Journal of Traumatic Stress, Vol. 8, No.

4, 1995

Change in Rape Narratives During Exposure

Therapy for Posttraumatic Stress Disorder
Edna B. Foa,' Chris Molnar,' and Laurie Cashman'

This paper presents a coding system developed to explore changes in narratives

of rape during therapy for posttraumatic stress disorder (PTSD)involving
repeated reliving and recounting of the trauma. Relationships between narrative
categories hypothesized to be affected by the treatment and treatment outcome
were also examined. As hypothesized narrative length increased fiom pre- to
post-treatment, percentage of actions and dialogue decreased and percentage
of thoughts and feelings increased particularly thoughts reflecting attempts to
organize the trauma memoy. Also as expected increase in organized thoughts
was correlated negatively with depression. while indices of fragmentation did
not significant3) decrease during therapy, the hypothesized correlation between
decrease in fragmentation and reduction in trauma-related symptoms was
detected
KEY WORDS F'TSD; rape; personal narrative; cognitive behavioral therapy; episodic memory.

It has been proposed that persistent emotional disturbances following

a highly distressing event indicate an inadequate processing of that event
(Foa & Kozak, 1986; Rachman, 1980). Accordingly, chronic posttraumatic
stress disorder (PTSD) indicates impaired processing of the trauma. Foa
and Riggs (1993) proposed that traumatic memories are often disorganized
and fragmented because they are encoded while the individual experiences
extreme anxiety. The natural process of recovery from a trauma, they sug-
gested, involves the organizing and streamlining of the memories. It follows
that the memories of individuals who fail to recover from the trauma, and
thus evidence chronic PTSD, will remain disjointed and that successful
'Medical College of Pennsylvania, Eastern Pennsylvania Psychiatric Institute, Philadelphia,
Pennsylvania.

675

0894-9867/95/1ow-o67S$0750/1 0 1995 International Society for Traumatic Strcu Studies

676 Foa et al.

treatment will promote cohesiveness of these memories (Foa & Riggs,

1993). The present study examines this proposition by analyzing transcrip-
tions of narratives of rape victims with chronic PTSD during the first and
last sessions of therapy that involved reliving the trauma.
The fragmentation of the trauma memory record can be explained
by the difficulty inherent in processing information under conditions of ex-
treme distress. First, heightened physiological arousal decreases the range
of stimuli to which the individual attends (Easterbrook, 1959; Eysenck,
1982; Mandler, 1975). More specifically, under arousing conditions indi-
viduals focus more on the arousing stimuli and encode less of the neutral
ones. The presence of selective processing in anxiety disordered individuals
was noted by Beck and Emery (1985) who stated that an anxious person
will be hypersensitive to any aspects of a situation that are potentially harm-
ful, but will not respond to its benign or positive aspects (p. 31). Many
experiments have demonstrated such an encoding bias. In one such experi-
ment, a research assistant confronted subjects with either a threatening ob-
ject (hypodermic syringe) or a nonthreatening object (pen). The group that
experienced exposure to the syringe was less accurate in identifying the
research assistant than the group that was exposed to the pen. Conversely,
those in the syringe group were more accurate in describing the threat ob-
ject and the hand holding it than those in the nonthreat group were in
describing the pen and the hand holding it (Maass & Kohnken, 1989). Simi-
larly, subjects who saw a slide sequence that included a weapon were less
able to report details about the person holding the weapon than those who
viewed the same slides without a weapon. This effect was strongest in sub-
jects who reported being anxious during the weapon sequence (Kramer,
Buckhout, & Eugenio, 1990).
A second way in which anxiety may impair information processing is
by increasing distractibility and decreasing concentration (Eysenck, 1982).
High distractibility and poor concentration is expected to result in disor-
ganized memory records. Eysenck and Keane (1990) have suggested that
anxiety and self-concern capture much of the available attention capacity
so that less is free for other tasks. In the case of a trauma victim, the
perception of threat to ones physical and psychological integrity may ap-
propriate much of the available attentional capacity during the trauma, thus
interfering with processing of threat-irrelevant information of the traumatic
event. Such interference, however, may not necessarily result in a more
accurate memory of threat-relevant than of threat-irrelevant information.
The two mechanisms described above suggest that trauma memories
will be fragmented, disorganized, and highly skewed towards threat repre-
sentations such as weapons and threat-related emotions like fear. If frag-
mented disorganized memories are associated with PTSD, then treatment
Change in Rape Narratives 617

