An Integrative Approach to Conceptualizing and Treating Complex Trauma

Complex trauma (CT) often presents with polymorphous symptoms (i.e., emotional dysregulation, dissociation, somatic distress) resulting from repeated and chronic exposure to traumatic stressors. While the public is increasingly aware of posttraumatic stress disorder (PTSD) and its accompanying symptoms, the phenomena of complex trauma is less recognized and understood. Since the trauma reactions with CT typically occur during childhood, and the symptoms go well beyond PTSD, the authors of this article assert that an integrative approach is needed that synthesizes the most effective elements of cognitive-behavioral therapy (CBT) while blending a self-psychological approach. A review of the literature addresses the definition of complex trauma, cognitive-behavioral conceptualizations and treatment approaches, self-psychological models, current theories of attachment, and advances in neuropsychoanalysis. An integrative model is then proposed, supported by clinicians in the trauma field, identifying three intertwined phases of treatment.     

Conversion Hysteria in a Pre-Adolescent Girl

Abstract

This paper is a case presentation of a 10-year-old girl with classic conversion hysteria symptomatology. Psychological test material as well as the ten session treatment is presented. The original Breuer/Freud conceptualization of hysteria and its linkage with trauma is considered. Current theories of trauma with the usual presenting symptoms of dissociation, abandonment fears, and repetition are also considered.     

Beyond trigger warnings: Toward a trauma‐informed andragogy for the graduate theological classroom*

Although development of trauma‐informed pedagogy for elementary and secondary classrooms has developed significantly, a dearth of resources for trauma‐informed andragogy in graduate theological classrooms remains. Theological classrooms are a unique context in which many students and professors carry experiences of trauma with them. This article makes the case for the need for a trauma‐informed andragogical model for the graduate theological classroom by: discussing the pervasiveness of trauma; providing definitions of key terms that need to be understood for elaborating a trauma‐informed andragogy; recommending trauma‐informed principles for course design and class‐session planning based in safety, trust, choice, collaboration, and empowerment; and identifying a few next steps for cultivating trauma‐informed classrooms and institutions at the graduate level.     

Unemployment in Iraqi refugees: The interaction of pre and post‐displacement trauma

Previous refugee research has been unable to link pre‐displacement trauma with unemployment in the host country. The current study assessed the role of pre‐displacement trauma, post‐displacement trauma, and the interaction of both trauma types to prospectively examine unemployment in a random sample of newly‐arrived Iraqi refugees. Participants (N = 286) were interviewed three times over the first two years post‐arrival. Refugees were assessed for pre‐displacement trauma exposure, post‐displacement trauma exposure, a history of unemployment in the country of origin and host country, and symptoms of posttraumatic stress disorder (PTSD) and depression. Analyses found that neither pre‐displacement nor post‐displacement trauma independently predicted unemployment 2 years post‐arrival; however, the interaction of pre and post‐displacement trauma predicted 2‐year unemployment. Refugees with high levels of both pre and post‐displacement trauma had a 91% predicted probability of unemployment, whereas those with low levels of both traumas had a 20% predicted probability. This interaction remained significant after controlling for sociodemographic variables and mental health upon arrival to the US. Resettlement agencies and community organizations should consider the interactive effect of encountering additional trauma after escaping the hardships of the refugee's country of origin.     

Trauma,causality and time: Some reflections: EPISTEMOLOGY STUDY GROUP,PORTO ALEGRE PSYCHOANALYTICAL SOCIETY1

Based on the studies and discussions of the Epistemology Study Group of the Porto Alegre Psychoanalytical Society, the authors aim to connect the notions of psychical determinism with the concept of trauma and temporality, from a perspective of the mind as a complex system. Following consideration of the concept of psychical determinism, they attempt to expand the discussion on causality. They propose that trauma be situated in the body of contemporary psychoanalysis, where emotional experience is favoured over factual events, leading to the need to rethink the concept of trauma and its usefulness. In the same way, in the light of recent developments, the authors revisit the Freudian etiologic equation, with a proposal that an i, for imaginary factor, be included, corresponding to an element of complexity. The question of temporality, connected with trauma and the therapeutic action of psychoanalysis, is approached within a vision of irreversible time, characteristic of complex systems, far‐from‐equilibrium‐which is how the authors understand psychical functioning.     

