Sexual and Relationship Therapy

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Positive or negative change in outlook on life

following sexual assault and associations to PTSD
severity

Nina Beck Hansen, Maj Hansen, Louise Hjort Nielsen & Ask Elklit

To cite this article: Nina Beck Hansen, Maj Hansen, Louise Hjort Nielsen & Ask Elklit (2017)
Positive or negative change in outlook on life following sexual assault and associations to PTSD
severity, Sexual and Relationship Therapy, 32:1, 36-45, DOI: 10.1080/14681994.2016.1169266

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SEXUAL AND RELATIONSHIP THERAPY, 2017
VOL. 32, NO. 1, 36 45
http://dx.doi.org/10.1080/14681994.2016.1169266

Positive or negative change in outlook on life following sexual

assault and associations to PTSD severity
Nina Beck Hansen, Maj Hansen, Louise Hjort Nielsen and Ask Elklit
National Research Centre for Psychotraumatology, Department of Psychology, University of Southern
Denmark, Odense, Denmark

ABSTRACT ARTICLE HISTORY

In a sample of female victims of sexual assault (n D 122) this study Received 3 July 2014
examined the possibility of a positive or negative change in outlook Accepted 13 March 2016
on life 3 and 12 months following the assault and associations to KEYWORDS
posttraumatic stress disorder (PTSD). The majority of women Sexual assault; rape; outlook
reported a negative change or no change in outlook on life on life; posttraumatic stress
following the sexual assault. The group of women who reported a disorder; life changes
negative outlook on life 3 months following the sexual assault had a
significant higher level of PTSD severity 12 months following the
assault. More research is needed to enhance our understanding of
the causal relationship between life changes and psychological
distress following sexual assaults.

Introduction
Traumatic experiences can have significant consequences on the person’s life, expecta-
tions for the future, and psychological well-being (Helgeson, Reynolds, & Tomich, 2006;
Kessler, Sonnega, Bromes, Highes, & Nelson, 1995). Previously, research has focused on
the negative consequences following traumatic events such as posttraumatic stress disor-
der (PTSD) and depression (e.g. Kessler et al., 1995). However, during the last 20 years an
increasing amount of studies suggest that people can also experience different positive
outcomes following trauma such as increased meaning in life, enhanced life satisfaction,
and a feeling of personal growth (Calhoun & Tedechi, 2006; Helgeson et al., 2006). Thus,
it is suggested that the study of posttraumatic adaption must include both negative and
positive outcomes (Joseph & Linley, 2008a; Joseph, Williams, & Yule, 1993; Joseph et al.,
2005).
A change in outlook on life refers to the possibility of victims reappraising their lives
and expectations for the future following a traumatic experience (Joseph et al., 1993,
2005; Linley, Joseph, & Goodfellow, 2008). The concept of outlook on life is related to the
theory of schematic changes following trauma exposure (Janoff-Bulman & Frieze, 1983;
Joseph et al., 2005). According to Janoff-Bulman and Frieze (1983) traumatic experiences
can influence the victim’s basic assumptions of the world in three ways: The belief in

