family survivors of homicide victims: theoretical perspectives and an exploratory study

15
Journal of Traumatic Stress, Vol. 2, No. I, 1989 Family Survivors of Homicide Victims: Theoretical Perspectives and an Exploratory Study Angelynne Amick-McMullan, 2.3 Dean G. Kilpatrick.2 Lois J. Veroneq2 and Susan Smith2 Accepted July 29, 1988 Little empirical in formation is available on the impact of homicide on sur- viving family members. Existing descriptionsfall into a dichotomy of grief theoty and those reporting symptoms of Post-traumaticStress Disorder. This pilot study offers a multidimensionalformulation which combines symptoms reported across previous studies. Participants were 19 survivors recruited through a victim witnessprogram and a victim rights organization. A learn- ing model, Mowrer’s Two Factor Theory, was applied to explain the acqui- sition and maintenance of post-traumatic symptoms. Consistent with this model, survivors reported recurrent homicide-related intrusions and avoidance behaviors on the Horowitz Impact of Event Scale (IES). Comparison of sur- vivors’ IES scores with those of victims of rape, loss of a family member, and other trauma revealed a high frequency of symptoms. Mean length of time since homicide was 2.5 years. The Derogatis Symptom Check List 90-Revised (SCL90-R) revealed a high level of general psychiatric distress, with 66% of survivors meeting “caseness”criteria, indicating a need for treat- ment intervention. A 7-point Likert scale measure of satisfaction with the criminal justice system was highly correlated with SCL90-R subscales of depression ( r = - 0.82) and anxiety (r = - 0.82). This link between dis- tress and perceptions of thejustice system provided preliminary support for an equity theory perspective on survivor attributions. Conceptual, research, and clinical imdications were discussed. ~ ~~ KEY WORDS: homicide; PTSD; and family survivors. ‘A preliminary version of this paper was presented at the Family Violence Research Confer- ence, Durham, NH, July, 1987. *Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, 171 Ashley Avenue, Charleston, South Carolina 29425-0742. ’Veteran’s Administration Medical Center, Charleston, South Carolina. 21 OXV~-YBh7/8V/OlW-002IS~ W/O 0 IYW Plcnum Publlshins Corporallon

Upload: angelynne-amick-mcmullan

Post on 15-Jun-2016

212 views

Category:

Documents


0 download

TRANSCRIPT

Journal of Traumatic Stress, Vol. 2, No. I , 1989

Family Survivors of Homicide Victims: Theoretical Perspectives and an Exploratory Study

Angelynne Amick-McMullan, 2 . 3 Dean G . Kilpatrick.2 Lois J. Veroneq2 and Susan Smith2

Accepted July 29, 1988

Little empirical in formation is available on the impact of homicide on sur- viving family members. Existing descriptions fall into a dichotomy of grief theoty and those reporting symptoms of Post-traumatic Stress Disorder. This pilot study offers a multidimensional formulation which combines symptoms reported across previous studies. Participants were 19 survivors recruited through a victim witness program and a victim rights organization. A learn- ing model, Mowrer’s Two Factor Theory, was applied to explain the acqui- sition and maintenance of post-traumatic symptoms. Consistent with this model, survivors reported recurrent homicide-related intrusions and avoidance behaviors on the Horowitz Impact of Event Scale (IES). Comparison of sur- vivors’ IES scores with those of victims of rape, loss of a family member, and other trauma revealed a high frequency of symptoms. Mean length of time since homicide was 2.5 years. The Derogatis Symptom Check List 90-Revised (SCL90-R) revealed a high level of general psychiatric distress, with 66% of survivors meeting “caseness”criteria, indicating a need for treat- ment intervention. A 7-point Likert scale measure of satisfaction with the criminal justice system was highly correlated with SCL90-R subscales of depression (r = - 0.82) and anxiety (r = - 0.82). This link between dis- tress and perceptions of the justice system provided preliminary support for an equity theory perspective on survivor attributions. Conceptual, research, and clinical imdications were discussed.

~ ~~

KEY WORDS: homicide; PTSD; and family survivors.

‘ A preliminary version of this paper was presented at the Family Violence Research Confer- ence, Durham, NH, July, 1987.

*Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, 171 Ashley Avenue, Charleston, South Carolina 29425-0742.

’Veteran’s Administration Medical Center, Charleston, South Carolina. 21

OXV~-YBh7/8V/OlW-002IS~ W/O 0 IYW Plcnum Publlshins Corporallon

22

INTRODUCTION

Amick-McMulhn ef 171.

The burgeoning literature on the psychological impact of crime has neglected a group of profoundly traumatized victims: surviving family mem- bers of criminal homicide victims (henceforth referred to as survivors). Crimi- nal homicide is defined as "the willful (nonnegligent) killing of one human being by another" (FBI Uniform Crime Reports, 1985, p. 7) and includes the crimes of murder and nonnegligent manslaughter. Few would dispute the seriousness of homicide. A national survey asking respondents to rate the severity of 204 illegal acts found the six rated as most serious involved homicide (Rand et al., 1983). Yet, the indirect victims, those who have lost a loved one to homicide, are nearly invisible in the existing literature. We have no information concerning the number of survivors, and have only scant information about the impact of homicide on their psychological adjustment.