Interoceptive Exposure Therapy Combined with Trauma‐related Exposure Therapy for Post‐traumatic Stress Disorder: a Case Report

Trauma‐related exposure therapy is a useful but not universally effective treatment for post‐traumatic stress disorder. Anxiety sensitivity may play an important role in this disorder, as it does in panic disorder. Studies have shown that interoceptive exposure therapy reduces anxiety sensitivity in panic disorder. The present case study was a preliminary investigation of the merits of including interoceptive exposure therapy in the treatment of post‐traumatic stress disorder, in order to improve treatment outcome for a patient who had no history of panic disorder or panic attacks. Interoceptive exposure therapy (4 sessions) was one component of treatment, combined with trauma‐related exposure therapy (4 sessions of imaginal exposure followed by 4 sessions of in vivo exposure). Treatment outcome was assessed with the Clinician‐Administered Post‐traumatic Stress Disorder Scale, a self‐report measure of post‐traumatic stress disorder symptoms, and measures of symptoms and cognitions commonly associated with post‐traumatic stress disorder. Scores on all outcome measures decreased over the course of treatment, with gains maintained at 1‐ and 3‐month follow‐up. Symptoms of anxiety sensitivity and post‐traumatic stress disorder decreased during interoceptive exposure therapy. The results indicate that interoceptive exposure therapy is a promising adjunctive intervention for post‐traumatic stress disorder. Further research is needed into the merits of combining interoceptive exposure therapy and trauma‐related exposure therapy as a means of boosting treatment efficacy.     

Complex Trauma Symptoms in Former Ugandan Child Soldiers

Children exposed to repeated interpersonal trauma often develop symptoms that exceed those documented in criteria for post-traumatic stress disorder (PTSD) and are better described with the emerging concept of developmental trauma disorder (DTD). This study examines complex trauma symptoms in a sample of 330 former Ugandan child soldiers (age 11–17 years, 49% female). Prevalence rates were 33.0% for PTSD, 36.4% for depression, and 78.2% for DTD. Whereas PTSD symptoms were significantly related to traumatic war experiences and depression, DTD symptoms were significantly associated with experiences of domestic violence, community violence, social support, and depression. Assessment tools and tailored interventions for DTD are urgently needed.     

Freud's view of hysteria in light of modern trauma research

Freud's earliest notion of the aetiology of hysterical symptoms was based on his hypothesis on the importance of trauma dissociation, upon which he began to construct his first theory of neurosis. Soon, his conception of trauma narrowed to apply only to sexual trauma, and later only to childhood experiences of sexual abuse by the father. He substituted these earliest variations on a theory of neurosis with the libido theory due to his discovery of infantile sexuality, the poor treatment results he had with hysteric patients, the frequency of hysteria symptoms, the difficulties he had in distinguishing between his patients' internal and external realities and the ambiguous nature of the reasons behind the patients' problems, presumably due to repression. Recent trauma research, however, has rediscovered trauma dissociation, which is separate from repression. This has led to a new theoretical understanding of trauma-originated dynamics and the development of corresponding treatment interventions. In this paper, the author analyzes the development of Freud's conceptions of hysteria in the social-clinical cultural context of his period, as well as the reasons which led Freud to abandon the notion that trauma dissociation was an underlying cause of hysteria symptoms.     

Influence of affective distractors on working memory capacity in relation to symptoms of posttraumatic stress disorder

Symptoms evoked in individuals with posttraumatic stress disorder (PTSD) when processing trauma‐relevant material arguably impair higher order cognitive functions. An example is working memory capacity (WMC), which has been shown to be disrupted by affective distractors. However, it is unknown whether this association varies across different types of PTSD symptoms. This study explored the association between WMC performed in affective (relative to neutral) contexts in relation to different symptoms of PTSD (avoidance, re‐experiencing, hyperarousal). Motor vehicle accident survivors with PTSD and without PTSD completed a delayed‐match‐to‐sample task including trauma‐related, neutral, and scrambled distractors in the interval between the presentation of the memoranda and the recognition target. The results showed that there was support for an indirect pathway between PTSD diagnosis and WMC performed in affective (versus neutral) contexts through re‐experiencing and avoidance symptoms. The findings suggest that avoidance symptoms in particular may benefit from interventions directed at improving WMC.     

Trauma‐related rumination mediates the effect of naturally occurring depressive symptoms but not momentary low mood on trauma intrusions

Comorbid depression is known to contribute to the maintenance of posttraumatic stress disorder (PTSD) including distressing intrusive trauma memories. It is theorised that depression is a risk factor for persistent PTSD through preventing optimal habituation of distress provoked by trauma memories and reminders, but the underlying cognitive mechanisms responsible are uncertain. The present study investigated trauma‐related rumination as a possible mediator for the effect of depression on trauma intrusions. Participants received a low mood induction or control procedure. Following viewing an analogue trauma film, frequency of film‐related intrusions and associated distress levels were measured and at 1‐week follow‐up. Between the two occasions, participants rated their levels of rumination about the film. Existing depression symptoms but not induced momentary sad mood predicted frequency of film intrusions and associated distress at 1‐week follow‐up. Some evidence was found that ruminative trauma processing mediated the relationship between baseline depressive symptoms and later intrusion frequency and associated distress. Future research is warranted to better understand the role of rumination in the depression–intrusion relationship, which may shed light on the clinical applicability of rumination‐targeted intervention for PTSD and comorbid depression.     

