Retraumatization

Assessment, Treatment, and Prevention

Melanie P. Duckworth, Victoria M. Follette

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781135237318
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Exposure to potentially traumatic events puts individuals at risk for developing a variety of psychological disorders; the complexities involved in treating them are numerous and have serious repercussions. How should diagnostic criteria be defined? How can we help a client who does not present with traditional PTSD symptoms? The mechanisms of human behavior need to be understood and treatment needs to be tested before we can move beyond traditional diagnostic criteria in designing and implementing treatment.

No better guide than Retraumatization exists to fulfill these goals. The editors and contributors, all highly regarded experts, accomplish six objectives, to:

• define retraumatization
• outline the controversies related to it
• provide an overview of theoretical models
• present data related to the frequency of occurrence of different forms of trauma
• detail the most reliable strategies for assessment
• to provide an overview of treatments.

Contained within is the most current information on prevention and treatment approaches for specific populations. All chapters are uniformly structured and address epidemiological data, clinical descriptions, assessment, diagnosis and prognosis, and prevention. It is an indispensible resource that expands readers' knowledge and skills, and will encourage dialogue in a field that has many unanswered questions.

Chapter 1

Introduction

Victoria M. Follette and Melanie P. Duckworth

Our clinical experience and knowledge of the research literature led us to the decision that there was a clear need for a book that addresses the complexities in treating individuals with multiple trauma experiences. While there is an excellent body of research on the etiology and treatment of trauma symptoms, most notably posttraumatic stress disorder (PTSD), a number of questions remain unanswered. In Brewin’s outstanding book, Posttraumatic Stress Disorder: Malady or Myth? (2003), he outlines the many controversies that have emerged over time regarding the fundamentals of the etiology of trauma symptoms and suggestions for treatment of immediate and delayed presentation of symptoms. He notes that these controversies are not new but rather can be traced back to Freud’s early conceptualizations about the causes of pathology.

At various points in time, “skeptics” have asserted that there really is no foundation for the diagnosis of traumatic stress and that the diagnosis is a “sociopolitical” construction. In more recent controversies, there have been questions about whether the mental health field should focus on victims or perpetrators and whether the goals of treatment, particularly in cases of interpersonal trauma, are related to the identification of legal responsibility for damages or helping victims without regard to how the treatment is associated with the legal system. In part, the involvement of mental health providers in the legal system led to the famous “memory wars” that led to both positive and negative outcomes in trauma research. (See Brewin 2003, for a more complete discussion of the debate.) On the positive side, there were a number of cautions regarding practice that resulted from a careful examination of our scientific knowledge of memory. While this information was critical to the field, many other areas of research in trauma were put on hold while the battle over memory played out. It has even been suggested that some academics changed the focus of their research in order to avoid the heated controversy. It is worth noting that for the majority of trauma survivors, memory for the event is not in question, and the memory issues were germane only in the debates around survivors of child sexual abuse. Discussion of this debate may seem tangential to this book; however, when we discuss retraumatization, there are many instances in which child abuse is the first trauma experience and thus becomes part of the research and clinical analysis.

Debates about memory and the rates of child abuse have not been the only focus of controversy. Some have suggested that we have become a society of victims, and that there has been an excessive focus on the impact of events that should be placed in a normal, albeit painful, set of life experiences. Moreover, many have claimed that mental health practitioners are “diagnosis happy” and that the field has in fact caused damage by diagnosis with the associated implication that all survivors are wounded. This controversy continues, and the issues became relevant in the creation of this book. In some ways, the most significant controversy surrounded whether there should even be a book on this topic. Scholars in the field questioned the need for a book that examines multiple trauma exposures, suggesting that such study may not add to our basic understanding of the underlying processes and of the focus on developing empirically based treatments. Even if one accepts the need for an analysis of retraumatization, a number of definitional issues come into play.

