ContinuingEdCourses.Net dba SocialWorkCoursesOnline.com, provider #1107, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. ContinuingEdCourses.Net dba SocialWorkCoursesOnline.com maintains responsibility for the program. ASWB Approval Period: 3/9/2015-3/9/2021. Social workers should contact their regulatory board to determine course approval. Course format (distance learning - online activity).
ContinuingEdCourses.Net dba SocialWorkCoursesOnline.com has been approved by the National Board for Certified Counselors (NBCC) as an Approved Continuing Education Provider (ACEP), ACEP #6323. Programs that do not qualify for NBCC credit are clearly identified. ContinuingEdCourses.Net dba SocialWorkCoursesOnline.com is solely responsible for all aspects of the programs.
This is a beginning to intermediate level course. After completing this course, mental health professionals will be able to:
The materials in this course are based on the most accurate information available to the author at the time of writing. The field of trauma psychology grows daily, and new information may emerge that supersedes these course materials. This course material will equip clinicians to have a basic understanding of trauma and its effects, and how to assess those effects across a broad range of diagnoses. This content may provoke painful feelings for some readers, or bring the reader’s own personal trauma experience to mind.
Psychological trauma has become recognized as a common risk factor for many problems that individuals experience, both psychological and somatic. Briere and Scott (2012), in their review of the literature, have identified exposure to trauma as a risk factor for a wide range of psychiatric diagnoses. While trauma has been specifically implicated etiologically in the diagnoses that constitute the Trauma and Stressor-Related Disorders section of the DSM-5 as well as in the development of Dissociative Identity Disorder (DID), research has indicated that trauma exposure accounts for significant parts of the variance of the development of depression, anxiety disorders, Cluster B personality disorders, many Somatic symptom and related disorders, and some kinds of psychosis. Additionally, trauma exposure is frequently present in the histories of people with compulsive and addictive behaviors, with substance abuse being one of the two most frequently diagnosed comorbid conditions for individuals with PTSD. Trauma is a biopsychosocial/spiritual-existential phenomenon whose effects can be seen in the forms of distress and dysfunction in almost every variable of human functioning.
Despite this near-ubiquity, training in trauma treatment is rarely offered during the professional education of psychotherapists. A 2011 survey conducted by the Education and Training Committee of the APA Division of Trauma Psychology was able to identify less than sixty doctoral programs in the U.S. wherein there is a faculty member with an interest in trauma who might offer coursework, research opportunities, or mentoring, and these data have not changed in a meaningful way over time. Trauma-informed care in mental health and medicine is emerging as an important aspect of providing high quality services to all patients, and yet training for trauma-informed care appears to be minimal in almost all disciplines. For psychotherapists further along in their careers, training in trauma has generally required sufficient pre-existing interest and commitment to attend continuing education courses and conferences or seek specialized consultation.
Because of this dearth of formal training on the topic of trauma, myths and misconceptions about what constitutes a traumatic stressor, definitions of trauma, assessment of post-traumatic phenomena, and appropriate treatment strategies abound. Self-care for psychotherapists working with trauma survivors is essential, yet training in the subtleties of such self-care is also generally absent from the experiences of professionals.
There are three courses in this series that are meant to be taken in sequence with one another, to offer basic information about trauma, to prepare psychotherapists to function effectively with trauma survivors, and to offer what is increasingly being referred to as trauma-informed care. A focus of these courses will be the development of a culturally-competent integrative model of trauma treatment that eschews a one-size-fits-all approach for a nuanced understanding of how events are experienced as traumatic by individuals. These courses will focus on the treatment of adult survivors of trauma, although a thorough understanding of developmental phenomena is a necessary foundation for working with adult trauma survivors, many of whom experience themselves as younger in their emotional and cognitive capacities than would be expected by their chronological ages. This first course, Becoming a Trauma-Aware Therapist: Definitions and Assessment, covers questions regarding what constitutes a trauma, and how to assess for its effects in a range of ways. The second course, Treating Trauma: Basic Skills and Specific Treatments, introduces an over-arching framework for trauma treatment, and then reviews the large variety of specific treatments for trauma that are now available, briefly reviewing recent meta-analyses of some of these treatments. That course also examines how the common factors of psychotherapy are essential components of trauma-informed therapy practice. The third course, Emotional and Cultural Competence in the Trauma-Aware Therapist, explores being sensitive to the patient's multilayered cultural identities when being treated for trauma, as well as that of the therapist working with the trauma patient. These courses reflect the recommendations of a task force convened by the APA Division of Trauma Psychology to development formal competency recommendations in trauma treatment (Cook & Newman, 2014).
