831526

research-article2019
JHPXXX10.1177/0022167819831526Journal of Humanistic PsychologyPeters

Radical Humanism, Critical Consciousness, and Social Change

Journal of Humanistic Psychology
1­–23
Demedicalizing the © The Author(s) 2019
Article reuse guidelines:
Aftermath of Sexual sagepub.com/journals-permissions
DOI: 10.1177/0022167819831526
https://doi.org/10.1177/0022167819831526
Assault: Toward a journals.sagepub.com/home/jhp

Radical Humanistic
Approach

Shannon M. Peters1

Abstract
An entrenched assumption in the mental health field is that if left “untreated”
the aftermath of sexual assault will inevitably lead to some diagnosable form
of emotional distress. This assumption has focused the search for pathology
on individual survivors rather than systems and led to societal pressure
for medical or psychotherapeutic treatment following unwanted sexual
experiences in the United States and globally. Humanistic psychology is
grounded in an existential phenomenological approach that privileges agency
and a sociopolitical context of lived experience. As such, it has great overlap
with the social justice mission of liberation psychology and is well equipped
to respond to sexual assault survivors and the oppressive and patriarchal
systems that perpetuate gender-based violence. This article explores the
rising use of neoliberal medicalized frameworks to respond to sexual assault
in therapy, analyzing both positive and negative aspects of medicalization.
Implications for responses to the global prevalence of sexual violence are
discussed. Suggestions for alternative epistemic and therapeutic approaches
that can be used by humanistic psychologists and that aim to enhance an
appreciation for the context of survivor’s experiences are provided.

1University of Massachusetts Boston, Boston, MA, USA

Corresponding Author:
Shannon M. Peters, Department of Counseling and School Psychology, University of
Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA 02125, USA.
Email: shannon.peters001@umb.edu
2 Journal of Humanistic Psychology 00(0)

Keywords
sexual assault, trauma, posttraumatic stress disorder, gender-based violence,
medicalization, neoliberalism, social justice, liberation psychology

Sexual assault is a global issue, with 35% of women worldwide experienc-

ing sexual violence (World Health Organization, 2013). More than 20 years
ago, Fine (1992) described the therapeutic hegemony paradox, “individuals
with the least control over the causes of their problems, much less the
means for structural resolution, are prescribed psychological models for
individual efficacy” (p. 72). Today, this paradox directly applies to sexual
assault survivors1 where the current paradigm for recovery from sexual
assault is often psychotherapy or medication rather than a critical examina-
tion of or a call to change the framework in which sexual assault occurs.
The discourse used to understand post-assault experiences has a profound
effect. Medical definitions and understandings of trauma validate many
survivors’ experiences and provide clarity for clinicians. However, they
may have iatrogenic consequences by ignoring the sociopolitical context in
which experience is always embedded. In addition, the imposition of
Western concepts of trauma and mental illness on global populations per-
petuates neocolonialism (Durazo, 2006; Summerfield, 1999; Washington,
2006). Humanistic psychologists have made significant contributions to
supporting survivors of sexual violence (e.g., Fisher, 2005) and critically
analyzing diagnoses often assigned to survivors, such as post-traumatic
stress disorder (PTSD; e.g., Burstow, 2005). Humanistic psychology is
grounded in an existential phenomenological approach that privileges
agency and a sociopolitical context of lived experience. As such, it has
great overlap with the social justice mission of liberation psychology and is
well equipped to respond to sexual assault survivors and the oppressive and
patriarchal systems that perpetuate gender-based violence, as well as
address the internationalization and medicalization of sexual “trauma.”
Recently, the prevalence of sexual assault in the United States has
received much warranted attention in the media and policy discussions,
with Time magazine’s 2017 Person of the Year being awarded to The
Silence Breakers who launched the #MeToo campaign to give voice to
survivors of sexual violence (Zacharek, Dockterman, & Edwards, 2017). A
U.S. national survey found that 19% of women and 2% of men reported
being raped in their lifetime, and 44% of women and 23% of men reported
experiencing some other form of sexual violence (Breiding et al., 2014).
Although sexual assault affects individuals across all demographic groups,
some populations are more likely to experience it. For example, 46% of
Peters 3

bisexual women experience rape and 47% of bisexual men experience

some form of sexual violence (Walters, Chen, & Breiding, 2013). An
astounding 64% of transgender individuals are raped in their lifetime
(Grant et al., 2011). In addition, more than half of biracial and indigenous
people in the United States experience sexual violence (Breiding et al.,
2014; see Durazo, 2006, for review of the medicalization of gender-based
violence against people of color). The disproportionately high rates of
sexual violence among many marginalized groups demonstrate how vio-
lence is an act of power and dominance that reinforces oppressive patriar-
chal systems (Freire, 1970/1994; hooks, 1990).
This article will explore the increasing use of neoliberalized biopsychiat-
ric frameworks to understand and develop interventions for sexual assault
survivors. Positive and negative aspects of medicalization will be examined.
In an attempt to more fully appreciate the diversity of survivors’ experiences
and to honor the historical context in which medicine became a valuable
authority on well-being, a deconstruction of medicalization, rather than a uni-
lateral dismissal, is offered. Both medical and psychotherapeutic approaches
to coping with post-sexual assault experiences will be critiqued, and an argu-
ment will be made for an alternative epistemic and therapeutic approach that
incorporates a liberation psychology framework.

