Rape Multiple Case Study

American Journal of Community Psychology, Vol. 26, No.
4, 1998
Innovative Community Services for Rape

Victims: An Application of Multiple Case
Study Methodology1
Rebecca Campbell2 and Courtney E. Ahrens
A qualitative multiple case study design was used to examine communities

across the United States that have developed coordinated community-based
programs to assist rape victims. Previous studies have suggested that
coordinated community programs help victims obtain needed resources and
services. This study provided a follow-up examination of how and why these
programs are helpful to rape victims. In-depth interviews were conducted with
rape victim advocates, rape crisis center directors, police officers, prosecutors,
doctors, nurses, and rape survivors from 22 communities with coordinated
programs. A comparison sample of 22 communities with fewer coordinated
programs was also obtained. Results indicated that the high coordination
communities had three types of programs to address sexual assault: coordinated
service programs, interagency training programs, and community-level reform
groups. Although not all of these programs directly address service delivery for
rape victims, they help create a community culture that is more responsive to
victims' needs. The research team and participants developed an explanatory
model of why these program are effective in addressing rape victims' needs. This
model hypothesizes that coordinated programs reflect an understanding of the
multiple contexts of service delivery and embody that knowledge in services that
are consistent with victims' needs. Narrative data from the interviews with service
providers and rape survivors are used to develop and support this model.
1
The authors thank Jim Kelly, Robin Miller, Vicki Banyard, Ken Miller, and the members of
the Psychology and Law Program at the University of Illinois at Chicago for their helpful
comments on this project; the members of the Community Response to Rape Project for their
assistance in data collection and coding; and the rape victim advocates and other community
workers who participated in this study for their time, expertise, and feedback on this manuscript.
2
All correspondence should be addressed to Rebecca Campbell, Department of Psychology
(M/C 285), University of Illinois at Chicago, 1007 West Harrison, Chicago, Illinois
60607-7137. E-mail: rmc@uic.edu.
537
0091-0562/98/U800-0537$15.00/0 C 1998 Plenum Publishing Corporation
538 Campbell and Ahrens
KEY WORDS: multiple case study design; rape victims; coordinated programs.
Social services have undergone a public reexamination in recent years,

which has included a new look at how our communities assist survivors of
sexual assault. Rape victims have diverse needs and may call upon the legal,
medical, and mental health systems for assistance. But these services are
often "organized" in a piecemeal and uncoordinated fashion—different sys-
tems perform different functions and there is infrequent contact among
service providers. To address these problems, some communities have re-
designed rape crisis services to form coordinated, integrated systems of care
(e.g., Boles & Patterson, 1997; Patterson & Boles, 1992, 1993). For exam-
ple, some communities have developed Sexual Assault Response Teams
(SARTs) that bring different service providers, such as police, prosecutors,
doctors, social workers, and rape victim advocates, to a single location to
work together as a unit to help rape survivors and their families.
These innovative coordinated service programs are few in number and
most have not been formally evaluated. But there are promising findings
from the limited number of studies that have examined these programs. In
communities where there is more coordination of rape crisis services, victims
are more likely to obtain needed resources and assistance (Campbell, 1998;
U.S. Department of Justice, 1994). However, these few studies raise more
questions than they can answer. Perhaps one of the most central issues for
this developing literature is to describe and understand these coordinated
service programs: What are they, and why are they helpful to rape survivors?
The goal of this study is to provide some descriptive and explanatory details.
This research employed a qualitative multiple case study design to examine
22 communities across the United States that have developed coordinated
service programs for sexual assault. A review of the previous studies that
have examined these alternative programs is presented first, followed by a
discussion of why qualitative methodology was chosen for this research and
an overview of the techniques of multiple case study designs.
THE COMMUNITY RESPONSE TO RAPE:

COORDINATED SERVICE DELIVERY
Findings from Previous Research
In 1994, the U.S. Department of Justice reported an intriguing finding:

"In an increasing number of communities, law enforcement and social serv-
ice agencies have formally coordinated their response to the crime of
Multiple Case Study Methodology 539
rape . . , [these] changes have helped [them] maintain a successful stance

against rape" (p. xi). The focus of the study was to describe four commu-
nities in the United States that have coordinated service programs for rape
victims. Although outcome evaluation was not a primary goal, this explora-
tory work indicated that these programs were helpful to survivors. A similar
descriptive approach was taken by Patterson and Boles's (1992, 1993) Look-
ing Back, Moving Forward program, which trains communities to create in-
tegrated sexual assault response systems. This curriculum recommends
conducting victim outcome assessments, but the focus thus far has been on
getting these programs started.
Building on this research, Campbell (1998) examined whether co-
ordinated service programs help rape survivors obtain needed commu-
nity resources. In this research, a nationally representative sample of
rape crisis centers was selected and the staff advocate at each center
participated in a phone interview. The rape victim advocates were asked
to describe the experiences of the most recent rape victim with whom
they had worked along four dimensions: (a) what happened in the as-
sault; (b) from which systems did the survivor seek assistance; (c) what
help was provided by each system; and (d) was the help provided con-
sistent with the survivor's needs. In addition, the advocates were asked
about the type and quality of services available for rape victims in that
community. Thus, the rape victim advocate sample was obtained for in-
formant interviewing to learn about the experiences of individual victims
across the country as well as the services available for rape survivors in
those communities.3
The results of the Campbell study suggested that rape victims' expe-
riences with the legal, medical, and mental health systems are quite diverse.
Cluster analysis was used to uncover three patterns of experiences with
social systems. The first cluster of victims had relatively positive experiences
with all three systems. Overall, these survivors were able to obtain most of
the services they desired. A second group had positive outcomes with only
the medical system, where they were able to receive desired help. But, in
the legal system, these victims saw their cases dismissed against their wishes,
and in the mental health system, they were unable to find counseling for
rape-related trauma. The final group of rape victims had negative experi-
ences with all three systems—they were not able to obtain even some of
the assistance they wanted. Of particular interest in this study was whether
community coordination of services would predict victims' outcomes (i.e.,
3
Campbell (1996) assessed the validity of the rape victim advocate reports by randomly
selecting 50 cases (of 168) and asking police and hospital staff identical questions as those
posed to the advocates. The findings revealed extremely high overlap among all service
providers answers.
cluster membership). In other words, if a victim lived in a community that

had a coordinated service program, would she be more likely to obtain
needed resources (i.e., be in the first cluster)? The results suggested that
victims who lived in communities where there was more coordination of
services for sexual assault survivors were indeed significantly more likely
to have positive experiences with social systems. Furthermore, community
coordination was statistically compared to other predictors (e.g., type of
rape, victim demeanor) and was found to predict a significant portion of
unique variance in the outcome variable (cluster membership). These find-
ings suggest that coordinated community service programs are an important
factor influencing whether rape victims obtain needed community re-
sources.
Unanswered Questions
Although these studies have provided initial descriptive information

about coordinated service programs and their effectiveness, several unan-
swered questions remain. For example, across all of these studies, descrip-
tive data about the programs have been sparse, which is somewhat expected
given that the focus was to demonstrate the existence of such innovative
programs. But it is not fully known how these programs function. Another
unanswered question is why these programs work. Campbell (1998) found
that coordinated programs facilitate service delivery, yet the mechanisms
that account for this effectiveness are unknown. The nature of these un-
answered questions calls for techniques that favor depth over breadth, or
as Huberman and Miles (1994) stated, "we [need] to get inside the black
box; we can understand not just that a particular thing happened, but how
and why it happened" (p. 434).
ANSWERING "HOW" AND "WHY" QUESTIONS:

EPISTEMOLOGY, METHODOLOGY, AND DESIGN
Developing an Epistemological and Methodological