CONTACT Nina Beck Hansen nbeck@health.sdu.dk

© 2016 College of Sexual and Relationship Therapists

 SEXUAL AND RELATIONSHIP THERAPY 37

personal vulnerability, the perception of the world as meaningful, and the perception of
oneself as positive. The original perspective by Janoff-Bulman and Frieze (1983) focused
on the negative schematic changes following trauma exposure but newer studies have
shown the development of positive schema changes and a more positive outlook on life
following trauma exposure (Joseph et al., 1993, 2005; Linley et al., 2008).
However, most research on life changes following traumatic experiences has been con-
ducted with patients of critical illnesses or disasters whereas only a few studies have inves-
tigated both negative and positive life changes following sexual assault (Helgeson et al.,
2006; Joseph & Linley, 2008b). Especially, there seems to be a lack of research examining
the potential positive life changes following a sexual assault. In a systematic literature
review on 39 studies investigating positive life changes following trauma exposure (Linley
& Joseph, 2004), only two studies were based on samples of victims of sexual assault
(Frazier, Conlon, & Glaser, 2001; Thompson, 2000). In addition, to the best of our knowl-
edge no known studies have assessed the possibility of a positive or negative change in
outlook on life following sexual assault in specific. It is, however, suggested that sexual
assaults might differ from other traumas (Frazier & Berman, 2008). Being the victim of a
sexual assault is associated with higher rates of PTSD than many other traumas (Kessler
et al., 1995), and it might be more difficult to experience positive life changes following a
sexual assault because of the interpersonal harm and stigma of the experience (Frazier &
Berman, 2008; Janoff-Bulman, 1985).
Furthermore, research examining the associations between negative and positive
changes following trauma and PTSD is scant. A systematic review identified only eight
studies that have investigated the association between positive changes and aspects of
posttraumatic stress. Only one of these studies was prospective and also included a mea-
sure of PTSD (Linley et al., 2008). Negative life changes following trauma have been asso-
ciated with a higher level of PTSD (Frazier & Berman, 2008; Janoff-Bulman & Frieze,
1983; Joseph et al., 1993, 2005), but the association between positive life changes and
PTSD seems more uncertain. Some studies have found a negative association between
positive life changes and distress (Frazier & Berman, 2008; Linley et al., 2008), whereas
others have found no correlation (Joseph et al., 1993) or a positive correlation (Dekel,
Ein-Dor, & Solomon, 2012).
The current study addresses the above mentioned research gaps by investigating the
possibility of a perceived positive or negative change in outlook on life 3 and 12 months
following a sexual assault. In addition, we examined whether perceived negative or posi-
tive outlook on life 3 months following a sexual assault was associated with PTSD severity
12 months following the assault. When investigating this relationship, we also controlled
for the effect of other potential risk factor for PTSD severity. The selected risk factors
were age at the time of the assault, perceived social support, and PTSD severity at 3
months post assault. These variables were selected based on other studies on risk-factors
for PTSD (Andrews, Brewin & Rose, 2003; Brewin, Andrews, & Valentine, 2000) and the
theoretical model of trauma reactions by Janoff-Bulman (1992). Research indicates that
whether or not social support constitutes a protective factor for posttraumatic symptoms
depends on the quality of and the satisfaction with the social support rather than simply
the availability of social support (Andrews et al., 2003; Elklit & Brink, 2004). Studies have
also found that positive aspects of social support were protective against the development
of posttraumatic symptoms, while negative aspects of social support were risk factors for
38 N. B. HANSEN ET AL.

posttraumatic symptoms (Elklit, 2002; Hansen & Elklit, 2011, 2013; Richards, 2000).
Thus, we controlled for the potential influence of perceived positive social support, per-
ceived negative social support, and social support satisfaction.

Method
Participants
The current study was based on a sample of 122 female victims of sexual assault recruited
from a Danish regional Center for Rape Victims (CRV; see Bramsen, Elklit & Nielsen,
2009). The included women were in an age range of 12 58 years. Most women (59%)
had experienced a completed rape and the remaining women had been exposed to
attempted rape (12%), other sexual acts (20%), or they could not recall the specific details
of the assault they had been subjected to (9%).

Data collection
The study was part of a larger, ongoing study conducted at the CRV (see Bramsen et al.,
2009; Elklit & Christiansen, 2013). The included women had a self-report questionnaire
mailed to them by post by an administrative staff member working for the CRV at 3 and
12 months following the assault. Each questionnaire included a stamped return envelope
for the women to return by mail. The women were offered psychological assistance to fill
out the questionnaires, if they found them too difficult to answer. Participation was volun-
tary and the women could decline further participation in the study at any time. The study
was carried out adhering to the ethical principles contained in the Declaration of Helsinki,
and was approved by the Danish Data Agency. Data was treated and anonymized accord-
ing to the agency’s guidelines.