Medical Neoliberalism
Medicalization refers to the increasingly popular, fundamental belief that the
complex human experience of distress is best understood as a disease or dis-
order (Conrad, 1992). Although medicine is traditionally thought to address
solely illness, injury or pathology, society has increasingly called on medi-
cine to improve human’s well-being and “happiness” (e.g., sexual function,
infertility, alcoholism, old age; Rose, 2007). Thus, “medicine is inextricably
intertwined with the ways in which we experience and give meaning to our
world” (Rose, 2007, p. 701). Concerns about the medicalization of “normal”
human experiences have been raised for decades (e.g., Jacobs & Cohen,
2010; Szasz, 2007; Ussher, 2010) and attributed to the field of psychiatry’s
movement to have more human behavior fall under its purview, thereby
securing more patients and the field’s future (Summerfield, 2004). Dominant
discourses can be used to exert social control by establishing norms and
accepted truths (Foucault, 1972), and when medical institutions have the
authority to respond to sexual assault, survivors may be led to interpret their
behaviors and emotions in terms of “symptoms.” In turn, pharmacological
and psychotherapeutic interventions are privileged. This medical gaze
4 Journal of Humanistic Psychology 00(0)

(Foucault, 1973) may affect how survivors, and providers, view or react to
post-sexual assault experiences.
The ways in which a medical model is used to exert social control may be
best understood through philosopher Michel Foucault’s (1976/1990) concept
of biopower, which he defined as “techniques for achieving the subjugation
of bodies and the control of populations” (p. 140). Biopower is how a nation
state can coopt the human body and with the subtle development of social
expectations use individuals within the society to hold other individuals—
and themselves—accountable to those social norms, thereby regulating
human behavior through self-surveillance, without any obvious presence of
the nation state (Foucault, 1976/1990). When responding to survivors of sex-
ual assault, a medical model may promote biopower and further scrutinize
and regulate survivors’ behaviors, rather than address systemic issues.
Medicalization has not occurred in a vacuum; it has been facilitated in the
United States by a culture that esteems neoliberal values of self-responsibil-
ity, independence, and productivity (Sugarman, 2015). In turn, neoliberalism
is reinforced via the medical model’s intraindividual, biological explanations
of distress because they perpetuate the idea that individuals are responsible
for their own recovery. Neoliberalism is reinforced through what Foucault
(2008) termed governmentality—“the way in which one conducts the conduct
of men” (p. 186), or the ways in which sociopolitical institutions police
human behavior. Foucault’s (2008) concept of neoliberal governmentality
reveals that the values of individualism and competition are not inherent in
individuals; rather they come to be instantiated at all levels of society through
social practices, programs, and techniques (Rose, 1999). Because of this,
Foucault (1976/1990) described biopower as “an indispensable element in
the development of capitalism” (pp. 140-141). The result of this interdepen-
dency is “a subject at once required to make its own life and heavily regulated
in this making—this is what biopower and discipline together accomplish,
and what neoliberal governmentality achieves” (Brown, 2006, p. 705).
Many scholars have addressed the ways neoliberalism has affected ther-
apy. Sugarman (2015) described the way humanistic therapy, and many other
psychotherapies, ascribe to neoliberal goals of autonomy, self-responsibility,
and self-actualization. Neoliberalism has also created an audit culture that “is
undermining our therapeutic relationships with patients; it’s undermining our
professional motivation and sense of vocation; and it’s undermining the pub-
lic’s trust in mental health professionals” (Rizq, 2014, p. 211). The rise in a
neoliberal agenda in Western society therefore presents new challenges for
clinicians, especially for those working with survivors of sexual assault.
Neoliberalism began affecting the women’s movement in the 1970s
(Knight & Rodgers, 2012). Like medicalization, neoliberalism can impede
Peters 5