aimed at reducing trauma-related anxiety should result in more organized

and less fragmented trauma memories, as evidenced by the narratives of
the trauma. Moreover, this effect should be related to treatment outcome.
The present paper examines these hypotheses.
Two bodies of research have lead us to hypothesize that treatment
involving repeated recounting of a traumatic event will produce longer nar-
ratives of that event. First, several studies found that with the passage of
time and with rehearsal, details of threat-related stimuli increase (cf. Chris-
tianson, 1992; Heuer & Reisberg, 1992; Koss, Tromp, & Tharan, in press).
Heuer and Reisberg (1992) proposed that the increase in recall over time
may be due to decreased arousal. If decrease of anxiety results in increase
of details for threat-related material, then treatment which focuses on re-
living the most threatening aspects of the trauma and that aims to alleviate
trauma-related anxiety should generate longer trauma narratives. The sec-
ond body of research that has led us to hypothesize a longer post-treatment
trauma narrative involves studies of hypennnesia. Hypermnesia refers to
an increase in recall with longer retention intervals and with repeated test-
ing. Reviewing studies investigating hypermnesia for non-affective words
and pictures, Payne (1987) concluded that repeated testing, longer recall
periods, and the use of imagery are all primary factors in producing hy-
permnesia. It follows that therapy that involves repeated prolonged imagi-
nal reliving of the trauma would produce longer narratives.
While we expected that the entire narrative would be longer, we hy-
pothesized that some types of details would increase while others would
decrease. Specifically, we predicted that at the end of treatment the trauma
narratives would contain a greater percentage of internal events such as
thoughts and feelings, particularly thoughts reflecting attempts to compre-
hend the trauma. This hypothesis is derived from the therapists instruction
that the client focus on feelings and thoughts associated with the traumatic
memory during its reliving. We further hypothesized that percentage of de-
tails about external events such as actions and dialogues would decrease
as a result of treatment. This hypothesis is derived from clinical impression
that when the emotional aspect of a traumatic memory becomes attenuated,
the need to remember what precisely transpired during the event (i.e., ac-
tions and dialogues) becomes less significant.
Many systems of content analysis have been devised to study affect,
but only a few have examined the content of traumatic memories. In an
attempt to systematically measure coping mechanisms that occur when vic-
tims process memories of sexual abuse; Roth and Newman (1991) analyzed
the content of female victims accounts of their childhood sexual abuse dur-
ing psychotherapy in order to identify affect (e.g., helplessness, rage, fear)
and schema (e.g., alienation, self-blame).
678 Foa e t al.

