Journal of the American Psychiatric Nurses Association

http://jap.sagepub.com/ Regret and Police Reporting Among Individuals Who Have Experienced Sexual Assault
Carol Anne Marchetti Journal of the American Psychiatric Nurses Association 2012 18: 32 originally published online 18 January 2012 DOI: 10.1177/1078390311431889 The online version of this article can be found at: http://jap.sagepub.com/content/18/1/32

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431889
iJournal of the American Psychiatric Nurses Association

JAP18110.1177/1078390311431889Marchett

Original Article

Regret and Police Reporting Among Individuals Who Have Experienced Sexual Assault
Carol Anne Marchetti1

Journal of the American Psychiatric Nurses Association 18(1) 3239 The Author(s) 2012 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390311431889 http://jap.sagepub.com

Abstract BACKGROUND: Sexual assault (SA) and the underreporting of SA are highly prevalent in the United States. Since regret is a complex, negative emotion linked to decision making, studying regret within the context of reporting SA is important. OBJECTIVE: To describe decisional regret regarding SA reporting. DESIGN: A cross-sectional, descriptive study design was used. The sample included 78 individuals, aged 18 to 25 years, who experienced SA during the past 5 years and completed an electronic questionnaire. A multiple regression model was generated to describe how selected independent variables explain variation in levels of regret. RESULTS: In the final model, four independent variables accounted for 33.3% (adjusted R2) of the variation in regret: weight change, stranger assailant, professional treatment, and police reporting. CONCLUSIONS: The findings inform clinical practice by describing postdecisional regret about the reporting of SA, and they provide a foundation to develop strategies (e.g., decision aids) that can assist clinicians to help patients as they struggle to make difficult health care decisions. Keywords advocacy for patients, emergency psychiatric nursing, public policy issues, sexual assault, womens mental health, regret, reporting sexual assault Regret has been defined as a negative emotion that results when one realizes that a situation would be more favorable if another choice had been made (Joseph-Williams, Edwards, & Elwyn, 2010). Regret has been inextricably linked to the decision making process, and thus, like decisions, regret pervades our lives (Zeelenberg & Pieters, 2007). The study of regret and health carerelated decision making, which is in its infancy (Diefenbach & Mohamed, 2007), can inform psychiatric nurses and other clinicians who care for individuals who struggle with difficult health care decisions. One such decision is whether or not to report a sexual assault (SA) to the police. The purpose of the study is to describe the experience of regret among individuals who experienced SA during the past 5 years. A multiple regression model was generated to address the following research question: To what extent, and in what manner, do selected independent variables explain variation in levels of decisional regret with regard to reporting SA to the police? Tjaden & Thoennes, 2006), an estimated 17% of women in the United States have been raped at some time during their lives. Some of the adverse health effects that result from SA include unplanned pregnancy, sexually transmitted infections (STIs), substance abuse, illness, and increased health care utilization (Nehls & Sallmann, 2005; Suris, Lind, Kashner, Borman, & Petty, 2004). Economic costs of SA have been estimated to be more than $261 billion annually (Post, Mezey, Maxwell, & Wibert, 2002). Also, there are significant intangible costs including psychological pain and emotional suffering (Briere & Jordan, 2004). SA is the most widely underreported violent crime in the United States (Fisher, Daigle, Cullen, & Turner, 2003). Tjaden and Thoennes (2006) reported from the NVAWS data that only 19.1% of women and 12.9 % of men reported rape to the police. Untoward consequences for individuals who do not report SA include limiting
1

Background
SA is a devastating, traumatic, prevalent crime that raises significant health and legal concerns. According to the National Violence Against Women Study (NVAWS;

Carol Anne Marchetti, PhD, RN, PMHCNS-BC, SANE, Northeastern University, Boston, MA, USA Corresponding Author: Carol Anne Marchetti, Northeastern University School of Nursing, Robinson Hall 408D, Boston, MA 02115, USA Email: c.marchetti@neu.edu