Framework for this Research
Coordinated service programs for rape survivors exist in some com-

munities across the United States and appear to be beneficial to women,
but why? In building such an descriptive and explanatory model, it is im-
portant to consider Gergen's (1985) challenging question to social scientists
regarding the epistemology of inquiry: "How can theoretical categories be
induced or derived from observation . . . if the process of identifying ob-

servational attributes itself relies on one's possessing categories" (p. 266).
In the context of this study, Gergen's challenge implied that if we attempted
to identify attributes of coordinated communities, but began this analysis
with preconceived categories, how could these descriptions truly be derived
through observation? Thus, the current study is rooted in a constructivist
epistemology (see Gergen, 1985) so as to place more conceptual emphasis
on describing coordinated communities from the perspective of the com-
munity members, not from the perspective of the researchers' a priori es-
timates of how these service programs organize and function.
The methodological paradigm followed in this study was based upon
the grounded theory perspective articulated by Strauss and Corbin (1990).
This model advocates that social scientists work "from the bottom up": to
derive theory from observations, not observations from theory. The meth-
odological goal of this study was to work with system personnel from these
innovative rape crisis programs to develop rich, detailed descriptions of
these programs. These observations were then used as the conceptual start-
ing point to develop an explanatory model of effectiveness (see also
Kincheloe & McLaren, 1994; Lincoln & Guba, 1985; Miles & Huberman,
1994; Schwandt, 1994; Tesch, 1990).
The specific method used in this study was a qualitative case study
design. The ability of the case study to answer "how" and "why" questions
within real-world contexts is an important strength, and one of noted in-
terest to community psychologists (Trickett, 1984, 1994). Yin (1994) de-
scribed this method as:
A case study is an empirical inquiry that investigates a contemporary phenomenon
within its real life context, especially when the boundaries between phenomenon
and context are not clearly evident. In other words, you would use the case study
method because you deliberately wanted to cover contextual conditions—believing
that they might be highly pertinent to you phenomenon of study . . . The case study
inquiry copes with the technically distinctive situation in which there will be many
more variables of interest than data points . . . In this sense, the case study is not
either a data collection tactic or merely a design feature alone but a comprehensive
research strategy. (Yin, 1994, p. 13)
A case study involves collecting in-depth observations in a limited num-
ber of cases—to focus on fewer "subjects," but more "variables" within each
subject. Researchers engage in direct observations of selected cases and/or
in-depth interviews with those cases. Regardless of the specific data collection
technique used (observation or interview), the goal is to obtain detailed tex-
tual data describing the cases. Case studies can follow one of two major de-
signs: a single case study where a single subject is examined in-depth, or a
multiple case study where several cases or events are studied. A multiple
case study design has all of the advantages of a single case design in capturing
real-world contexts, but in repeating the procedures on multiple cases, this

replication enhances the validity and generalizability of the findings (Galloway
& Sheridan, 1993). Furthermore, in analyzing and interpreting multiple case
designs, each case should be viewed as if it were a separate experiment, rather
than a single sampling unit, thereby following a replicating logic (Yin, 1994).
Consequently, multiple case designs can be viewed as follow the same logic
as cross-experiment designs (Yin, 1982, 1994).
In this study, a multiple case study design was used: The researchers
interviewed multiple types of service providers (e.g., police, nurses, rape vic-
tim advocates) who work in innovative rape crisis programs across multiple
communities throughout the United States. These community workers were
asked to describe their programs in their own words, and these narratives
were used to develop typologies of innovative programs, to describe each
type of program in rich detail, and to guide the construction of an explana-
tory model articulating why these programs are beneficial to rape survivors.
Rigor and Quality in Multiple Case Study Methodology
A multiple case study design may be an appropriate choice for many

studies in community psychology, but psychologists have been reluctant to
choose this strategy due to misconceptions about this method. Previously
reported case studies have been criticized for allowing investigator bias to
permeate the research, not employing methodological rigor in describing
procedures, and failing to address reliability and validity (Kazdin, 1981;
Kennedy, 1979). The qualitative methodology literature contains many sug-
gestions for addressing these potential criticisms.
Reliability refers to the extent to which consistent results would be
obtained if the same procedures were followed by different researchers.
Two strategies are often recommended to enhance the reliability of multiple
case study designs. First, Yin (1982) suggested the use of a field guide,
which delineates the basic theory or hypotheses of interest, the type of in-
formation that will be collected, and the information that should be ex-
cluded. This guide outlines the procedures so that other researchers could
replicate the study. This precise documentation of the process of research
has also been referred to as maintaining a chain of evidence (Wells, 1987).
Second, using multiple coders to review and analyze textual data can help
to ensure a level of objectivity,4 allow for the computation of inter-rater
4
The value placed upon "objectivity" varies considerably within the qualitative methods
literature. Some authors, such as Gergen (1985), question whether there is ever true
objectivity in research, quantitative or qualitative.
reliability, and enhance the findings by allowing for a convergence of mul-

tiple interpretations (Larsson, 1993; Sackman, 1991; Yin & Heald, 1975).
With respect to the validity of multiple case studies, a central concern
is external validity— the extent to which the findings from a small number
of cases can be generalized. As mentioned above, multiple case studies rep-
resent an improvement over single case studies due to the replication in-
herent in the design, which enhances confidence in the generalizability of
the findings. Researchers have also discussed this issue as one of compa-
rability (Stake, 1994) or transferability (Lincoln & Guba, 1985), and em-
phasized the importance of supplying detailed information to the reader
about the process of conducting the research and the decisions made by
the research team so that the audience can evaluate the utility of the work
for their own endeavors. Alternatively, Yin (1994) argued that the notion
of generalizability should be understood as analytical, rather than statistical,
and the goal is to generalize the results to a theory rather than a particular
population. In this vein, the results from the case study either corroborate
or refute theoretical assumptions and are useful in this regard.
Internal validity, or the extent to which the reported findings accu-
rately reflect the concept under investigation, is an additional methodo-
logical concern for case study research. Once again, replication is the key
to confidence in the findings. Triangulation—the use of multiple measures
and/or assessment points—is critical in evaluating the credibility of the find-
ings (Huberman & Miles, 1994; Lincoln & Guba, 1985; Sackman, 1991;
Wells, 1987; Yin, 1981). Interview data can be supplemented with obser-
vations (Sackmann, 1991), documentary information (Maton & Salem,
1995), or questionnaires (Banyard, 1995). To further enhance the validity
of the interpretations, Lincoln and Guba (1985) noted the importance of
negotiating outcomes, or incorporating informants' input about the accu-
racy of interpretations. Banyard (1995) utilized many of these techniques
in her study of the coping responses of homeless women. Specifically, she
used methods of prolonged engagement that called for familiarizing herself
with the setting by spending time there; triangulation; peer debriefing,
which involves using experts and the research team to review the emerging
themes; and member checking to verify the findings with the opinions of
someone who has actually experienced homelessness.
The case study as a comprehensive research strategy offers several
benefits to the field of community psychology. Through in-depth analysis
of single or multiple cases, this methodological technique can capture mul-
tiple perspectives in real-world contexts. With attention to the reliability
and validity of data analysis and interpretation, researchers can have
greater confidence in the applicability of their findings.
THE CURRENT STUDY
The current research is a qualitative follow-up to Campbell (1996,

1998), which suggested that coordination of community services had bene-
ficial outcomes for rape victims. This quantitative research identified cases
that could be recontacted for in-depth study to understand how and why
their programs were effective. From the initial sample of 168 communities,
the 22 communities that had coordinated service programs, which had been
predictive of positive outcomes for survivors, were asked to participate in
this follow-up study. An additional comparison sample of 12 communities
that had fewer coordinated service programs, which had been predictive
of negative outcomes for rape survivors, was also collected. In all of these
communities, data were collected from multiple sources: rape victims ad-
vocates, directors of the rape crisis centers, hospital personnel, police,
prosecutors, and rape survivors. Multiple methods of data collection were
also employed: interviews and archival records documenting the community
programs. From these data, the research team developed a description of
the types of coordinated programs in these communities, and worked with
service providers and rape survivors to interpret these descriptions to ex-
plain why these programs benefit victims.
METHOD
Development of the Field Guide
Yin (1982) recommended that researchers develop a field guide to

steer data collection in case studies that specifies: the research questions
to be asked, the rationale for selection of the cases for study, the samples
to be obtained, and the data to be collected. A field guide was developed
at the conclusion of the quantitative study to prepare for this qualitative
follow-up.
Research Questions
The goals of this qualitative study were twofold: (a) to collect descrip-
tive information about coordinated service programs for sexual assault in
communities across the United States; and (b) to examine why such pro-
grams are effective in promoting positive outcomes for rape victims.
Fig. 1. Selection of cases for multiple case study design.
Rationale for Case Selection
To understand how and why coordinated service programs are effec-

tive, it is necessary to study not only those communities that have these
programs but also those that do not. The addition of a comparison sample
of communities with fewer coordinated programs may help reveal what is
beneficial about coordinated services. Thus, two groups of cases were se-
lected: high coordination communities and low coordination communities.
The previous quantitative findings from Campbell (1996, 1998) were
used to inform case selection for this qualitative follow-up study. Figure 1
summarizes the logic of case selection. Cases for the high community co-
ordination sample were selected for study if they met both of two criteria:
(a) The victim in the target case described by the advocate had a positive
outcome with community systems (defined as being a member of the first
cluster—needed resources were successfully obtained from all three social
systems); there were 53 cases in this cluster. (b) The community in which
the victim lived, as described by the advocate, scored high on the Commu-
nity Coordination Scale. The advocates were asked how many multiagency
sexual assault service programs, interagency training programs, and any
other community groups addressing sexual assault existed in their commu-
nities. The Community Coordination Scale was developed by summing the