In our advice to our authors, we suggested that they consider a traumatic event is an experience that causes intense physical and psychological stress reactions. Examples of traumatic events included in the book include childhood abuse, loss, violence, physical and psychological assault, serious physical injuries, exposure to war, exposure to natural disasters, and torture. In this book, we define retraumatization as traumatic stress reactions, responses, and symptoms that occur consequent to multiple exposures to traumatic events that are physical, psychological, or both in nature. These responses can occur in the context of repeated multiple exposures within one category of events (e.g., child sexual assault and adult sexual assault) or multiple exposures across different categories of events (e.g., childhood physical abuse and involvement in a serious motor vehicle collision during adulthood). These multiple exposures increase the duration, frequency, and intensity of distress reactions. We would like to recognize that the term retraumatization has been used in a much more circumscribed way to capture distress that occurs with the retelling of a trauma narrative. Our use of the term retraumatization is more literal, emphasizing traumatic stress symptoms that occur in response to traumatic events rather than distress symptoms that occur in the context of treatment. Our definition of retraumatization is intended as a unifying guide across chapters, but we encouraged authors to address other definitions and conceptualizations of retraumatization that are germane to their work.

As we consider the definition of retraumatization, it is also important to note that the definition of PTSD is in transition with the development of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) entering its final phases. Even though PTSD is not the primary focus of this text, a brief review of the diagnosis is relevant to our basic conceptualizations about trauma outcomes. It is worth noting that at a more meta level, there are questions about the fundamental nature of the DSM, including suggestions about structural changes and about the utility of a categorical or dimensional system. Additional suggestions include ideas such as the reorganization of the diagnostic groupings with a focus on a variety of shared risk and clinical factors and movement away from a model that is so closely aligned with medical diagnosis. Even though these controversies provide some general context for the debates regarding trauma, we will confine ourselves to some of the specific concerns about the current PTSD diagnosis. McNally (2003) has been a key figure in these discussions and notes a particular concern about the issue of “bracket creep” that is defined in part as an increase in what constitutes exposure to a traumatic stressor. One concern is that individuals whose only exposure to trauma involved witnessing an event should not be included as candidates for the diagnosis of PTSD. In general, the specific nature of what should be included as a Criterion A event and how we can reliably use that criteria have been two key controversies in the continuing evolution of the diagnosis (Weathers & Keane, 2007). Brewin (2003) suggests that one alternative would be to remove the Criterion A event in that the many attempts to define triggering events have only led to an increased lack of clarity. However, questions about the adequacy of the current criterion go beyond issues of what constitutes a traumatic event. Instead of a focus on the traumatic event, it has been suggested that the presence or absence of core symptoms, particularly re-experiencing in the present moment, should be the primary criterion for diagnosis.

Brewin, Lanius, Novac, Schnyder, and Galea (2009) provide a useful discussion of several issues that have been raised in regard to the reformulation of the PTSD diagnosis. There are a number of points raised in their paper, and the authors point out three significant concerns directly relevant to the book at hand. First, there has been concern that the experience of normal events has been pathologized, ignoring the fact that exposure to painful events is a part of the normal human experience and that generally people experience a normal path of recovery. Second, they note the concern that the overlap of the PTSD criteria with other diagnoses has lessened its utility. Finally, Brewin et al. also note a biological profile associated with PTSD.

We considered many of these arguments in developing a plan for this text. In our view, although it is clear that exposure to traumatic events puts individuals at risk for developing a variety of psychological disorders including PTSD, it is important to develop an expanded conceptualization of how we consider both number of exposures to potentially traumatic events (PTEs) and the varied outcomes that may occur. Recently, it has become clear that a large percentage of trauma survivors may be exposed to more than one traumatic experience. There is a growing empirical literature examining the impact of repeated exposures to traumatic events on psychological well-being. Multiple exposures to trauma and increases in the duration, frequency, and intensity of exposure to potentially traumatizing experiences are associated with increases in PTSD and related trauma symptomatology, especially in comparison to a single exposure to a traumatic event. The literature provides some evidence on empirically supported treatments for survivors of traumatic experiences, but there are a number of lacunae in that literature. For example, much less is known about repeated exposure to combat stress. The increasing number of individuals who experience multiple deployments has made treatment of these Veterans a significant concern. Moreover, there is documentation of some Veterans reporting both combat stress and sexual trauma related to military service. Also, much less is known about the treatment of individuals who experience multiple sexual traumas. As a result of these questions, it became clear to us that it was time to bring together leaders in this area to document the current state of the field in an edited text.