Experts have recently begun to acknowledge that homicide produces indirect victims who suffer considerable emotional trauma (American Psy- chological Association Task Force on Victims of Crime and Violence Report, 1984; Attorney General's Task Force on Family Violence Report, 1984; Bard et al., 1981; Frieze et ol., 1987; Getzel and Masters, 1984; Klaus et al., 1983; Masters ei ai., 1988; President's Task Force on Victims of Crime Final Report, 1982). Clinicians and criminal justice professionals are often staggered by the depth of emotional suffering experienced by survivors. In addition to the sudden violent loss of a family member, a majority of these victims also face the prospect of protracted involvement with the criminal justice system. Virtually all homicides are reported to police and involve a seemingly end- less process of investigation, prosecution, and appeals. The quality of posthomicide contacts with others has been described as critical for success- ful survivor adjustment (Bard and Connolly, 1982; Frieze et al., 1987).

This report describes an exploratory study of survivor reactions which introduces a learning theory conceptualization of post-traumatic symptom acquisition and maintenance. In addition, the relationship between adjust- ment and satisfaction with the criminal justice system is explored, and an attributional perspective is introduced to help explain this relationship. Be- fore presenting these pilot data, we will briefly review extant literature on survivors from both grief theory and Post-traumatic Stress Disorder per- spectives.

GRIEF THEORY

Early studies of the consequences of homicide for survivors relied on stage theories of grief (e.g., Bowlby, 1980; Lindenmann, 1%5; Parkes, 1972) to explain survivor reactions (Bowman, 1980; Burgess, 1975; Doyle, 1980;

Family Survivors of Homicide Victims 23

Poussaint, 1984). This perspective defined survivor reactions as progressing through a series of stages, the last of which represented resolution of the reaction. The number of stages varied across studies with Burgess (1975) describing a two-stage process and Poussaint (1984) noting three stages. These studies were methodologically limited by nonstandardized assessment and use of small, help seeking samples. However, several consistent findings emerged. The clinical presentations of survivors diverged from uncompli- cated bereavement both in the depth of horror, rage and vengefulness, and in the persistence of anxiety and phobic reactions observed. Additionally, prolonged involvement with the criminal justice system appeared to impede the adjustment process. The stress engendered by criminal justice proceed- ings was noted in Rinear’s (1984) study of grieving among members of the organization, Parents of Murdered Children.

Such early studies suggested that grief theory per se is not sufficient to comprehensively explain the range of reactions reported by survivors, although grief was certainly one aspect observed. Grief theory predicts that reaction to loss should be a problem but offers no explanation for the de- velopment of anxiety-related problems evidenced by survivors. Nor does it account for the potential impact of the criminal justice system on the sur- vivor’s adjustment process. A third limitation of the grief perspective, re- cently demonstrated in the Lehman et al. (1987) study of family survivors of motor vehicle fatality victims, is that post-traumatic sequelae often per- sist for years rather than resolving in a timely fashion as grief theory would predict.

POST-TRAUMATIC STRESS DISORDER

Bard (1 982) expanded the grief conceptualization of survivor reactions by specifically assessing symptoms of Post-traumatic Stress Disorder (PTSD; American Psychiatric Association, 1980) to which earlier studies has only alluded. As defined by Goldenson (1984), “PTSD is an anxiety disorder produced by an uncommon, extremely stressful event (e.g., assault, rape, military combat, flood, earthquake, death camp, torture, car accident, head trauma), and characterized by (a) reexperiencing the trauma in painful recollections or recurrent dreams or nightmares, (b) diminished responsive- ness (emotional anesthesia or numbing), with disinterest in significant ac- tivities and with feelings of detachment and estrangement from others, and (c) such symptoms as exaggerated startle response, disturbed sleep, difficulty in concentrating or remembering, guilt about surviving when others did not, and avoidance of activities that call the traumatic event to mind,” (p. 573). Bard’s (1 982) study provided evidence of PTSD among survivors of homi- cide, suicide, and automobile fatality victims. Confirming this work, Rynear-

24 Amick-McMullan et ul.

son (1984) noted symptoms of PTSD in 15 survivors. Evidence for PTSD was also found by Stillman (1986) who administered the Derogatis Symptom Checklist (SCL-90-R; 1977) and collected PTSD diagnostic information from 175 survivors of police killed in the line of duty.

To summarize, work in this area has progressed from an anecdotal, descriptive phase to a more empirically based stage of exploration. Previous formulations of survivor reactions have fallen into a rough dichotomy be- tween those invoking grief theory and those identifying symptoms consis- tent with PTSD. In spite of this dichotomy, however, general agreement exists across studies with respect to actual symptoms reported along cognitive, af- fective, physiological, and behavioral dimensions.

