Implementing Trauma-Informed Care in Primary Medical Settings: Evidence-Based Rationale and Approaches

ABSTRACT

Chronic stress stemming from trauma exposure and posttraumatic stress disorder (PTSD) leads to many health problems that are typically seen by primary care providers. Unfortunately, providers rarely identify trauma as the root cause of patient difficulties. The present paper provides an evidence-based rationale for implementing trauma-informed care principles and processes into medical primary care systems. Beginning with a review of prevalence of trauma exposure and PTSD in primary care clinics, this article elucidates relationships between trauma exposure and behavioral and medical health problems, as well as clinical and physiological pathways that lead from trauma exposure to illness. The article concludes with exposition of trauma-informed interventions that can be implemented in primary care clinics, and discussion of future directions.     

Understanding Social Factors in the Context of Trauma: Implications for Measurement and Intervention

One of the most important factors predicting the presence of posttraumatic stress disorder (PTSD) after trauma exposure is social support, yet the construct is theoretically complex and remains variably defined. To better inform the trauma literature on the impact of social factors, a theoretical review of social support and PTSD was conducted, and implications for measurement and intervention are outlined. Type of trauma, sex of participant, timing of social support, and support providers are described as significant moderators of the association between social factors and PTSD. The developmental trajectory of the association between social factors and PTSD occurrence is outlined, emphasizing the positive influence of social support initially following trauma, and the deterioration effect of PTSD symptoms on social support over the longer term. Possibilities for future research and intervention at multiple levels and at different time points are described.     

Trauma,Treatment, and Religion

Abstract

When children and youth are traumatized, caretakers must attend to behavioral, cognitive, physiological, ecological and spiritual/existential aspects of their reactions. This article focuses on the latter facet of traumatization. The Hebrew Scriptures and the New Testament offer little about the traumatic symptoms of victims. Using many of the same sources, Fundamentalist Christians, Jews, mainline Christians and secularists may offer children different interpretations of the meaning of trauma events. Understanding these interpretations is crucial for children who develop symptoms which suggest a diagnosis of PTSD. Caretakers, other than mental health professionals, can understand and use various techniques explicated in the TREAT model for treatment of PTSD. Concepts discussed can be used, within a spiritual/existential framework, to support traumatized youngsters.     

Spirituality and Trauma: The Role of Clergy in the Treatment of Posttraumatic Stress Disorder

An increased awareness of the spiritual aspects of health and illness has recently led to changes in psychiatry residency training as well as hospital accreditation requirements. The spiritual impact of trauma has been an area of particular interest, as trauma evokes certain existential questions and crises. It is estimated that from 5–11% of trauma survivors will go on to develop posttraumatic stress disorder (PTSD). Given the spiritual challenges of the experience of trauma, patients with PTSD could benefit from spiritual assessment and intervention as part of their overall treatment plan, and clergy can be utilized to perform this. The literature exploring the spiritual impact of trauma and the use of clergy in the treatment of trauma survivors is reviewed. The methods used by three chaplains in a residential treatment program for PTSD at one facility are described and discussed. Both the literature and the experiences of the clergy suggest that exploration of trauma-related existential conflicts in patients with PTSD is beneficial. However, there is a notable dearth of controlled scientific studies evaluating the effectiveness of spiritual interventions with this treatment population. The need for controlled studies to verify the usefulness of spiritual assessment and intervention in patients with PTSD is noted, and a more rigorous analysis of how clergy can best serve this treatment population is encouraged.     

A Cross-Lagged Panel Approach to Understanding Social Support and Chronic Posttraumatic Stress Disorder Symptoms in Veterans: Assessment Modality Matters

Although there is a strong and consistent association between social support and posttraumatic stress disorder (PTSD), the directionality of this association has been debated, with some research indicating that social support protects against PTSD symptoms, whereas other research suggests that PTSD symptoms erode social support. The majority of studies in the literature have been cross-sectional, rendering directionality impossible to determine. Cross-lagged panel models overcome many previous limitations; however, findings from the few studies employing these designs have been mixed, possibly due to methodological differences including self-report versus clinician-administered assessment. The current study used a cross-lagged panel structural equation model to explore the relationship between social support and chronic PTSD symptoms over a 1-year period in a sample of 264 Iraq and Afghanistan veterans assessed several years after trauma exposure. Approximately a third of the sample met criteria for PTSD at the baseline assessment, with veterans’ trauma occurring an average of 6 years prior to baseline. Two separate models were run, with one using PTSD symptoms assessed via self-report and the other using clinician-assessed PTSD symptoms. Excellent model fit was found for both models. Results indicated that the relationship between social support and PTSD symptoms was affected by assessment modality. Whereas the self-report model indicated a bidirectional relationship between social support and PTSD symptoms over time, the clinician-assessed model indicated only that baseline PTSD symptoms predicted social support 1 year later. Results highlight that assessment modality is one factor that likely impacts disparate findings across previous studies. Theoretical and clinical implications of these findings are discussed, with suggestions for the growing body of literature utilizing these designs to dismantle this complex association.     