The purpose of this book is to provide the most current information on the epidemiology, theory, and treatment issues related to multiple trauma experiences. The first section of the proposed book will include chapters that address epidemiological and theoretical issues related to multiple trauma experiences. Other chapters will be designed to specifically address retraumatization occurring across military and interpersonal violence contexts. However, the primary focus of the text is related to the most recent work addressing prevention and treatment approaches for specific populations. Although there is not extensive empirical literature on these groups, the work presented here generally is based on empirically supported concepts.

As clinical scientists, we consider a basic theoretical foundation as the key to building both research questions and clinical interventions. The field has seen a number of advances in the clarity of a number of theories that have been used to conceptualize the long-term impacts of traumatic exposure. We do not intend to present every current theoretical perspective in these chapters, but we have tried to provide chapters that represent some of the fundamental work in the field at this time. However, we certainly acknowledge that there are a number of promising new lines of research emerging that may provide additional depth and breadth to our current conceptualizations of the retraumatization literature.

Cognitive behavioral theory, with its foundation in basic learning principles, has been at the forefront of trauma work for many years. In Zayfert’s discussion (Chapter 2), she describes the development of the model for PTSD using Mowrer’s two-factor theory, in which both the acquisition of and maintenance of fear are explained. The use of behavioral and cognitive avoidance is considered the primary mechanism for the maintenance of fear related to traumatic stimuli. Kudler (Chapter 3) presents a psychoanalytic perspective of the study of trauma that includes a comprehensive review of the history surrounding some of the seminal work in this area. In a discussion that transcends all perspectives on the conceptualization of traumatic reactions, he points out the distinction between the external and internal representations of the experience. In his discussion of more current analytic perspectives, he makes clear the importance of considering multiple systems that can impact the flexibility of functioning, and that adaptation can lead to balance and growth. The literature surrounding the neurobiological issues related to exposure to trauma has grown dramatically in recent years as developing technology has allowed for more fine-grained analysis of neurological phenomena. King and Liberzon (Chapter 4) provide comprehensive coverage of what is known about the impacts of trauma, what are the limits of the data, and where we might expect the field to go based on current research.

In their discussion of a Resource Conservation Conceptualization of retraumatization, Hobfoll and colleagues (Chapter 5) focus on changes in a wide range of resources that can significantly impact the response to trauma. Although this work was initially developed with a focus on losses associated with one specific trauma experience, their contextual view of the intersection of a range of systems provides a strong foundation for understanding retraumatization. In a sense, they demonstrate how the impact of exposure to multiple traumas can create a complex set of feedback loops that exacerbate the initial exposure. Alexander’s description (Chapter 8) of the relationship of attachment theory to retraumatization also brings contextual elements to the analysis of the response to repeated traumas. Attachment theory’s focus on both the impact of early relationships on the response to trauma and relationship outcomes related to those early experiences enriches our analysis in developing a comprehensive assessment of the client’s experience. Courtois (Chapter 7) provides an integrative and thoughtful discussion of a complex set of trauma-related symptoms that are frequently associated with adult trauma that is overlaid on a history of child sexual abuse. The sequelae of multiple trauma experiences such as this can result in a range of difficulties including issues with emotion regulation and interpersonal relationships. This complex symptom presentation can present the therapist with a fundamental dilemma about the necessary basic components of treatment and the temporal ordering of those treatment components.

Developing a comprehensive assessment of the clinical needs of a client who presents for treatment following exposure to repeated trauma experiences is essential for planning effective treatment. In Chapter 6, Bonow and W. Follette take a broad approach to assessment, elaborating on the use of functional analysis as a foundation for assessment in this population. Because of the contextual and flexible process that is an inherent part of a functional analysis, it is particularly relevant to the clinical problems associated with retraumatized clients. Considering variables that range from the intrapersonal to the interpersonal is essential in developing an approach to treatment that may involve a variety of contributing current and historical factors. The examination of contextual variables that range from intimate relationships to cultural influences can enhance a practitioner’s case conceptualization, regardless of theoretical orientation.