number of programs and/or groups that existed in each advocate's/victim's
community. The distribution of scores on the Community Coordination
Scale ranged from summed totals of 0-11, and an upper-quartile split was
used to operationally define high coordination for this follow-up qualitative
study (communities with scores of 8-11). There were 42 cases in the upper
quartile of the scale distribution. When these two selection rules were con-
sidered jointly, 22 cases met both criteria (in the cluster with positive out-
comes and scored in the upper quartile of the Community Coordination
Scale).
Cases for the low community coordination sample were selected if they
met both of two different criteria: (a) the victim in the target case described
by the advocate had a negative outcome with community systems (defined
as being a member of the third cluster—needed resources were not suc-
cessfully obtained from all three social systems); there were 50 cases in
this cluster. (b) The community in which the victim lived, as described by
the advocate, scored low on the Community Coordination Scale. Of the
42 communities that scored in the bottom quartile of this scale, most (20)
had scores of zero. To have at least some programs to discuss in the fol-
low-up interviews, the research team decided to define "low coordination"
as scores between 3-5 (scores that were found in the bottom quartile, but
were not zero); 18 cases scored in the bottom quartile, with scores between
3-5. When these two selection rules were considered jointly, 12 cases met
both criteria (in the cluster with negative outcomes and scored in the bot-
tom quartile of the Community Coordination Scale, with scores between
3-5).
Although there was considerable variability in these samples of com-
munities, there were no statistically significant differences between the high
coordination sample and the low coordination comparison sample in geo-
graphic region of the country, urban or rural setting, size of the community,
and the length of time that their rape crisis center had been in existence.
Samples to Obtain
In this qualitative study, a "case" is an identified community in the

United States about which we had some initial information about its serv-
ices and about one rape victim in that community who sought help. There-
fore, in this follow-up study, the rape victim advocates in the 22 high
coordination communities and advocates in the 12 low coordination com-
munities were recontacted to discuss their community services in more de-
tail. To supplement this information, the executive directors of the
advocates' rape crisis centers were also interviewed. To assess the validity
of the rape victim advocates' perspectives, it was also necessary to obtain
a sample of other service providers in all of the target communities (e.g.,
police, prosecutors, and hospital staff). Finally, it is also important to un-
derstand the rape survivors' perspectives, so some of the victims, who had
been described to us by the advocates in the first quantitative study, were
also interviewed.
Data to Collect
All of the service providers interviewed (rape victim advocates, rape

crisis center directors, police, prosecutors, and hospital staff) were asked
to describe in detail their multiagency sexual assault programs. These in-
terviews were supplemented by examining the written literature (e.g., pam-
phlets, training manuals) about each program in each community. The rape
survivors were asked to describe their experiences with the various service
providers and how those interactions affected them and their recovery from
the assault.
Samples Recruited
Once this field guide had been developed, the research team began
recruiting the necessary samples from the high and low coordination com-
munities. The rape victim advocates and agency directors were recontacted
and asked to participated in this follow-up study (22 high coordination com-
munities and 12 low coordination communities). They were not told that
they had been defined as a high (or low) coordination community, only
that we were interested in learning more about some of the service pro-
grams in their community. All rape victim advocates and rape crisis center
directors agreed to participate.
Ideally, the research team would have liked to interview police, prose-
cutors, and hospital staff from each target community, but due to limited
resources, this was not feasible. Instead, at least one of these service provid-
ers was interviewed in every community (the "primary validity source"),
and in half of the cases (randomly selected), two or more service providers
were interviewed in addition to the rape victim advocates and rape crisis
center directors (the "secondary validity sources"). The primary validity
sources in the 34 communities studied were randomly selected and fairly
evenly distributed across the different service providers: 10 police officers,
10 prosecutors, 14 hospital workers (6 doctors, 8 nurses). The secondary
validity sources (collected in half of the communities studied, i.e., 17 com-

munities) were selected so as to not overlap with the primary validity
sources. If the primary source had been a police officer or prosecutor, then
the research team made the decision to seek secondary input from a medi-
cal staff person. This purposive sampling was done because several coor-
dinated service programs were based in hospital emergency rooms and we
felt it was important to gather the medical system perspective whenever
possible. If the primary source had been a medical professional, then the
secondary source was randomly selected to be a police officer or prosecu-
tor. All of the primary and secondary validity sources agreed to participate
in this study.
Finally, a small sample of rape survivors was recruited. To protect the
confidentiality of the survivors, the majority of the advocates were not
asked to disclose the women's names, which made it impossible to obtain
complete validating information in each case. Instead, a random sub-sample
of advocates (stratifying for whether they were in a high or low coordination
community) were asked if they would be willing to contact the rape victim
they described in the quantitative interview to see if she would talk with
the primary investigator about her experiences. In the five high coordina-
tion communities targeted for victim participation, four of the advocates
agreed to contact the survivor and request participation; all four women
agreed to participate. In the five low coordination communities targeted
for victim participation, only three of the advocates agreed to contact the
victim and request participation; two of the three women agreed to par-
ticipate.5
Data Collection
In preparation for the follow-up interviews with the rape victim advo-
cates, the primary researcher reviewed the advocates' prior quantitative in-
terview to become familiar with the programs in that community. Three
main types of multi-agency programs were recorded: coordinated service
programs, interagency training programs, and community-level reform
groups. Coordinated service programs provide resources to victims through
5
All of the advocates expressed some concern about recontacting the rape survivors to
participate in these interviews. As one advocate stated, "It's hard to ask, even in the name
of science and for a caring scientist, a survivor to open-up everything all over again . . . I
feel a great sense of obligation to protect them from additional stress, no matter how good
the cause may seem." The research team agreed with these advocates and their stance to
protect survivors in recovery (especially for those victims who had had negative experiences
seeking help from their communities). Therefore, we did not push for more survivor
interviews in the low coordination communities.
multiagency response teams. Interagency training programs conduct pro-

fessional training among rape crisis service providers (e.g., rape crisis center
staff training police and prosecutors). Community-level reform groups do
not focus specifically on service delivery, but instead promote community-
wide education and awareness about sexual assault. In the follow-up inter-
view, the advocates were asked one question about each program: "You
mentioned in your previous interview with us that your community had
--- (program or group). Could you tell us some more about that pro-
gram?" Sample probes for this question included: What actions are taken
in this program? Who from the community is involved? How did this pro-
gram get started? What are the functions of the program? What have been
some of the problems with this program? What have been some of the
successes of this program? How would you describe the effectiveness of
this program? The advocates were also asked if there were any other pro-
grams or groups that had been recently developed or not previously men-
tioned; if so, the question and probes were used to collect information
about these additional programs. The phone interviews lasted from 30 min-
utes to 3 hours, and were tape recorded and transcribed. All advocates
were sent a printed copy of their transcription to review and correct if nec-
essary.
In the interviews with the other service providers (rape crisis center
directors, police, prosecutors, and hospital staff), a similar format was used:
a single question ("I understand that you have --- (program or group)
in your community. Could you tell us some more about that program?")
with multiple follow-up probes. These phone interviews were much shorter
(30-45 minutes), and were tape recorded and transcribed. All service
providers were sent a printed copy of their transcription to review and cor-
rect if necessary.
The interviews with the rape survivors were also semistructured and
open-ended. The victims were asked to describe what happened when they
sought help from different community service organizations and how they
interpreted those experiences. They were also asked to describe how seek-
ing help from the police, hospital, and rape crisis centers affected them.
These phone interviews were quite long (2-4 hours) and were tape re-
corded and transcribed. All women were sent a printed copy of their tran-
scription to review and correct if necessary.
In addition to these interviews, archival data about each community's
programs were collected: pamphlets, public service announcements, train-
ing manuals. These written materials were used by the research team to
supplement descriptive details about each program or group that were not
mentioned or were unclear in the original interviews.
RESULTS
The rape victim advocates and other service providers described three
main types of multiagency sexual assault programs: (a) coordinated service
programs; (b) interagency training programs for sexual assault service provid-
ers; and (c) community-level reform groups that promoted community-wide
education and awareness about sexual assault. Our analyses of these programs
unfolded in two phases. In the first phase, the goal of the analysis was to
provide a reliable description of these programs. The unit of analysis was the
raw data transcriptions, which were summarized by the research team into
an agreed upon set of descriptors. Half of the rape victim advocates were
asked to provide feedback through this process of organization and descrip-
tion. In the second phase of data analysis, the set of descriptors derived from
the first phase were examined by the research team, the other half of the
rape victim advocate sample, other community service providers, and rape
survivors to develop an explanatory model of the effectiveness of coordinated
community systems. In presenting the results of these two phases of data
analysis, we follow Yin's (1982, 1991, 1994) suggestions to present a descrip-
tion of how the analyses were conducted (e.g., what steps were taken, how
reliability and validity were assessed) as well as the substantive findings.
Data Analysis Phase 1: Program Descriptions and