The associations between adult attachment,posttraumatic symptoms,and posttraumatic growth

Background and Objectives: Individual differences after trauma vary considerably and can range from posttraumatic stress disorder (PTSD) to posttraumatic growth (PTG). Current theoretical models cannot fully explain this variability. Therefore, we integrated attachment theory with Ehlers and Clark's model of PTSD to understand whether attachment style is associated with negative appraisals of a traumatic event(s), posttraumatic stress symptoms (PTS), and PTG. Our aim was to test this integrated model PTSD in an analog sample who had experienced at least one traumatic event. Design: We used structural equation modeling to test the association of adult attachment and posttraumatic cognitions (self and world/others) with PTS and PTG using a cross-sectional, correlational design. Methods: The sample comprised 393 university staff and students (Range_Age= 18–49, 85% females) who completed online measures. Results: Attachment anxiety and negative posttraumatic self-cognitions were positively associated. Negative posttraumatic self-cognitions were positively associated with PTS. Attachment anxiety had an indirect effect (via negative posttraumatic self-cognitions) on PTS, whereas attachment avoidance predicted more negative posttraumatic world cognitions and lower perceived PTG. Conclusions: The study highlights the importance of considering how attachment styles influence posttraumatic emotion regulation and cognitive processing of the trauma to determine posttraumatic mental health.     

PTSD and the influence of context: The self as a social mirror

The principal accepted models of posttraumatic stress disorder (PTSD) are based on both memory processing and biological/brain changes occurring when one's life or well-being is threatened. It is our thesis that these models would be greatly informed by community studies indicating that PTSD is predicted to a greater extent by earlier life experience and experiences that occur distant from the threatening event. These findings suggest posttraumatic responding is best conceptualized through the lens of the self-in-context, as opposed to imprinting that results from a given event at a given time. Moreover, studies of non-Western populations often do not express trauma as PTSD, or at least not primarily as PTSD, which argues against specific neural or memory encoding processes, but rather for a more plastic neural process that is shaped by experience and how the self develops in its cultural context, as a product of a broad array of experiences. We posit that fear and emotional conditioning as well as the ways traumas are encoded in memory are only partial explanatory mechanisms for trauma responding, and that issues of safety and harm, which are long term and developmental, are the common and principal underpinnings of the occurrence of posttraumatic distress, including PTSD.     

Race,psychosocial vulnerability and social support differences in inner-city women's symptoms of posttraumatic stress disorder

Background/Objectives: Inner-city Black women may be more susceptible to posttraumatic stress disorder (PTSD) than White women, although mechanisms underlying this association are unclear. Living in urban neighborhoods distinguished by higher chronic stress may contribute to racial differences in women's cognitive, affective, and social vulnerabilities, leading to greater trauma-related distress including PTSD. Yet social support could buffer the negative effects of psychosocial vulnerabilities on women's health. Methods/Design: Mediation and moderated mediation models were tested with 371 inner-city women, including psychosocial vulnerability (i.e., catastrophizing, anger, social undermining) mediating the pathway between race and PTSD, and social support moderating psychosocial vulnerability and PTSD. Results: Despite comparable rates of trauma, Black women reported higher vulnerability and PTSD symptoms, and lower support compared to White Hispanic and non-Hispanic women. Psychosocial vulnerability mediated the pathway between race and PTSD, and social support moderated vulnerability, reducing negative effects on PTSD. When examining associations by race, the moderation effect remained significant for Black women only. Conclusions: Altogether these psychosocial vulnerabilities represent one potential mechanism explaining Black women's greater risk of PTSD, although cumulative psychosocial vulnerability may be buffered by social support. Despite higher support, inner-city White women's psychosocial vulnerability may actually outweigh support's benefits for reducing trauma-related distress.     

Towards a cognitive-behavioral model of PTSD in children and adolescents

Posttraumatic stress disorder in children and adolescents has been studied only for the past 15–20 years and is the subject of a burgeoning corpus of research. Much research has focused on examining whether children and adolescents have the same responses to trauma as those experienced by adults. Many of the research tools used to investigate children's responses are taken from measures designed for use with adults, and these measures have proven to be useful. However, it has not been established that children's responses to traumatic events are related to the same underlying processes as are adults' responses. The possible application of 2 recent cognitive models of PTSD in adults to understanding PTSD in children and adolescents is discussed in this paper, within the context of what is already known about children's reaction to trauma and existing theoretical accounts of childhood PTSD. Particular attention is paid toward the nature of children's memories of traumatic events and how these memories relate to the reexperiencing symptoms of PTSD, and cognitive processes that may play a role in the maintenance of PTSD. It is proposed that the adoption of a more specific cognitive–behavioral framework in the study of this disorder may be beneficial and lead to better treatment outcomes.     