MULTIDIMENSIONAL SYMPTOM FORMULATION

Within the cognitive dimension, studies were unanimous in reporting the existance of intrusive, repetitive thoughts and/or nightmares (Bard, 1982; Burgess, 1975; Getzel and Masters, 1984; Poussaint, 1984; Rinear, 1984; Rynearson, 1984). Ruminations tended to focus on intrusive images of the murders and persistent, consuming thoughts of revenge. Consensus also emerged along the affective dimension, with survivors displaying intense, overwhelming levels of affect which were typically labeled as variations of rage, terror, numbness, and depression (Bard, 1982; Burgess, 1975; Getzel and Masters, 1984; Poussaint, 1984; Rinear, 1984; Rynearson, 1984). Studies addressing the physiological dimension also showed considerable agreement regarding survivor symptomology (Bard, 1982; Burgess, 1975; Poussaint, 1984; Rinear, 1984; Rynearson, 1984). Disturbances in sleep and appetite, increased heart rate, headaches, gastrointestinal upset, and increased startle responses were frequently noted. Finally, although the behavioral symptom dimension received only limited attention, no major discrepancies emerged between PTSD and grief studies. Behavioral changes included phobic avoidance of homicide-related stimuli and increased self-protective behavior (Burgess, 1975; Rynearson, 1984); changing roles in the family and relation- ship disruption (Burgess, 1975; Getzel and Masters, 1984; Poussaint, 1984; Rinear, 1985; Rynearson, 1984); and a tendency to try to hunt for the killer (Poussaint, 1984).

Thus, based on this multidimensional formulation of symptoms, to think of survivors as suffering from either PTSD or grief reactions is a mis- leading oversimplification. Either label, PTSD or grief, underestimates the complexity of what appears to be a fairly consistent, very debilitating pat- tern of posthomicide reactions. With empirical investigation of survivor ad- justment in its infancy, a theoretical perspective that captures the full complexity of survivor reactions has yet to be proposed.

Family Survivors of Homicide Victims 25

A LEARNING THEORY PERSPECTIVE

At this early stage in the exploration of survivor reactions, it is useful to draw from an existing model of post-traumatic responses that has been applied to both sexual assault victims (Holmes and St. Lawrence, 1983; Kil- patrick et af., 1982) and combat veterans (Keane et ul., 1985). This model is based on Mowrer’s Two Factor Learning Theory (1960) and offers partic- ular promise in explaining the acquisition and maintenance of intrusive cog- nitions, aversive emotional responses, physiological hyperarousal and phobic avoidance.

Being told of the murder of a loved one is a profoundly traumatic, threatening experience which is likely to elicit powerful unconditioned (un- learned) stress responses such as physiological hyperarousal, intense fear, rage, sorrow, and very aversive homicide-related thoughts. According to the model, classical conditioning occurs as previously neutral stimuli (e.g., a telephone ringing, a police officer at the door) become associated with the traumatic event, thereby acquiring the capacity to elicit at some future point learned (conditioned) responses similar to the initial, unlearned cognitive, affective and physiological responses to the traumatic news. Mowrer’s Factor One describes this classical conditioning paradigm, through which a great variety of previously benign stimuli such as news reports, criminal justice officials, and even one’s own home become cues for very aversive responses. Through a process known as stimulus generalization, stimuli similar to those present during the initial traumatic experience also acquire the capacity to evoke aversive responses. For example, a loud buzzer, which may sound simi- lar to the telephone initially associated with traumatic news may come to elicit powerful, aversive emotional responses for a survivor. The criminal justice system itself presents a host of such homicide-related stimuli. The abundance of such homicide cues and the repetitive pattern of their occur- rence helps to account for the chronic nature of survivor reactions (Masters et ul., 1988).

Once classical conditioning has occurred, an individual naturally seeks to avoid those stimuli that elicit traumatic responses. Many survivors come to avoid people and situations which are in any way reminiscent of the mur- der or the victim. Mowrer’s Factor Two postulates that such avoidance be- havior actually maintains the strength of the classically conditioned traumatic responses by preventing opportunities for extinction of the responses. Ex- tinction could occur if a survivor were repeatedly exposed to a conditioned aversive stimulus (e.g., the telephone ringing) without that stimulus being paired with traumatic news. Over time, the association between the telephone and trauma would diminish and aversive responding would fade. However, if a survivor avoided telephones, the aversive responses would have no op- portunity for extinction. A secondary danger of such avoidance behavior

26 Amick-McMullan cr al.

is that survivors are likely to isolate themselves from much needed sources of support during their periods of crisis. It is not unusual for survivors to find themselves avoiding helping professionals and even family members and friends who have become reminders of the homicide or of their lost loved ones.

To briefly summarize the learning theory perspective, Mowrer’s Two Factor Model suggests that aversive post-traumatic cognitive, affective, and physiological responses are acquired through a form of learning known as classical conditioning which occurs during the original traumatic situation (Factor One). Once acquired, these learned, aversive responses are often main- tained through avoidance behavior (Factor Two).

Based on this model, we predicted that survivors would experience per- sistent intrusive cognitions and aversive emotions long after their initial stress reactions to the homicide. We also predicted that survivors would exhibit behavioral avoidance of homicide-related stimuli. The Impact of Event Scale (Horowitz et al., 1979), which measures trauma-related cognitive intrusions and avoidance behaviors, was used to evaluate these hypotheses.