As the large number of Veterans return from combat in Iraq and Afghanistan, the need for treatment that focuses on retraumatization has become increasingly apparent. There has been an increased awareness of the potential for early trauma experiences to have an impact on how individuals respond to exposure to combat. While the mechanism underlying any increase in vulnerability based on repeated exposure remains unclear, there is a growing body of literature that suggests increased symptomology in those with multiple traumas. In their chapter on multiple combat exposures (Chapter 9), Kuhn and his colleagues explore factors associated with multiple deployments, which has become a more frequent practice in the current war. Examination of proximal and distal outcomes associated with combat exposure has always been complex; however, advances in the assessment of trauma-related symptoms have become more sophisticated, allowing for a more detailed symptom profile across time. Ongoing research that examines individuals prior to deployment, in the battlefield, and at multiple points post-deployment is likely to produce important findings. This longitudinal research is essential for understanding the course of multiple symptoms over time, as well as the factors that predict resilience and recovery. One key issue related to this type of research is that it can lead to the development of programs to better prepare soldiers for combat exposure.

Wartime experiences can also have outcomes that go beyond direct exposure to combat. Moreover, exposure to war-related stressors is not limited to Veterans in the field but can also include civilian and refugee victims. In examining multiple trauma exposures in theater, Iverson and her colleagues () discuss the clinical issues in those Veterans who are exposed to sexual violence while serving in combat. This is an emerging area of study, and it is fraught with problems, including issues related to reporting the sexual trauma and assessment of treatment priorities. These authors present a compelling argument for the need for more treatment guidelines for our returning Veterans with sexual violence that is concurrent with combat traumatic experiences. In La Bash and Papa’s chapter (Chapter 11) on the plight of refugees and civilian casualties, they point out the need to expand our horizons in examining the victims of combat. Life-threatening injuries, loss of family members, resource loss, and sexual victimization are just a few of the problems that represent some of the “collateral damage” of combat.

Even though treatment of Veterans with combat exposure has been long been identified as an important priority, the consideration of treatment for survivors of violence on the home front is relatively new. Interpersonal victimization in the form of child abuse and partner violence has been more recently recognized, relatively speaking. Ghimire and Follette (Chapter 12) provide a comprehensive review of the multiple streams of research that address the particular issues associated with multiple sexual victimization experiences. They examine data on the interaction of the increased risk for substance abuse, particularly alcohol, and risky sex in survivors of child sexual abuse, which has contributed to a more complex set of research questions. Although this relationship has been documented in numerous studies, the interpretation of these findings remains controversial. The primary question at hand is the identification of the underlying mechanism that mediates the relationships between child and adult victimization. However, identifying the mediators and moderations that impact this type of revictimization is complex. A clearer understanding of these factors is essential to the development of effective prevention and treatment programs. Couples violence is one of the many outcomes seen at increased rates in survivors of child abuse. By its very nature, domestic violence is often a multiply occurring event that can occur over several years and frequently occurs in a climate of secrecy and isolation. Lee and Fruzzetti (Chapter 13) provide an interesting discussion of the complex interpersonal dynamics associated with the development and maintenance of violence in couples. For a number of reasons, the development of ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Editors
• Contributors
• 1. Introduction
• 2. Cognitive Behavioral Conceptualization of Retraumatization
• 3. A Psychodynamic Conceptualization of Retraumatization
• 4. Neurobiology of Retraumatization
• 5. Conservation of Resources Theory: The Central Role of Resource Loss and Gain in Understanding Retraumatization
• 6. A Functional Analytic Conceptualization of Retraumatization: Implications for Clinical Assessment
• 7. Retraumatization and Complex Traumatic Stress: A Treatment Overview
• 8. Retraumatization and Revictimization: An Attachment Perspective
• 9. Multiple Experiences of Combat Trauma
• 10. Dual Combat and Sexual Trauma During Military Service
• 11. Multiple Traumas in Civilian Casualties of Organized Political Violence
• 12. Revictimization: Experiences Related to Child, Adolescent, and Adult Sexual Trauma
• 13. Multiple Experiences of Domestic Violence and Associated Relationship Features
• 14. Retraumatization Associated With Disabling Physical Injuries
• 15. Controversies Related to the Study and Treatment of Multiple Experiences of Trauma
• 16. Conclusions and Future Directions in the Assessment, Treatment, and Prevention of Retraumatization
• Index