Measures
Perceived change in outlook on life was assessed at 3 and 12 months following the assault
using the same single question as Joseph et al. (1993) when they developed the Change in
Outlook Questionnaire (CiOQ): “Do you feel that the assault has changed your outlook
on life in a positive or negative way?” The victims’ answers were coded into the three fol-
lowing categories: negative change, no change, and positive change.
PTSD severity was assessed at 3 and 12 months following the assault using the Danish
version of the Harvard Trauma Questionnaire (HTQ; Mollica et al., 1992). The HTQ
measures the intensity of the three core symptom groups of PTSD (intrusion, avoidance,
and arousal) and consists of 30 items, 16 of which correspond to the DSM-IV. The
answers are scored on a 4-point Likert-type scale (1 D not at all, to 4 D all the time). Pos-
sible total HTQ scores are in the range of 32 128. The Danish version of the HTQ has
shown good reliability and validity (Bach, 2003). In the present study, the Cronbach’s
alpha value for the total HTQ scale at treatment start was .94.
Perceived social support post-assault was assessed 3 months following the assault using
the Danish version of the Crisis Support Scale (CSS; Joseph, Andrews, Williams, & Yule,
1992). The scale is comprised of the following seven items: (1) perceived availability of
 SEXUAL AND RELATIONSHIP THERAPY 39

someone to listen; (2) contact with people in a similar situation; (3) the ability to express
oneself; (4) received sympathy and support; (5) practical support; (6) the experience of
being let down; and (7) general satisfaction with social support. In accordance with previ-
ous studies (Andrews et al., 2003), the summated score of the first five items is used as a
measure of positive support, item six is used as a single measure of negative support (feel-
ing let down), while item seven is used as a single measure of overall satisfaction with
received social support. Responses are rated on a 7-point Likert-type scale (1 D never, to
7 D always). The Danish version of the CSS has shown good reliability and validity (Elklit,
Pedersen & Jind, 2001). In the present study, the inter-item correlation was .23.

Statistical analyses
The percentages of missing values were low (.00% 8.3%). Thus, the expectation-
maximization (EM) algorithm was used for imputing missing values. Correlation analyses
were conducted for the included variables. The strengths of the associations were assessed
according to Cohen’s guidelines (Cohen, 1988). A hierarchical regression analysis was used
to investigate the impact of outlook on life 3 months following the sexual assault on PTSD
severity 12 months after the assault. The three life outlook groups (i.e. negative, no change,
and positive) were dummy coded into two variables that represent the distinction between
the comparison group (group with no change) and the two other groups in questioning.
We controlled for the impact of age at the time of the assault and perceived social support
at 3 months post assault. The dependent variable (PTSD severity 12 months post assault)
was normally distributed and there were no problems with multicollinearity. All analyses
were conducted using the Statistical Package for Social Sciences (SPSS) version 21.

Results
Perceived outlook on life
Table 1 presents the descriptives of the sample and the means and standard deviations of
the main study measures. The majority of women reported that their outlook on life had
changed in a negative way (43.4%) or had not changed (39.3%) following the sexual
assault. There was an increase in the number of women who reported a more positive out-
look on life following the assault from 3 to 12 months post assault. Also, there was a

Table 1. Descriptives of the study’s main measures.

3 months post assault (n D 122) 12 months post assault (n D 122)
Age (SD) 23.98 (10.19) 23.98 (10.19)
Outlook on life
Negative change (%) 53 (43.4%) 44 (36.1%)
No change (%) 48 (39.3%) 53 (43.4%)
Positive change (%) 21 (17.2%) 25 (20.5%)
HTQ total (SD) 38.53 (9.94) 35.58 (10.16)
CSS NEG (SD) 4.18 (2.05) 3.72 (1.97)
CSS POS (SD) 18.83 (4.12) 22.25 (4.98)
CSS SAT (SD) 5.78 (1.42) 5.69 (1.35)
Note: CSS NEG (feelings of being let down), CSS POS (positive social support), CSS SATISFAC (social support satisfac-
tion), HTQ (PTSD severity).
40 N. B. HANSEN ET AL.

