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. 2026 Sep 30;9(9):e2636353. doi: 10.1001/jamanetworkopen.2026.36353

Skills Training in Affective Recovery Video and Text Programs for Recent Sexual Assault Survivors

A Pilot Randomized Clinical Trial

Kate Walsh 1,✉, Cynthia A Stappenbeck 2, Ron Acierno 3,4, Anne-Marie Schipani-McLaughlin 5, K Nicole Mullican 5, Andrea A Massa 6, Jasper Oliver 6, Samuel A McLean 6, Shay McKay 7, Britney Carroll 7, Amy L Stier 8, Gordon Reed 8, Kimberly Curran 9, Sanika Panwalkar 1, Amanda K Gilmore 5
PMCID: PMC13628317  PMID: 42814464

Key Points

Question

Does a brief video and text message program for skills training in affective recovery delivered in the month after sexual assault reduce posttraumatic stress, pain, and substance misuse?

Findings

In this pilot randomized clinical trial of 50 women, those randomized to the study’s video program were less likely to meet the threshold for acute stress and had lower pain at 1 week compared with those randomized to treatment as usual. The study’s text program was associated with reduced pain at 4 weeks compared with treatment as usual.

Meaning

This study’s results suggest that the video and text programs are easy-to-administer interventions that support survivors coping with the burdens of acute stress, posttraumatic stress, or pain in the immediate aftermath of sexual assault.

This pilot randomized clinical trial assesses the preliminary effectiveness of a brief video program and 3-week daily text message program on reducing posttraumatic stress and substance misuse symptoms among recent sexual assault survivors.

Abstract

Importance

Three-quarters of sexual assault (SA) survivors meet criteria for posttraumatic stress disorder (PTSD) 1 month after SA, and PTSD is highly comorbid with substance use disorders. Intervening early is critical to preventing the onset or escalation of these conditions.

Objective

To assess the preliminary effectiveness of Skills Training in Affective Recovery (STAR), a brief video, and TextSTAR, a 3-week daily text message program on reducing posttraumatic stress and substance misuse symptoms among SA survivors during an SA medical forensic examination.

Design, Setting, and Participants

This pilot sequential, multiple-assignment randomized clinical trial recruited women from 4 US SA medical forensic examination programs from March 12 to November 3, 2025, who had experienced past 7-day SA. Participants were randomized to the video program or treatment as usual (TAU; no video) at the SA medical forensic examination and reassessed at 1 week; nonresponders—those above the threshold for acute stress or opioid misuse—were randomized to the text program or no text program. Participants completed weekly follow-up surveys for 1 month. Data analysis was conducted from December 2025 to April 2026.

Interventions

The study’s video program is a 17-minute video that educates and encourages social support, positive coping including mindfulness, and self-exposure to feared but safe stimuli. The study’s text program is a 3-week daily text message program that emphasizes social support, positive coping, and exposure.

Main Outcomes and Measures

Primary outcome of acute or posttraumatic stress was measured at 1 and 4 weeks via the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Primary outcome of drug use was measured at 1 and 4 weeks with the Tobacco, Alcohol, Prescription Medication, and Other Substance Use Part 1. Exploratory outcome of pain was measured at 1 and 4 weeks with the Brief Pain Inventory.

Results

Fifty women (mean [SD] age, 28.9 [10.1] years) were enrolled in the study. Those randomized to the study’s video program had lower odds of acute stress (odds ratio, 0.13; 95% CI, 0.02-0.78). Those randomized to the video program also had lower pain at 1 week (mean [SD] score, 2.1 [2.2]) compared with those assigned to TAU (mean [SD] score, 3.6 [2.6]). Linear regression revealed that the video (mean [SE] estimate, −0.25 [0.14]; z = −1.73; P = .08) and text (mean [SE] estimate, −0.41 [0.14]; z = −2.95; P = .003) programs were negatively associated with week 4 pain scores.

Conclusions and Relevance

In this preliminary randomized clinical study for recent SA survivors, the video program was associated with immediate reductions in acute stress and pain; the text program was associated with reductions in week 4 pain. These results suggest that the study’s video and text programs were easy-to-administer interventions that can be used in the short-term clinical setting where survivors receive care in the immediate aftermath of SA.