Reliability Assessment
Methods of Analysis
In the first phase of data analysis, four coders reviewed the transcripts
of the interviews with the rape victim advocates and other service providers.
Two issues became readily apparent. First, the variety of coordinated service
programs was much more diverse than the research team expected to find.
Additionally, the high coordination communities had other types of mul-
tiagency programs that addressed sexual assault, but did not specifically
focus on service delivery (e.g., interagency training programs and commu-
nity-level reform/education groups). Thus, the scope of description included
coordinated service programs as well as coordinated training and education
programs. A second issue was that limited data emerged from the inter-
views with the low coordination communities. Of the three main types of
multiagency programs (coordinated service programs, interagency trainings,
and community-level reform groups), the only type that existed in any of
the low coordination communities was interagency training programs.
To develop a reliable system of coding the types of programs that existed

in all of these communities, the members of the research team independently
read over all of the transcripts and developed an initial list of program types
and dimensions along which they could be described. The team compared
notes, developed a final list of domains along which the programs would be
compared, and wrote operational definitions of each unit to be coded. Dis-
agreements in coding were discussed until all members of the team agreed
upon the revisions. The resulting coding scheme was represented in three
blank tables (see Tables I, II, and III) that each coder would fill in to describe
each community. All interviews were coded by at least two raters, and 50%
of the interviews were coded by all four raters. Disagreement was operation-
alized as any inconsistency in the content of the material (as opposed to
minor variations in the language used to describe the programs) described
in each coder's tables. The average intercoder agreement was 95% with a
range of 92 to 98%. Average kappa was .93 (Cohen, 1960).
Once an agreed upon set of summary tables describing each service or
training/education program had been obtained, half of the rape victim advo-
cates (randomly selected) were sent a copy of the summary tables for feed-
back. A group conference telephone call with these advocates was held over
two meetings of 2 hours each to discuss the summaries. The advocates made
no changes in the organization of the tables; their feedback required clarifi-
cation on the differences among the community-level reform groups in some
communities. These revisions were made after all of the advocates and all
members of the research team understood and agreed upon the changes.
Substantive Findings
In the high coordination communities, three types of multiagency pro-

grams existed: coordinated service programs, interagency training pro-
grams, and community-level reform groups. In the low coordination
communities only interagency training programs existed.
Coordinated Service Programs
These programs were specifically developed to address many of the

shortcomings of current models of service delivery (e.g., fragmentation of
services, victim-blaming treatment of rape survivors [(secondary victimiza-
tion)]). In these communities, services were redesigned to increase the like-
lihood that survivors would be able to obtain the assistance they need
following a rape. Five types of coordinated service programs existed across
Table I. Characteristics of Coordinated Service Programs for Rape Victims

Coordinated service programsa
Crime
Domestic reparation
SART Drug/alcohol violence assistance
Characteristic programs programs Churches shelters programs
Setting Emergency Drug/alcohol Churches DV Shelters (none)
room treatment
programs
Systems in- Medical, Mental Clergy, RCC RCC, DV RCC,
volved police, health medical,
prosecutor, workers, police,
RCC, RCC prosecutor
hospital
social worker
Focus of Comprehen- Provide rape Provide rape Provide Help rape
service pro- sive, one-site services crisis shelter to victims with
gram services for during drug counseling rape victims filing for
victims & alcohol in church crime
recovery setting reparation
treatment
Reasons for Prevent Links Church is Safety Financial
service pro- cases from between used as an concerns for assistance to
gram slipping rape and alternate rape victims rape victims
through the substance source of is available,
cracks; abuse support for but not
increase some rape easily
quality of survivors accessible
care
Struggles Competing Competing Clashing Space Lack of
faced imple- agendas of agendas of values availability formal
menting pro- service service between in domestic program for
gram providers in providers in church and violence this
the team program rape crisis shelters assistance
community
"RCC = Rape Crisis Center; DV = Domestic Violence Shelter.
the 22 high coordination communities studied: one community had no co-

ordinated service programs, 10% had three programs, 60% had four pro-
grams, and 26% had all five programs.6 Some of the coordinated services
were formal programs, others were informal procedures for service delivery,
but what was common to all programs was that they were recent innova-
tions (developed within the past 5 years), involved staff from multiple com-
munity agencies (e.g., legal, medical, mental health, rape crisis centers,
domestic violence shelters, churches), and focused on improving service de-
livery for victims. Table I presents a summary of these programs.
'The most common coordinated service program was SART (Sexual Assault Response Team),
which was in 21 of the 22 communities studied.
SART Programs. Sexual Assault Response Teams are coordinated serv-

ice programs that were developed on the premise that a rape victim should
not have to seek out all the different services she may need, but that all
the service providers should come to her. Traditional models of service
delivery require that victims make multiple individual appointments with
system personnel (which can span weeks or months to obtain the desired
information and referrals). As a result, it is not uncommon for some vic-
tims to "slip through the cracks" and not receive help. By contrast, SART
programs are based in hospital emergency rooms, which are often the first
place victims are told to go following an assault. All of the service provid-
ers (doctors, nurses, police, prosecutors, rape victims advocates, hospital
social workers) come to this one location to work as a team to assist vic-
tims. In this alternative model of care, the hospital social workers and
rape victims advocates are often the first providers to make contact with
a victim in the emergency room. They provide crisis counseling and explain
the next steps of the medical exam and police procedures. The doc-
tor/nurse then attends to the victim's medical needs, and the legal per-
sonnel take the victim's statement. The social worker and/or victim
advocate meets with the survivor again and answers any additional ques-
tions and provides follow-up referrals. The rape victim advocates we in-
terviewed stated that SART programs were well-received by victims and
service providers alike. They also noted, however, that these programs
struggled with perpetual "turf wars": service providers often have different
agendas and styles of interacting with rape victims, and each wanted to
claim their approach as "right" and their time with victims "more impor-
tant." Yet despite these difficulties, many advocates noted that these pro-
grams enhanced communication among service providers as well as
between victims and system personnel. One advocate summarized the
SART programs:
Because we (the service providers) all have to work as a team, we get better insight
into what each system needs—like now the doctors and nurses are more careful
with the medical evidence collection because now they understand, because of
working with the police and prosecutors, what that evidence will be used for and
how important it is ... But what really matters is that we're able to offer better
services for survivors. The program relieves women of some of the burden of chasing
all over town trying to get information and referrals from six or seven different
agencies. Many women give up long before they get all the information they
wanted—and who could blame them? Here, the community takes a more active
role in helping survivors than the traditionally passive, and frankly, revictimizing
role, it's worked under for decades.
Drug/Alcohol Programs. A second type of coordinated service program
addresses the connection between sexual assault and drug/alcohol abuse.
One victim advocate provided an explanation for why there needs to be
programs uniting rape crisis services and substance abuse treatment pro-
grams:
It's really not all that uncommon for women to turn to drugs and alcohol as a way
of coping with rape. But, services haven't really been set up to address this. Because
there's so much shame involved in rape, some women may not go to the police or
to a rape crisis center or even tell anyone. But, they might later on show up in a
drug and alcohol treatment program. And low and behold, during the course of
that treatment, the pain and trauma of the rape resurfaces. Substance abuse
counselors aren't often prepared for working on sexual assault recovery.
As a result, some communities formed liaisons between mental health
workers who provide drug and alcohol treatment and rape crisis center
staff. These programs provided a full-time counselor at the drug and alco-
hol treatment center that was specifically trained in counseling and advo-
cacy for sexual assault. The costs of supporting this staff position were
shared equally between the rape crisis center and substance abuse program.
As with the SART programs that brought different service providers to-
gether, advocates who were familiar with these integrated recovery pro-
grams noted occasional problems with "turf wars":
This program has been an incredible asset to our community, but we sometimes
struggle because we have different visions of what should come first. Sometimes
the other substance abuse counselors want to focus first and foremost on the drug
dependency, and then work on the sexual assault issues. We often see it the other
way—address the issues of rape recovery, which will go a long way to remove the
need for the drugs, making it easier to then work on the substance abuse issues.
Overall, many of the advocates who have worked with these programs
noted that disagreements between the rape crisis center and substance
abuse treatment center were relatively infrequent. Instead, they emphasized
how much these integrated programs enhanced communication between
service providers. Additionally, by bringing the rape crisis services to victims
(in whatever agency they may seek assistance from) some of the barriers
to seeking help can be removed.
Churches. Some survivors of sexual assault never report the rape to
the police or seek medical treatment in an emergency room, and instead
turn to other supports in their communities, such as their churches. Coun-
seling is a integral part of pastoral care, but in some of the communities
in this study, the staff of the rape crisis centers were concerned that the
clergy may not have adequate information for working with rape survivors.
As a result, they formed partnerships with local churches to create a church
outreach counseling position. Although employed by the rape crisis center,
this counselor was rarely at the center, and instead worked in different
churches across the community to provide on-site assistance to women. The
advocates who were familiar with these programs noted that although the
churches were very receptive to their work, there were occasional differ-
ences in ideology between the church and the sexual assault counselors.
For example:
The pastors have been very welcoming and really great about getting the word out
to the women and men in their congregations that there's counseling available at
the church. But, what do you do when a woman discloses that she has been raped
by her husband—the church tells her marriage is sacred and she should work it
out. We [the advocates] often have a tough time with that message—we want to
respect women's choices, but it's just that—we want women to have a choice, to
be able to make a choice, to get the information they need to make a choice, not
to be told what to do. . . But, by and large, we've been able to work through our
differences.
This partnership between rape crisis centers and churches is another model
of expanding service delivery to the wide variety of settings in which women
may disclose sexual assault. Again, services are brought to rape victims,
rather than placing all of the responsibility on the survivors for findings
assistance.
Domestic Violence Programs. Sexual assault can occur within battering
relationships, and domestic violence shelters often provide counseling, ad-
vocacy, and temporary emergency housing in cases of marital rape and date
rape. Yet, many rape survivors do not feel safe in their homes following
an assault regardless of whether the assault was committed by someone
known to them or by a stranger. To address these needs, some of the com-
munities in this study had open service agreements between rape crisis cen-
ters and domestic violence shelters to provide safe housing for victims,
regardless of whether they were in a battering relationship. Staying in the
shelter provides rape victims with counseling and advocacy services 24
hours a day. Unfortunately, there is often a shortage of space in domestic
violence shelters, which can limit the availability of these programs. For
example, one advocate summarized the advantages and disadvantages of
this integrated care:
On the one hand, this has been a tremendous help to rape survivors and our rape
crisis center. It provides women with a safer place to sleep. It also puts them in
contact with other women . . . it reduces their shame and they see they're not
alone. But on the other hand, the response to this program has been overwhelming.
We don't have enough beds in the shelter to handle all the cases of domestic
violence that don't involve sexual assault, let alone providing beds to women who
have 'only' been assaulted. That doesn't mean we should stop—it means we need
more funds to continue the program.
In this type of coordinated service program, communities provided addi-
tional service options to rape victims that were previously unavailable. Like
the other coordinated programs, these rape crisis center-domestic violence
shelter partnerships opened up a new site for services for rape victims.
Crime Reparation Assistance Programs. A final type of coordinated serv-
ice program found in some communities was crime reparation assistance
programs. Most states provide some financial reimbursement to rape survi-