Table 2. Correlations between the study variables and PTSD severity.

HTQ total 3 months HTQ total 12 months
Outlook on life 3 months ¡.37 ¡.31
Outlook on life 12 months ¡.13 ¡.25
Age ¡.03 ¡.06
CSS NEG ¡.04 ¡.03
CSS POS ¡.34 .25
CSS SAT ¡.47 ¡.36
Note: CSS NEG (feelings of being let down), CSS POS (positive social support), CSS SATISFAC (social support satisfac-
tion), HTQ (PTSD severity).

p D < .01

p D < .001, two-tailed.

decrease in the number of women who reported that the assault had a negative effect on
their outlook on life from 3 to 12 months post assault.

Correlation analyses
Table 2 shows correlation analyses between the study variables and PTSD severity at 3 and
12 months post assault. A more positive outlook on life, more perceived positive support,
and more perceived social support satisfaction 3 months post assault were associated with
less PTSD severity 3 months post assault. The associations were in the medium range
(r D ¡.37 to ¡.47, p < .001). A more positive outlook on life at 3 and 12 months post
assault as well as more perceived positive support and more perceived social support satis-
faction 3 months post assault were associated with less PTSD severity 12 months post
assault. The associations were in the small to medium range (r D ¡.25 to ¡.36, p < .001)

Outlook on life and PTSD severity

Table 3 shows the regression coefficients for the outlook on life groups and the selected
risk factors. Age and perceived social support were entered at Step 1, explaining 14.7% of
the variance in PTSD severity. After entry of outlook on life groups at Step 2, the total var-
iance explained by the model as a whole was 19.9%, F(6,115) D 4.75, p < .001. Outlook on
life explained an additional 5% after controlling for age at the time of the assault and per-
ceived social support, R2 change D .05, F change (2,115) D 3.94, p < .05. In the final
model, only level of perceived social support satisfaction and negative outlook on life

Table 3. Hierarchical multiple regression analysis. Predicting PTSD severity 12 months following sexual
assault.
Variable B SE b t p
(Constant) 48.50 4.741 10.22 .000
Step 1 Age .08 .09 .08 .94 .439
CSS NEG .58 .45 .12 1.28 .348
CSS POS ¡.22 .28 ¡.09 ¡.78 .005
CSS SAT ¡2.27 .79 ¡.32 ¡2.86 .203
(Constant) 43.35 5.11 8.48 .000
Step 2 Negative outlook 4.37 1.95 .21 2.25 .027
Positive outlook ¡1.72 2.45 ¡.06 ¡.70 .484
Note: CSS POS (positive social support), CSS NEG (feelings of being let down), CSS SATISFAC (social support
satisfaction).
 SEXUAL AND RELATIONSHIP THERAPY 41

were statistically significant with perceived social support satisfaction recording a higher
beta value (b D ¡2.86, p < .01) than negative outlook on life (b D 2.25, p < .05).