ATTRIBUTIONAL VARIABLES

In addition to considering the acquisition and maintenance of classi- cally conditioned post-traumatic symptoms, we believe it is fruitful to exa- mine attributional processes among survivors. Equity theory (e.g., Walster et al., 1978) is an attributional perspective which appears relevant to the very painful and sometimes seemingly unresolveable issue of the murder of a loved one. This perspective focuses on the extent of harm perceived by survivors to have occurred, their emotional distress, and the extent to which they have been treated in an inequitable fashion. In the case of homicide, survivors of the murder victim find themselves in an extremely inequitable position vis-a-vis the murderer. This profoundly inequitable position is thought to be associated with tremendous psychological distress.

As Frieze et al. (1984) note, there are only two ways that survivors can reduce feelings of inequity: (1) by increasing the survivors’ outcomes and/or (2) by reducing the offender’s outcomes. Survivors’ outcomes can be increased by treating them well and by providing them with services. Offenders’ out- comes can be reduced by either direct retaliation by the victim or by timely punishment by the criminal justice system. Hernon and Forst (1984) found that the most frequent suggestion by crime victims as to how relations might be improved between victims and the courts was to treat offenders more harshly, a finding that provides support for equity theory. If the criminal justice system is an agent of equity and feelings of inequity are associated with distress, it is reasonable to hypothesize that survivor satisfaction with

Family Survivors of Homicide Victims 21

the justice system would be negatively correlated with psychological distress. To examine this hypothesis, criminal justice satisfaction was measured via a 7-point Likert scale and psychological adjustment was measured by the Symptom Checklist %Revised (Derogatis, 1983).

METHOD

Sample

Participants were recruited from two sources, (a) the Ninth Judicial Circuit Victim/Witness Program in Charleston, S.C., and (b) a local crime victims’ rights organization. Recruitment of Victim Witness referrals involved an initial telephone contact to ascertain willingness (a) to participate in a brief telephone interview, (b) to complete an assessment packet, and (c) to attend a support group. Of 25 initial telephone contacts, 24 survivors completed the telephone interview; 13 persons completed assessment packets, and 4 at- tended the group meetings. In a second recruitment effort, 15 crime victims’ rights group members who attended a special meeting for survivors of homi- cide victims were given assessment packets. Of this group, six packets were completed and returned.

The following data were gathered from the 19 survivors who completed assessment packets. We have little data on the 20 remaining contacts who agreed to participate, but failed to complete and mail in packets. However, chi square analyses revealed no significant differences between participants and noncompleters on gender (x2(df = 1) = 0.02, NS), previous psychiatric treatment (x2(df = 1) = 0.12, NS) or relationship to victim (x2(df = 2) = 2.00, NS).

It is important to note limitations of this sample. Specifically, it was not a random sample of the entire population of survivors and it was small in size. This small size limited the statistical power available for detecting significant relationships among variables. In spite of these limitations, this sample was of value in providing some preliminary data on a population about which little is known. One strength of the sampIe is that it was not a treat- ment-seeking group.

Demographically, the respondents were primarily female (n = 13 wom- en, 6 men), white (n = 16 white, 3 black), and married (n = 15 married, 2 single, 2 widowed). The majority reported yearly income exceeding $25,000 (n = 15 greater than $25,000, 4 less than $25,000). Chi square analyses re- vealed no significant demographic differences between participants from the two referral sources (gender, x2(df = 1) = 0.02; race, x2(df = 1) = 0.07; marital status, x2(df = 1) = 0.14, all nonsignificant).

28

Assessment Instruments

Amick-McMullon ef ol.

The assessment packets evaluated the following general areas: (a) demo- graphics, (b) specifics of the homicides, (c) psychological adjustment, and (d) perceptions of the criminal justice system.

The Survivor Questionnaire, developed specifically for this pilot project, assessed demographics and homicide specifics via multiple choice items. Respondents’ satisfaction with the handling of the case by the criminal justice system was assessed by a 7-point Likert scale.

Measures of psychological adjustment included the Symptom Check- list WRevised (SCL90-R; Derogatis, 1983) and the Impact of Event Scale (IES; Horowitz er al., 1979). Briefly described, the SCL-90-R is a 90-item symptom checklist that generates three overall scores and nine symptom dimensions: somathtion, depression, anxiety, hostility, phobic anxiety, para- noid ideation, obsessive-compulsive, interpersonal sensitivity, and psychoti- cism. High scores on these scales reflect greater symptomatology. Non-patient comparison norms are available. The IES is a 15-item scale developed to mea- sure two key elements of PTSD: (1) event-related intrusion (intrusively ex- perienced ideas, images, feelings, or bad dreams) and (2) event-related avoidance (consciously recognized avoidance of certain ideas, feelings, or situations). The choice of these instruments was based on previously demon- strated sensitivity to behavioral symptoms experienced among victim popu- lations (Calhoun ef al., 1982; Kilpatrick el a/., 1981; Kilpatrick and Veronen, 1983; Kilpatrick ef af., 1979; Kilpatrick et al., 1987; Lehman et a/., 1987).