What constitutes a trauma is often naively thought of as self-evident. All traumas are large, frightening, uncommon events – or so goes the mythology about trauma. However, for psychotherapists wishing to competently address experiences that are responded to with post-traumatic symptom pictures, an expanded understanding and definition of trauma is necessary. Some events that constitute a trauma are not perceived as such until weeks, months, or years after the fact, although post-traumatic symptoms will be emerging well before individuals appraise themselves as having been exposed to a traumatic experience. Some trauma exposures are small and private, more confusing or disorienting in the moment than horrifying, a reality reflected in the DSM-5 changes to the definition of Criterion A. Some post-trauma symptoms manifest immediately, but are masked by their very nature because they represent the numbing and dissociative symptoms of the trauma response. Others are florid, obvious, dysregulating, and sometimes daunting to the clinician, sometimes leading to misdiagnosis and inappropriate care if trauma exposure is not taken into account.
A more complete and nuanced paradigm for what constitutes trauma will serve as the foundation for this course. Understanding how trauma has come to be formally defined in diagnostic manuals, and how certain kinds of experiences have been included or excluded from diagnostic criteria and definitions, can assist a clinician in developing a more precise diagnostic formulation for patients presenting problems. Considering how an experience may have been subjectively traumatic for an individual, and learning how to contextualize that subjective perception of experience, can enhance empathy, which is foundational to good clinical practice no matter what the clinician’s theoretical orientation. Trauma-informed psychotherapy is not the same as treating PTSD. It is, rather, about taking trauma’s extensive effects on mind, body, spirit, and community into account in assessment, diagnosis, treatment planning, and development of a therapeutic alliance.
Post-traumatic stress disorder has been observed and identified for millennia under a variety of names. Homer, in the Iliad, describes the combat-related PTSD of Achilles after the death of his beloved companion Patroclus (Shays, 1995). The biblical prophet Ezekiel, a survivor of war and forced exile, speaks eloquently of his intrusive images and “heart of stone.” Perhaps because trauma has been ubiquitous in human experience, and because psychological problems were – until the end of the 19th century – mostly coded in Western cultures as spiritual dilemmas, the relationship between trauma and problems of psychological distress and behavioral dysfunction was not elucidated until the advent of the railroad, and with it, mass casualty accidents.
Trauma suddenly became visible outside the realm of combat. From these railroad accidents and their aftermath arose the construct of “railway spine,” persistent chronic pain whose organic causes could not be determined by the medical practitioners of the day. However, the ascriptions made for these symptoms were still primarily biological in nature.
The French psychiatrist Pierre Janet was the first to prominently draw the connections between a trauma and symptoms, and to use a psychological paradigm, rather than a biological one, for understanding the relationship between the two. In the late 19th and early 20th Centuries, Janet described hundreds of cases of what he termed “hysterics,” mostly women incarcerated in psychiatric hospitals. Beginning with L’automatisme psychologique, published in 1889, and in subsequent writings over the succeeding fifty years, Janet elegantly described how a traumatic event led to what he called an “idée fixe," a complex of symptoms emerging from the narrowing of consciousness around the trauma which could only be resolved by uncovering and metabolizing that trauma. Janet has been credited with being the first to describe dissociative disorders, and to discuss the profound effects of sexual assault on the psyche.
However, because of the powerful influence of Freud on Western mental health traditions, and his early abandonment of the so-called “seduction theory,” which had joined with Janet’s in identifying a trauma as the etiology of symptoms of sexual abuse, Janet’s work, and a focus on trauma as etiological, became temporarily lost to Western psychology and psychiatry. It resurfaced briefly during each of the World Wars in the works of Rivers, a British psychiatrist who treated victims of so-called “shell shock”, and Kardiner, an American psychiatrist who dealt with men suffering from what he describe as the “traumatic neurosis of war.” But as Judith Lewis Herman poignantly noted in her classic volume, Trauma and recovery (1992), “The study of psychological trauma has a curious history – one of episodic amnesia. Periods of active investigation have alternated with periods of oblivion.” (p. 7). When it reentered the consciousness of the mental health disciplines in the late 20th century, it did so in a narrow and particular manner that has affected how clinicians think about trauma in their clients.
The Diagnostic and Statistical Manual, Fifth Edition, (American Psychiatric Association, 2013) defines a traumatic stressor, Criterion A of the diagnosis of Post-traumatic stress disorder, as “Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s) 2. Witnessing, in person, the event(s) as it occurred to others. 3 Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).” (American Psychiatric Association, 2013, p. 271). This most recent version of Criterion A describes a particular type of traumatic stressor, and what it describes is indeed psychological trauma.
The definition of Criterion A has not, however, been immutable, and it is important to understand its history so that it does not become mistaken for the universe of what constitutes psychologically traumatizing experiences, nor treated as the sole and defining statement about trauma. The definition of a trauma has been a moving target since Post-traumatic stress disorder (PTSD) was introduced into the DSM III in 1980. The original Criterion A famously defined trauma as “an event outside the range of usual human experience that would be frightening or threatening to almost anyone.” This initial definition reflected a particular epistemology of trauma that located trauma in extreme, public events such as combat, the Nazi Holocaust, or natural disasters. Violent sexual and physical assaults were also generally seen as coming under this definition. Trauma was conceptualized as a fear-based phenomenon, which made perfect sense given the traumas informing the field at that time.