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Marchetti their opportunities to access victim services, which have the potential to mitigate psychiatric and other health consequences of SA (McCall-Hosenfeld, Freund, & Liebschutz, 2009). From a public safety perspective, it is clear that society would benefit if more assaults were reported and if these reports led to convictions and punishments that prevented the assailants from sexually assaulting others. Additionally, there are more tangible benefits to be gained. Underreporting is a costly obstacle as data on the incidence and prevalence of SA used for planning program and policy initiatives are likely underestimated; therefore, individuals and geographic areas at high risk for SA are likely failing to receive adequate attention (Fisher et al., 2003).

33 injury are more likely to be reported to the police (Bachman, 1998). The factors that describe the barriers and facilitators can be categorized into one of three groups of descriptor variables: demographic information, assault characteristics, and health outcomes. For this study, these three groups of descriptor variables were examined as groups of independent variables because they are significant correlates associated with the experience of SA and they influence individuals decisions about whether or not to report. Multiple regression analysis allowed for examination of how these groups of independent variables explain variation in levels of regret about the decision to report the SA to the police.

Review of the Literature

Beginning in the 1980s, researchers began to study regret as an important component of formal decision theory (Bell, 1982). Classical decision making theory maintains that humans make decisions based on a desire to maximize optimal outcomes (e.g., profit, pleasure, safety, etc.; Landman, 1987). Modern theorists assert that choice depends not only on the probability and the value of the chosen outcome but also on the amount of regret for alternatives not chosen (p. 135). Therefore, perhaps unconsciously at times, individuals tend to assess the potential for regret when making a decision. According to Svensons differentiation and consolidation theory of decision making, individuals strive to limit cognitive dissonance and avoid regret by distinguishing choices from one another (Svenson, 1992). Support for the study of regret as an important component of decision making also comes from the Ottawa Decision Support Framework (ODSF; OConnor, 2006). According to the ODSF, regret is an important factor used to assess decisional quality in crisis situations. The framework illustrates that people evaluate the quality of their decisions based, in part, by how much decisional regret is experienced. Therefore, regret is an important indicator of decisional quality that influences the decision making process. There is a paucity of research about decisional regret and police reporting among SA victims; however, there is considerable research that describes the barriers and facilitators to reporting SA. Fisher et al. (2003) reported that many crimes on college campuses go unreported because of the roles played by contextual factors such as alcohol and drugs, and that college women who are raped by someone known to them are less likely to report the SA to the police than their counterparts who are raped by strangers. Investigators have suggested that victims are more likely to report when they perceive their assault to be serious and assaults involving the highest degree of

Method Study Design

For this study, a cross-sectional, ex post facto, descriptive design employing an electronic survey format was used. Ethical approval for the study was received from the Boston College Institutional Review Board. Participants were given a website address that contained a link leading to the questionnaire. SurveyMonkey software was used to design and administer the self-report, electronic, secure, encrypted, 34-item questionnaire, which required approximately 20 minutes to complete. Each participant was provided with a copy of the consent form. Participants were advised that they could withdraw from the study at any time without consequences and that their responses were confidential. They were informed that while there were no obvious direct benefits from participating in the study, they might derive satisfaction from knowing they have contributed to the research on this topic. After completing the survey, participants were given an opportunity to record any comments about their reactions to participation in the study.

Study Sample
Participants in the study included 78 women and men, between the ages of 18 and 25 years, who had experienced SA during the past 5 years. The study sample size was estimated based on guidelines established by Tabachnick and Fidell (1999), who recommended a minimum of 5 to 10 times as many cases as there are independent variables in the regression equation (four independent variables were entered into the regression analysis). Individuals between the ages of 18 and 25 years were chosen because Fisher et al. (2003) provided substantial documentation that college students, who tend to fall into this age group, are at high risk for SA and are unlikely to report an SA to the police. The

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34 participants were required to read English and have computer access, as the survey format was electronic. Recruitment was accomplished through fliers, listserv invitations, and Craigslist. Participants were predominantly female and White, with 5% Black and 4% Hispanic. The mean age of the respondents was 22.1 years (SD = 2.1 years), and the mean age at the time of assault was 19.5 years (SD = 2.1 years). Forty-one percent of the participants had earned a college degree, and more than half (53%) were currently enrolled as college students; 41% percent of the participants identified themselves as nonstudents and employed; 44% reported an annual income of $10,000 to $50,000; and 19% earned less than $10,000.