Trial Registration

ClinicalTrials.gov Identifier: NCT06456190

Introduction

More than half of US women will experience unwanted or nonconsensual sexual contact or sexual assault (SA) in their lifetime.1 SA is associated with deleterious mental and physical health consequences, including pain, unwanted pregnancy, sexually transmitted infections, posttraumatic stress disorder (PTSD), depression, suicidality, and substance misuse.2,3,4 SA is the traumatic event most likely to lead to a PTSD diagnosis, with approximately 75% of survivors meeting criteria 1 month after SA and 40% meeting criteria 12 months after SA.5 SA and PTSD are both associated with substance misuse6 and acute7 and chronic8,9,10 pain, including gynecologic pain.11,12 Pain can be a reason survivors misuse substances.13,14 Comorbid PTSD and substance misuse complicate recovery.15

Intervening early to prevent the onset or escalation of PTSD and substance misuse is critical, yet few interventions are designed for the short-term period after SA. In one exception, a 9-minute prevention of postrape stress (PPRS) video presented during an SA medical forensic examination was associated with 6-month reductions in posttraumatic stress (PTS)16,17 and alcohol, marijuana, and nicotine use18,19,20 compared with treatment as usual (TAU; receipt of an SA medical forensic examination only) among those with preassault SA histories and substance use, respectively. However, an active comparison mindfulness video was associated with reductions in opioid misuse compared with SA medical forensic examination–only TAU,21 corroborating literature emphasizing mindfulness for opioid misuse.22 Mindfulness also has been successfully used to reduce pain.23 Thus, we integrated the PPRS and mindfulness videos into the new Skills Training in Affective Recovery (STAR) video and developed a brief text message program called TextSTAR to allow survivors to interact with content in their own time,24 given the potential for short-term distress at the SA medical forensic examination.25 In a pilot trial,26 recent SA survivors found the video program and the text program moderately to extremely acceptable.

This study examines the preliminary effectiveness of video and text programs in reducing acute stress and PTS symptoms and substance use in the month after SA. We examined whether (1) receipt of the video program was associated with lower odds of acute stress and substance misuse at 1 week compared with TAU and (2) receipt of the video program plus text program was associated with lower odds of PTS and substance misuse at 4 weeks compared with receipt of the video program only, text program only, or neither intervention. We also explored whether the video or text program was associated with reduced pain severity at 1 week and 1 month. Given the pilot nature of this sequential, multiple-assignment randomized clinical trial (SMART), power was lower than optimal to detect differences.

Methods

Design

This pilot SMART involved 2-stage simple randomization with a 1:1 allocation at each stage. Initial simple randomization to STAR (the study’s video program) occurred within Qualtrics at the SA medical forensic examination; secondary randomization to TextSTAR (the study’s text program) occurred at 1 week only among nonresponders (ie, acute stress at or above the clinical threshold or opioid or heroin use in the previous week) (Figure 1). Secondary randomization occurred among unbalanced initial video program groups based on responder status. SMARTs can be used to develop individualized treatment sequences27 and to inform adaptive intervention design.28 This pilot SMART examined the preliminary effects of the video program alone or in combination with the text program and the text program alone compared with TAU in reducing PTS and substance misuse. Procedures were approved by the University of Wisconsin, Madison Institutional Review Board. The trial protocol can be found in Supplement 1. This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines.29

Figure 1. Study Schematic.

Flowchart of emergency visit, randomization, follow-ups, and text program assignment. Upper center rectangular node labeled T0 Emergency department visit plus baseline assessment. A vertical connector descends to an orange circle labeled R at upper center, with two horizontal branches. Left branch leads to a light blue rectangle labeled No video; right branch leads to a light blue rectangle labeled Video. Both arms reconnect into a single downward connector to a wide light blue rectangle centered on the page labeled T1 1-Week assessment. From the lower edge of the T1 box, a horizontal connector spans across the figure and splits into four downward arrows to four light blue rectangles arranged left to right. The first box at left reads Above threshold at 1 week. Beneath it, an orange circle labeled R sits on a short horizontal connector that splits to two lower boxes: at lower left, a light blue rectangle labeled 3-week text message program; at lower center-left, a light blue rectangle labeled No text program. The second box from the left reads Below threshold at 1 week and connects downward to a central light blue rectangle labeled T2-T3 2- and 3-week assessments. The third box from the left also reads Below threshold at 1 week and connects downward to the same T2-T3 2- and 3-week assessments rectangle. The fourth box at right reads Above threshold at 1 week. Beneath it, an orange circle labeled R sits on a short horizontal connector that splits to two lower boxes: at lower center-right, a light blue rectangle labeled No text program; at lower right, a light blue rectangle labeled 3-week text message program. From the bottom of the T2-T3 rectangle, a vertical connector descends to a wide light blue rectangle at the bottom labeled T4 1-month assessment. A long horizontal line near the bottom links the lower intervention boxes toward the central downward path leading to T4.