Lisak (1994) examined the content of verbatim transcriptions of auto-

biographical memories elicited from a group of male survivors of sexual abuse
who exhibited FTSD symptoms. Interestingly, many of the same themes re-
ported in female sexual abuse victims emerged in male victims. Prevalent
themes included anger, isolation and alienation, negative schema about self
and others, fear, helplessness, self-blame, guilt, shame, and humiliation.
Several content analyses have been conducted in the context of stud-
ies that examine the health benefits of disclosure of traumatic memories.
Pennebaker and colleagues have found long-term benefits on health and
immune function following both verbal and written disclosure of traumatic
events (Harber & Pennebaker, 1992; Pennebaker & Beall, 1986; Penne-
baker, Kiecolt-Glaser, & Glaser, 1988). Based on informal inspection of
the narratives, Harber and Pennebaker suggested that the narratives of in-
dividuals with improved health functioning were marked by their organi-
zation, connectedness, and emotional vividness.
Influenced by the work of Pennebaker and his colleagues, other re-
searchers have conducted content analyses to examine narratives elicited
from trauma victims. In one study subjects were assigned to three groups
(Murray, Lamnin, & Carver, 1989). One group was instructed to write about
the content of their room (trivial essay group). The second group was asked
to write about a current or past traumatic or disturbing event (traumatic
essay group). The third group was instructed to describe a current or past
traumatic or disturbing event within the context of brief psychotherapy that
encouraged expression of emotions and cognitive reappraisal of the event.
Content analysis focused on expressed emotion, tension, self-feelings, reap-
praisal, and coping behavior. No relations between disclosure and health
were found in this study nor in a later and similar study that eliminated the
psychotherapy group (Murray & Segal, 1994).
All the studies described above focused on the content of the narra-
tive. No study sought to examine the cohesiveness of narratives and thus
no method for measuring this aspect has been devised. Therefore, we have
developed a coding system to formally measure degree of organization and
fragmentation of trauma narratives.

Method

Subjects

Fourteen female sexual assault victims, who received exposure treat-

ment in the context of a study investigating the efficacy of cognitive-be-
havioral treatment for PTSD post sexual and nonsexual assault, comprised
Change in Rape Narratives 619

the sample for the present study. We included in the study a l l sexual assault
victims who received exposure treatment and for whom an audible first
and last exposure tape were available. Eleven victims were Caucasians and
three were African-Americans. Mean age was 30.1 years (SD = 9.4; range
1848 years), mean number of years of education was 14 (range 10-18),
and mean time since assault was 4.85 years (SO = 7.9 years; range 3.3
months-28.9 years). Four victims were raped by acquaintances and ten by
strangers. All had sought treatment for psychological symptoms related to
their assault and met DSM-III-R diagnostic criteria for PTSD based on
the SCID-R (Spitzer, Williams, & Gibbon, 1987). Victims were excluded
from the treatment outcome study if they met DSM-III-R criteria for
schizophrenia, organic mental disorder, substance abuse, or bipolar disor-
der or if they did not speak English. Victims who were assaulted by a
spouse, family member, or intimate partner were also excluded if they were
still involved with the perpetrator at the time they sought treatment.

Procedure

Participants in this study received cognitive-behavioral treatment for

assault-related PTSD. Treatment consisted of nine biweekly individual ses-
sions lasting 90 min each. The first two sessions were devoted to gathering
information about the trauma and the clients symptoms; the remaining
sessions involved active intervention. Active treatment sessions included the
repeated reliving of the traumatic event. Instruction for the reliving of the
trauma was as follows:
Im going to ask you to recall the memories of the assault as vividly as possible. I
dont want you to tell a story about the assault in the past tense. Rather, I would
like you to describe the assault in the present tense, as if it were happening now,
right here. Id like you to close your eyes and tell me what happened during the
assault in as much detail as you remember. This includes details about the
surroundings, your activities, the perpetrators activities, how you felt and what your
thoughts were during the assault.

The reliving continued for 45 to 60 min. The therapist probed for

more details when the client did not provide enough details about the
trauma. When the recounting of the trauma lasted less than the time al-
located for the reliving, the client was asked to repeat it again and again.
Thus, reliving often constituted recounting the trauma several times. Each
session of recounting was audiotaped and the tape was given to the client
with the instructions to listen to it at home daily and to try to engage emo-
tionally in the memories while doing so. Thus, during the course of treat-
ment clients had the opportunity to relive their assault anywhere between
680 Foa et al.

35 to hundreds of times depending on the length of their narrative and

the number of homework assignments they completed.
The therapist and the client then discussed the reliving experience,
focusing on the clients emotions during that experience. The reduction in
distress that had taken place during the session was pointed out to the
client with the emphasis that the direct confrontation of the memory did
not result in loss of control or going crazy.
Clients were assessed within 2 weeks before treatment and immedi-
ately after the last treatment session.