The coherence of memories for trauma: Evidence from posttraumatic stress disorder

Participants with posttraumatic stress disorder (PTSD) and participants with a trauma but without PTSD wrote narratives of their trauma and, for comparison, of the most-important and the happiest events that occurred within a year of their trauma. They then rated these three events on coherence. Based on participants’ self-ratings and on naïve-observer scorings of the participants’ narratives, memories of traumas were not more incoherent than the comparison memories in participants in general or in participants with PTSD. This study comprehensively assesses narrative coherence using a full two (PTSD or not) by two (traumatic event or not) design. The results are counter to most prevalent theoretical views of memory for trauma.     

A prospective study of appraisals in childhood posttraumatic stress disorder

This study investigated the predictors of posttraumatic stress disorder (PTSD) in children following a diagnosis of traumatic injury. Children (N=76) aged between 7 and 13 who were admitted to hospital following injury were assessed within a month of trauma for acute stress disorder (ASD), negative appraisals, as well as parental stress reactions. Children (N=62) were re-assessed 6-months later for PTSD and negative appraisals. The majority of the variance of chronic posttraumatic stress was accounted for by negative appraisals about future harm. This study supports cognitive models of PTSD, and suggests that younger children who exaggerate their vulnerability after trauma exposure are high risk for PTSD after trauma.     

PTSD Severity and Cognitive Reactions to Trauma Among a College Sample

ABSTRACT

Two hundred twenty-one undergraduate education students were assessed to determine trauma history and cognitive responses to traumatic events. Participants completed a demographic questionnaire, the Cognitive Distortions Scale, and the PTSD Symptom Scale (for those reporting a trauma history). The most common types of traumatic events were domestic violence, natural disasters, and severe transportation accidents. Differences in cognitive distortions of individuals with and without a trauma history also were assessed. Individuals with a trauma history were significantly higher on Preoccupation with Danger and Self-Blame subscales. Number of previous traumatic events and the subscale of Preoccupation of Danger significantly predicted PTSD severity.     

Brain-derived neurotrophic factor Val66met polymorphism and plasma levels in road traffic accident survivors

Background: Alterations in brain-derived neurotrophic factor (BDNF) expression and release may play a role in the pathogenesis of post-traumatic stress disorder (PTSD). Design: This study evaluated road traffic accident (RTA) survivors to determine whether PTSD and trauma-related factors were associated with plasma BDNF levels and BDNF Val66Met carrier status following RTA exposure. Methods: One hundred and twenty-three RTA survivors (mean age 33.2 years, SD?=?10.6 years; 56.9% male) were assessed 10 (SD?=?4.9) days after RTA exposure. Acute stress disorder (ASD), as assessed with the Acute Stress Disorder Scale, was present in 50 (42.0%) of the participants. Plasma BDNF levels were measured with enzyme-linked immunosorbent assay and BDNF Val66Met genotyping was performed. PTSD, as assessed with the Clinician-Administered PTSD Scale, was present in 10 (10.8%) participants at 6 months follow-up. Results: Neither BDNF Val66Met genotype nor plasma BDNF was significantly associated with the presence or severity of ASD or PTSD. Plasma BDNF levels were, however, significantly correlated with the lifetime number of trauma exposures. Conclusions: In RTA survivors, plasma BDNF levels increased with increasing number of prior trauma exposures. Plasma BDNF may, therefore, be a marker of trauma load.     

Indigenous Healing Practices in Australia

ABSTRACT

Indigenous Australian women are among the most disadvantaged women in the world. Over two centuries of colonization have had a damaging impact on perceptions of their gender roles and status as well as many other consequential oppressions. These experiences have affected the social and emotional wellbeing of Indigenous women of all ages, resulting in socio-economic ghettoization, higher suicide rates, psychological distress, illness, and poverty. Generations of women have experienced the forced removal of their children, resulting in complex forms of historical trauma. Despite this, Indigenous women have also maintained strong leadership roles and have kept families and communities intact. In the last few decades, the Australian Indigenous mental health movement has emerged within the context of a broader self-determination movement, restoring and strengthening women’s traditional therapeutic practices. This article offers an overview of the social and emotional wellbeing of Indigenous women within neocolonial Australia and explores women’s relationship to traditional therapeutic practices. Future directions and key issues for the capacity building of Indigenous women’s healing are explored.     