change at the societal level and hinder the ability to end sexual violence.
The increase of neoliberal governance, with its “glorification of individual
self-help and responsibility” (Beres, Crow, & Gotell, 2009, p. 142), is repri-
vatizing sexual assault and undoing previous feminist work to have sexual
violence conceptualized as a social problem. In neoliberalism, people are
considered fully responsible for their success and happiness (Sugarman,
2015), which also implies that people are responsible for their failures and
distress. The cause of problems is not in the sociopolitical realm but solely
within the individual. In this way, neoliberalism perpetuates victim blam-
ing—people are responsible for what happens in their lives and therefore
survivors are partially or fully at fault for their assault. This message can
have significant negative consequences, leading many survivors to feel
intense shame and self-blame (Ahrens, Cabral, & Abeling, 2009).
Not only does a neoliberal agenda make it difficult to end sexual violence,
but it also makes it more difficult for recovering survivors. For example,
productivity is highly valued in neoliberalism. Yet sexual assault survivors
who are experiencing great amounts of distress often struggle to be produc-
tive. Insofar as Western trauma theory compares the brain after trauma to a
broken machine (Summerfield, 1999), it runs the risk of reducing humans to
their output ability. Also, in a neoliberal culture, sociability, confidence, and
ingenuity are prized (Sugarman, 2015), but these traits may be very difficult
for sexual assault survivors to exude, making it harder for them to be accepted
and valued. In addition, neoliberalism disregards the value of interdepen-
dence and collectivism (Sugarman, 2015), and therefore survivors may try to
rely solely on intraindividual resources at the expense of community or cul-
turally based resources that may be helpful.
The medicalization of post-sexual assault experiences—experiences that
disproportionately affect women and other marginalized populations—occurs
when providers, clinicians, and survivors themselves view experiences in the
aftermath of sexual assault as disordered (e.g., distressing emotions and
behaviors are seen as “symptoms”) and requiring treatment (e.g., pharmaco-
therapy—psychotherapy for symptom reduction) to “fix” the distress. With
sexual assault, a biopsychiatric framework individualizes the problem so that
survivors are held accountable for their recovery, and societal forces contrib-
uting to sexual violence are ignored. Survivors may begin to identify the
locus of the problem within themselves and become discouraged if they con-
tinue to live in fear and are unable to “feel better” and regain a sense of con-
trol over their lives. When survivors of sexual assault view their reactions as
symptoms and adopt an injured identity (Gilfus, 1999), they are robbed of the
opportunity not only to be agents of change in their own life but also to be
involved in greater social change.
6 Journal of Humanistic Psychology 00(0)

Women’s experiences in particular have been noted for being increas-

ingly pathologized and, by extension, regulated (see, e.g., Becker’s, 2010,
discussion on the medicalization of stress, or Tiefer’s, 2002, review of the
medicalization of women’s sexual problems). “The gendered nature of this
medicalization results in an insidious creeping of pathologization into
women’s lives” (Ussher, 2010, p. 14). Many critiques of the medicalization
of women’s distress (Liebert, 2010; Ussher, 2010, 2013) have centered on
women being diagnosed with depression almost twice as frequently as men
(Strine et al., 2008). Researchers have raised the issue that an intra-individ-
ual diagnosis obscures contextual factors, especially in non-Western set-
tings (e.g., a depression diagnosis in low-income mothers in South Africa
concealed their anger at the impossibility of meeting ideal parenting stan-
dards while living in poverty; Kruger, van Straaten, Taylor, Lourens, &
Dukas, 2014). A “Western medical model of disease deflects political cau-
sation and individualizes the origin of the problem/illness. Likewise, the
medical industrial complex (MIC), yet another partnering of the state and
capital, co-opts social justice issues by taking them under its jurisdiction”
(Durazo, 2007, p. 120; see Spade, 2003, for a critique and deconstruction of
the MIC as it applies to gender and transgender/gender nonconforming
individuals). Women are also disproportionately represented in the diagno-
sis of borderline personality disorder (BPD), especially women who have
experienced childhood sexual abuse (Shaw, 2005), demonstrating an impor-
tant intersection between the pathologization of women’s distress and gen-
der-based violence.

Understanding the Medicalization of Sexual

Assault: The Shift From Posttraumatic Distress to
“Symptoms”
The inception of PTSD in the Diagnostic and Statistical Manual of Mental
Disorders, Third Edition (DSM-III) in 1980, occurring shortly after Burgess
and Holmstrom’s (1974) groundbreaking study supporting the existence of
“rape trauma syndrome,” was supported by many feminist activists because
it externalized the blame of survivors’ symptoms. This reification of PTSD
was made possible due to an increasingly prevalent assumption, both in the
general population and within the field of psychology, that the aftermath of
trauma will inevitably result in pathology (i.e., the medicalization of post–
sexual assault experiences). In questioning the application of PTSD in
global contexts, Summerfield (1999) challenges the assumption that “from
the beginning of history, people exposed to shocking experiences had been
Peters 7