vors for the costs of medical care (and some other expenses incurred from
being raped) through their Victims of Crime Act funds. Although this service
is available in most states, it is difficult to navigate through the regulations
and forms of documentation required to receive reimbursement (e.g., police
report, letter from prosecutor on status of case, copies of medical records).
As a result, some communities have created informal programs that bring
together rape crisis centers, medical personnel, police, and prosecutors to
help streamline the process of reimbursement. Unlike all of the other co-
ordinated community services we found in this study, these programs did
not have a formal setting (i.e., there was no central place for victims to go
to or for service providers to meet). As a result, it was often the rape crisis
centers who took the lead on coordinating meetings and findings places for
the reparation team to meet. This informality was noted as the primary
struggle facing these programs. For example, as one advocate stated:
This program has been really helpful to all of us—not only to help women get
financial reimbursement, which is no small matter—a rape exam can cost up to
$1500 and the victim is the one who's billed for it and has to pay it or get her
credit rating trashed. But it's been good for all of us (the service providers) to work
together on something, to get to know each other better, and to realize just how
ridiculously complicated this process is. But, because it's being done on an as needed
basis with us meeting wherever we can find room—in a empty conference room in
a courthouse, in the ER doctors' lounge, in coffee shops, just wherever—to work
on a case, I worry that we won't be able to keep it up.
The crime reparation assistance programs help women find their ways
through the maze of state regulations by providing them with an integrated
team of service providers to serve as guides. This is a more informal pro-
gram than others described in this paper, but shares the same feature of
placing active responsibility on the community for assisting rape victims.
Inter-agency Training on Rape
Interagency training programs were found in both the high and low
coordination communities. Yet, the characteristics of the trainings offered
in these two types of communities were quite different. Table II contrasts
these training programs.
In the high coordination communities, training programs between the
rape crisis centers and other community agencies were reciprocal: The rape
crisis centers were allowed to conduct training with other community per-
sonnel, and representatives from these other community groups were in-
vited back to the rape crisis center to participate in the training of the
centers' staff and volunteers. The trainings among the agencies were rela-
Table II. Characteristics of Interagency Training on Rape/Sexual Assault

Communities with higher Communities with lower
coordination of services coordination of services
Characteristics of training (better outcomes for victims) (poorer outcomes for victims)
Mode of training RCC trains other RCC trains other
community personnel; other community personnel
community personnel asked
to train RCC staff
Frequency of training Short, repeated, regular Short or long (more
contacts common), infrequent
contacts
Content of training Lecture material; question Lecture material; some
& answer sessions; role question & answer sessions
plays; "media talk"
Auidences reached by rape Police, prosecutors, judges, Police, prosecutors, nurses,
crisis center nurses, doctors, mental mental health workers
health workers, domestic
violence workers, police
academy students, medical
school students, medical
residents (ER & OB-
GYN), nursing school
students, social work
students, psychology
programs; churches (clergy
& members) elementary &
high schools; universities &
colleges; military posts
Why training is conducted Usually is voluntary for Often mandatory for
community personnel, community personnel
ocassionally mandatory
tively short in duration (programs less than 1 hour), but frequent (most
were once a month). One advocate described the rationale behind this plan:
Our goal in training is to create regular contact and dialog. To make us familiar
to them and them to us—so we can get to know each other, so we're not strangers
to each other—we become people, people we know and are comfortable with . . .
We keep the programs short—'cause you know their attention spans are short. And
let's face it, the police often have other things on their minds, just like doctors and
nurses and everyone else we work with. The idea is to be respectful of their
time—just a few moments here and there, but it adds up to a lot of instruction
time.
In these sessions, the advocates and other community service personnel

engaged in a variety of learning formats: some presentations of lecture ma-
terial (only to present factual information), question and answer sessions,
role plays, and "media talk"—open discussions and debates about highly
publicized rape trials. The audiences reached in these programs were re-
markably diverse, including traditional service providers (e.g., police, prose-
cutors, judges, doctors, nurses), students in a variety of programs training
to become service providers (e.g., police academy students, medical school

students and residents, social work students), schools, and other community
groups (e.g., churches, military bases). These trainings were usually volun-
tary for both the rape crisis center staff and the other service providers.
In the communities with low coordination of services, the training pro-
grams were less diverse. Training tended to be unidirectional: The rape
crisis centers trained other community groups, who were not asked to par-
ticipate in the centers' trainings. This training was more infrequent (most
were conducted only once a year) and the programs themselves were of
long duration, typically more than 2 hours. One advocate raised several
concerns with this format:
This format is a real pain for all of us—we only get in there a couple a times of
year, if we're lucky, and we get completely insane with the idea that we have to
cram it all in—so it turns out to be this dry, boring afternoon. We don't really get
a chance to interact and get to know each other—we're just these nameless, talking
faces.
The audiences reached in these programs were only established service

providers (e.g., police, prosecutors, nurses, mental health workers), and this
training was usually mandatory for the participating agencies (e.g., city
funding sources required that training occur yearly).
Community-Level Reform Groups
A final type of program, which was found only in the high coordination
communities, was community-level reform groups. In contrast to the coor-
dinated service programs, these groups did not focus on service delivery.
Instead, their goals were to promote community education about sexual
assault and policy reform. As one advocate summarized, "This group works
on all the behind-the-scenes issues that allow our (coordinated) service pro-
gram to focus on individual survivors." The community-level reform groups
also differed from interagency training programs in that their target audi-
ence extended beyond service providers to the community as a whole. Two
subtypes of groups were found, and Table III contrasts these programs.
Interagency Task Forces. These steering groups consisted of service
providers and other community leaders (e.g., representatives from the
mayor's office, the media), who met regularly to address three goals: a) to
monitor specific cases progressing through the criminal justice system; b)
to conduct educational programs in the community; and c) to advocate for
legislative reform on issues of violence against women. Although some ef-
fort is spent on individual cases, the primary thrust of these groups is to
Table III. Characteristics of Community-Level Reform Groups Addressing Rape