However, there were almost immediately debates among mental health professionals as to whether other experiences that intuitively seemed traumatic met the definition of a trauma for purposes of diagnosing PTSD. For instance, childhood sexual abuse was known to be confusing to many of its victims, but frightening or threatening only to some at the time it occurred. Acquaintance sexual assaults also frequently fell under this experiential rubric, with victims of this form of interpersonal violence frequently initially appraising the experience as unpleasant, but not as a cause of fear or a trauma. Additionally, each of these forms of violation seemed clearly not to be “outside the range” of human experience, with statistics emerging during the decade of the 1980’s indicating that as many as one third of the U.S. population had some kind of interpersonal violence exposure, usually at the hands of parents or intimates. before age 18. Nonetheless, the validity of this definition was sometimes heatedly defended, in part because of a need on the part of some of the first generation of late 20th century trauma clinicians to define trauma as an exceptional, rather than normative, event. One of the founders of an international trauma society, at a public discussion of Criterion A held at a conference in 1993, said that to remove the unusualness component of it would say things about the world that were unacceptable to him. But the final nail in the coffin of the original Criterion A emerged during general population field trials for the DSM IV, in which interpersonal violence traumas were reported by upwards of 70% of some general population samples (Davidson & Foa, 1993).
The current Criterion A has developed over time. The first set of modifications following those findings regarding high population rates of trauma removed the requirement for unusualness, and located the response to the event within the individual’s subjective perceptions of the experience rather than within general population norms. This allowed for variability in response, and took into account the fact that only around 20% of those exposed to a Criterion A event experienced it as sufficiently traumatic to develop PTSD. The DSM-5 definition also included the requirement that people exposed to trauma have a particular emotional response to it, e.g., fear, horror or helplessness.
However, this definition also faced challenges. Briere (2004) has noted that for many traumatic stressors in which the person’s immediate response is a numbing or dissociative one, there is no feeling of fear, horror, or helplessness until well past the time of the trauma. Such an individual would report feeling nothing, numb, or far away. Social pressures to deny fear in certain cultures (e.g., a combat unit, emergency first responders) also operated to bring the power of social conformity dynamics to generate outright denials that fear or helplessness had been present during a trauma. Briere has noted that experiences of degradation, humiliation, and coerced activities in which power was abused to induce unwanted behaviors, even when an overt threat of violence was absent, can all be experienced phenomenologically as traumatic for some persons. He also found that feelings of disgust were more common for some kinds of trauma, particularly sexual traumas, than were fear. Additionally, betrayal, both individual (Freyd, 1996) and institutional (Smith & Freyd, 2015) to be discussed at length later in this course, has recently been empirically shown to be a more potent factor than fear in the development of PTSD (Kelley, 2009).
The DSM IV defined as trauma as “a threat of death or injury, or a threat to physical integrity.” What constitutes these phenomena was also not intuitively obvious. The happy bungee jumper, who leaps out into space tethered by one foot to a long cord is objectively risking her life, but rarely does that jumper, or those witnessing the event, experience it as a traumatic stressor. While there is often initial fear involved, those who have engaged in this sport tend to describe the experience as fun, exhilarating, and even transformational. Similarly, the Formula One racecar driver who spins out and crashes during a race is unlikely to see the experience as traumatic, but rather as part of the “living on the edge” draw of the sport. Farley (1991) has described persons who seek out such life-threatening yet pleasurable experiences as exhibiting “Type T” behavior. These experiences are purposefully sought, and subjectively perceived as being under the control of those partaking in them, no matter their danger.
Contrast this choice with the same racecar driver emerging from the wreck of her car’s encounter with a drunk driver on a city street. The life-threatening aspects of that accident are likely to loom larger in the foreground, and may in fact evoke feelings of fear and helplessness, far more than do even more objectively dangerous components of the car crash occurring in the controlled environs of the racetrack. In this instance, the driver feels alone and in danger, as well as out of control; the other driver, rather than being a colleague and friendly rival, is experienced as reckless and thus willing to engender harm in another driver.
In those dominant cultures, such as that of the U.S., which value the illusion that persons have control over their lives, participation in objectively life-threatening activities that are coded as under the control of their participants (e.g., rock-climbing, sky-diving) is seen as evidence of fearlessness, which is a valued character trait in Western cultures. Such fearlessness can become a risk factor for exposures to traumatic stressors when the situation spins out of control. Consequently, a prior history of fearlessness cannot necessarily predict whether an individual will experience a similar event as traumatic when the factors of control and mastery are stripped out of it.
It is possible for a person to experience threat to life and physical integrity simply from a word being spoken. Despite the children’s chant that “sticks and stones may break my bones but names will never hurt me,” some names carry the power to invoke fear and feelings of unsafety just as much as physical violence can.