RESULTS

Data analyses fell into three basic categories: (1) presentation of descrip- tive information regarding the homicides, (2) evaluation of survivor psycho- logical adjustment, and (3) determination of relationships between perceptions of the criminal justice system and psychological adjustment. Although all 19 participants provided data regarding demographics and characteristics of the homicides, some respondents failed to complete the standardized assess- ment instruments. Consequently, the actual n’s for each measure are stated throughout this section.

Characteristics of the Homicides

Among this sample, an average of 2.5 years (SD = 2.5 years) had elapsed since the homicide. Sixty-eight percent (n = 13) of survivors were parents of the victim (47% mothers; 21% fathers); 26% (n = 5) were sib-

Family Survivors of Homicide Victims 29

lings; and one son was included. Forty-nine percent of survivors had actual- ly spoken with the victim on the day of, or one day prior to death. All had spoken with the victim at least three days prior to the murder. Only one respondent was present at the scene of the murder. Approximately one-half of the murders were committed by strangers (47%; n = 9), 37% (n = 7) by acquaintances, and 16% (n = 3) by relatives.

Individual Psychological Adjustment

Of the 14 survivors completing the SCL-90-R, 9 (64%) met the “case- ness” criterion, defined by Derogatis (1983) as an indicator of psychiatric impairment sufficient to warrant further assessment and treatment. To meet the operational rule for caseness, a respondent must have two subscale T scores, or a general symptom score of at least 63. Subscales most frequently meeting the caseness criterion were depression, somatization, anxiety, and phobic anxiety. Caseness was not related to amount of time since the homi- cides (x2(df = 3) = 5.30, NS), gender (x2(df = 1) = 0.50, NS), or vic- tim/offender relationship (acquaintance/family/stranger, x2(df = 2) = 1.8, NS). This suggests that current symptoms were unrelated to gender, length of time since the homicide, or the relationship of the victim to the offender.

Each of the 16 survivors completing the IES reported some degree of event-related symptomatology characteristic of PTSD. A Pearson product moment correlation revealed no relationship between time since homicide and IES scores (r = 0.06, NS). Likewise, a point biserial correlation showed IES scores to be unrelated to gender (r = 0.10, NS). Thus, men and women had similar IES scores, and there was no evidence that the length of time since the homicide was associated with diminished IES scores.

The following three studics provided reference points for the evalua- tion of IES data: (a) In their cross-validational study of the IES, Zilberg et al. (1982) assessed both outpatients and a non-patient field sample of per- sons who had experienced the death of a parent; (b) Wilson et al. (1985) in- cluded in their comparative study of PTSD a subsample who had lost a significant other through death, suicide, miscarriage, or abortion; and (c) data from the Kilpatrick and Veronen (1984) longitudinal study of rape vic- tims allowed comparison of the IES scores of survivors with those of rape victims at 2 years postassault. Inspection of Table I reveals that our survivor sample reported the highest frequency of traumatic intrusions across studies. The survivor avoidance mean score is exceeded by only that in the Zilberg et al. (1982) study. It is noteworthy that the survivor sample was not a treatment-seeking sample and that this sample had the greatest mean time since trauma reported across these studies. Although these samples are in no way matched demographically, on time since trauma, or even on type

M Amick-McMuilan et ul.

Table I. Impact of Event Scale Scores across Studies

Present study

Kilpatrick and Veronen (1 984)

(1985) Wilson et al.

Zilberg et PI. (1 982)

Time since Trauma N trauma Intrusion Avoidance Total

Homicide 16 Means = 24.6 16.9 41.3 of family 2.5 years member

Rape 23 2 years 11.2 16.0 27.2

Death of 96 Not specified 5.3 16.6 32.2 significant

other Death of 35 Approximately 21.2 20.0 41.3 parent 7 months

of trauma, the comparison points available suggest the existence of severe post-traumatic intrusions and avoidance behaviors among homicide survivors.

Criminal Justice Satisfaction

Fifty-eight percent (n = 11) of survivors reported some degree of satis- faction with criminal justice system handling of the homicide case, whereas, 42% (n = 8) were dissatisfied. Interestingly, the SCL-90-R caseness index of psychiatric impairment was significantly related to criminal justice satis- faction (X2(df = 1) = 5.83, p < 0.025). Highly significant negative correla- tions were observed between criminal justice satisfaction and SCL-90-R subscales of anxiety (r = -0.82, p < O.OOOl), depression (r = -0.82. p < O.OOOl), and general symptom severity (r = -0.84, p < 0.O001). The overall IES score was also negatively correlated with criminal justice satis- faction (r = -0.42, p < 0.05). On all measures, greater symptom seventy was associated with greater dissatisfaction.

DISCUSSION

The results of this exploratory study must be viewed with caution, given its retrospective design, lack of comparison groups, and small, nonrepresen- tative sample. Particularly limiting aspects of this sample are the racial (84% white) and socioeconomic (78% with income greater than $25,000) biases. Unfortunately, the problem of nonrepresentative sampling is one common to existing studies of survivors of homicide victims.