Journal of the American Psychiatric Nurses Association 18(1) Threats/weapons used. This variable addressed the use of threats and/or weapons during the assault. Potential response options included verbal threats, choking, biting, hitting, weapons, and chemical restraint. Health complications. This variable concerned health complications related to the assault. Potential response options to these multiple-choice questions included unplanned pregnancy, STIs, anxiety, suicidality (i.e., suicidal thoughts or attempts), weight change (loss/gain), and no health complications reported. Nonhealth complications. This variable asked about other complications related to the assault. Potential response options included work, economic, social, and other complications.

Adverse Health Outcomes

Measurement of Study Variables Regret. The Decision Regret Scale (DRS; Brehaut et al.,
2003) was used to measure regret regarding the decision of whether or not to report SA to the police. The DRS employs a 5-point, Likert-type response format. A score of 5 indicates no regret, and a score of 25 indicates high regret. For descriptive purposes, the responses to the DRS were categorized according to low (5-11), medium (12-18), and high (19-25) levels of regret. Brehaut et al. (2003) reported that the instrument has good internal consistency and reliability. In this study, reliability, as measured by Cronbachs alpha, was .93.

Professional Treatment. This variable (yes/no response) addressed whether or not the victim sought professional treatment following the assault. Depression. The Patient Health Questionnaire (PHQ-9)
is a 9-item, self-administered questionnaire used to assess the severity of depressive symptoms (Pfizer, Inc). The PHQ-9 scores range from a low of 0 to a high of 27 and the items are summed to yield a single measure of depression, which is suggested by a score equal to or more than 8. This instrument has demonstrated excellent testretest reliability and internal consistency (Spitzer et al., 1994). For this study, reliability, as measured by Cronbachs alpha coefficient, was .91.

Demographic

Information. Seven demographic, multiple-choice questions were adapted from the Massachusetts Sexual Assault Evidence Collection Kit (Massachusetts Executive Office of Public Safety & Security, 2008) to gather data about participants current age, age at time of SA, gender, race, education, occupational status, and annual income.

Posttraumatic Stress Disorder (PTSD). The specific

event version of the PTSD Checklist (PCL-S; Weathers, Litz, Herman, Huska, & Keane, 1993) measures PTSD symptomatology as related to a specific stressful event. The self-report instrument is composed of 17 items and has demonstrated favorable psychometric properties (Norris & Hamblen, 2003). Items on the PCL-S were rated on a 5-point scale and results ranged from a low of 17 to a high of 85. A total score of 44 or more is suggestive of PTSD in the general population. For this study, reliability, as measured by Cronbachs alpha, was .92.

SA disclosure. This variable (yes/no response) asked if the SA had been disclosed to anyone. Police report. This variable (yes/no response) asked if the SA had been reported to the police. SA criminal case status. This variable was posed only to participants who reported the SA to the police and it inquired about the favorability of the criminal case status. Relationship to assailant. This variable addressed the relationship between the participant and the assailant(s). Potential response options included stranger, acquaintance, friend, boyfriend/girlfriend, or date. Injuries. This variable addressed physical injuries sustained during the assault. Potential response options included physical (i.e., bruises, scrapes/cuts, head, and muscle/bone) and genital injuries.