liable to a psychiatric condition which only in 1980 had been fully discov-
ered and named” (p. 1450).
Today, PTSD—a common diagnosis for survivors of sexual assault—is
the epitome of the medicalization of trauma. PTSD was originally conceptu-
alized as a “normal” response to “abnormal” events (Herman, 1997).
However, since the rates of sexual assault are so high—more than 40% for
women in the United States (Breiding et al., 2014)—these events cannot be
considered abnormal, and therefore, PTSD may be better conceptualized as a
normal response to normalized events. Likewise, 24% to 58% of women
sexual assault survivors in the United States are diagnosed with PTSD (Walsh
et al., 2012). These incredibly high rates alone make one wonder about the
validity of PTSD as a “mental illness.”
Researchers are increasingly focused on trauma’s neurobiological effects
(Miller, Wolf, & Keane, 2014), and medication is used more and more as a
first-line treatment. There has also been a proliferation of short-term, evi-
dence-based practices to treat PTSD, with a focus on randomized control
trials and brain imaging to demonstrate efficacy (a literature search in
PsychINFO for PTSD and evidence-based practice yields more than 1,900
results). Lafrance and McKenzie-Mohr (2013) recognize the value in a diag-
nostic classification system that can validate people’s suffering but contended
that this validation is an illusion: “The biomedical discourse dominates, not
because it reveals ‘truth’, but due to its ability to construct a particular ver-
sion of reality” (Lafrance & McKenzie-Mohr, 2013, p. 120). In addition, the
validity, reliability, and utility of the DSM, including the diagnosis of PTSD,
have been questioned by many humanistic and feminist scholars (e.g.,
Burstow, 2005; Georgaca, 2013).
In much the same way that humanistic psychologists have critically
assessed diagnosis, medical anthropologists approach psychiatric diagnostic
categories, such as PTSD, with “skepticism,” acknowledging them as human
inventions that may be reductive and absent of cultural validity (Jenkins,
2014). From this perspective, diagnosis can be seen as a starting point that
aids in providing a shared language and framework for research in Western
contexts but is insufficient for fully understanding the complexity of human
experience. Acknowledging that trauma is often not a one-time event but may
be repeatedly experienced in an oppressive environment, Jenkins (2014)
questions if the “vast range of nosological and therapeutic application is
called for in light of the reality of the broad range of all-too-common human
suffering, or if the diagnosis simply misses or is inadequate to the task of
defining and healing” (p. 53). This question is especially relevant when con-
sidering a diagnosis of PTSD for sexual assault, since sexual violence is so
commonly experienced by marginalized groups.
8 Journal of Humanistic Psychology 00(0)

Rape Crisis Centers (RCCs) have played a vital role in supporting indi-
viduals who have experienced sexual violence since they were first estab-
lished in the 1970s (Campbell & Martin, 2001). Today, RCCs are an
invaluable resource to survivors of sexual assault with almost a quarter of
female survivors accessing their services (Planty, Langton, Krebs,
Berzofsky, & Smiley-McDonald, 2013). RCCs, founded via grassroots
efforts during the second-wave feminist movement to combat an oppres-
sive culture that facilitated sexual violence and originally staffed by vol-
unteer peer counselors, were at the forefront of developing alternatives to
the medical model (Maier, 2011). Yet, in a neoliberal society, rape crisis
services have undergone “professionalization” (i.e., services are provided
by professional staff rather than volunteers) and have been increasingly
pressured to adapt to a medical model (e.g., use diagnostic labels). Funding
agencies want RCCs to demonstrate the effectiveness of their services,
often based on non–client-centered outcomes or the number of client hours
(Maier, 2011). Durazo (2007) warned strongly against becoming reliant on
external funding because she believes that “funding, whether government
or foundation money, emerges from the deepest ravages of capitalist
inequality . . . it will not fund the movement to end violence against
women” (p. 126). It has been questioned whether professionalization has
been beneficial and necessary for the survival of RCCs (Campbell, Baker,
& Mazurek, 1998) or damaging to the antirape movement (Beres et al.,
2009). Regardless, research is showing that RCCs are shifting toward
more medicalized frameworks (e.g., diagnosing clients, using symptom-
based language, brief treatment models; Peters, 2018).

When to Adopt or Think More Critically About a

Biopsychiatric Discourse
Neuroscientist Peter Whitehouse (2013) is one of many scholars to critique
our biopsychiatric discourse. Although he does not explicitly identify as a
humanistic psychologist, Whitehouse’s reconceptualization of Alzheimer’s
disease is very congruent with humanistic psychology’s promotion of client
agency and consideration of sociocultural context. Whitehouse objects to
reductionist, oversimplified medical approaches to “Alzheimer’s disease” that
are inadequate for explaining the etiology of age-related cognitive decline or
informing a cure and calls for more innovative, ecopsychosocial approaches.
Ultimately, he is challenging one of the most naturalized disorders in the DSM
(i.e., Major or Mild Neurocognitive Disorder due to Alzheimer’s Disease) that
many assume is fundamentally anatomically based. Despite the deeply held
theory that Alzheimer’s is a physical disease, so far this framework has been
Peters 9