We know of only one study, currently in progress, which provides demo- graphic data on a nationally representative sample of adult survivors (Kil-

Family Survivors of Homicide Victims 31

patrick and hick-McMullan, 1987). Preliminary data from this nationally representative sample reveal the following racial composition: white, 65.8% ; black, 28.8%; native American, 1.4%; hispanic, 2.7%; other, 1.4% (Amick- McMullan et al., 1988). With respect to socioeconomic status, 60% of the national sample reported yearly incomes of less than $25,000. Thus in com- parison with preliminary data from the national study, our small pilot sam- ple is skewed racially and in terms of yearly income. Further research is required to ascertain the impact of socioeconomic and ethnic variables on survivor adjustment. Related to this question, Masters et al. (1988) have ob- served that within their Victims Services Agency in New York City, “. . . psy- chological reactions to the murder of poor, working-class, and middle-class clients did not differ significantly. Clients of widely differing ethnic, eco- nomic and social backgrounds showed common emotions, defensive patterns, and processes of working through their pain” (p. 113).

As noted previously, our pilot sample does offer the advantage of being non-treatment seeking. Although some of our participants were located through a victims’ rights organization, and some through the prosecutor’s office, no significant differences were found on demographic variables be- tween these two groups. In spite of sample limitations, these pilot data lay preliminary groundwork for development of theoretical models of symptom acquisition and maintenance. Although no single, unified theoretical model emerges from this work, these data suggest the heuristic value of both learn- ing theory and equity theory perspectives.

With respect to symptom topography, these results are consistent with previous work which noted a variety of symptoms along cognitive, affec- tive, physiological and behavioral dimensions (Bard, 1982; Burgess, 1975; Getzel and Masters, 1984; Poussaint, 1984; Rinear, 1984; Rynearson, 1984). Although previous studies typically presented symptoms as falling into either grief or PTSD formulations, a multidimensional approach which includes cognitive, affective, physiological and behavioral dimensions seems to more effectively capture the full complexity of survivor reactions.

As predicted from the learning theory model of post-traumatic responses, we found high frequencies of homicide-related intrusive phe- nomena and behavioral avoidance of homicide cues. The intrusive phenomena reported on the Impact of Event Scale were consistent with the classically conditioned emotional responses predicted by Mowrer’s Factor One. These results suggest that reminders of the homicide do elicit aversive intrusive thoughts and feelings. The IES findings also supported the prediction, based on Mowrer’s Factor Two, that survivors would engage in avoidance behaviors to avoid homicide cues. In comparison with rape victims (Kilpatrick and Vero- nen, 1984), persons losing a parent (Zilberg et af., 1982), and a group who suffered various traumatic losses (Wilson et al., 1985), survivors had extremely high levels of both cognitive intrusions and avoidance behaviors. Obvious-

32 Amick-McMullan cf al.

ly, these comparisons were limited by the varied traumatic experiences, in- consistent times since the traumatic incidents, and demographic differences across studies.

In addition to demonstrating significant psychological distress among survivors, our findings suggest a striking relationship between psychological adjustment and satisfaction with how the criminal justice system handled the homicide cases. Although the small sample size precluded extensive mul- tivariate exploration, the single item Likert scale measure of satisfaction with the criminal justice system showed high, negative correlations with depres- sion, anxiety, and general symptom severity. The fact that almost two-thirds of the variance in the SCL-90-R subscales of anxiety and depression could be accounted for by a single variable, satisfaction with criminal justice sys- tem treatment, strongly suggests the importance of perceived criminal justice support and perhaps social support in general for survivors.

The strong link between adjustment and satisfaction with the criminal justice system suggests the relevance of equity theory for understanding post- traumatic responses. If survivors view the justice system as an agent of equity, then equity theory would predict the negative correlation we found between distress and satisfaction with the system. Refinement of the global satisfac- tion rating used in this pilot study is needed to identify specific behaviors which are associated with enhanced or diminished coping. Also, further ex- ploration of survivors’ perceptions of their treatment relative to the treat- ment of the offender would be required to more fully determine the relevance of equity theory for explaining the correlation between distress and satisfac- tion with the system. Such information would be extremely valuable for both criminal justice and mental health professionals who attempt to facilitate survivor coping.

Other virtually unexplored but potentially important cognitive or at- tributional variables include the extent to which survivors’ perceptions of their unique invulnerability are shattered (Perloff, 1983), the extent to which sur- vivors feel helpless versus competent in the aftermath of the homicide (e.g., Peterson and Seligman, 1983), and the extent to which they derive meaning from the tragedy (Silver et al., 1983). Lehman et al. (1987) noted that a sud- den, traumatic loss is especially likely to shatter a survivor’s assumptions of the world as an orderly, fair place. Particularly in the aftermath of the murder of a loved one, a survivor’s world view, sense of security and trust in others are profoundly threatened (Frieze et al., 1987). Extensive empirical explora- tion of attributional elements of survivors’ adjustment is needed, with an important goal being development of interventions to facilitate cognitive coping.