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R indicates randomized; T, time.

Participants and Setting

A sample size of 50 balanced the ability to collect enough data on acceptability, outcomes, and recruitment rates with the sponsor’s requirement to expediently complete this pilot before moving to the large-scale randomized clinical trial. Eligible participants were women 18 years or older who experienced an SA within the previous 7 days and received an SA medical forensic examination at 1 of 4 US SA medical forensic examination programs in the Better Tomorrow Network (BTN).

Procedures

Between March 12 and November 3, 2025, nurses connected interested survivors virtually to an on-call BTN team member for eligibility screening and consent. Participants needed to understand English, be willing to receive text messages, provide informed consent at or within 72 hours of the SA medical forensic examination, and agree to nurses releasing visit data to the researchers. A waiver of written consent was obtained. The BTN team member documented verbal consent or exclusion reasons in REDCap (Research Electronic Data Capture) and provided participants with the baseline Qualtrics survey link, within which participants were randomized to the video program or TAU (no video). SurveySignal pushed SMS survey reminders and the text program if participants were randomized to that condition after completing the week 1 survey.

For 4 weeks, participants received an email with a survey link. At week 1, those who screened above threshold on acute stress, heroin use, or prescription opioid misuse were randomly assigned to receive the text program or no text program (Figure 2). Participants received $50 for the baseline and all 4 weekly surveys ($250 total) along with mental health and substance use resources.

Figure 2. CONSORT Flow Diagram.

Participant flow diagram with screening, randomization, exclusions, and follow-up counts. Top center rectangular node labeled 60 Screened. A vertical connector descends to a right-side rectangular box labeled 10 Excluded, followed by four indented lines: 4 Too tired at examination; did not attend rescheduled appointment; 4 Did not attend appointment scheduled after examination; 1 Not interested; 1 Not comfortable participating in English. The main vertical connector continues downward to a centered rectangle labeled 50 Baseline assessment, then to a centered oval labeled 50 Randomized. From the oval, two diagonal connectors branch left and right. On the left branch, a rectangle labeled 25 STAR video. From this left branch, a horizontal connector points to a small rectangle labeled 1 Lost to follow-up before 1-week assessment. Below the 25 STAR video box, two downward connectors lead to two rectangles: left rectangle labeled 16 Above threshold and right rectangle labeled 8 Below threshold. From the 16 Above threshold box, two downward connectors lead to two smaller rectangles labeled 6 TextSTAR and 10 No TextSTAR. On the right branch from the randomization oval, a rectangle labeled 25 No video (TAU). From this right branch, a horizontal connector points to a small rectangle labeled 2 Lost to follow-up before 1-week assessment. Below the 25 No video (TAU) box, two downward connectors lead to two rectangles: left rectangle labeled 3 Below threshold and right rectangle labeled 20 Above threshold. From the 20 Above threshold box, two downward connectors lead to two smaller rectangles labeled 8 TextSTAR and 12 No TextSTAR. All nodes are light gray with dark text; connectors are thin gray lines with arrowheads indicating direction.

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STAR indicates Skills Training in Affective Recovery; TAU, treatment as usual.

Interventions

Video Program vs TAU

The study’s video program24 is a 17-minute video that was refined with feedback from a sexual assault community advisory board and emphasizes evidence-based strategies, including seeking out and engaging with supportive people,6 recognizing when safe situations have become paired with fear and avoidance and how to use therapeutic exposure to address fear-related avoidance,30 recognizing factors that increase the likelihood of using substances to cope,31 and engaging in activities that are incompatible with substance use or using a mindfulness technique, such as urge surfing.32 In the TAU group, all participants received an SA medical forensic examination, which may include a physical examination and injury treatment, pregnancy and sexually transmitted infection prophylaxis, evidence collection, and/or referrals and resources.

Text Program vs No Text

In the study’s text group, participants received a single text message for 21 days, organized into supportive, educational, and skills-focused messages that emphasized social support; positive coping, including mindfulness techniques; and exposure to safe but feared stimuli in one’s environment. Text messages were constructed using content and phrasing from the video and were refined with feedback from the community advisory board.24 A sample text is as follows: “Feeling alone? Support is important for healing. Try reaching out to a supportive person today.” In the no-text group, participants did not receive daily text messages but completed paid weekly surveys and received resources after each survey.