insufficient for fully explaining the lived experience of those diagnosed with
it, and no clear biomarkers for diagnosis have been found (Fotuhi, Hachinski,
& Whitehouse, 2009). Whitehouse’s (2013) refusal to accept solely intraindi-
vidual, biological explanations for Alzheimer’s disease, and instead focus on
descriptions that honor a person’s full experience, can be used as a model for
combating a reductionist medicalized explanation for distress post–sexual
assault. The push to conceptualize the aftermath of sexual assault as a disorder
fails to capture a survivor’s strength and resilience and obscures relational
struggles or sociopolitical issues that may be better described with an ecopsy-
chosocial model (e.g., Campbell, Dworkin, & Cabral, 2009; Neville &
Heppner, 1999). An important aspect of Whitehouse’s (2013) work is that he
does not ignore the real and debilitating cognitive decline that many experi-
ence with aging. Likewise, questioning a medicalized conceptualization of
distress post-assault should not deny the very real suffering of trauma survi-
vors; rather, it can help contextualize that distress.
As Michel Foucault (1984) astutely noted, it is “not that everything is
bad, but that everything is dangerous” (p. 343). This aptly applies to the
partnership between medicine and psychology. The medicalization of sex-
ual trauma has positive and negative effects, and rather than viewing it
from a dichotomous perspective—either one is “pro” or “anti” medicaliza-
tion—it would be helpful to have a more informed discussion about when
a medical discourse is useful or harmful. Gender-based violence was ini-
tially medicalized by emphasizing physical problems (e.g., sexually trans-
mitted diseases) and mental health problems as a way to decrease stigma
and provide survivors with more access to services (Lamb, 1999; Ticktin,
2011). There have been numerous benefits to a biopsychiatric model of
trauma, such as advancing knowledge about PTSD symptoms and provid-
ing more access to treatments by having an alternative diagnosis to BPD or
major depressive disorder (MDD; both commonly assigned to individuals
who have experienced trauma) that can be used for third-party reimburse-
ment. And, despite the focus on pathology, a medical model does not have
to be disempowering; many are finding ways to use neuroscience and
other medical frameworks in validating and affirmative ways (e.g., scien-
tifically authenticating the negative mental and physical effects of poverty
or discrimination; Ivey & Zalaquett, 2011). For example, a survivor who is
concerned she is going “crazy” because she is in incredible distress may
benefit from psychoeducation about PTSD symptoms of hyperarousal and
flashbacks. This information could make her feel less alone because many
others experience the same symptoms. Having a list of symptoms also
provides names for her experiences, which the survivor may choose to
incorporate in her self-narrative. In addition, the survivor and clinician
10 Journal of Humanistic Psychology 00(0)

now have a shared language to talk about the survivor’s distress, and treat-
ments can be directly tied to those experiences (e.g., trauma-based cogni-
tive behavioral therapy to manage flashbacks). As this example shows, a
medicalized discourse of sexual trauma is a tool that can be used to frame
a survivor’s experience. The problem arises when it is the only tool a clini-
cian is aware of, and is used indiscriminately, without space to accommo-
date alternative models that better fit an individual survivor’s experiences
or address the larger social structures and environment.
A danger of medicalization is that it may further broaden what behaviors
or experiences are defined as symptoms versus typical distress (Jacobs &
Cohen, 2010). In addition, stark gender differences were found in the years
following the inclusion of PTSD in the DSM, with women more likely than
men to be assigned a diagnosis of BPD over PTSD (Becker & Lamb, 1994).
And for many women, understanding their experience as a “disorder,” regard-
less of the diagnosis, is neither accurate nor helpful. Clinicians are primed by
the dominant discourse of the medical model to understand the aftermath of
sexual assault as PTSD, without thinking about alternative perspectives or
explanations. This raises the question, “Is this diagnosis truly honoring survi-
vors’ experiences or is it pathologizing them in a way that fails to appreciate
the complexity of their lived experience?” May it do both simultaneously? In
fact, the discourse of PTSD has been called “one of the worst thieves” (Lamb,
1999, p. 111) of survivor agency and resiliency.
As an illustration, imagine a woman who has experienced childhood
sexual abuse and has faced systemic racism throughout her life. She experi-
ences extreme sadness and self-hatred, has difficulty maintaining relation-
ships, and engages in self-harm to relieve the significant pain she feels.
After a clinical interview, this individual may be given a diagnosis of PTSD,
MDD, and/or BPD, and if so, a manualized treatment, such as prolonged
exposure therapy or dialectical behavior therapy, may be recommended.
Additionally, she will likely be prescribed a psychotropic medication. In
fact, the DSM-5 not only primes clinicians to think about distress in terms
of a disorder but for MDD makes the explicit note that “recovery may be
facilitated by antidepressant treatment” (American Psychiatric Association,
2013, p. 155). Even before the DSM-5 was published, Sturza and Campbell
(2005) found 38 out of 102 women survivors were prescribed either seda-
tives or antidepressants. In this example, the diagnosis and treatment stems
from a reductionist medical model that focuses on symptom-based diagno-
sis and treatment aimed at symptom reduction. Moreover, the survivor is
given the message that her distress, while perhaps perpetuated by negative
life experiences of oppression and abuse, is ultimately caused by a biologi-
cal malfunction within her.
Peters 11