Assault Characteristics

Alcohol. T-ACE is a mnemonic for a 4 item, selfadministered alcohol screening questionnaire (Sokol, Martier, & Ager, 1989). The questionnaire required a yes or no answer to questions about tolerance to alcohol. T-ACE scores ranged from a low of 0 to a high of 4. A summed score of two or more points indicated highrisk alcohol use. Medications and Drugs. Two questions about drug and
medication usage (yes/no response) were adapted from

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Marchetti the Drug Abuse Screening Test (Skinner, 1982), a 20-item questionnaire designed to screen for substance abuse.

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Results Descriptive Analyses

The following descriptive statistics for the independent variables that were included in the regression, and for regret, are reported: 49% of the participants reported that they experienced a weight change (loss or gain) following the assault, 17% described their relationship to the assailant as a stranger, 51% indicated that they sought professional treatment following the assault, and 36% reported the assault to the police. Overall, the mean regret score, which ranged from a low of 5 to a high of 25, was 13.46 (SD = 5.8). A total of 26.9% reported low regret (scores of 5-11), 47.4% experienced medium regret (scores of 12-18), and 25.7% reported high regret (scores of 19-25).

Sexual Assault Screening. Although participants

acknowledged being sexually assaulted when they agreed to participate in the study, the Sexual Experiences SurveyShort Form Version (SES-SFV) was used as an additional screening instrument to confirm that the participant reported being sexually assaulted. The SES-SFV (Koss et al., 2007) is a 10-item, self-report questionnaire designed for use among young adults to assess victimization and perpetration of unwanted sexual experiences. For this study, a positive response to any of the first seven items in the SES-SFV was used to indicate that the person was sexually assaulted. Cronbachs alpha values more than .70 have been reported (Cecil & Matson, 2006).

Data Analysis Plan

SPSS, Version 17, was used to manage and analyze the data. The data were examined for missing and skewed data and to ascertain that the assumptions for multiple regression were met. Descriptive statistics were calculated for all study variables. Pearson and Spearman rho correlations were generated and results were interpreted as appropriate to the measurement scales of the respective variables (Polit & Beck, 2004). The analyses proceeded in two phases. During Phase 1, correlation analyses were conducted, and during Phase 2, selected variables were entered into a sequential multiple regression analysis. Phase 1. Correlation between the dependent variable (regret) and the independent variables, and correlations among the independent variables themselves, were evaluated. Guidelines for selecting independent variables for the multiple regression analysis included those that correlated with regret (r .26) and those that did not highly correlate (r .70) with each other (Hazard Munro, 2005). Phase 2. Four independent variables that had a statistically significant effect on regret were entered into a sequential multiple regression analysis designed to describe the extent and manner in which these variables describe variations in decisional regret. These variables included weight change (loss or gain) following the assault, assailant identified as a stranger, professional treatment sought following the assault, and filing a police report. The first block included two variablespolice report and stranger assailantwhich were classified as assault characteristics. In addition to police report and stranger assailant, the second block included weight change and professional treatment, which represented the variable category of health outcomes. The final regression model describes the relationship between regret and these selected independent variables.

Correlation Analyses
Reporting the assault to the police (rs = .37) and identifying the assailant as a stranger (rs = .43) were both negatively correlated with regret (p < .001). Additionally, being assaulted by a stranger was correlated with an increase in police reporting (rs = .38, p < .001). Experiencing a weight change (i.e., loss/gain) was correlated (rs = .26) with an increase in regret (p < .05). Seeking treatment following the assault was correlated (rs = .31) with a decrease in regret (p < .001) and with an increase (rs = .41) in reporting the assault to the police (p < .001). Results for selected study variables are presented in Table 1.