Many African Americans report that when they hear the epithet commonly referred to as “the N word,” or are repeatedly exposed to racially tinged jokes by those around them, they feel at risk because of the resonances between that kind of verbiage and historical violence against their communities. Depending on the circumstances, some individuals who have also had histories of Criterion A events, such as combat trauma, from which they emerged unscathed psychologically, have experienced being exposed to such racist verbiage as more dangerous to them than enemy missiles. As one such individual, who was on the receiving end of racially tinged so-called pranks in the workplace put it, “No one there’s got my back. Everyone thinks they can do whatever they want with me, and HR tells me to get over it, that I’m over-reacting. I felt safer with those damn Iraqis lobbing Scuds at me than I do in that office, wondering when I’m going to come out and find my tires slashed.” In circumstances such as these, it is often the unpredictability and invisibility of potential perpetrators of violence who had already exposed a willingness to engage in lower-level behaviors that feels threatening. The isolation inherent in such circumstances also creates feelings of life threat; as Hobfoll (2001) has found, the presence or absence of social support can be the factor making an experience traumatic or not.
Similar stories are told by women sexually harassed in the workplace. Being referred to by crude names for female genitalia, or as a species of female dog, carries with it a deeply felt symbolic threat of violence for many women. Similarly, members of LGBT communities have reported having fear engendered when the terms “faggot” or “dyke” are hurled as epithets, since such verbiage has often been the human equivalent of the attacking animal’s roar that precedes the vicious assault. Microaggressions (Sue, 2010), also known as insidious trauma (Root, 1992), will be discussed at length in the chapter on cultural competence, and it is important to begin to widen one’s view of what is traumatic to include that kind of experience for a target group member.
Although some authors have argued that it is impossible for sexual harassment to rise to the level of a Criterion A stressor absent an actual sexual assault, Fitzgerald (1993) notes that it is what the gender hostility represents to its target that leads to the phenomenology of being unsafe. Many sexually harassed women speak of developing a fear that their harasser, who seems not to be stopped by requests or threats, will escalate to more violent or physical forms of sexual assault. Thus, the crude jokes about a woman’s breasts or the pictures of women’s genitals taped into her locker are rape threats, not just words and pictures. Similarly, targets of racist or homophobic epithets will commonly perceive a threat of physical violence underlying verbal taunts. Accurately understanding what constitutes a trauma for an individual consequently requires seeing the experience in the context of the individual’s multiple and intersecting identities (Brown, 2009).
The most recent version of Criterion A appears to have responded to the debate by narrowing the parameters of the criterion. However, DSM-5 has also placed PTSD in a new category of Trauma and Stressor-Related Disorders, rather than lumping it in with the Anxiety Disorders. As a result of the creation of this category, PTSD is now clearly related to Adjustment Disorder, which can be given to individuals exposed to stressors that do not fall within the increasingly stringent boundaries of Criterion A, while conveying that the stressor in question is on a continuum with a Criterion A stressor. Additionally, a new diagnosis of Other Specified Trauma-and-Stressor-Related Disorder was created to allow for diagnosis of a post-trauma picture that “does not meet the full criteria for any of the disorders in the trauma-and-stressor-related disorders category.” This diagnosis allows clinicians to note the centrality of trauma of any sort, not simply a Criterion A trauma, in an individual’s distress and behavioral dysfunction. That diagnosis appears to be applicable in most of the situations discussed above such as sexual harassment, exposure to repeated microaggressions, or institutional betrayal where the specifics of Criterion A, or the full symptom picture of PTSD, may not be present.
Thus, while some authors argue strenuously against using a trauma framework for understanding people whose experiences do not fit within the parameters of Criterion A, I suggest that this argument may apply only to whether it is appropriate to give a formal diagnosis of PTSD. The new “Other Specified” diagnosis appears to be an attempt to find a formal diagnostic ground in the middle of this debate. The formal DSM-5 definition continues to reflect political and epistemic differences among trauma-informed clinicians and researchers as much, if not more, as it reflects competing scientific narratives about whether trauma is fear-based, attachment-based, or some combination of both depending on the specifics of the traumatic stressor.
The debate regarding what constitutes a traumatic stressor reflects a tension between several epistemic themes regarding what lends a traumagenic cast to an experience. The central theme of the debate has to do with the nature of trauma. Is it a fear/anxiety phenomenon, a dissociative phenomenon, an affective phenomenon, a relational and attachment-based phenomenon, or some combination of all of these? Several of the more prominent diagnoses for which trauma exposure is the entry criterion indicate the preeminence of one perspective. Criterion A continues to reflect the fear/anxiety paradigm for trauma.