Placing Post–Sexual Assault Experiences Within a

Sociopolitical Context
A major achievement of the second-wave feminist movement was position-
ing sexual assault as a sociopolitical issue (see Webster & Dunn, 2005, for a
history of feminist therapists, researchers, and activists who led the move-
ment to develop social approaches to combatting gender violence). The next
step is to not only position the occurrence of sexual assault within a sociopo-
litical context but also on how survivors are expected to react and what sup-
ports are offered in the aftermath of sexual assault. Humanistic psychologists
have used a feminist lens to explore the multiple victimizations experienced
by women within the current sociopolitical climate (Matos, Conde,
Gonçalves, & Santos, 2015). However, medicalization can lead to a focus on
intra-individual problems, emphasizing a person’s deficits, and inhibit social
justice work. It also undermines an appreciation for the fact that responding
to sexual violence is a social, not solely individual, problem. Durazo (2006)
highlights a number of issues with the medicalization of sexual violence from
a social justice perspective, as it (a) individualizes the problem to focus on
survivors, (b) ignores racial and social inequities that create an environment
conducive to sexual violence, and (c) prevents larger social change from
occurring. Current frameworks in counseling have been critiqued due to a
focus on intrapsychic problems that can inadvertently maintain oppressive
social structures (e.g., Greenleaf & Bryant, 2012).
The threat of sexual violence differs for individuals based on gender, race,
sexual orientation, and the intersection of a number of other factors that are con-
nected to who has or does not have privileged status in the current society (Breiding
et al., 2014; Crenshaw, 1991; Edwards et al., 2015). From a social justice perspec-
tive, more work is needed to address the inequities in the prevalence of sexual
violence within different populations, as well as individuals’ disparate access to
resources (e.g., medical, legal, mental health) post-assault. A traditional medical or
psychological model that maintains an intraindividual focus may not have the
complexity to address issues such as intersectionality, oppression, and power
dynamics that are at the forefront of social justice concerns.

Defining Experiences Post–Sexual Assault

In light of the power imbalance between survivors and their providers who
are diagnosing (i.e., labeling) those experiences, assigning a mental health
diagnosis may undermine survivors’ ability to define their own experiences.
This epistemic injustice (Fricker, 2007) ignores survivors’ experiences as
valuable forms of knowledge. Therefore, it is important to investigate how
12 Journal of Humanistic Psychology 00(0)

individuals who have experienced sexual assault make sense of those expe-
riences and how hegemonic discourses and practices affect their under-
standing and meaning making. Language shapes self-understanding, and
the language and terminology used in survivor narratives will have a pro-
found effect on their sense of self, relationship to the world, and future.
Survivors differ in the language they use. For example, some survivors
prefer the term recovery over healing because it holds a less medical con-
notation (Anderson & Hiersteiner, 2008), which matches language used by
consumers of psychiatry and substance abuse services. Not only should
clinicians mirror clients’ language and explicitly ask survivors what lan-
guage they would like to use to refer to their distress post assault, but clini-
cians should also aid clients in exploring sociopolitical factors that influence
the terminology they choose.
The average person’s perceptions of sexual assault predominantly
include assumptions that it is always traumatic and that professional sup-
port is very important to recovery (Gavey & Schmidt, 2011). These rigid,
pathologizing understandings of sexual assault could dictate limited paths
for recovery and restricted ways for survivors to describe the impact of
their assault. And yet these assumptions could also be validating for many
survivors and mean that there is reduced stigma around the incredibly dis-
tressing experiences many survivors have post assault. How do clinicians
balance supporting survivors who identify as traumatized or symptomatic,
while also providing space for survivors whose experiences do not fit a
medical model? And for survivors who value a biopsychiatric model, how
does one know if it is because it truly matches their experiences or simply
that it is the only discourse provided to them to understand their emotions
and experiences?
Humanistic psychologists remain attuned to their clients’ narratives as
a way to understand their histories and relational patterns (Bland &
DeRobertis, 2017). It is often beneficial for survivors to examine the nar-
ratives they tell both to themselves and to others and to have a space to
separate themselves from their stories and re-author their stories in more
empowering ways (e.g., narrative therapy; White & Epston, 1990).
Survivor narratives often involve a great deal of discontinuity (Harvey,
Mishler, Koenen, & Harney, 2000; Riessman, 1989), and this discontinuity
can be difficult for listeners, even postmodern feminist clinicians, to toler-
ate as they may be tempted to impose a rational narrative (see Cosgrove,
2007, for a critique of how rationality becomes naturalized in humanistic
psychology). Survivors may find a narrative approach limiting if there is
not space for contradiction and especially when a focus on individual nar-
ratives ignores racial and social inequities and does not facilitate social
Peters 13

action. Ussher’s (2000) discursive-analytic methodology, which allows for

a deeper appreciation of the sociopolitical context of experience and aids
researchers in attuning to multiple, conflicting, or discontinuous narra-
tives, may be beneficial (also see D. J. Johnstone’s, 2016, use of Brown
and Gilligans’s, 1992, Listening Guide method to investigate survivor’s
simultaneous knowing, not knowing, and ambivalence around whether to
label their experience as sexual assault).
Along with a paradigm shift in how the field as a whole views post–
sexual assault experiences, individual clinicians must put this new per-
spective into practice, and the challenges they will face should also be
noted. There are many real-world barriers to the demedicalization of sex-
ual trauma, above and beyond changing popular discourse. Perhaps the
most practical barrier is the limitations placed by a managed-care system
that emphasizes short-term therapy. Clients can become labeled as “prob-
lematic” and “chronic” (Pack, 2008, p. 38) if they require longer-term
treatment. In addition, survivors who decline therapy or medication may
be labeled as resistant or in denial. How do clinicians support the incredi-
bly diverse population of survivors and move away from a system that
stigmatizes some survivors for utilizing too many services and others for
utilizing too few? Although many humanistic psychologists are engaging
in social justice activism, and pushing the boundaries of counseling and
psychology to incorporate new forms of treatment, a radical shift is needed
to truly meet the needs of all sexual assault survivors.