Assessment Measures-Interview

Structured Clinical Interview for DSM-III-R I and 11 Diagnoses (SCID).

SCID (Spitzer et al., 1987) is a diagnostic interview to acquire information
about DSM-III-R Axis I and I1 criteria. Diagnostic interviews were con-
ducted by masters and doctoral-level psychologists who were trained in the
use of the SCID-R, and who reached at least a .90 level of interrater re-
liability.
PTSD Symptom Scale (PSS).PSS (Foa, Riggs, Dancu, & Rothbaum,
1993) is a standardized interview consisting of 17 items that correspond to
the DSM-III-R symptoms of PTSD. Each item is rated on a severity scale
of 0 (being lowest) to 3 (being highest) so that the total score ranges from
0 to 51. Internal consistency for the scale was .85 and test-retest reliability
across one month was r = .80. Interrater reliability for the interview was
kappa = .91 for diagnosis and r = .97 for symptom severity. It is strongly
correlated with Intrusion (r = .73) and Avoidance (r = .63), subscales of
the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979) and with
Kilpatricks (1988) Rape Aftermath Symptom Test (r = .79). The PSS has
been found sensitive to treatment effects (Foa & Riggs, 1993).

Assessment Measures -Self-Report

The State-Trait A m & Inventory (STAI). STAI (Spielberger, Gorsuch,

& Lushene, 1970) contains 40 items, 20 for state anxiety and 20 for trait
anxiety. Only the state measure was used since only state anxiety was ex-
pected to change from pre-treatment to post-treatment.
Rape Afiennath Symptom Test (RAST). RAST (Kilpatrick, 1988) is a
70-item self-report inventory of psychological symptoms and potentially
fear-producing stimuli rated on 5-point Likert type scales. The RAST in-
cludes those items from the Derogatis SCL-90-R (1977) and the Veronen-
Change in Rape Narratives 681

Kilpatrick Modified Fear Survey (1980) that most differentiated rape vic-
tims from nonvictims.
Beck Depression Inventory (BDI). BDI (Beck, Ward, Mendelsohn,
Mock, & Erbaugh, 1961) is a 21-item inventory measuring depressed mood
and vegetative symptoms of depression. The inventory has a split-half re-
liability coefficient of .93. Correlations with clinician ratings of depression
range from .62 to .66.

Narrative Coding System

The first rape narrative of the initial exposure treatment session and
the last rape narrative of the final exposure session were transcribed and
submitted to content analysis according to a manual for the study (the cod-
ing manual is available upon request). The beginning of a rape narrative
was defined as the first expressed realization of danger and the end was
defined as the first expressed realization that threat had terminated. Be-
cause some clients included in their narrative information about events oc-
curring before or after these points, while others did not, we decided to
analyze the actual rape experience only. More importantly, our hypotheses
pertained only to the threatening portion of the memory, which started
with the realization of danger and ended with the realization of safety.
Narratives were divided into utterance units. An utterance unit was
defined as a clause containing only one thought, action, or speech utter-
ance. Examples of utterances are: I know he is going to kill me, Im
going down the street, I said get off me now. Frequency of utterances
in each category were to be converted to percentages because stories vaned
greatly within and across subjects. Consequently, each utterance could be
assigned to only one coding category.
Because utterances could in principle be coded as belonging to several
categories, coding priorities had to be decided a priori. The order of priority
assigned to each category was determined by its pertinence to the hypothe-
ses examined in the study. Degree of cohesiveness of trauma narratives
was the main concept of interest. Therefore, we assigned greater priority
to categories that seemed to best assess organization and fragmentation.
When an utterance met criteria for more than one category, it was assigned
to the highest priority category. The 13 utterance categories are presented
in Table 1 and are described below in the order of their priority.
Repetition Utterances. The category of repetition was thought to be
the most direct index of fragmentation, and therefore this category was
assigned the highest priority. An utterance was considered to be a repeti-
tion when it was repeated more than once within five lines.
682 Foa et al.