Interestingly, however, the actual symptoms of PTSD and ASD as listed in the DSM draw upon the other three epistemic threads. Criterion B, the intrusive symptom cluster, which includes flashbacks and intrusive thoughts and dreams, can be conceived of as describing primarily dissociative symptoms. Criterion C, the avoidance cluster, describes the most common set of post-traumatic coping strategies. Affective and cognitive changes in the wake of trauma have now been given their own Criterion D grouping, and but include dissociative amnesia in addition to more depressive symptoms. Finally, the new Criterion E, the hyperarousal cluster, consists primarily of anxiety symptoms. DSM-5 allows the diagnosing clinician to specify the presence of prominent dissociation symptoms, formally recognizing for the first time in the DSM the relationship between trauma and dissociation.
While dissociation appears to be a common human response to fear, with biological roots in the phenomenon of tonic immobility, the “freeze” response, and can thus be considered to have trauma as etiological, the dissociative disorders exist in a separate section of the DSM from the Trauma and Stressor-Related Disorder. Peritraumatic dissociation, which commonly occurs at the time of fear-trauma exposure, and which has been associated with the later development of PTSD (Marmar, Weiss, and Metzler, 1998) is now finally included in the DSM.
Other-specified trauma and stressor related disorder does not, due to its apparently purposefully ambiguous nature, promote a particular model of trauma. Consequently it can support a paradigm of attachment, relational, or betrayal trauma as an etiology for post-traumatic symptoms.
The DSM-5 does not require exposure to a traumatic stressor for the diagnosis of any of the dissociative disorders. The introductory paragraphs of the Dissociative Disorders section does note, however, that “The dissociative disorders are frequently found in the aftermath of trauma, and many of the symptoms…are influenced by the proximity to trauma” The text notes that the Dissociative Disorders were placed next to the Trauma-and-Stressor-Related Disorders so as to convey the close relationship between trauma and dissociation. Dissociation itself, however, is not only a fear response. Research also appears to indicate that in children, dissociation is an attachment phenomenon, occurring where the child has an inescapable disorganized attachment relationship with a caregiver (Steele, Boon, & van der Hart, 2016). Thus dissociation, particularly in its most disabling and persistent forms, is also relational in nature, rather than solely or primarily a fear response.
Complex trauma (Herman, 1992, Courtois & Ford, 2009, 2013), also referred to as Developmental Trauma or Disorders of Extreme Stress Not Otherwise Specified (DESNOS), represents a post-traumatic phenomenon that, despite a large body of evidence supporting its existence, was not included in the DSM-5. As Herman (2009) notes, CT, unlike PTSD or ASD, is “not a simple collection of symptoms, rather it is a coherent formulation of the consequences of prolonged and repeated trauma” (p. xiii). Nonetheless, it constitutes a well-defined and adequately empirically researched post-traumatic response set, usually found in individuals with histories of childhood exposure to repeated trauma and neglect, although it is also seen in torture survivors, trafficked individuals, and people with extreme intimate partner violence experiences. CT has been conceptualized as a relational, dissociative, affective, and anxiety disorder. Because of the importance of thoroughly understanding CT, it will be discussed at greater length in the next section of this course.
Why is it important to consider multiple paradigms for what constitutes a traumatic stressor beyond the formal DSM definition? It has been my experience that the symptoms with which a client presents in response to a trauma will not necessarily be those of PTSD or ASD. However, an exploration of the possibility of trauma as a factor may be an important variable in helping both clinician and client understand why the client is suffering as s/he is, and what interventions to bring to bear on those difficulties. Failing to comprehend the varieties of trauma can also lead to misdiagnosis, usually in the direction of inaccurate assignment of a personality disorder diagnosis to an individual, or for failed treatments, in the case of substance abuse disorders catalyzed by trauma exposure. It is not uncommon for individuals whose traumata are more difficult for others to see, or do not have the requisite elements to fit within Criterion A, to be so diagnosed, and frequently stigmatized by treatment providers who miss the traumagenic elements of their difficulties. One well-accepted paradigm for the personality disorders (Millon & Davis, 2001) conceives of precisely this kind of distress emerging in the absence of a clear Criterion A stressor as evidence of an underlying personality disorder. Millon’s model posits that having symptoms evoked by stressors that the “normal” person would respond to asymptomatically is the evidence of the characterological pathology. The new “Other Specified” diagnosis may, in time, be more frequently adopted as clinicians become more trauma-informed and able to see that the collection of symptoms being observed is in fact rooted in trauma exposure of both Criterion A and non-Criterion A varieties.
Trauma-informed practice allows a clinician to instead carefully consider how the notion of “normal” is an increasingly problematic construct. It highlights the reality that differences in identities, and in personal and cultural histories may lend excess meaning to an experience absent underlying pathology. The meaning of an event, a person’s meaning-making system, and their own idioms of distress frequently inform whether or not the person will go on to develop post-traumatic symptoms from exposure to it.
To better understand the fuller range of forms that trauma takes, and the common biopsychosocial/spiritual-existential consequences, let us take a closer look at each of them.