Characteristics of programs Interagency task forces Grass roots women's groups
Systems involved RCC, DV, police, Women in community,
prosecutors, doctors, nurses, RCC, DV
social workers, other
community leaders
Focus of program Create team of service Collaborate with service
providers and community providers to raise
leaders to monitor community awareness about
individual cases, conduct rape, and monitor
community education legislative reform
programs, and advocate for
legislative reform
How program began By service providers to Grass roots organizing by
address services & women's groups
prevention of sexual
assault; soem started to
address other violence (e.g.,
DV, child abuse) then
expanded focus
Example activities Individual case advocacy, Clothesline project, court
sexual assault prevention, watch programs
programs in secondary
schools
engage in community-level education and reform. For example, one advo-

cate stated:
This is a 'higher-order group.' It's really above the day-to-day work of service
provision. But, the group's made up mainly of service providers, so they have lived
in the trenches, they know individual cases, know and remember specific survivors.
They bring this knowledge to these policy discussions, reform initiatives, and
community education.
Some task forces were formed by service providers specifically to address

sexual assault, but others were initially formed to address domestic violence
or child abuse, then expanded over time to include adult sexual assault.
But, regardless of how the task force began, the current work of these
groups emphasized community education through formal presentations to
community leaders and other community groups (e.g., teachers, members
of the clergy, members of service groups).
Grass Roots Women's Groups. A second subtype of community-level
reform group was grass roots women's groups. Many communities in the
larger quantitative study had relatively active women's communities
(e.g., a NOW chapter), but what distinguished the high coordination
communities was that their grass roots women's groups engaged in col-
laborative relationships with service providers. These collaborative rela-
tionships were formed through overlapping roles (e.g., off-duty police
officers were volunteers in these women's groups), frequent informal

contacts (e.g., the women's groups inviting ER nurses to lunch), and
jointly sponsored community events (e.g., the Take Back the Night
March). The goals of these groups were to work with service providers
on sponsoring and conducting community education and policy reform.
In community education efforts, the women's groups did not emphasize
formal educational presentations (as did the interagency task forces),
but rather developed informal, interactive opportunities to learn about
sexual assault. For example, some of these groups organized a yearly
presentation of the Clothesline Project, which an innovative and emo-
tionally moving public demonstration of the effects of violence against
women. Survivors of violence write messages on T-shirts to communicate
to themselves and others how they feel about the violence they have
endured, and these T-shirts are hung on clotheslines for people to walk
by and read. People learn about sexual assault from the victims them-
selves. Other women's groups created court watch programs, which in-
volved organizing women to attend and fill to capacity court rooms in
sexual assault trials to provide support for the survivor and to send a
collective message of concern to the judge and the community as a
whole. One advocate stated:
Court watch has to be one of the most effective things that our local women's
group has ever organized. It's an amazing example of grass roots organizing. Women
pour into court for every rape case that goes to trial. It reminds everyone that
women as a group are victimized every time an individual woman is raped—we're
all hurt—and this group presence symbolizes that. But it's also to watch, too: you
know, "we're watching you, we will be holding you—the court—accountable for
what you do to our sister." The judge, the prosecutors, the lawyers, and the media
take notice. It's a very powerful method of public education.
Thus, these programs differ from the interagency task forces in that they
are independent of service systems, but sometimes work in collaboration
with them for public education. Whereas interagency task forces tend to
use traditional public presentations and speaking engagements, these grass
roots women's groups have formed creative alternatives to stimulate dis-
cussion and awareness about sexual assault.
Data Analysis Phase 2: Higher Order Explanations

and Validity Assessment
Methods of Analysis
In the second phase of data analysis, the focus shifted from description
and reliability ("how" questions) to explanation and validity ("why" ques-
tions). This phase began with the research team reviewing the program
summaries generated in the first phase of data analysis as well as the tran-
scripts from the rape survivors' interviews to develop a conceptual model
explaining why coordinated programs are beneficial. A written first draft
of this model was sent for feedback to the other half of the rape victim
advocates and half of the other service providers who participated in the
validity interviews. The research team reviewed the participants' comments,
discussed disagreements, and made revisions to the model. This revised
model was again sent to the advocates and other service providers, and a
series of group conference telephone calls, including the primary re-
searcher, four of the advocates (all from high coordination communities)
and three other service providers who could make time to participate, were
held to refine the model. It took four conference calls of approximately 2
hours each to arrive at the final explanatory model. A written summary of
the model was sent to the rape survivors who participated in the validity
interviews for their comments. They added a few more examples, but made
no substantive changes to the model.
Substantive Findings
Why do coordinated community programs help rape survivors obtain

needed resources? The explanatory model developed by the research team,
rape victim advocates, other service providers, and rape survivors hypothe-
sizes that coordinated programs reflect an understanding of the multiple
contexts of service delivery and embody that knowledge in services that are
consistent with victims' needs. Specifically, this model proposes that atten-
tion to three issues of context explain these programs' effectiveness: the
context of service delivery, the context of sexual assault in the lives of
women, and the context of sexual assault as one of many forms of violence
against women.
The Context of Service Delivery
One reason why coordinated community programs may be effective in

assisting rape survivors is that they reflect an examination and rejection of
traditional models of service delivery. There have been long-standing prob-
lems of miscommunication and lack of communication between service
providers who assist rape victims. Representatives from each system (legal,
medical, mental health, rape crisis centers) may be well-connected to their
own system, but have rarely been so across systems. As a result, many
providers have lacked a fundamental understanding of "who does what"

or "who could do what." To further exacerbate this problem, many com-
munity workers also noted that they receive little support from their work
settings—they too experience stress, which has not been addressed. It is in
this culture of confusion that rape victims are supposed to receive help, so
it is not surprising that many do not receive adequate care. One of the
emergency room nurses interviewed in this project captured the essence of
this problem:
You know how it used to work? A bunch of service people—who have never really
talked, never really gotten along, never really even understood what the other was
doing and why-would try to help a hurt and confused woman. And let's face it, on
some level all of us probably felt guilty—guilty about what's happened to her (the
victim) and guilty because our minds are anywhere else. As an ER nurse, I'm in
triage mode—from a medical standpoint, a rape can't take up as much of my mind
and attention as a heart attack two curtains down. I think it's the same for the
police—we're always focused on what's worse, rather than what is, what is here,
and now, before us. The old system of service delivery wasn't set up to really help
women. That's what's different about the SART program—you know, it turns
everything upside down. It acknowledges the problems of the old system and designs
right around them . . . it acknowledges that all service providers have different
expertise and we can draw on those skills from each and work together, so that as
a unit we can do a better job. I think it makes things easier on us as providers,
takes some pressure off—I know I am not the be all and end all, I'm one part,
and if we all do our small part, the overall effect works.
The "old" context of care did not create opportunities for service providers
to get to know each other, learn from each other, and support each other.
Coordinated systems create that regular, sustained interaction, and in doing
so, create a new context of care. In the high coordination communities,
opportunities for dialog were created through service programs, interagency
trainings, and other community education programs. In other words, the
high coordination communities had multiple ways for service providers to
educate and support each other. As one advocate stated, "Even if a pro-
gram is not specifically about service, it helps direct service—anything that
makes us human to each other helps." Through this examination of the
problems of traditional care emerged a variety of systems that facilitate
communication and shared responsibility among providers.
The Context of Sexual Assault in the Lives of Women
One of the rape survivors interviewed in this study expressed the sec-
ond contextual theme very clearly: "They need to remember what the rape
did to me." Service providers in the high coordination communities created
a system of care that acknowledges and responds to those effects. To be
raped is to have control stripped, to have integrity violated, to have wishes
and needs ignored and overruled. To seek help immediately following a