Measures

Baseline

Demographics

To monitor racial diversity in this clinical trial, National Institutes of Health–defined race (Alaska Native, American Indian, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, or multiracial or other [write-in option]) was queried. Participants also reported on Hispanic or Latine ethnicity (yes or no), sexual orientation (heterosexual or straight vs gay or lesbian, bisexual, asexual, two-spirit, or another orientation), physical or mental disability (yes, no, or unsure), highest educational level (high school equivalent or less, some college, or bachelor’s or graduate degree), whether they moved to the US from another elsewhere (yes or no), whether they have a steady place to live (yes or no), annual income (<$10 000 to ≥$60 000), and current relationship status (married or cohabitating; separated, divorced, or widowed; or single).

Preassault Trauma and PTSD

The Primary Care PTSD Screen for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PC-PTSD-5)33 includes a yes or no question about lifetime exposure to trauma (eg, unintentional injury, natural disaster, war, rape or SA, seeing someone killed or seriously injured, and others). Those who experienced a lifetime trauma were asked whether in the month before the assault they (1) had nightmares or thought about the trauma when they did not want to; (2) tried hard not to think about the trauma or went out of their way to avoid things that reminded them of it; (3) felt constantly on guard, watchful, or easily startled; (4) felt numb or detached from people, activities, or surroundings; and (5) felt guilty or unable to stop blaming themselves for the trauma with yes or no responses. Affirmative responses to 4 or more items indicated a positive screen result for probable preassault PTSD.34,35 The PC-PTSD-5 has excellent diagnostic accuracy, with an area under the receiver operating characteristic curve of 0.94; a cut score of 4 yields a sensitivity of 0.83 and a specificity of 0.91.33

Preassault Substance Use

Item 1 of the 8-item Alcohol, Smoking and Substance Involvement Screening Test36 identified substance use and associated health risks and disorders. The first question assesses any lifetime use of illicit drugs (cannabis, cocaine, methamphetamine, inhalants, hallucinogens, street opioids, or other drugs) and nonmedical use of prescription drugs (stimulants, sedatives, or opioids).

Week 1 to 4 Surveys: Primary Dependent Variables

Acute Stress or PTS

The 20-item PTSD Checklist for DSM-5 (PCL-5)37 measured acute stress or PTS symptoms, including intrusions, avoidance, negative mood and cognitions, and arousal in the past week. Responses ranged from 0 (never) to 4 (extremely), with total scores ranging from 0 to 80 and higher scores reflecting more severe symptoms. The PCL-5 has excellent psychometric properties, including strong internal consistency, test-retest reliability, and convergent validity with the gold standard Clinician-Administered PTSD Scale for DSM-5.37,38 The Cronbach α was 0.94. A cut score of 31 indicated acute stress at week 1 and PTS at week 4. Secondary analyses used week 1 and 4 severity scores.

Substance Misuse

We modified the Tobacco, Alcohol, Prescription Medication, and Other Substance Use Part 139 to ask how often in the past week (vs past 12 months) participants (1) used nicotine; (2) drank 4 or more drinks in a single sitting; (3) used any drugs, including marijuana, cocaine or crack, heroin, methamphetamine or crystal methamphetamine, hallucinogens, ecstasy, or 3,4-methylenedioxymethamphetamine; or (4) used any prescription medications more than prescribed or not prescribed for the participant. Response options were modified for the past week to 0 (never), 1 (1 day), 2 (2-3 days), 3 (4-5 days), and 4 (daily or almost daily). Those who reported using at least 1 day were asked whether they had used heroin or prescription opioid pain relievers not as prescribed; these questions were used to determine whether participants were above threshold for opioid misuse in the previous week.

Exploratory Dependent Variable: Pain

The 4-item pain severity subscale from the Brief Pain Inventory40 measured pain at baseline and all follow-ups. The Brief Pain Inventory is a reliable and validated measure of acute and chronic pain.40 Participants report their worst pain during the past week, least pain during the past week, average pain, and current pain. Responses range from 0 (no pain) to 10 (pain as bad as I can imagine). Items were averaged, with higher scores indicating greater pain.