Table 1. Means and Standard Deviations of Percentage of Utterances in

First and Last Narrative
Utterance Category First Narrative Last Narrative
Repetitions 4.2 (2.7) 3.3 (2.7)
Desperate thoughts 2.5 (2.8) 2.6 (24)
Disorganized thoughts 5.2 (3.0) 5.6 (5.4)
Organized thoughts 5.7 (4.3) 9.0 (4.2j
Unfinished thoughts 11.3 ji0.i) 9.8 (7.6)
Negative feelings 3.4 (2.6) 4.9 (4.1)
Sensations 4.6 (3.7) 6.0 (3.6)
Action perpetrator 14.8 (8.7) 13.5 (8.8)
Action self 13.6 (10.7) 10.7 (4.6)
Dialogue perpetrator 5.4 (4.6) 4.1 (2.6)
Dialogue self 7.3 (9.8) 6.1 (7.1)
Speech filler 2.9 (3.9) 4.6 (4.1)
Details 19.1 (7.5) 19.8 (5.9)

Thought Utterances. Next, we were interested in how treatment af-

fected thought utterances, so all categories of thoughts were assigned the
next highest priority. Utterances which implied that all coping strategies
were unavailable were categorized as desperate thoughts. Examples are: Ive
given up completely, There is nothing I can do to escape this, and He
is going to do whatever he wants to me. Utterances which implied con-
fusion or disjointed thinking were coded as dkorganized thoughts. Examples
of disorganized thoughts are: I dont remember how my leg got cut, I
dont know where he took me next, and I dont know why he said that.
An utterance indicating realization, decision making, or planning was coded
as organized thoughts. Examples of organized thoughts included, I am
keeping my eyes closed so I cant identlfy him and he wont have to kill
me, and If I let myself go numb it wont hurt any more. Unfinished
thoughts received the lowest priority among the thought categories in order
to avoid loss of information about fragmentation or organization. For ex-
ample, and then I realized . . ., was coded as an organized thought rather
than an unfinished thought, whereas the utterance, while he . . . was
coded as unfinished thought.
Negative Feefing Utterances. Negative feelings were conceptualized as
unpleasant emotions such as humiliation, fear, shock, and dissociative ex-
periences such as numbing or freezing. Examples of utterances coded as
negative feelings included, I am frozen with fear, I am scared to death,
and I couldnt feel my body anymore. An utterance such as Imafraid
he will kill me, was coded as a desperate thought and not a negative feel-
Change in Rape Narratives 683

ing due to the decision to assign higher priority to thought utterances rather
than feelings.
Sensation Utterances. Utterances were coded as sensations when they
made reference to one of the five senses. Examples included, I hear him
He feels heavy on me, I cant see anything, and He smells
so horrible. Utterances implying dissociation, such as, by now, I cant feel
anything, and my whole body is numb, were coded as negative feelings.
Action Utterances. Utterances involving descriptions of actions were
coded according to who engaged in the action. Actions the victim engaged
in were coded as action self and actions of the assailant were coded as
action perpetrator Examples of action self are: I walked to the door, I
am crying, whereas He is walking out of the front door, and He started
undressing me, are examples of action perpetrator.
Dialogue Utterances. Any verbalizations made were coded as dialogue.
Dialogue utterances were classified according to speaker (self or perpetra-
tor). Examples of dialogue Perpetrator are: He says, I will kill you if youre
not quiet. and He told me to take my clothes off. Dialogue self included:
I said, leave me alone, I begged him dont hurt me.
Speech Fillen. These utterances did not compete with the other coding
categories and therefore they were assigned the lowest priority. Examples
are: CCum,?7 like, and but anyway.
Lso,) ((