Responses to the September 11, 2001, Terrorist Attacks: Experience of an Indirect Traumatic Event and Its Relationship With Perceived Benefits

Little is known about how people might benefit from an indirectly experienced traumatic event. The authors examined the relationship between perception of benefit and trauma symptoms in response to a relatively severe, but indirectly experienced, traumatic event. The authors sampled from 2 colleges located in the southeastern United States (N = 136). Individuals responded to questionnaires that assessed perceived benefits and trauma symptoms 1-2 weeks after the terrorist attacks of September 11, 2001, and again approximately 10 weeks later. Participants did perceive benefits from witnessing this event, although their perception of benefit declined over time. Level of trauma symptoms correlated positively with perception of benefit, and experiencing a previous trauma also correlated positively with perceived benefits. Additional analysis indicated that level of trauma symptoms mediated the relationship between previous trauma and perception of benefit. These findings help to elucidate understanding of the development of perceived benefits in response to indirectly experienced events.     

Striving Towards Empowerment and Medication Adherence (STEP-AD): A Tailored Cognitive Behavioral Treatment Approach for Black Women Living With HIV

In the U.S. Black women with HIV face numerous psychosocial challenges, particularly trauma, racism, HIV-related discrimination, and gender role expectations, that are associated with negative HIV health outcomes and low medical treatment adherence. Yet many of these factors are unaddressed in traditional cognitive behavioral approaches. This study presents a case series of a tailored cognitive behavioral treatment approach for Black women living with HIV. Striving Towards EmPowerment and Medication Adherence (STEP-AD) is a 10-session treatment aimed at improving medication adherence for Black women with HIV by combining established cognitive behavioral strategies for trauma symptom reduction, strategies for coping with race- and HIV-related discrimination, gender empowerment, problem-solving techniques for medication adherence, and resilient coping. A case series study of five Black women with HIV was conducted to evaluate the preliminary acceptability and feasibility of the treatment and illustrate the approach. Findings support the potential promise of this treatment in helping to improve HIV medication adherence and decrease trauma symptoms. Areas for refinement in the treatment as well as structural barriers (e.g., housing) in the lives of the women that impacted their ability to fully benefit from the treatment are also noted.     

Caregiver Behaviors and Child Distress in Trauma Narration and Processing Sessions of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an effective treatment for children impacted by trauma, and non-offending caregivers play an important role in this treatment. This study aims to identify correlates of four caregiver variables that have been identified as predictors of child outcomes in TF-CBT: support, cognitive-emotional processing, avoidance, and blame/criticism. Audio recorded sessions were coded from a community effectiveness trial of TF-CBT that included 71 child-caregiver dyads participating in the trauma narration and processing phase of treatment. Regression analyses were conducted to examine caregiver trauma history and child baseline symptoms (internalizing, externalizing, and posttraumatic stress disorder [PTSD] symptoms) as predictors of caregiver behavior during the trauma processing sessions. Caregivers who reported exposure to more trauma types exhibited more in-session avoidance and also processing during the trauma processing phase of treatment. Child symptoms at baseline did not predict caregiver in-session behaviors. Bivariate correlations were used to investigate concurrent associations between mean levels of in-session caregiver behaviors and in-session child distress (negative emotion, hopelessness, negative behaviors). More caregiver blame/criticism was associated with more in-session child distress on all three measures. Caregiver avoidance was associated with more child negative emotion and hopelessness. Findings may help identify therapeutic targets when working with caregivers to promote change and enhance TF-CBT outcomes.     

Client‐centred group therapy for survivors of interpersonal trauma: A pilot investigation

Group therapy for trauma survivors provides an opportunity to share experiences with others in a supportive environment. Client‐centred groups have received very little attention as a way of working with traumatised people. Such groups promise to promote psychological growth following trauma. In this paper we present pilot data from a client‐centred group of six survivors of interpersonal violence who were experiencing complex posttraumatic stress reactions. Results suggested that those who perceived the presence of empathic listening within the group therapy sessions benefited from the group, showing greater positive changes. Clinical implications for working with trauma survivors, methodological considerations and directions for future research are discussed.     