Discussion
This study investigated perceived changes in outlook on life following a sexual assault and
associations to PTSD severity. We found that the majority of women exposed to a sexual
assault reported that their outlook on life had changed in a negative direction or had not
changed both at 3 and 12 months following the assault. It has been suggested that it could
be more difficult to experience positive life changes and a positive outlook on life follow-
ing sexual assaults compared to non-interpersonal traumas such as disasters and illnesses
because of the interpersonal aspect involved in these crimes (Frazier & Berman, 2008;
Janoff-Bulman & Frieze, 1983). In accordance with this, Shakespeare-Finch and
Armstrong (2010) found that a group of bereaved persons reported more positive life
outcomes compared to victims of sexual abuse. Frazier and Berman (2008), though,
reported that 91% of their sample of victims of sexual assault could report some positive
life changes following the assault. However, at the same time 95% of the victims also
reported negative life changes. Despite studies in the area being sparse, the few existing
studies indicate that a negative outlook on life and the experience of negative life changes
are common posttraumatic reactions in women of sexual assault. However, more women
reported a positive outlook on life 12 months following the assault than at 3 months. This
finding may support the notion that positive posttraumatic life changes develop over time
(Calhoun & Tedechi, 1998; Frazier and Berman, 2008; Janoff-Bulman, 2006). Also, Frazier
and Berman (2006) reported on a sample of victims of sexual assault that positive changes
increased and negative changes decreased over time. Therefore, it is possible that a longer
follow-up period would find a higher percentage of women reporting a positive change in
outlook on life following a sexual assault.
As hypothesized, we found that the group of women who experienced a negative
change in outlook on life following sexual assault had a significant higher level of PTSD
severity 12 months following the assault compared to the group of women who reported
no change. However, we did not find that the group of women who reported a positive
outlook on life had a significant lower level of PTSD severity compared to the group of
women who reported no change in outlook on life. This finding, though, is consistent
with results reported by Kennedy, Davis, and Taylor (1998) who found that the effect of
negative changes in spirituality on psychological distress was larger than the effect of posi-
tive life changes on psychological distress based on a sample of victims of sexual assault.
Similarly, Joseph et al. (1993) reported that negative changes in outlook following a ship-
ping disaster were associated with more psychological distress, while positive changes in
outlook on life were not significantly associated with the level of psychological distress.
These results indicate that negative changes following sexual assault seem to hurt more
than positive changes help. This seems supportive of the notion by Janoff-Bulman (2006),
who suggested that positive life changes following the trauma may develop over time but
that the painful negative representation is always present, ready to dominate the survivor’s
psychological world.
Also, consistent with the hypotheses we found that outlook on life at 3 months were
predictive of longer-term PTSD severity following a sexual assault. This finding lends
42 N. B. HANSEN ET AL.

support to the argument that the development of positive life changes following traumatic
experiences may be a foundation for therapeutic work (Linley & Joseph, 2004; Zoellner &
Maercker, 2006). However, considering the finding that especially a negative outlook on
life (as opposed to a positive outlook on life) was associated with more PTSD severity
could indicate that the important therapeutic target is to hinder the spreading of the nega-
tive consequences of the assault to the victims’ world view and expectations for the future
rather than the target should be to develop a positive outlook on life following the assault.
The current study, though, also found that the effect of outlook on life on PTSD severity
was small, with outlook on life explaining 5% of the variance in PTSD severity when con-
trolling for the effect of age, positive social support, negative social support, and social
support satisfaction. In this study, social support satisfaction following the sexual assault
was just as important variable for PTSD severity as negative outlook on life was.
In the current study, we hypothesized that outlook on life at 3 months would be predic-
tive of longer-term PTSD severity. However, the relationship between life changes and
PTSD has been debated (for a review, see Dekel et al., 2012). A group of studies have
found that positive changes were related to later reduction in distress (Frazier et al., 2001;
Linley et al., 2008). Less researched is the reverse path that the experience of positive or
negative life changes is the outcome of the level of psychological distress following the
trauma. As such, Dekel et al. (2012) found that PTSD predicted positive life changes in a
sample of Israeli ex-prisoners. The small effect of outlook on life at 3 months following
the assault on PTSD severity at 12 months could be explained by the possibility that it is
PTSD severity which predict outlook on life and not vice versa. However, in the current
study we only found a significant correlation between outlook on life 3 months post
assault and PTSD severity at 12 months post assault whereas the correlation between
PTSD severity 3 months post assault and outlook on life at 12 months post assault was
not significant. This could indicate that outlook on life following a sexual assault is affect-
ing PTSD severity although the effect in this sample was in the smaller range. At the
moment, though, research in the area is sparse and most studies have been conducted on
cross-sectional study designs (Helgeson et al., 2006). Further studies are needed in order
to explore the relationship between psychological distress and life changes following
trauma exposure before any firm conclusions can be drawn.