Finally, we cannot overstate the profound need for appropriate clini- cal intervention among survivors of homicide victims. Our clinical experience

Family Survivors of Homicide Victims 33

attests to the tremendous challenge presented by survivors who seek treat- ment (Amick-McMullan er al., in press). Striking characteristics of their clinical presentations are the sheer magnitude of distress and the need to ventilate deeply rageful and fearful feelings. A clinical implication of the Two Factor Theory is the potential utility of stress management tech- niques such as relaxation training, covert modeling, and guided self dialogue to aid coping with conditioned emotional responses and avoidance behavior. The efficacy of these treatment strategies has been previously demonstrated with victims of sexual assault (Veronen and Kilpatrick, 1983) and needs to be evaluated with survivors. We also find that some basic education is help- ful in facilitating coping with the criminal justice system. We are only begin- ning to address the complex attributional aspects of having a family member fall victim to homicide, however, it is clear that this is a critical aspect of survivor adjustment.

Finally, at this early stage of exploration of survivor responses to homi- cide, we are faced with a myriad of questions. We have some information regarding symptom topography and very early work on theoretical forrnula- tions has begun. However, many questions'remain unanswered. For exam- ple, what is the impact, if any, of ethnic and socioeconomic factors on survivor coping? What cognitive and attributional processes facilitate or im- pede survivor adjustment to such a horrific event? What is the impact of the homicide of a loved one on interpersonal, and particularly intrafamilial relationships? Does a lifetime history of other trauma predispose a survivor to poor or effective coping? These and other important questions pose ex- citing clinical research and public policy challenges.

REFERENCES

American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders (third edition), American Psychiatric Association, Washington, D.C.

American Psychological Assodation Task Force on Victims of Crime and Violence (1984). Ameri- can Psychological Association Task Force on the Victims of Crime and Violence Final Report. American Psychological Association, Washington, D.C.

Amick-McMullan, A. E., Kilpatrick. D. G., and Veronen. L. J. (in press). Family survivors of homicide: A behavioral analysis. Behav. Ther.

Amick-McMullan, A., Kilpatrick. D. G., Saunders, B. E.. and Resnick, H. S. Indirect victims of homicide: An epidemiological study. Society of Behavioral Medicine, Boston, Mass., April 1988.

Attorney General's Task Force on Family Violence (September 1984). Attorney General's task force on family violencefinal report, US. Government Printing Office, Washington, D.C.

Bard, M. (1982). A retrospective study of homicide survivor adaption. (Final Report, Grant No. R01 MH31685). National Institute of Mental Health, Rockville, Md.

Bard, M., Amone, H. C., and Nemiroff, D. (1981). Homicide survivor-victims: Psychological theory and legal policy, Paper presented at the Biennial Convention of the American Psychology-Law Society, Cambridge (October).

34 Amick-McMulhn et al.

Bard, M., and Connolly, H. (1982). A retrospective study of homicide adaptation. National Institute of Mental Health, Rockville, Md.

Bowlby, J. (1980). Attachment and Loss, Vol. IIf: Sadness and Depression, Hogarth Press, London.

Bowman, N. J. (1980). Differential Reactions to Dissimilar Types of Death: Specifically the Homicide/Murder, Unpublished doctoral dissertation. United States International University.

Burgess, A. W. (1975). Family reaction to homicide. Am. J. Orthopsychiat. 45: 391-398. Calhoun, K. S., Atkeson, B. M., and Resick, P. A. (1982). A longitudinal examhation of fear

Derogatis, L. R. (1977). SCL-90: Adminitrration. Scoring and Procedure Manual-I for the R

Derogatis, L. R. (1983). SCL-90-R Adminkfration, scoring andprocedures manual-If, Clinical

Doyle, P. (1980). Griej Counseling and Sudden Death, Charles C Thomas, Springfield, Ill. Federal Bureau of Investigation (1985). Crime in the United States, U.S. Department of Justice,

Washington, D.C. Frieze. I. H.. Hymer, S., and Greenberg, M. S. (1984). Describing the victims of crime and

violence. In Kahn, A. S. (ed.), Final Report of the American Psychological Association Task Force on the Victims of Crime and Violence, American Psychological Association, Washington, D.C.

Frieze, I. H.. Hymer, S., and Greenberg, M. S. (1987). Describing the crime victim: Psycho- logical reactions to victimization. Prof. Psychol. Res. Practice 18(4): 299-315.

Getzel. G. S., and Masters, R. (1984). Serving families who survive homicide victims. Social Casework J. Contemp. Social Work (March), 138-144.

Goldenson, R. M. (1984). Longman Dictionary of Psychologv and Psychiatry, Longman. New York.

Hernon. J . C., and Forst, B. (1984). The Criminal Justice Response to Victim Harm, US. Dept. of Justice, National Institute of Justice, Research Report. U.S. Government Printing Office, Washington, D.C.

Holmes, M. R., and St. Lawrence, J . S. (1983). Treatment of rape-induced trauma: Proposed behavioral conceptualization and review of the literature. Clin. Psychol. Rev., 3: 417433.

Horowitz, M., Wilner, N., and Alvarez, W. (1979). Impact of event scale: A measure of sub- jective distress. Psychosom. Med., 41(3): 209-218.

Keane, T. M., Zimering, R. T., and Caddell, J. M. (1985). A behavioral formulation of post- traumatic stress disorder in Vietnam veterans. Behav. Ther., 8: 9-12.