Mkcellaneous Utterance Categoty. In addition, any utterances that did

not meet definitional criteria for any of the above categories were assigned
to the details categov. This includes utterances involving description such
as, His eyes are blue, He has a mask on his face, and It is midnight.
Inter-Rater Reliability. Two raters were trained by the principal author
to divide narratives into utterance units and to code each utterance into
the categories described above. Inter-rater agreement for dividing narra-
tives into utterance units was .93 in a random sample of 12 of the 28 coded
rape narratives. Inter-rater reliability of coding the utterances of these nar-
ratives was .94. The remaining narratives were also divided into utterance
units and coded independently by each of the two raters. The few disagree-
ments that occurred were resolved by the principal author.

Results

Treatment Efficacy

Means and standard deviations were calculated for pre- and post-
treatment scores of all measures of psychopathology. These are presented
in Bble 2. All fourteen clients improved from pre- to post-treatment on
684 Foa et al.

Table 2. Means and Standard Deviations of Pwchouatholow Measures

Pretreatment Posttreatment I df P
PTSD 30.42 (9.39) 9.29 (8.51) 6.93 13 < .mi
RkST 142.29 (56.69) 60.76 (25.46) 5.79 13 < .001
STAI-S 51.36 (14.70) 34.64 (13.43) 4.21 13 < .001
BDI 18.86 (10.72) 8.86 (6.56) 4.23 13 < .001

the FTSD measure; mean percent improvement over pretreatment levels

was 68.54. Also, 13 of the 14 clients improved on the measure of depres-
sion; the mean percentage improvement for depression was 50.63. Paired
t-tests indicated significant decreases in psychopathology on all measures.

Data Reduction

Due to the large number of categories and to the small number of

utterances in some (see Table l), categories that were judged to belong to
the same construct were combined, forming three categoq groups: (1) frag-
mentation, (2) thoughts and feelings, and (3) actions and dialogues.
Fragmentation was conceptualized as lack of flow in the narrative; it
consisted of repetitions, unfinished thoughts and speech fillers. The
thoughts and feelings category was comprised of utterances which reflected
internal, nonobservable events. It included organized thoughts, disorgan-
ized thoughts, desperate thoughts, unfinished thoughts, and negative feel-
ings. Actions and dialogues of the victims and the perpetrator were
combined, representing overt, observable events. In addition to these three
category groups, the organized thoughts category was analyzed separately
because it was taken as an index of effort to process or understand the
meaning of the traumatic event.

Changes Between First and Last Narratives

To test the hypothesis that narrative length would increase from be-
ginning to end of treatment, means and standard deviations were computed
for the first and last narratives. Mean number of utterances in the first
narrative was 141.09 (SD = 37.71) and the mean number of utterances in
the last narrative was 216.85 (SD = 57.96). A paired t-test revealed a trend
in the predicted direction (t = (13) = - 1 . 9 6 , ~< .08). Because of the small
sample size p values of less than .10 will be reported. Because narratives
Change in Rape Narratives 685

varied in length within and across subjects, percentages of utterances in

organized thoughts, fragmentation, thoughts and feelings, and actions and
dialogues were computed separately for each subject and for each narrative.
Means and standard deviations were then calculated for each of these four
categories and were submitted to analyses. The means and standard devia-
tions are presented in Table 3.
The distribution of the percentages of each utterance category dem-
onstrated sufficient variability across subjects. Therefore paired t-tests,
rather than non-parametric tests, were used to examine the changes in the
percentage of categories from the first to the last narrative. A paired t-test
analysis was consistent with the hypothesis that the last narrative would
contain a greater percentage of organized thoughts than the first narrative
(t(13) = 2 . 5 0 , ~< .03). The hypothesis that percentage of utterances in-
dicating fragmentation would decrease from first to last narrative was not
supported by the data. As predicted, percentage of utterances expressing
thoughts and feelings in the last narrative was significantly greater than in
the first (t(13) = -2.19,~< .05). Finally, there was a trend in the predicted
direction for the hypothesis that the percentage of action and dialogue ut-
terances would be smaller in the last narrative than in the first (t(13) =
2 . 0 7 , ~< .06).