Covariates: Pain Medication and Treatment Receipt

Participants were asked if they had received a prescription for pain medication in the past week (yes, no, or not sure). Participants were asked whether they sought help from a physician, psychiatrist, psychologist, therapist, social worker, counselor, or healer in the past week (yes or no).

Statistical Analysis

Descriptive analyses were conducted in SPSS, version 30 (IBM Corp); hypothesis testing and exploratory analyses were conducted in Mplus, version 9.1 (Muthén & Muthén). Missing data were handled via full information maximum likelihood estimation with robust SEs. Attrition was examined by demographics and preassault characteristics with χ2 or 2-tailed, unpaired t tests. Hypothesis 1 was tested with separate logistic regressions estimating the proportion of respondents above the PCL-5 threshold of 31 or any drug use by randomization to the video program vs TAU controlling for preassault probable PTSD and preassault drug use, respectively. Odds ratios (ORs) and 95% CIs were reported. Secondary analyses of primary outcomes and exploratory analyses for pain used t tests and reported effect sizes.

To examine whether receipt of video plus text was associated with lower PTS and substance misuse at week 4 compared with video only, text only, or neither intervention, we used logistic regression with randomization to the video and text message condition as independent variables controlling for preassault probable PTSD and substance use (depending on model). ORs and 95% CIs were reported. Secondary analyses of primary outcomes and exploratory analyses for pain used 2-tailed, unpaired t tests and reported effect sizes. A 2-sided P < .05 was considered statistically significant. Data analysis was conducted from December 2025 to April 2026.

Results

Fifty women (mean [SD] age, 28.9 [10.1] years; 30 [60.0%] Black or African American, 0 Native Hawaiian or Other Pacific Islander, 16 [32.0%] White, 3 [6.0%] multiracial or other, and 1 [2.0%] prefer not to answer) were included in the study. Most identified as straight or heterosexual (35 [70%]), single (35 [70%]), and stably housed (33 [66%]) and had household incomes below $30 000 (31 [62.0%]). Most (36 [72%]) were not disabled, and there was relatively even distribution across education (Table 1). A total of 45 of 50 participants (90%) completed week 4. Completers did not differ from noncompleters on age, race, Hispanic or Latine ethnicity, disability, income, educational attainment, prior PTSD, or prior substance use. At baseline, 21 (42%) met the criteria for probable preassault PTSD. A total of 36 (76%) were at or above the PCL-5 threshold of 31 at week 1; only 26 (58%) met the threshold by week 4. A total of 34 (68%) reported preassault illicit drug use, whereas 14 (32%) reported illicit drug use at weeks 1 and 4. A total of 26 (12%) reported preassault nonmedical prescription drug use, although this prevalence increased to 6 (15%) at week 1 and decreased to 4 (9%) by week 4. A total of 4 (8%) reported baseline opioid misuse, but 0 reported any opioid misuse over follow-up. Pain decreased from a mean (SD) of 2.8 (2.5) to 2.1 (2.3), and 13 (26%) received prescription pain medication. Across follow-ups, 21 participants (50%) reported receipt of treatment and a decrease pain severity, and 13 (26%) received prescription pain medication. There were 0 adverse events (Table 2).

Table 1. Characteristics of the Study Participants.

Characteristic No. (%) of participantsa (N = 50)
Age, mean (SD), y 28.9 (10.1)
Race
Alaska Native 0
American Indian 0
Asian 0
Black or African American 30 (60)
Native Hawaiian or Other Pacific Islander 0
White 16 (32)
Multiracial or otherb 3 (6)
Prefer not to answer 1 (2)
Sexual orientation
Straight or heterosexual 35 (70)
Gay or lesbian, bisexual, asexual, two-spirit, or another orientation 12 (24)
Prefer not to answer 3 (6)
Disabled
No 36 (72)
Yes 4 (8)
Unsure 8 (16)
Prefer not to answer 2 (4)
Educational level
High school or less 18 (36)
Some college or associates 20 (40)
Bachelor’s or graduate degree 12 (24)
Relationship status
Married or cohabitating 4 (8)
Divorced, separated, or widowed 9 (18)
Single, never married 35 (70)
Prefer not to answer 2 (4)
Annual income, $
<10 000 14 (28)
10 000-29 999 17 (34)
>30 000 8 (16)
Do not know 10 (20)
Prefer not to answer 1 (2)
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a

Unless otherwise indicated.

b

Two of the 3 respondents who were classified as multiracial or other selected both Black and White; 1 respondent selected other and wrote in Hispanic.