The transgenerational trauma and resilience genogram

The understanding of trauma within counseling has expanded to include the salience of ecosystemic factors and to acknowledge the importance of multicultural and social justice considerations. Transgenerational trauma and resilience offers a framework that examines trauma across generations, attends to ecosystemic concerns, and adheres to a strengths-based perspective. However, given the complexity of trauma counseling and attending to the multitude of ecosystemic factors, counselors and psychologists may struggle to conduct comprehensive assessments and interventions with their clients. Genograms have long been used to clarify complex family and psychological patterns through visual representations, and are, therefore, a promising tool to meet this need. The Transgenerational Trauma and Resilience Genogram (TTRG) was created as a dynamic tool that can assist practitioners in conducting compressive trauma assessment and intervention from a transgenerational trauma and resilience framework. The TTRG emphasizes an ecosystemic view of trauma, culturally relevant and strength-based interventions, and attention to sociopolitical concerns that may impact trauma and recovery. The author explicates the use of the TTRG in trauma counseling, including the theoretical foundations and implications for trauma and recovery. A case example of the use of the TTRG and implications for counseling practice using the TTRG and its guiding principles are provided.     

Hopelessness as a Risk Factor for Post‐traumatic Stress Disorder Symptoms Among Interpersonal Violence Survivors

Post‐traumatic stress disorder often co‐occurs with depression, and they may share common risk factors. One possible common cognitive risk factor is hopelessness. Thus, we examined whether hopelessness was related to symptoms of post‐traumatic stress disorder. Participants were 202 female survivors of interpersonal violence. Relationships between self‐reported and interviewer‐rated measures of hopelessness gathered at 2 weeks post‐trauma and self‐reported and interviewer‐rated symptoms of post‐traumatic stress disorder gathered at 2 weeks and 3 months post‐trauma were examined. Hierarchical, simultaneous regression analyses that co‐varied trauma type revealed that hopelessness was related to self‐reported symptoms of post‐traumatic stress disorder, both concurrently and prospectively. Follow‐up analyses revealed that relationships between hopelessness and symptoms of post‐traumatic stress disorder were due almost entirely to shared variance with depression. No relationships were found between hopelessness and interviewer‐rated symptoms of post‐traumatic stress disorder.     

Adolescents in Secure Accommodation in Scotland: Exposure and Impact of Traumatic Events

The current study sought, for the first time, to assess the nature of trauma exposure and resultant symptoms in adolescents (n = 17) in secure accommodation in Scotland. A case study mixed methods design involved analysis of case files, trauma history interviews, and standardized trauma symptom questionnaires with adolescents and program staff in 1 facility. A developmental trauma framework was applied to file analysis. Despite extensive abuse and resultant symptoms identified in files, few explicitly reported traumatization. Adolescents in interview, however, reported numerous domestic and institutional traumatic events. High levels of posttraumatic stress (65%), depression (65%), and dissociation (18%) were identified. It appears adolescent traumatization is pervasive in 1 secure accommodation facility in Scotland. Studies across Scotland’s secure facilities are needed to assess reliability of findings. Indications are that staff in secure accommodation need to have an understanding of trauma exposure, resultant symptoms, and how to respond to traumatized adolescents.     

Characteristics of memories for traumatic and nontraumatic birth

Evidence for memory characteristic differences between trauma and other memories in non‐clinical samples is inconsistent. However, trauma is frequently confounded with the event recalled. This study compares trauma and nontrauma memories for the same event, childbirth, in a non‐clinical sample of 285 women 4–6 weeks after birth. None of the women met diagnostic criteria for post‐traumatic stress disorder. Traumatic birth, defined by the DSM‐5 event criterion, was reported by 100 women. The ratings of some memory characteristics did not differ between memories for traumatic and nontraumatic birth: All were rated highly coherent and central to women's lives, with moderate sensory memory. However, women who experienced traumatic births reported more involuntary recall, reliving, and negative/mixed emotions. Thus, trauma memories differed from nontrauma memories. In this non‐clinical sample, this is likely to be due to encoding during trauma rather than the distinctive memory profile for memories retrieved by those experiencing trauma symptoms.     

Meta‐Analysis of Trauma‐Focused Therapies for Treating the Symptoms of Posttraumatic Stress Disorder

This meta‐analysis of 46 between‐groups studies published between 1997 and 2015 detected treatment effects ranging from large to small when comparing trauma‐focused therapies with no treatment (g = ?1.05), supportive interventions (g = ?0.91), other interventions (g = ?0.57), and non‐trauma‐focused cognitive behavior therapies (g = ?0.08) for the treatment of posttraumatic stress disorder (PTSD). The independent random‐effects models detected modest publication bias and a negligible influence of moderating variables on treatment outcomes. Considerations for counselors who treat PTSD and suggestions for researchers are provided.     

Recognizing Trauma and Posttraumatic Stress Disorder Symptoms in Individuals With Psychotic Disorders

The majority of individuals diagnosed with a psychotic episode also meet symptom criteria for posttraumatic stress disorder (PTSD; Mueser, Lu, Rosenberg, & Wolfe, 2010 ). Unfortunately, trauma from both previous life events and the experiences of a psychotic episode as well as PTSD symptoms are rarely recognized in this population. Steps to assessing trauma history and PTSD symptoms and initiating treatment in a client diagnosed with a psychotic disorder are highlighted.