Alternatives and Additions to the Medical Model

Humanistic psychology developed in response to the limitations of experi-
mentalism and behaviorism (Bland & DeRobertis, 2017), limitations which
are also evident in a medical model. Therefore, humanistic psychothera-
pists are uniquely primed to address the limitations of a medical model and
enact alternative perspectives when responding to sexual violence. Post
assault, survivors often have a new understanding for how cultural and
patriarchal structures facilitate sexual violence. As Lebowitz and Roth
(1994) note, “Being raped acts as a floodlight which allows the survivor to
see what was present all along but which previously was unrecognizably
embedded in the social landscape” (p. 371). This process is similar to Paulo
Freire’s (1998) concept of “conscientization,” where individuals become
aware of sociocultural systems of oppression, as well as their ability to
transform these systems. In fact, 80% of survivors report positive changes
of increased empathy and concern for others in similar situations just 2
weeks post-assault (Frazier, Conlon, & Glaser, 2001). Engaging in
14 Journal of Humanistic Psychology 00(0)

collective action has been linked to feeling more empowered (Drury,

Cocking, Beale, Hanson, & Rapley, 2005), and a pilot study found that
engaging in activism and antirape work can assist rape survivors in recov-
ery (Barnes, Gomez, Nguyen, & Ahrens, 2016). Therefore, survivors of
sexual assault may benefit from liberation psychology (Martín-Baró, 1994),
with an emphasis on validating survivors’ newly raised consciousness and
empowering survivors to engage in social change work.
Assumptions such as the need to define experiences post-assault or the
societal pressure to see a professional in order to “move forward” after sexual
assault need to be reexamined. Fundamental to this shift is the conceptualiza-
tion of distress within a sociopolitical context (Lafrance & McKenzie-Mohr,
2013) and a collaborative relationship between client and therapist. Examples
of humanistic alternative approaches that involve clients in the diagnostic pro-
cess include the collaborative diagnostic approach developed by Pavlo,
Flanagan, Leitner, and Davidson (2018) and the case formulations approach
by L. Johnstone (2018). These approaches, which are currently being studied
as alternatives to the DSM, incorporate clients’ strengths and future goals.
Rather than a single phrase diagnosis (e.g., post-traumatic stress disorder),
case formulation approaches may be multiple paragraphs long to capture cli-
ents’ complex experiences in their own words. These diagnostic approaches
could be a beneficial practice with survivors because they can assist the clini-
cian and the survivor to jointly make meaning of distress experienced post
assault. In addition, the collaborative process promotes survivor agency. This
collaboration requires clinicians to have epistemic humility (Wardrope, 2015),
honoring the expertise of their clients due to their lived experience, a concept
already prized in humanistic psychology (Bland & DeRobertis, 2017).
Ecological models, such as Neville and Heppner’s (1999) culturally inclu-
sive ecological model of sexual assault recovery (CIEMSAR), or Campbell
et al.’s (2009) extension of that model, also provide valuable alternatives to a
solely biopsychiatric approach. These ecological models intentionally incor-
porate sociopolitical and cultural factors (e.g., Ballou, Matsumoto, &
Wagner’s, 2002, feminist ecological model) and highlight the idea that “men-
tal health consequences of rape are caused by multiple factors beyond char-
acteristics of the victim or the assault” (Campbell et al., 2009, p. 238). In
addition, they provide multiple access points for intervention beyond the
medical model’s individual level. For example, at the microsystem level, an
intervention could involve improving responses from family members and
friends to disclosures of sexual assault (e.g., Edwards & Ullman, 2016,
Supporting Survivors and Self training for college students). Ecological
frameworks that acknowledge multiple levels of influence further contextual-
ize survivors’ experiences. In doing so, they also provide opportunities for
Peters 15