Table 2. Posttraumatic Stress, Substance Use, Pain, Treatment Engagement, and Prescription Medication Use in the Study Participants.

Variable No. (%) of participantsa
Preassault baseline (n = 50) Week 1 (n = 47) Week 2 (n = 43) Week 3 (n = 44) Week 4 (n = 45)
Acute stress or PTS stress score, mean (SD) 3.5 (1.7)b 45.2 (18.5) 41.9 (19.8) 38.4 (22.1) 36.3 (21.1)
Above threshold on acute stress or PTS 21 (42) 36 (77) 29 (67) 27 (61) 26 (58)
Any illicit drug use 34 (68) 15 (32) 12 (29) 15 (35) 14 (32)
Any nonmedical prescription drug use 6 (12) 7 (15) 6 (14) 5 (11) 4 (9)
Any opioid (heroin or prescription) misuse 4 (8) 0 0 0 0
Pain severity score, mean (SD) 4.1 (2.6) 2.8 (2.5) 2.3 (2.3) 2.1 (2.3) 2.1 (2.3)
Any treatment NA 27 (61) 26 (60) 21 (48) 23 (51)
Started taking new medications NA 6 (13) 2 (5) 3 (7) 1 (2)
Pain medication prescription NA 9 (20) 2 (5) 4 (9) 0
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Abbreviations: NA, not applicable; PTS, posttraumatic stress.

a

Unless otherwise indicated.

b

At baseline, we asked about prior trauma and screened for past-month probable posttraumatic stress disorder using the Primary Care PTSD Screen for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), which has a range of 0 to 5, with affirmative responses to 4 or more items indicating a positive screen result.

Week 1

Acute Stress

Video program participants were less likely to be at or above the acute stress threshold at week 1 compared with TAU (OR, 0.13; 95% CI, 0.02-0.78; B = −2.03; SE = 0.91; P = .03); 16 (90.9%) in the TAU group met the PCL-5 threshold of 31 compared with 16 [66.7%] in the video program. Findings were consistent when PTSD was examined continuously (Hedges g = 0.52), with a clinically meaningful 10-point difference in scores (mean [SD] of 40.6 [19.8] in the video program vs 50.1 [15.8] in TAU).41

Drug Use

No significant differences emerged in week 1 drug use (OR, 3.20; 95% CI, 0.82-12.59; B = 1.16; SE = 0.70; P = .10) or nonmedical prescription drug use (OR, 0.63; 95% CI, 0.13-3.11; B = −0.46; SE = 0.81; P = .57) for video vs TAU. Findings were similar when examined continuously, and effect sizes were small (Hedges g = −0.30 to 0.18).

Week 4

Posttraumatic Stress

All participants who were below the PCL-5 threshold at week 1 remained below the threshold at week 4. Among those randomized to the text program, logistic regression controlling for preassault likely PTSD and treatment received from weeks 1 to 4 revealed that neither the video (OR, 2.65; 95% CI, 0.43-16.29; B = 0.98; SE = 0.93; P = .29) nor text program (OR, 0.75; 95% CI, 0.15-3.81; B = -0.29; SE = 0.83; P = .74) were associated with PTSD at week 4. No differences emerged when PTSD was modeled continuously.

Drug Use

Logistic regression controlling for preassault use of the same class of substances revealed that neither the video (OR, 1.85; 95% CI, 0.39-8.87; B = 0.62; SE = 0.80; P = .44) nor text program (OR, 1.77; 95% CI, 0.34-9.32; B = 0.57; SE = 0.85; P = .50) was associated with drug use at week 4. Neither the video (OR, 0.42; 95% CI, 0.04-4.00; B = −0.87, SE = 1.15, P = .45) nor text program (OR, 1.03; 95% CI, 0.14-7.62; B = 0.03; SE = 1.02; P = .98) was associated with nonmedical prescription drug use at week 4. No differences emerged when frequency of drug or nonmedical prescription drug use was examined.

Exploratory Analyses

Week 1 and Week 4 Pain Severity

A Wald test revealed lower pain severity scores for those randomized to the video program (mean [SD] score, 2.1 [2.2]) vs TAU (mean [SD] score, 3.6 [2.6]) (Wald = 4.22; Hedges g = 0.59; P = .04). Linear regression revealed that the video (mean [SE] estimate, −0.25 [0.14]; z = −1.73; P = .08) and text (mean [SE] estimate, −0.41 [0.14]; z = −2.95; P = .003) programs were negatively associated with week 4 pain scores. Week 4 means and prevalences are given in the eTable in Supplement 2. Across the initial nonresponder arms, the prevalence of PTS ranged from 58% in the text only condition (n = 12) to 100% in the STAR plus text condition (n = 5).

