and gets me into trouble when I dwell on my angry thoughts).

Steyn (2005) maintained that guilt and shame are closely associated to each other in response to sexual abuse and trauma. When a victim has self-guilt, there is the tendency for the individual to feel responsible for the event accompanied by embarrassment or disgrace. However these feelings are not only limited to sexually abused victims to be trauma survivors in general.  It should be emphasized that guilt is the attempt of the survivor to learn valuable life lessons from and establish a sense of power and control over oneself. Self-blame has been considered as an influential factor on how the victim may respond to her being sexually abused. Both guilt and self-blame are closely linked because behind the guilt is blaming oneself for experiencing the trauma. The response of the victim after the rape depends on self-blame and is noted to greatly affect the victim psychologically. Meyer and Taylor (as cited in Steyn, 2005) also found that self-blame is associated with adjustment and depression after rape and increased anxiety, hostility, and greater confusion of core beliefs about ones existence and the world.
Use of prolonged exposure, eye movement sensitization, and relaxation training

In exposure therapy, the rape survivor is subjected to imaginal exposure which allows her to revisit the traumatic event in a safe environment. In practice, the therapist guides and encourages the client in imagining, narrating, and emotionally processing the traumatic experience within the safe and supportive confines of the clinicians office. It has a low threat to the client and de-conditions the disorder through the habituationextinction process (Rizzo et al. 2009).

EMDR is a PTSD treatment method utilizing exposure and cognitive restructuring in a relatively short time without having to subject patients to prolonged anxiety and with the aid of the therapist the patient makes saccadic bilateral eye movements. The action of EMDR could be attributed to the conditioning process brought about by the accelerating function of the eye movements and the activation of a neurobiological substrate modulating the emotional responses, thereby leading to homeostasis (Well Care Health Plans Inc, 2008).

Klein (2007) mentioned that relaxation techniques are helpful in treating DSM-IV diagnosis most particularly trauma, depression, and anxiety. In the treatment session, patients are provided tools which do not only sooth themselves but also help develop healing positive self-talk statements.

Hogberg et al. (2007) observed that EMDR has a short-term effect on PTSD based on the Global Assessment of Function (GAF) and Hamilton Depression (HAM-D) scores. Then in 2008, the same authors found that the symptom-reduction effects of EMDR on 20 subjects presenting chronic PTSD remained stable 35 months after the therapy. In their study, the participants underwent five sessions of EMDR.

Rothbaum, Astin and Marsteller  (2005) noted improvement in PTSD especially among the PE and EMDR groups compared to the control group. However, no significant difference in depression, dissociation, and state anxiety were found in PE and EMDR from baseline to either post treatment or 6-month follow-up.

Stapleton, Taylor and Asmundon (2006) investigated anger and guilt before and after prolonged exposure, eye movement sensitization and reprocessing and relaxation training.  The study also showed that the treatments had significantly reduced anger and guilt, even among patients who had high levels of these emotions.

III. Methodology
Research Design
The proposed study will use a pre-test post-test experimental design because the purpose is to compare groups resulting from experimental treatments which in the context of this study are the cognitive-behavioral strategies in treating PTSD among Native American rape survivors.

Participants and Sampling
Participants will be Native American rape survivors who experienced most severe PTSD based on physician referrals. Only those that presented severe PTSD using the DSM-IV diagnosis, more than 18 years of age, signed the written informed consent, and willing to suspend any psychological treatment and keep doses of any psychotropic medication constant throughout the duration of the study. Rape survivors with mental retardation or psychotic disorder and has changed medication within the last three months will be excluded.  Respondents will be assigned randomly to each of the treatments in the study.

Measures 
The respondents will be asked to fill out information regarding trait- and trauma-related anger and guilt aside from the psychosocial profile based on age, civil status, highest educational attainment, employment, and history of violence. To measure trait anger, the State Trait Anger Expression Inventory will be used. It has 44 items and divided into five subscales namely state anger, trait anger, anger-in, anger-out, and anger control. The statements will be rated using a four-point frequency scale (0-almost never to 3-almost always).  Trait guilt levels of rape survivors will be assessed using the Guilt Inventory. This tool is a 45-item self-report indicative of state guilt, trait guilt, and moral standards where subjects will be asked to respond using a five-point Likert scale from strongly disagree (1) to strongly agree (5). For both trauma-related anger and guilt, evaluation was made by an item that asked the frequency of anger and guilt for the past week. The item will be rated on a four-point frequency scale from 0 (not at all) to 3 (almost always).

Procedure
Before conduct of study is commenced, permission will first be obtained from Institutional Review Board (IRB) of the University. Permission will also be secured from the Dean of the Graduate School after Oral Examination. Afterwards, another letter will be sent to the president of a local organization of Native Americans or local clinics stating the intent of the researcher to seek their participation and coordination. 

Prospective participants referred to by local organizations and physicians will be invited for screening for the inclusionexclusion criteria. Those who passed will be asked to carefully read the written informed consent before baseline evaluation. The researcher will then randomize assign the subjects to any of the following interventions prolonged exposure, eye movement sensitization, or relaxation training. There will also be a control group. The structured questionnaires will be administered during the pre-treatment, post-treatment (one month after end of intervention), and follow-up (three months after the post-treatment). Several ethical considerations will be taken into account. The answers to the structured questionnaires will be kept confidential and PTSD records will only examined by the researcher. Furthermore, permission to use information will be requested and secured prior to data analysis. Lastly, no monetary incentives will be offered to participate in the study.

Data Analysis
After questionnaire administration, tabulation and data analysis will follow. The first problem will be addressed by computing for frequency and percentage. Means and standard deviations in anger and guilt in the pre-treatment, post-treatment, and follow-up periods will be obtained to answer the second problem. Statistical inferences will be based on the results of the t-test for Dependent Sample Means at 5 level of significance. Comparison will be between pre- and post-treatment and pre- and follow up phases of the study. 

Internal Validity
It is expected that this study will test the null hypothesis that no significant difference exists in the anger and guilt of the Native American rape survivors before and after treatment with cognitive-behavioral strategies at 95 level of confidence. Therefore there is a high degree of certainty that the result is attributed to the treatment.

External Validity
There will be a high external validity since the participants will be randomly assigned to a treatment or intervention. Thus, there are no sampling discrepancies which will introduce error and bias into the results. The selection of respondents also guarantees the same.