A group of authors have proposed models of what has been called “insidious trauma” (Root, 1992) or “micro-aggression,” (Sue, 2003, 2010; Sue, Bucceri, Lin, Nadal, and Totino, 2007). These authors, whose work has for the most part emerged from the field of ethnic minority psychology rather than trauma psychology, have posited that the insults of daily life, taken cumulatively in the lives of members of marginalized groups, constitute a traumatic stressor for those populations. The experiences of trauma described earlier in this chapter having to do with being subjected to name-calling, pranks, and harassment fall within this construct. However, insidious trauma need not be that overt. Sue and his colleagues have found that insidious traumata can include being repeatedly asked “where are you from,” requests to touch one’s hair, commentary on the exoticism of one’s looks, and jokes containing stereotypes about one’s group.
Discriminatory public discourse can also be insidiously traumatic or micro-aggressive. Russell (2004a, 2004b, 2003) has documented the traumagenic impact on LGBT people of public discourse in states where laws have been passed outlawing marriage equality or threatening or denying protections against employment and housing discrimination. Similar recent public discourse about immigration is likely to have parallel negative effects on the mental health of immigrants, with the 2011 President of the American Psychological Association appointing a task force to review the effects of anti-immigrant sentiment and legislation. All of these can be construed as forms of insidious trauma.
Some of these insidious traumata are very painful. A well-publicized example of this sort of micro-aggression trauma occurred in 2007 when the well-known sports talk radio host Don Imus dumped viciously racist and sexist verbal acid on the heads of a group of talented young woman athletes, the Rutgers women’s basketball team, simply because they were women and African American. Such nearly quotidian reminders of the threat of violence underlying everyday racism, sexism, homophobia, classism, ablism, and so on (Essed, 1991) generates a survival level of consciousness in its recipients, a form of chronic hyperarousal and hypervigilance, that may ultimately yield post-traumatic symptoms. More recently, statements made by a presidential candidate during the 2016 U.S. election cycle about immigrants, Mexicans, women, and people with disabilities were noted to be forms of microaggression.
Both Sue and Root have argued that it is not the one event or experience itself that is traumatic for the person. Rather, these exposures are conceptualized as small drops of psychic acid falling on the stone of the self that have the effect over time of reducing resiliency and creating feelings of alienation, disconnection, and ultimately absence of safety. Root (1992) has argued that when a person is subjected to insidious traumatization, that individual experiences a gradual and often imperceptible erosion of the psyche. The experience of daily micro-aggressions may initially and even over time generate resilient coping responses. Yet each drop of emotional acid creates just enough damage to render the next drop more damaging. At times, the dilution of the acid is such that the particular microaggression is barely perceived; at other times, its sting is more apparent. Over time, a fissure develops in the form of an emotional and physiological vulnerability that is invisible so long as certain aspects of the biopsychosocial/spiritual environment remain steady or supportive and the person’s coping strategies are sufficient to contain the chronic hypervigilance and hyperarousal engendered by the chronic state of being on guard.
However, at some point, says Root, the insidiously traumatized person may develop symptoms of post-traumatic stress when the apparent psychosocial stressor seems small and non-threatening. Root argues it is in the nature of insidious traumatization that symptoms are the result of cumulative micro-aggressions, each one not large enough to be a traumatic stressor, but all taken together to yield a traumagenic experience for the individual that manifests in post-traumatic distress when enough acid has fallen, or when the environment shifts sufficiently so as to affect coping strategies.
Insidious trauma may also reflect historical variables such as genocide or colonization in the individual’s cultural heritage. Scholars of indigenous experience have described “post-colonial trauma” (Duran, Duran, Braveheart, & Yellowhorse-Davis, 1998) as a systemic experience of individuals living in previously colonized cultures that leads to post-traumatic symptoms even in the absence of personal exposure to a Criterion A event. Danieli (1998) and others have described “intergenerational trauma” in children of survivors of the Nazi Holocaust, while other authors have reported this phenomenon in the children of Vietnam veterans with PTSD. Again, individuals experiencing this kind of trauma were not themselves trauma-exposed, but rather were raised in the emotional atmosphere pervaded by their parents’ Criterion A exposure.
In these paradigms, the cultural contexts of the experience and the symbolic meanings and weight given to experience by those contexts need to be understood and explored. Giving trauma-informed care requires clinicians to examine possible sources of these kinds of traumas in a person’s life in order to better comprehend their difficulties.
“Victims are threatening to non-victims, for they are manifestations of a malevolent universe rather than a benevolent one.” (Janoff-Bulman, 1992, p. 148) Janoff-Bulman (1992) has advanced a paradigm of trauma based on the social psychological construct known as the “just world hypothesis” (Lerner, 1980). She argues that most human beings possess three “fundamental assumptions” (p. 6) which reflect our working models of interpersonal and social reality. She argues that these three assumptions are:
Although not all people hold all three assumptions, many – particularly dominant culture Americans – do, to the extent that they are likely to be optimistic about themselves and their lives even when they are able to see that the world is doing badly. Such assumptions tend to go hand-in-hand with an external locus for the source of problems, an internal locus of control about the solution to problems, and the illusory belief that one is in control of one’s life and destiny. Persons strongly holding “just world” viewpoints are likely to see themselves as immune to trauma so long as they engage in correct behaviors, and consequently ascribe personal blame to most traumatized individuals, particularly when the trauma is of the interpersonal violence variety.