Relationship Between Treatment Outcome and Change in Narrative

To evaluate the relationship between outcome and narrative changes

we first calculated each subject's percent change in utterances of organized
thoughts and fragmentation from first to last narrative. Percent change
scores were used rather than difference scores to obtain a more accurate
index of change from pre- to post-treatment.
Next, we computed for each subject percent change scores from pre-
treatment levels for each of the three anxiety-related symptom measures:
PSS, RAS'I: and STAI-Sscores. These three percent change scores were
averaged to obtain a global index of improvement. The rationale for this

Table 3. Means and Standard Deviations of Category Groups in the First and Last
Narrative
First Narrative Last Narrative
Organized thoughts 5.72 (4.30) 9.02 (4.20) f(13) = 2.50, p < .03
Thoughts/feelings 16.80 (7.80) 22.03 (9.60) f(13) = 2.19, p < .05
Actioddialogues 41.06 (17.00) 34.39 (15.30) r(13) = 2.06, p = .06
Fragmentation 18.40 (12.10) 17.68 (11.00) (13) = 43, ns
686 Foa et at.

global index of trauma-related anxiety comes from the DSM-IV (1994) defi-
nition of PTSD as consisting of three symptom clusters: reexperiencing,
avoidance, and increased arousal. The PSS assessed all three of these symp-
tom clusters. The RAST is conceptually related to the reexperiencing and
avoidance clusters of PTSD, while the STAI is conceptually related to in-
creased arousal. It was thought that the use of multiple measures would
increase the reliability of assessing the construct of trauma-related anxiety.
Percentage improvement in depression was obtained from the BDI scores.
Pearson correlations were computed between percent change scores
in anxiety and depression and both organized thoughts and fragmentation.
The hypothesis that fragmentation would be related to improvement was
supported by the data: reduction in the index of fragmentation was posi-
tively correlated with reduction in the global index of trauma-related anxi-
ety (r(13) = .73, p < .002) but not with depression (r(l1) = .35,ns). The
hypothesis that increase in an index of organization would relate to im-
provement was supported for depression ((11) = -.63, p < .02), but not
for trauma-related anxiety (r(l1) = .07, ns). Reduction in trauma related
anxiety, however, was highly correlated with reduction in depression (r(13)
= .71, p < .02).

Discussion

The present study is consistent with previous studies in demonstrating

the efficacy of treatment that includes repeated imaginal reliving of the
trauma (Foa, Rothbaum, Riggs, & Murdock, 1991; Keane, Fairbank, Cad-
dell, & Zimering, 1989). All clients improved substantially on the PTSD
measure and all but one client improved on the depression measure.
The present results are consistent with the proposition that narratives
of traumatic memories recounted by rape victims change over the course
of repeated imaginal reliving of the trauma. First, as hypothesized, the nar-
ratives as a whole tended to become longer, perhaps reflecting the victims
increased ability or willingness to engage in the processing of the trauma
as anxiety decreases over the course of treatment. Alternatively, the in-
crease in narrative length found in the present study may have been due
simply to the fact that the treatment utilized prolonged and repeated imagi-
nal reliving of the trauma. Indeed, in his review of hypermnesia studies
that used nonaffective words and pictures, Payne (1987) concluded that
repeated testing, longer recall periods; and the use of imagery produced
hypermnesia.
Only a few studies have examined hypermnesia of affective material
and no studies have investigated this phenomenon in trauma victims. To
Change in Rape Narratives 687

examine hypermnesia for emotional events, Scrivner and Safer (1988)