Kilpatrick, D. G., and Amick-McMullan, A. E. (1987) Criminal Homicide ond Alcohol-Related Vehicular Homicide: A National study of Surviving Family Members (Grant No. 87-IJ-CXM)17), National Institute of Justice, Washington, D.C.

Kilpatrick, D. G.. Veronen, L. J., and Resick, P. A. (1979). The aftermath of rape: Recent empirical findings. Am. J. Orthopsychiat., 49: 658-669.

Kilpatrick, D. G., Resick, P. A.. and Veronen, L. J . (1981). Effects of a rape experience: A longitudinal study. J. Social Issues 37: 105-122.

Kilpatrick, D. G., Veronen, L. J., and Resick, P. A. (1982). Psychological sequelae to rape: Assessment and treatment strategies. In Doleys, D. M., Meredity, R. I., and Ciminero, A. R. (eds.), Behavioral Medicine: Assessment and Treatment Strategies, Plenum, New York.

Kilpatrick, D. G., and Veronen, L. J. (1983). The Aftermath of Rape: A Three-Year Follow- Up, Paper presented at the 17th Annual Convention of the Association for Advance- ment of Behavior Therapy, Washington, D.C.

Kilpatrick. D. G., and Veronen, L. J. (1984). Treatment of Feur and Anxiety in Victims of Rape (Final Report, Grant No. R01 MH29602). National Institute of Mental Health, Rockville, Md.

Kilpatrick. D. G., Veronen, L. J., Saunders, B. E., Best, C. L., Amick-McMullan, A., and Paduhovich, J. (1987). Psycho/ogicalfmpact of Crime: A Study of Randomly Surveyed Crime Victims, Final Report, National Institute of Justice Grant 84-1 J-CX-0039. Na- tional Institute of Justice, Washington, D.C.

reactions in victims of rape. J. Counsel. Psychol. 29: 655-661.

(revised) Version. John Hopkins University School of Medicine, Baltimore.

psychometric research, Towson. Md.

Family Survivors of Homicide Victims 35

Klaus, P. A., Rand, M. R., and Taylor, B. M. (1983). The victim. In Zawitz, M. W. (ed.), Report to the Nation on Crime and Justice: The Data (Document No. NCJ-87068, October, 1983). U.S. Department of Justice, Bureau of Justice Statistics, Washington,

Lehman, D. R., Wortman, C. B., and Williams, A. F. (1987). Long-term effects of losing a spouse or child in a motor vehicle crash. J. Personal. Social Psychol., 52(1): 218-231.

Lindenmann, E. (1965). Symptomatology and management of acute grief. In Death and Iden- tity Wiley, New York, pp. 186-201.

Masters, R., Friedman, L. W., and Greuel, G. (1988). Helping families of homicide victims: A multidimensional approach. J. Truum. Stress, l(1): 109-125.

Mowrer, 0. H. (1960). Learning Theory and Behavior, Wiley, New York. Parkes, C. M. (1972). Bereuvement: Studies of Grief in Adult Lge, Pelican Books, London. Perloff, L. S. (1983). Perceptions of vulnerability to victimization. J. Sociallssues 3x2): 41-61. Peterson, C., and Seligman, M. E. P. (1983). Learned helplessness and victimization. J. Social

Poussaint, A. F. (1984). The Grief Response following a Homicide, Paper presented at the an- nual meeting of the American Psychological Association, Toronto, Canada (August).

President’s Task Force on Victims of Crime (1982). President’s Task Force on Victims of Crime Final Report. U.S. Government Printing Office, Washington, D.C.

Rand, M. R., Klaus, P. A., and Taylor, B. M. (1983). The criminal event. In Zawitz, M. W. (ed.), Report to the Nution on Crime and Justice: The Data pp. 1-16 (Document No. NCJ-87068, October 1983). Department of Justice, Bureau of Justice Statistics, Washing- ton, D.C.

Rinear, E. E. (1984). Parental Respond to Child Murder: An Exploratory Study, Doctoral dis- sertation. University Microfilms International, Ann arbor, Mich.

Rynearson, E. D. (1984). Bereavement after homicide. Am. J. Psychiut. 141(11): 1452-1454. Silver, R. L., Boon, C., and Stones, M. H. (1983). Searching for meaning in misfortune: Making

Stillman. F. (1986). Personal communication, March. Veronen, L., and Kilpatrick. D. G. (1983). Stress management for rape victims. In Meichenbaum,

D., and Jarenko, M. E. (eds.), Stress Reduction und Prevention, New York, Plenum,

Walster, E., Walster, G. W., and Berscheid, E. (1978). Equity: Theory and Research, Allign and Bacon, Boston.

Wilson, J. P.. Smith, W. K., and Johnson, S. K. (1985). A comparative analysis of PTSD among various survivor groups. In Traumo und Its Wake. New York, Bruner/Mazel, pp. 142-172.

Zilberg, N. J., Weiss, D. S., and Horowitz, M. J. (1982). Impact of event scale: A cross- validational study and some empirical evidence supporting a conceptual model of stress response syndromes. J. Consult. Clin. Psychol. 50(3): 407-414.

D.C., pp. 17-27.

ISSU~S 39(2): 103-116.

sense of incest. J. Social Issues 39: 81-102.

pp. 341-374.