Trauma, says Janoff-Bulman, happens when those assumptions about the goodness, meaningfulness and safety of the world, and the power of individual agency to affect the outcome of one’s life, are shattered by life events. Members of dominant U.S. and other Western cultures are particularly vulnerable to trauma arising from shattering of “just world” expectations and the belief in one’s invulnerability and personal agency. This is not to say that persons whose identities are rooted in cultures that deemphasize personal agency as the cause of one’s experiences, both good and bad, do not experience this variety of trauma. However, in keeping with our focus on the importance of understanding identity and context in making sense of what feels traumatic to people, and what may heighten the power of an experience to become a severe traumatic stressor, it is useful to consider how coming from a “just world” culture makes “just world” traumas harder for members of such a culture to bear.
The philosophies of life and death most prominent in the shaping of Western cultures are those which make connections between good actions and good outcomes, and which convey a spurious sense of control over one’s life to those who unconsciously adopt them (Langer, 1975). In these contexts, the bad thing happening to the self-identified good person is more likely to be experienced as a trauma because it undermines the relationship between individual conduct and control over one’s behaviors and a safe, happy life and leaves the person with a frightening sense of life being out of control. The sense of loss of control may be the etiology of the fear as much or more than the experience per se, as we discussed in the story of the racecar driver and her two crashes earlier in this course.
Janoff-Bulman points out that when one ascribes to the “just world” hypothesis one’s expectations of life reflect that hypothesis. We do not expect bad things to happen so long as we are behaving well. Problem-focused coping (Lazarus & Folkman, 1984) in which the individual believes in the ability to apply effort to solving a problem often is seen in such individuals, reflecting their belief in individual agency. The original definition of Criterion A, that an event was “unusual and outside the range of human experience” reflects that model of reality; bad things should be uncommon, unusual, or not normative, since life is good. To engage in trauma-informed practice that is also culturally aware, a psychotherapist must inquire carefully into what the client’s assumptions about reality and coping strategies were prior to the experience of trauma.
Ironically, having had a life full of misery and difficulty does not necessarily reduce the possibility of having assumptions shattered. It is possible to apply some component of the “just world” hypothesis to certain aspects of one’s life, even when the empirical data of life do not conform to anyone’s idea of justice. An excellent, and very painful example of this, can be seen in cases where psychotherapists have become sexually involved with their clients. Such clients almost uniformly report that at some point they come to appraise the sexual relationship as a traumagenic experience, largely because of shattering of expectations that the world of therapy, unlike other components of their lives, will be just and safe. Pope and Bouhoutsos (1986) and Pope (1989) described the “Therapist-Patient Sex Syndrome” whose symptom picture closely resembles that of traumatized individuals.
Trauma-informed practice that is attentive to context and meaning allows for the conceptualization of such experience, while not directly threatening to life or physical safety, as traumatic because they destroy an existential system and worldview that had generated a sense of safety, even a minimal one.
When a client presents to therapy with symptoms suggestive of trauma exposure in the absence of any apparent Criterion A event, it can be extremely clinically helpful to inquire into the ways in which assumptions have been shattered for this person. An example of this can be found in women who were stay-at-home primary caregivers of their children and lost custody to the formerly disengaged father when the father had the means to employ an attorney and the mother did not. This experience does not meet Criterion A in any way, but is frequently experienced as a just-world trauma by the mother who has played by the rules of femininity and now finds herself punished because of the absence of financial resources to hire an advocate who will vigorously defend her relationship to her children. Exploring how an experience has undermined or robbed a person of their ability to employ usual problem-focused coping strategies may also assist in uncovering the presence of “just world” trauma. Cultural and contextual locations may be the factors informing both those assumptions and the ways in which they have been shattered. In this regard, the existential/spiritual component of trauma may be a particularly important lens through which to view the experience and define it as trauma.
In the early 1990’s, a controversy arose regarding whether children who had been sexually violated by family caregivers could lose access to their knowledge of such terrifying experiences, only to have conscious knowledge return to them later in life. This debate over what were variously called “repressed memories” or “recovered memories” of childhood abuse yielded a great deal of heat and light, but was also a source of a new scientific model of what constitutes trauma. Freyd (1996, Birrell & Freyd, 2006, Freyd & Birrell, 2013) proposed the concept of Betrayal Trauma (BT) as a paradigm for understanding both the phenomenon of delayed recall of childhood abuse, and also for conceptualizing such experiences as traumatic.