rape is to take this very private pain very public. This is the context of
rape in women's lives, and understanding this context is another critical
factor in redesigning community-based assistance. Training programs and
public education programs help explain the effects of sexual assault, and
are an integral part of improved service. Coordinated service programs at-
tempt to reflect these issues more directly by streamlining services, which,
in turn, helps reinstate a sense of control for victims. On survivor explained
what the SART program in her hospital meant to her:
It's like they somehow knew where I was at . . . said it without words . . . that they
knew I could only absorb things one by one, and I can't remember all of it at once.
You know, that I can't deal with the exam, and the police report, and the
information about HIV, and the counseling referrals, and the everything else all at
once. They broke it down into smaller parts, but they weren't condescending either.
It really wasn't like I was being babied or talked down to. I could stay in one place,
I mean like, really, one room, and they came to me and gave me what I needed
in small, steady steps. I have to admit, I really liked that they all came to me—like
I was important again, like I mattered again.
One rape victim advocate provided the view from the other side:
If all of us—rape crisis centers, hospitals, police, all of us—would just spend a little
more time and energy upfront helping women right after the assault, I'd bet we
could prevent so many of the problems they have later on. And it's not like we
should all have to remember to say to survivors, "I know you're in pain, I know
you're traumatized." No, instead we should create a system that sends that message,
that in everything it does, it communicates that to them. That doesn't mean we
can continue to be assholes—no, what I'm talking about is that both in words and
in our environment, we send the repeated message of caring and reinstatement of
control.
It is also important to remember that because rape has such wide-
spread effects on women's lives, survivors may seek assistance from multiple
community agencies. Some of these service providers are used to helping
rape victims (e.g., emergency rooms), but some have not historically defined
themselves as rape crisis services. Women may disclose a history of sexual
assault in a variety of community settings, and those settings should be
trained and capable of providing assistance. One of the prosecutors inter-
viewed referred to this strategy of expanding care into alternative settings
as the "Principle of Saturation":
The thing that keeps coming to my mind as we're talking is 'saturation'—saturate
the entire community with knowledge and resources about rape . . infiltrate all of
the places rape victims could go. So I'd guess I'd call this the 'Principle of
Saturation.' And I think it's why we're pretty effective in helping rape victims.
Many of the high coordination communities seemed to be working under
this principle—saturate all the places rape victims may turn to with infor-
mation about rape. For example, some women turn to drugs and alcohol
to cope with rape, which may later lead them to drug/alcohol treatment
programs. One survivor described what it meant to her to have rape crisis
counseling available in a drug and alcohol treatment program:
It just kept coming up—throughout rehab. They wanted me to take responsibility
for my alcohol use and I really wanted to, but I also wanted to just stand up and
scream 'Hey-I've been drinking because some violent pervert raped me!' But, I was
afraid they would just say that's another excuse . . . So, it was a great relief to me
the day a new counselor joined the group and said she was from the rape crisis
center, and was here to help those of us who experienced both sexual abuse and
substance abuse . . . It was like they finally got it. I was so happy it was all there
for me—that I could address both, get them both worked through at the same
time.
Rape has multiple effects on women, and as a result, they may seek
assistance from multiple settings, some of which may be "atypical" outlets
for rape crisis services. The high coordination communities in this study
made more settings typical and fewer atypical. As one advocate stated:
We tried to really think through what it means to women to be raped, what they
may need, and where they may go—and then to go there, to make all those places
receptive. We know everyone is not gonna call the rape hotline—I guess you could
say that we want to infiltrate all the places women could turn to, make them all
their own little hotlines. We can't be arrogant enough to assume that we can help
all women or that all women would want to come to us—there's been too much
racism and classism in social systems and in the feminist movement to really believe
that all women can trust us. As predominantly White women and White institutions,
we have to reach out to others. Women know where they're comfortable, we can
just try to make those places even more comfortable and helpful.
These quotes suggest that one of the defining features of the high
coordination communities is that they reflect comprehensive understanding
of women's needs. This knowledge was used to create multiple settings that
would be responsive to those needs, and as a result, survivors are more
likely to have their needs met when they seek assistance.
The Context of Sexual Assault in Violence Against Women
Sexual assault does not exist in isolation, but within a larger societal
problem of violence against women. Raising public awareness about vio-
lence against women was a frequent activity in the high coordination com-
munities. For example, one emergency room doctor stated:
It's all interrelated—rape is a form of violence against women; violence against
women is done through rape. We can't consider one without the other. We have
to remember the bigger picture here, the larger system that contributes to violence
against women in general, and rape in particular. So, to be effective as a community,
some of our attention must go to public awareness and consciousness raising about
gender inequality and about systems of oppression that make rape commonplace.
In the high coordination communities, there were a variety of

groups that sponsored public education campaigns that were intended
to help create a culture that punishes violence and support survivors.
Helping rape victims obtain needed community resources comes about
not only through redesigning rape crisis programs, and not only through
expanding the number of settings in which victims can receive assistance,
but also by teaching the community at large about rape. In a supportive
community culture, rape victims may feel less shame and stigma, which
is a critical first step in seeking assistance. For example, one survivor
described how a court watch program influenced her decision to seek
help:
I saw it on the news and in the papers—another woman was raped and was brave
enough to report to the police and go to trial. There were so many women at court
for her—the TV news showed them all lined-up to support her. It was unbelievable
to me that so many cared. I had been raped about a week before I saw this, and
was too scared to do anything, too ashamed. But when I saw this, I thought, "I
could do this, too. People care, people will care about me."
Another rape survivor described how viewing the Clothesline Project af-
fected her:
One of things that was so helpful to me was being able to go see the Clothesline
Project. It was about 6 to 9 months after I was raped—the worst of it was over,
but still, it never really goes away. But the counselor I was going to at the [rape
crisis] center told me about this event [Clothesline] that was going on ... It was
put together by this group of women . . . It was amazing to see—men and women
openly crying after reading these T-shirts . . . to know, I mean really know, that I
wasn't alone anymore . . to know that other people in my town really cared about
this, cared enough to bring this demonstration to our park. It was like this big
public declaration that own town understood and wasn't gonna put up with rape
and domestic violence anymore.
Raising public awareness about sexual assault and violence against
women can create the backdrop for designing alternative systems of care.
As one advocate stated, "It creates the fertile ground that allows our pro-
grams to grow."
DISCUSSION
Historically, the community response to rape has been disorganized at

best, revictimizing at worst (Campbell, 1998; Madigan & Gamble, 1991).
Traditional models of service delivery have required rape victims to pursue,
actively and vigilantly, the services they need, while the community main-
tains a passive role. As a result, it has not been uncommon for many women
to avoid social services altogether, or to give up seeking help long before
they actually obtain desired assistance. In response to these problems, some

communities across the United States have redesigned their social service
delivery systems for sexual assault. These new models of care require an
active role on the part of the community to integrate, coordinate, and
streamline services for rape victims. Through a variety of service and edu-
cation programs, these communities have tried to raise overall public
awareness about sexual assault, educate specific service providers, and cre-
ate new settings for helping rape victims. Instead of requiring victims to
track down and plead with the community for help, the community will
come to them.
In this research, a qualitative multiple case study design was used to
examine 22 communities across the United States that have created alter-
native service systems. Campbell (1998) found that these alternative service
models helped victims obtain needed resources. This was an intriguing find-
ing with important policy implications, but many of the details as to how
and why these coordinated systems helped victims were lacking. To gain
some insight into the underlying processes of these programs, a qualitative
approach was chosen for this follow-up study. This constructivist perspec-
tive was necessary to capture and understand the complexities of these al-
ternative service models within their real-world contexts (Yin, 1982, 1994).
From in-depth interviews with rape victim advocates, rape crisis center
directors, police officers, prosecutors, doctors, nurses, and rape survivors,
this research discovered that how these coordinated community programs
worked was quite complex. Coordinated service programs that directly as-
sisted rape victims were actually only one part of a larger package of co-
ordinated care. In addition to coordinated service programs, such as Sexual
Assault Response Teams, drug and alcohol treatment programs with rape
crisis counseling, crime victim reparation assistance programs, several com-
munities also had interagency training programs and community-level re-
form groups. As one advocate stated, "Service is bigger than you think—to
do service well, you have to think through everything that comes before the
actual service and redesign it, too."
Three types of coordinated programs were found in the high coordi-
nation communities. First, many communities had integrated service deliv-
ery programs. For example, some hospitals had developed a Sexual Assault
Response Team for their emergency rooms. These programs brought police,
prosecutors, doctors, nurses, hospital social workers, and rape victims ad-
vocates to one location to work together as team to help rape victims.
These programs could capitalize on the unique strengths and skills of each
service provider, so that no one person was entirely responsible for pro-
viding all help. If each person in the team did their own part, the overall
effect would be quality care. But, some survivors never seek emergency
medical treatment, so other coordinated programs focused on reaching out