Discussion

Findings from this pilot trial suggested that the video program, delivered to survivors during post-SA medical care, had positive effects on PTS and pain severity compared with TAU. For primary PTS and substance misuse outcomes at week 4, the text program did not significantly augment the effects of the video program, although text was associated with lower pain severity at week 4. The video program was not statistically significantly associated with lower week 4 pain in this pilot. Prior trials16,17 with the PPRS found effects of the video alone on substance misuse during a 6-month period; thus, larger trials with longer follow-up periods may be needed to observe effects for PTS and substance misuse.

At week 1, 68% of those randomized to receive the video program were above the threshold for acute stress compared with 91% of those randomized to TAU, suggesting that the video program had immediate effects on PTS. In prior PPRS randomized clinical trials, the first assessment point was at 6 weeks,16,17 so this study represents a novel opportunity to observe the more immediate effects of STAR. A substantial proportion of initial nonresponders continued to meet the PTS threshold at week 4, suggesting that more intensive early intervention may be needed. Week 1 video program responders remained below the PTS threshold by week 4. Better understanding the characteristics of those who showed an initial response to the video program will be important for future adaptive intervention work.

More than two-thirds of the sample reported lifetime illicit drug use, and one-third reported weekly use. Rates of nonmedical prescription drug use were more variable but approximately 10%. The video and text programs were not associated with either type of substance use at weeks 1 or 4. Prior video trials18,19 have observed effects at 6 months, so change in substance use may be more gradual and a response to changes in PTS42 or pain. We did not assess motives for substance use or motivations for change43; however, interventions could be tailored to personal motives for use,44 and reasons for change could be integrated into content, consistent with motivational interviewing.45

Although 8% of the sample reported preassault lifetime opioid misuse, no participants reported opioid misuse in the 4 weeks after the assault. However, 26% reported receiving a prescription for pain medication at the SA medical forensic examination or during the 4-week follow-up period, so longer follow-up periods may be necessary to examine whether the video program or text program is differentially associated with the development of pain medication misuse. The video program showed promising initial effects on pain severity, and the text program was associated with lower pain at week 4 compared with TAU. Consistent with cognitive behavioral approaches to pain management,46 the daily messages promoting social support, exposure, and mindfulness skills may improve mood and reduce pain.

Limitations

This study has some limitations. The current pilot study was not fully powered to detect treatment effects, and we ran several tests but did not adjust P values due to the small sample. It is possible that some findings were due to chance. We also did not assess preassault treatment, which could influence how participants respond to interventions. Interventions were designed for women because 97% of those who present for SA medical forensic examination care are women,47 but future work could develop interventions for men. Survivors who receive a SAMFE may not be representative of all survivors; identifying additional dissemination avenues will be important. Additionally, validated self-report questionnaires were used to assess acute stress or PTS; future studies could use clinician-administered interviews. Lastly, we did not collect data on specific disabilities.

Conclusions

This pilot randomized clinical trial found the video program to be associated with immediate reductions in PTS and pain; the program was associated with lower pain severity by week 4. Because pain is an important therapeutic target for substance use interventions,48 future studies should continue to refine and test these interventions.

Supplement 1.

Trial Protocol

jamanetwopen-e2636353-s001.pdf (683.7KB, pdf)
Supplement 2.

eTable. Means (SDs) and Prevalence of Week 4 Posttraumatic Stress, Substance Use, and Pain by SMART Arm

jamanetwopen-e2636353-s002.pdf (241.8KB, pdf)
Supplement 3.

Data Sharing Statement

jamanetwopen-e2636353-s003.pdf (17KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

Trial Protocol

jamanetwopen-e2636353-s001.pdf (683.7KB, pdf)
Supplement 2.

eTable. Means (SDs) and Prevalence of Week 4 Posttraumatic Stress, Substance Use, and Pain by SMART Arm

jamanetwopen-e2636353-s002.pdf (241.8KB, pdf)
Supplement 3.

Data Sharing Statement

jamanetwopen-e2636353-s003.pdf (17KB, pdf)

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