Multiple Regression Analysis

The following four variables were entered in the regression models: weight change, stranger assailant, professional treatment, and police report. The variables that were categorized as assault characteristics (i.e., police report and stranger assailant) were entered in Block 1 and accounted for 18.5% of the variability in the overall regret scores (F = 9.75, df = 2, p < .001). Block 2 included police report, stranger assailant, and the variables that were classified as health care outcomes, weight change, and professional treatment. Overall, the four variables together accounted for 33.3% of the variance (F = 10.61, df = 4, p < .001); thus, 33.3% of the variability in the overall regret scores could be explained by those four variables. In the final model only weight change ( = .38) and stranger assailant ( = -.36) were statistically significant (p < .001). However, all four variables were retained in the analysis because a stronger model (as measured by an increased adjusted R2 and a decreased standard error of the mean) resulted when all four variables were included in the model. The results from the regression analysis are reported in Table 2.

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36

Journal of the American Psychiatric Nurses Association 18(1)

Table 1. Spearman Rho Correlations (rs) Among Selected Study Variables Regret Regret Police Report Stranger Assailant Weight Change Professional Treatment 1.00 .37*** .43*** .26* .31** Police Report 1.00 .38*** .13 .41*** Stranger Assailant 1.00 .18 .23* Weight Change 1.00 .13 Professional Treatment 1.00

*p < .05. **p < .01. ***p < .001 (Bonferroni-adjusted alpha level, p < .01).

Discussion
Findings from this study must be evaluated in light of the study limitations. The sample was limited to individuals between the ages of 18 and 25 years, who experienced SA during the past 5 years and recruitment was done primarily on college campuses in the Boston area, so the sample represented a rather demographically homogenous group. The electronic, online survey format, which gathered self-report data, and the cross-sectional design, which allowed for the collection of data at only one point in the lives of the participants, are limiting factors. Also, the survey questions designed to elicit information about weight change (loss or gain) and professional treatment sought following the assault were posed broadly and lacked specificity. Weight change was positively correlated with regret and was the independent variable that made the greatest contribution to the regression equation. Participants who reported a weight change following the assault were more likely to experience regret about their decision to report. Given that regret has been defined as one of the most powerful negative emotions (Camille et al., 2004), this finding is consistent with research addressing emotional eating, which has been defined as the tendency to overeat in response to negative emotions such as anxiety or irritability (van Strien et al., 2007, p. 106). Furthermore, stress has been associated with changes in eating and weight because of cortisol reactivity that might cause some individuals to gain whereas others might lose weight (Block, He, Zaslavsky, Ding, & Ayanian, 2009). It is important to note that the survey question was designed to elicit information about either a weight gain or loss. Additionally, the weight change could have occurred during the past 5 years. Thus, this finding should be interpreted with caution in light of the lack of specificity and the well-known and diverse influences on weight change (Torres & Nowson, 2007). Certainly these results raise interesting questions such as: Are people who are more likely to experience body weight changes after experiencing a trauma such as SA also more likely to be regretful about other decisions as well; or more generally, are

people who are prone to experience regret also prone to emotional eating? Also, it is important to consider if weight changes could serve as a proxy for past depression or an underlying anxiety disorder. Following weight change, identification of the assailant as a stranger explained the most variance in the final regression model and it is correlated with decreased regret. This finding parallels those of researchers who have studied the barriers and facilitators to reporting SA and reported that individuals are less likely to report a SA if the assailant is known to the person who has been assaulted (Fisher, Daigle, Cullen, & Turner, 2000). Understanding that victims who are assaulted by someone they know are less likely to report the assault, and are more likely to regret the decision to not report, has important implications both for both the development of treatment strategies in the aftermath of SA and for policies that are designed to support people to file a police report. In the final model, seeking professional treatment following the assault correlated negatively with regret; therefore, people who sought treatment following their assault were more likely to experience decreased regret regarding their decision to report. Seeking professional treatment can be categorized as a help-seeking behavior, which has been defined as one that is used to solve problems (Anderson & Danis, 2007). This finding complements the work of others who have reported that college-aged women who have experienced domestic violence and exhibit help-seeking behaviors are more likely to be identified as victims and seek help (Amar & Gennaro, 2005). These findings have important implications for improving care and meeting the needs of those who have been assaulted. One of the most salient findings from this study is that people who reported their assaults to the police experienced significantly less regret about their decision to do so as compared with those who did not report. Although reporting an SA may not be in the best interest of every individual, it should be an option that is readily available to all, and it is important that clinicians are informed about the complex decision-making process involved in

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Marchetti
Table 2. Summary of Sequential Regression Analysis of Police Report, Stranger Assailant, Weight Change, and Professional Treatment on Regret (N = 78) Model 1 Variable Police Report Stranger Assailant Weight Change Professional Treatment R2 R2 Adjusted F values
*p < .05. **p < .01. ***p < .001.