to other places in the community that might be working with rape survivors.
As a result, some rape crisis centers formed partnerships with drug and
alcohol treatment programs, churches, and domestic violence programs to
bring rape crisis services into these other settings. As one advocate stated,
"So no matter where a victim may turn to, we've got the bases covered—
they can get help in lots of different places."
A second type of community service addressing sexual assault was in-
teragency training programs. Although both the high and low coordination
had interagency training programs, there were several characteristics that
distinguished these communities. For example, in the high coordination
communities, training programs consisted of diverse learning formats that
reached a wide variety of audiences. In the low coordination communities,
training was conducted in a traditional lecture-style format with a limited
number of agencies. Perhaps most telling, in the high coordination com-
munities, these training programs were voluntary, but the in low coordina-
tion communities the agencies were forced to participate. As one police
officer stated, "There's nothing that will kill an already strained relationship
faster than forcing us [the police] to have these training programs with the
rape center."
A final type of coordinated community program was community-level
reform groups, which were found only in the high coordination communi-
ties. These programs focused on creating community-level change through
public education, legislative reform, and public demonstrations. The focus
of these programs was not specifically on service delivery, but rather on
changing the climate in which service delivery would occur. As one rape
crisis center director stated, "This program is as much about service as the
Sexual Assault Response Team. Without community awareness, even the
best service program in the world will still flop."
From this understanding of how these coordinated community pro-
grams worked, we turned our attention to examining why they work. Why
do these programs benefit rape survivors? The explanatory model devel-
oped by the research team and the participants argues that the key to
innovative service delivery is to understand the social context of rape.
This context must be understood from the perspective of the service
providers, the survivors, and the community as a whole. Sexual assault
has different meanings to these different stakeholders, and when these
meanings are understood and addressed, an alternative system of care
can emerge.
Specifically, the model proposes that three factors explain why coor-
dinated community programs are beneficial to rape survivors. First, these
programs reflect an understanding of the context of social service delivery
from the perspective of the providers. For years, service providers have
worked under conditions of confusion, hostility, and miscommunication. As
one emergency room nurse stated, "It's been years of 'us' versus 'them'
and I'll be damned if the 'us' and 'them' weren't constantly changing. The
system wasn't set up to facilitate communication." Many of the service
providers interviewed in this study spoke of their frustrations of not un-
derstanding what other providers were doing and why, not understanding
of how their job fit into the bigger picture of rape prosecution and rape
crisis counseling, and not having opportunities to get to know each other
and support each other. Put simply, the context of social service delivery
was not designed to facilitate the communication necessary for better care
for victims. The communities studied in this research created the resources
necessary to change that context. As one rape victim advocate stated, "We
had to change the environment around us for this to work—we had to
make ways to interact and learn from each other."
A second key ingredient in the successful communities was that the
perspective of the victim was reflected in this new system of care. In other
words, it is not enough that the providers now have outlets for communi-
cation; they must use those outlets to discuss what is important to rape
victims. Understanding the context of rape in women's lives is vital. Rape
is a fundamental violation of control, and, as a result, social service pro-
grams must be designed to help reinstate that control. As one prosecutor
said, "In everything we do, we have to remember what it means to women
to be raped. We have to remember that we are there to reinstate control
and integrity—to value her."
Finally, it is important to understand the larger social context of
rape itself. Rape is only one form of violence against women, and is
part of a larger context of gender inequality. This context must also be
addressed to promote an effective community response to rape. In the
high coordination communities, considerable attention was devoted to
raising public awareness, particularly through innovative formats, such
as the Clothesline Project and court watch programs. As one rape sur-
vivor noted, "We have to all understand why rape happens. If we put
all of our attention into education for the police, for example, it's like,
why bother? That misses the boat. It's like that political slogan: 'it's
about the economy, stupid.' Here, it's like, 'it's about oppression, stupid.'
Gotta see the bigger picture."
When interpreting the results of this study, it is important to note three
methodological limitations of this research. First, complete validity data were
not collected from all stakeholders in all communities. Steps were taken to
ensure that the rape victim advocate interviews were validated by at least
one other service provider in all communities, but the research team did
not have the resources to interview all relevant system workers and all
rape survivors in all communities. It is possible that these absent perspec-
tives could have influenced both phases of data analysis. Second, in both
the initial quantitative study by Campbell (1998) and in this follow-up
qualitative work, the experiences of only one rape survivor in each com-
munity were captured. Although the advocates rated the cases told to us
in the interviews as "typical" or "highly typical," this methodological con-
straint suggests that the voices of the survivors are not numerous in either
study. It is possible that with more participation from rape survivors, a
different interpretation of the importance of coordinated community care
could emerge. A final problem to note is that in the second stage of data
analysis, building the explanatory model, not all of the service providers
who were interviewed could devote additional time to participate in the
conference call meetings to interpret the findings. Efforts were made to
include their perspectives by sending them written summaries of the model
as it was being developed for their feedback. But, it is also important to
note that the participants recruited in this study were highly motivated
and cooperative with the research process. The reliability and validity of
these findings have undoubtedly been strengthened due to their efforts
and dedication.
To improve the community response to rape, the communities in
this study stepped outside the boundaries of traditional models of serv-
ice delivery. Through reflection on the multiple contexts of rape, they
redesigned programs to coordinate service providers and streamline care
for rape victims. To understand the uniqueness of these programs, this
study also had to step outside the boundaries of traditional models of
research. The constructivist perspective inherent in qualitative ap-
proaches to research facilitated our understanding of how and why these
programs worked, and grounded this understanding in their real world
settings.
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American Journal of Community Psychology, Vol. 26, No.

Innovative Community Services for Rape

Rebecca Campbell2 and Courtney E. Ahrens

A qualitative multiple case study design was used to examine communities

Social services have undergone a public reexamination in recent years,

THE COMMUNITY RESPONSE TO RAPE:

Findings from Previous Research

In 1994, the U.S. Department of Justice reported an intriguing finding:

rape . . , [these] changes have helped [them] maintain a successful stance

cluster membership). In other words, if a victim lived in a community that

Although these studies have provided initial descriptive information

ANSWERING "HOW" AND "WHY" QUESTIONS:

Developing an Epistemological and Methodological

Coordinated service programs for rape survivors exist in some com-

induced or derived from observation . . . if the process of identifying ob-

real-world contexts, but in repeating the procedures on multiple cases, this

Rigor and Quality in Multiple Case Study Methodology

A multiple case study design may be an appropriate choice for many

reliability, and enhance the findings by allowing for a convergence of mul-

THE CURRENT STUDY

The current research is a qualitative follow-up to Campbell (1996,

Development of the Field Guide

Yin (1982) recommended that researchers develop a field guide to

Fig. 1. Selection of cases for multiple case study design.

Rationale for Case Selection

To understand how and why coordinated service programs are effec-

nities. The Community Coordination Scale was developed by summing the

In this qualitative study, a "case" is an identified community in the

All of the service providers interviewed (rape victim advocates, rape

validity sources (collected in half of the communities studied, i.e., 17 com-

multiagency response teams. Interagency training programs conduct pro-

Data Analysis Phase 1: Program Descriptions and

To develop a reliable system of coding the types of programs that existed

In the high coordination communities, three types of multiagency pro-

Coordinated Service Programs

These programs were specifically developed to address many of the

Table I. Characteristics of Coordinated Service Programs for Rape Victims

the 22 high coordination communities studied: one community had no co-

SART Programs. Sexual Assault Response Teams are coordinated serv-

programs. Most states provide some financial reimbursement to rape survi-

Inter-agency Training on Rape

Table II. Characteristics of Interagency Training on Rape/Sexual Assault

In these sessions, the advocates and other community service personnel

to become service providers (e.g., police academy students, medical school

The audiences reached in these programs were only established service

Community-Level Reform Groups

Table III. Characteristics of Community-Level Reform Groups Addressing Rape

engage in community-level education and reform. For example, one advo-

Some task forces were formed by service providers specifically to address

officers were volunteers in these women's groups), frequent informal

Data Analysis Phase 2: Higher Order Explanations

Why do coordinated community programs help rape survivors obtain

The Context of Service Delivery

One reason why coordinated community programs may be effective in

providers have lacked a fundamental understanding of "who does what"

The Context of Sexual Assault in the Lives of Women

and needs ignored and overruled. To seek help immediately following a

The Context of Sexual Assault in Violence Against Women

In the high coordination communities, there were a variety of

Historically, the community response to rape has been disorganized at

they actually obtain desired assistance. In response to these problems, some

medical treatment, so other coordinated programs focused on reaching out

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