conversations with survivors about systemic oppression and patriarchal

structures in relation to sexual violence.
Changes must also be made in research methods that inform clinical prac-
tice. Participatory action research (PAR) welcomes stakeholder voices as
necessary and integral to the development of new interventions from the
ground up and has been used to support clinicians in expanding the boundar-
ies of their counseling roles specifically around sexual violence (Howton,
2011). Researchers and clinicians are encouraged to create and utilize inter-
ventions based on more complicated research frameworks such as PAR. For
example, there is an explicit awareness within PAR of power dynamics, an
awareness that is not always found when practitioners assign DSM diagnoses
to survivors. PAR’s principle to conduct research “with” participants, rather
than “on” them (Howton, 2011) can be expanded to the diagnostic process to
facilitate a more robust appreciation for practitioners’ power over survivors.
Transdisciplinary research partnerships, such as psychologist collaborations
with medical anthropologists and sociologists, may aid in a more nuanced
analysis of medicalization and PTSD that is neither “anti” nor “pro” but that
takes both the individual and the societal into account simultaneously.
Also, researchers and clinicians typically rely on disease-oriented out-
come measures that emphasize symptom reduction (e.g., the PTSD
Checklist [PCL]; Weathers et al., 2013). It may be beneficial for both clini-
cians and sexual assault researchers to broaden their definitions of recov-
ery to include lived experience and a sense of meaning and connection
versus just the absence of symptoms often captured by these measures
(Slade, Williams, Bird, Leamy, & Le Boutillier, 2012). Pelletier, Davidson,
and Roelandt (2009) note that “recovery aims at allowing people with
mental health problems to find dignity, and to exercise citizenship and
agency while continually developing personal skills and learning to deal
with obstacles to full community inclusion such as social stigmatization
and self-denigration” (p. 46). Citizenship, in this context, refers to “the
strength of individuals’ connections to the rights, responsibilities, roles
and resources that society offers to people through public and social insti-
tutions” (Rowe, Kloos, Chinman, Davidson, & Cross, 2001, p. 15). More
research is needed to extend Pelletier et al.’s (2009) work on recovery and
citizenship to individuals who have experienced sexual assault and inves-
tigate what barriers these individuals face to full citizenship. As new inter-
ventions like the ones outlined above are developed, clinicians need to
remain vigilant about treatments—both medical and psychotherapeutic—
that could be iatrogenic and be open to new definitions of trauma, treat-
ment, and recovery.
16 Journal of Humanistic Psychology 00(0)

Conclusion
It is time for a paradigm shift toward the demedicalization of post-sexual
assault experiences in therapy, and humanistic psychology is primed to lead
this movement. During this shift to address neocolonialism in psychology
(e.g., Washington, 2006), the field must resist the temptation to adopt a
dichotomy that vilifies medicalization and ignores the historical context
within which medicine became a valuable authority on general well-being in
Western society. Rose (2007) suggests, “The term medicalisation might be
the starting point of an analysis, a sign of the need for an analysis, but it
should not be the conclusion of an analysis” (pp.701-702).
A neoliberal, biopsychiatric model may undermine important conversations
around social inequities, pathologize survivors’ experiences, and lead to an
overemphasis on medication as the dominant treatment. However, a medical
model has also benefited survivors by reducing stigma and facilitating access
to services, as well as providing explanations and validation for many survi-
vors’ experiences. In addition, the important work done by feminist activists
and victims’ rights advocates since the 1970s to support survivors of sexual
assault by harnessing the power of a medical model should not be discounted.
More research is needed on the effects of a biopsychiatric model on the thera-
peutic process with sexual assault survivors. This includes transdisciplinary
partnerships, PAR, and qualitative studies directly exploring both the positive
and the negative effects of the medical model on survivors’ narratives and their
experiences of citizenship, as well as clinicians’ case conceptualizations and
treatment methods. With more research, there can hopefully be a deeper under-
standing of the impact of medicalization, which can inform new approaches to
recovery. Also, humanistic psychology’s emphasis on agency (Cosgrove, 2007)
can be harnessed to empower survivors and facilitate social change work.
Abraham Maslow (1966) perceptively stated, “I suppose it is tempting, if
the only tool you have is a hammer, to treat everything as if it were a nail”
(p. 15). Indeed, when clinicians’ main tool is a medicalized framework that is
reinforced by dominant psychiatric taxonomy (i.e., the DSM-5), they are
bound to see “symptoms” and “disorders” in their clients and may inadver-
tently perpetuate oppressive, patriarchal systems. In turn, their clients may be
left with an impoverished sense of self, focusing predominantly on ways in
which they are damaged or deficient. Survivors of sexual assault cannot be
free to fully explore their experiences until their therapists are encouraged to
put away the hammer.

Acknowledgments
The author would like to thank Dr. Lisa Cosgrove for her support and helpful feed-
back on earlier drafts of this article.
Peters 17

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author received no financial support for the research, authorship, and/or publica-
tion of this article.

Note
1. The author recognizes that the use of the term survivor upholds the dichotomy
of victim/survivor that imposes a certain meaning on someone’s experience that
may or may not be valid. However, working within the limitations of the current
discourse, survivor is considered the more respectful and empowering label and
therefore will be used throughout this article.

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Author Biography
Shannon M. Peters is a fifth-year doctoral candidate in
counseling psychology at the University of Massachusetts
Boston. She is engaged in research on institutional cor-
ruption and how medicalization and neoliberalism influ-
ence our understanding of distress and recovery. She has
also been volunteering on rape crisis hotlines for the past
9 years. Her clinical interests include emerging adult-
hood, feminist therapy, LGBTQ identity development,
and sexual trauma.