37

Model 2 0.23* 0.31** B 2.21 5.50 4.39 2.18 SE B 1.29 1.57 1.09 1.18 0.333*** 0.152 10.61*** 0.18 0.36*** 0.38*** 0.19

B 2.76 4.82

SE B 1.33 1.71

0.185*** 0.185 9.75***

making the choice of whether or not to report, which is often a difficult choice for victims of SA. Studying regret is one way to understand this complex decision-making experience. There is a need to study individuals perceptions of barriers to reporting SA and work toward eliminating these so that individuals will feel empowered to make their choice to report based on personal issues as opposed to issues of access. Understanding the role of regret and its influence on the evaluation of decisional quality can advance the study of these barriers. Furthermore, a better understanding of regret, an important component of the decision-making process, could influence interventions that can assist people in their decision-making and, ultimately, lead to an increase in reporting. From a public safety perspective, increasing police reporting is beneficial as doing so increases the chances that dangerous assailants will be brought to justice and removed as threats.

decision-making aids) nurses and other clinicians could use to assist people with their decision making. The principal investigator is developing one such instrument titled, The Reporting of Sexual Assault Decision Aid (The ROSADA). Not only can such strategies help individuals but they also have the potential to inform public policies about the reporting process. It is reasonable to presume that a better understanding of the decision making process that surround police reporting of SA can lead to the development of improved police reporting protocols that may result in an increase in the reporting of SA. Increasing the reports of SA is an important first step in bringing the assailant to justice through the court system.

Conclusion
The study of regret and decision making about police reporting among individuals who have experienced SA is in its infancy. Because regret is a powerful, universal, negative emotion that influences the complex process of decision making, there are many implications for research on this topic that could be pursued by investigators in fields such as psychiatric nursing, victimology, law enforcement, and public policy. Landman (1993)a psychologist and the foremost expert in the study of regretcomments eloquently on the utility in advancing our understanding of regret: We have the ability to compare the actual to the possible; this means we risk regret. Far from being irrational or a waste of time, regret has transformative powers that help us to learn and change in positive ways. . . . Regret, like grief, is transformed by working it through, which is lingering with it long enough to experience it deeply [both] emotionally and intellectually. (p. 1)

Implications
The findings fill a gap in the psychiatric nursing literature and inform clinical practice by describing post decisional regret. Knowledge about regret derived from the study of individuals who have experienced SA brings us closer to understanding the benefits of this complex, negative emotion and its role in the decision making process. Such knowledge could be of great value to psychiatric nurses and other clinicians who work with patients who have experienced SA both recently and in the past. Also, this research can inform clinicians such as SANEs and emergency department hospital staff personnel who work with victims of SA acutely, in the immediate aftermath of the assault. The findings also have implications for more concrete interventions as they provide a foundation for future researchers to describe the development of strategies (e.g., the development of

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38 Acknowledgment
I would like to acknowledge Dr. Christine Murphy, Keith Chan, Rani Dalgin, and Dr. Allen Burgess for their statistical consultation and Drs. Ann Burgess and Joellen Hawkins for their help in preparing this article.

Journal of the American Psychiatric Nurses Association 18(1)

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Author's Notes
This article is based on data that were also used in my doctoral dissertation, which I completed at Boston College Connell School of Nursing.

Declaration of Conflicting Interests

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

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was funded, in part, by a grant from the Alpha Chi Chapter of Sigma Theta Tau International.

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