measured recall for details of a videotape containing a violent shooting.
After 48 hr, the number of details recalled significantly increased compared
to the number of details recalled immediately after viewing the video. Simi-
lar results were reported by Burke, Heuer, and Reisberg (1992), who tested
recall for emotionally arousing slides immediately after the viewing and
one week later.
We hypothesized that although the overall length of the narratives
would increase as a result of treatment, the percentage of change in utter-
ances would vary across categories. Specifically, we predicted that the per-
centage of thoughts and feelings would increase while the percentage of
actions and dialogue would decrease from first to last narrative. The results
of the study were consistent with our hypothesis. These changes may indi-
cate a shift in emphasis toward greater processing of emotions and meaning
associated with the trauma and reduced attention to the details of the as-
sault itself, which become less relevant as the memory becomes less threat-
ening. Support for the view that a greater focus on comprehending the
trauma occurs during treatment comes from the finding that the increase
in percentage of organized thoughts, defined as thoughts indicating at-
tempts to understand the events of the assault, was particularly large.
Whether or not the natural decline of symptoms after a trauma are also
related to the same changes in trauma narratives remains to be studied.
The results that organized thoughts increase from first to last narra-
tive provide empirical support for Harber and Pennebakers (1992) obser-
vation that, . . .for trauma victims the business of connection seems to
be of vital importance (p. 383). They also are consistent with Pennebakers
impression that organization in the trauma narratives was associated with
improved immune functioning. Indeed the presence of PTSD was found
related to physical problems (e.g., Davidson, Hughes, Blazer, & George,
1991) and rape victims were found to utilize health services more than non-
victims (e.g., Koss, Koss, & Woodruff, 1991).
The hypothesis that increased organization and decreased fragmen-
tation would be related to treatment outcome was partially supported. Our
correlational analyses indicated that decrease in indices of fragmentation
were highly related to improvement. Increase in thoughts reflecting at-
tempts to comprehend the trauma was related to decrease in depression,
but unrelated to decrease in trauma-related anxiety. These results are puz-
zling because reduction in trauma related anxiety was highly correlated with
reduction in depression and yet organized thoughts were related to im-
provement in depression only. Future studies should further explore the
relationships among fragmentation, organization and psychopathology us-
ing more sophisticated correlational analyses such as regression analyses.
688 Foa et al.

Unfortunately, such statistics could not be used in the present study due
to the small sample size. An examination of the narratives of those bene-
fitting least from treatment indicated that they expressed more negative
feelings, particularly helplessness, both at the beginning and end of treat-
ment. Further, these narratives contained a greater percentage of descrip-
tions of what the victim said to the perpetrator, which seem to reflect
feelings of helplessness and hopelessness (e.g., please dont). Finally,
these narratives contained more repetitions (an index of fragmentation)
than did those of individuals benefitting most from treatment, further sug-
gesting fragmented narratives reflect the absence of emotional processing.
Future studies should examine whether fragmentation and organization are
two aspects of the same process or they reflect two different processes.
Our results suggest that fragmentation is not simply an absence of organi-
zation and that the two are related differently to outcome on trauma-re-
lated anxiety and on depression. While fragmentation was related to
trauma-related anxiety, organization was related to depression.
The present study should be viewed as piloting a method for assessing
narrative organization in an attempt to investigate the processing of trau-
matic events. If the present results are replicated, and the validity of the
method introduced here is established, future research should examine
changes in narratives within and between treatment sessions. In addition
further studies should attempt to elucidate the relationship between
changes in narratives and established indicators of emotional processing
such as activation and habituation of physiological fear responses (Foa,
Riggs, Massie, & Yarczower, in press; Kozak, Foa, & Steketee, 1988).

Acknowledgrnents

The authors wish to thank Nader Amir for his help in statistical analy-
sis, Elizabeth Turk, Karen Bogert, and Patty DiSavino for their help in de-
veloping the manual and coding the narratives. We also wish to thank the
emergency room staff at Thomas Jefferson University for their help in re-
cruiting participants for ongoing treatment studies. This study was sup-
ported by National Institute of Mental Health Grant MH42178 awarded
to the first author.

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