Encompassing experience: Meanings and methods in health psychology

Abstract

Health psychology is limited by its almost exclusive use of a positivist quantitative research paradigm, and the adoption and use of qualitative methods by health psychologists will provide increased understandings of health and illness. Qualitative methods provide a means to incorporate the social world into our research, and furnish ways to investigate the meanings of health and illness experience. We present a brief consideration of the qualitative paradigm and some important underlying issues related to its use. We describe three qualitative approaches - grounded theory, narrative analysis, and discourse analysis - chosen for their relevance and diversity. We provide illustrations of the use of each in health research, and suggest how these approaches could be utilised by health psychologists to enrich understanding in the health field. We conclude that health psychologists have a great deal to gain from joining other social science health researchers in adopting qualitative approaches in their research.     

Emotional working memory capacity in posttraumatic stress disorder (PTSD)

Participants with a lifetime history of posttraumatic stress disorder (PTSD) and trauma-exposed controls with no PTSD history completed an emotional working memory capacity (eWMC) task. The task required them to remember lists of neutral words over short intervals while simultaneously processing sentences describing dysfunctional trauma-related thoughts (relative to neutral control sentences). The task was designed to operationalise an everyday cognitive challenge for those with mental health problems such as PTSD; namely, the ability to carry out simple, routine tasks with emotionally benign material, while at the same time tackling emotional laden intrusive thoughts and feelings. eWMC performance, indexed as the ability to remember the word lists in the context of trauma sentences, relative to neutral sentences, was poorer overall in the PTSD group compared with controls, suggestive of a particular difficulty employing working memory in emotion-related contexts in those with a history of PTSD. The possible implications for developing affective working memory training as an adjunctive treatment for PTSD are explored.     

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.     

Abusive relationships: Is a new category for traumatization needed?

The concept of a spectrum of posttraumatic disorders has been postulated by a variety of major contributors to the field of psychotraumatology. Although Posttraumatic Stress Disorder (PTSD) is one trauma-based mental health disorder, there are other posttraumatic illnesses that do not qualify for PTSD, nor are they accurately described by other diagnostic categories in the DSM-IV. The present paper proposes and delineates a new syndrome, entitled Posttraumatic Relationship Syndrome (PTRS), which is a function of the experience of trauma in the context of an emotionally intimate relationship. It differs from PTSD in four fundamental ways: (1) the nature of the Stressor criterion; (2) the response to the Stressor; (3) the inclusion of a category of relational symptoms; and (4) the way of coping with the trauma (i.e., it lacks the emotional numbing and avoidance of stimuli associated with the trauma). The latter is the most salient difference as it involves a qualitatively different experience of the “world of trauma”-a primarily conscious experience in PTRS and an often unconscious experience in PTSD.     

Abusive relationships: Is a new category for traumatization needed?

The concept of a spectrum of posttraumatic disorders has been postulated by a variety of major contributors to the field of psychotraumatology. Although Posttraumatic Stress Disorder (PTSD) is one trauma-based mental health disorder, there are other posttraumatic illnesses that do not qualify for PTSD, nor are they accurately described by other diagnostic categories in the DSM-IV. The present paper proposes and delineates a new syndrome, entitled Posttraumatic Relationship Syndrome (PTRS), which is a function of the experience of trauma in the context of an emotionally intimate relationship. It differs from PTSD in four fundamental ways: (1) the nature of the Stressor criterion; (2) the response to the Stressor; (3) the inclusion of a category of relational symptoms; and (4) the way of coping with the trauma (i.e., it lacks the emotional numbing and avoidance of stimuli associated with the trauma). The latter is the most salient difference as it involves a qualitatively different experience of the “world of trauma”-a primarily conscious experience in PTRS and an often unconscious experience in PTSD.     

价值观对蓄意创伤受害者创伤后应激障碍症状的影响

探讨价值观对蓄意创伤受害者创伤后应激障碍（Posttraumatic Stress Disorder ,简称PTSD）症状的影响方式。方法：采用事件冲击量表、受害人认可评价量表、施瓦兹价值观量表作为测查工具,测查了163 名蓄意创伤受害者。结果：（1）蓄意创伤受害者的PTSD三大症状表现有显著差异,闯入症状水平最高,回避症状水平次之,高警觉症状水平最低。（2）蓄意创伤受害者所持的价值观和对外界接纳的评价能较好地预测PTSD三大症状。（3）内敛价值类型通过诸如社会接纳等反映外在标准的因素影响PTSD的闯入症状。结论：蓄意创伤受害者PTSD症状表现有其自身的特点,对外界接纳的评价和自身所持的价值观对其PTSD症状有直接或间接的影响