Limitations
The current study has several limitations. First, the sample consisted of female victims of
sexual assault and results are therefore only applicable to this gender. In addition, the
study was conducted based on a convenience sample and limited to the women who
returned questionnaires and thereby participated in the study. This introduces the risk of
sampling bias and the results may not be representative of all female victims of sexual
assaults.
Furthermore, we only controlled for the effect of perceived social support and age at
the time of assault. Some of the women in this sample also received psychotherapy which
we were not able to assess the effect of. Other variables are also likely to influence the
experience of change in outlook of life. As stated by Tedechi & Calhoun (2004), positive
posttraumatic life experiences develop through the personal experience of struggling with
a traumatic event. Variables such as personality traits, coping mechanisms, and the
 SEXUAL AND RELATIONSHIP THERAPY 43

severity of the assault are likely to influence the personal consequences of a traumatic
event. Future studies would benefit from controlling for the effect of these variables. More
knowledge of the variables that affect the final outcome or what type of trauma that affects
the outcome regardless of the personal variables is important information for future
studies.
Finally, outlook on life was assessed with a single item and not a standardized measure
such as the CiOQ (Joseph et al., 1993). This study was conducted in relation to a larger
study and therefore the length of the questionnaire was a factor in the choice of measure-
ment instrument. It is possible that this single item does not represent the total concept of
life outlook and therefore the inferences which can be drawn from this question are also
limited. A more nuanced measure (such as the CiOQ) would have increased the validity
of the participants’ responses and should preferable be used in future studies. However,
the single item used in this study was similar to the item from which the CiOQ was origi-
nally generated (Joseph et al., 1993) and hopefully we were able to assess some of the
aspects of the concept of outlook on life with this single question.

Conclusions
Despite its limitations, the current study adds to the limited amount of existing research
on positive and negative life changes following sexual assault. Our results indicated that
the majority of female victims of sexual assaults reported a negative change or no change
in outlook on life at 3 and 12 months post assaults. Results also indicated that the experi-
ence of a negative outlook on life was a risk factor for a higher level of PTSD severity fol-
lowing a sexual assault whereas positive life changes were not significantly associated with
PTSD severity. However, more research is needed to enhance our understanding of the
causal relationship between life changes and psychological distress following trauma
exposure in general and sexual assaults in specific. Personal posttraumatic consequences
develop though complex interactions between the personal characteristics, the characteris-
tics of the trauma and the social surroundings. Research investigating these interactions
are needed.

Disclosure statement
No potential conflict of interest was reported by the authors.

Notes on contributors
Nina Beck Hansen is a PhD fellow at the Department of Psychology at the University of Southern
Denmark. Her dissertation research examines how going through the judicial system affects victims
of rape and sexual assault.

Maj Hansen is an assistant professor at the Department of Psychology at the University of Southern
Denmark. Her research examines the psychological impact of interpersonal violence.

Louise Hjort Nielsen is a PhD fellow at the Department of Psychology at the University of Southern
Denmark. Her dissertation research examines how the legal, medical, and mental health systems
44 N. B. HANSEN ET AL.

respond to the needs of victims of rape and sexual assault and how this contact affects victims of
rape and sexual assault.

Ask Elklit is a professor of psychology at the University of Southern Denmark and the head of the
National Centre for Psychotraumatology. His research covers a wide array of areas in the field of
psychological trauma, crisis intervention, and crisis management. He is currently involved in sev-
eral major studies regarding domestic violence, war veterans, traumatized immigrants, sexual
assault, and detecting traumas in infants, among many other projects.

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