BT theory provides a cognitive science model of how interpersonal and psychosocial dynamics can make an event traumatic even when threat to life or physical safety is apparently absent, which is frequently the case when children are sexually abused by family or other caregivers such as parents, priests or teachers. Freyd, drawing upon evolutionary psychology, suggests that humans are acutely attuned to the possibility of interpersonal betrayal so as to know how to choose with whom to closely associate. Human children are highly dependent on their adult caregivers for safety and nurturance, and because those adults control children’s lives, a child who is being abused by a caregiver will be placed in the intolerable position of having to manage betrayal and the need for dependency.
Freyd has argued that this intolerable situation leads abused children to store their knowledge of the abuse in separate neural networks that are unavailable cognitively until such time as the child is either no longer dependent on the abusive adult, or cues in the interpersonal or physical environment retrieve the information and bring it to consciousness (e.g., an abused child, now an adult, has a child and it reaches the age at which the parent’s own abuse experiences began to occur). Research by Freyd and her colleagues (Freyd, DePrince, and Zurbriggen, 2001) has found that individuals with delayed recall of childhood trauma are significantly more likely to have been traumatized by family members than individuals who never forget the abuse experiences.
The BT model posits that betrayal traumas are traumatic emotionally for humans when the extent of the betrayal becomes knowable. It is similar to Koss’s conceptualizations of acquaintance rape, where the experience becomes traumatic only when the victim reappraises the meaning of the experience from merely unpleasant to one of violation. The BT model tells us not only why memories for childhood abuse can become elusive or unavailable for many years, but also why experiences that are confusing and unpleasant, but not an immediate cause of fear, horror, or sense of danger to life, can become traumagenic for people.
Betrayal trauma can also occur in contexts where people can reasonably assume that a powerful institution is looking out for their interests and welfare; thus, a betrayal trauma does not require a family relationship of caregiving in order to occur. Additionally, betrayal traumas have been observed in situations of marital abandonment when one spouse has been highly dependent emotionally or financially on the other. In several cases where this author consulted forensically, exposure of betrayal yielded the same kinds of peritraumatic dissociative symptoms as have been reported for Criterion A events. Freyd and I (Brown & Freyd, 2008) proposed that the moment of knowing betrayal functions as the Criterion A of BT. For adults, BT may also be linked to “just world” trauma. Smith and Freyd (2013, 2014) have recently published empirical evidence regarding the traumagenic effects of institutional betrayal, focusing on the experiences of women sexually assaulted on college campuses, finding that the failure of the institution to act protectively adds an additional traumatic experience to the original trauma of sexual assault.
As noted earlier in this course, Complex Trauma (CT) is a construct proposed by Herman and her colleagues in the early 1990’s to describe the more extensive picture of distress and dysfunction found in individuals with histories of repeated, inescapable trauma exposure, frequently in the context of emotional or physical neglect. Courtois & Ford (2009) state, “We define complex psychological trauma as involving traumatic stressors that are (1) repetitive or prolonged; (2) involve direct harm and/or neglect and abandonment by caregivers or ostensibly responsible adults; (3) occur at developmentally vulnerable times in the victim’s life, such as early childhood: and (4) have great potential to compromise severely a child’s development” (p.1). They note that the sequelae of such experiences are also severe and complex, with problems of attachment and relationship, emotion regulation, self, dissociation, somatic difficulties, and spiritual/existential confusion. When a clinician is not trauma-informed, the client’s problems may be seen through the lens of the presenting symptom: chronic pain, compulsive behaviors, a pattern of failed or violent relationships, self-inflicted violence, emotional lability, or personality disorder presentations. Focusing on the symptom or the specific diagnosis in the absence of a framework that includes the perspective of CT may lead to frustration for all parties. Trauma, unaddressed, continues to inform the survivor’s experiences of relationships, including that of psychotherapy.
While many individuals with CT present to treatment functioning at low levels of capacity, others, due to a variety of resilience factors, may have had success in academic and vocational settings, often utilizing those as coping strategies. Over-work, over-exercise, and other forms of over-involvement in otherwise healthy activities as a means of dissociative coping may lead such persons to appear high-functioning when they first enter treatment with lower-level psychological complaints such as mild anxiety or depressed mood, only to appear to decompensate rapidly soon after therapy begins. Such clients also often have difficulties with and press upon the boundaries of psychotherapy, experiencing these rules and norms as rejecting and cold, and will frequently take lengthy periods to develop a sense of trust in a therapist, leading to disruptions in the therapeutic alliance.
Complex trauma is best conceptualized as having its roots in disorganized attachment (Main & Solomon, 1990), which leads to problems of self-regulation, due to an absence of regulating and soothing nurturance, adequate and consistent mirroring, and exposure to objective threats. The child developing under these circumstances comes to experience other humans as dangerous, predatory, and unpredictable, and acquires a repertoire of coping strategies that will allow for the maintenance of some form of connection, no matter how dubious its quality, with the problematic caregivers. Dissociation of both affect and knowledge of events, moral ambiguity so as to encompass the often inappropriate or cruel treatment received, and various forms of acting-out behavior can all be seen in children living in such situations. Reactive attachment disorder is the diagnosis currently in the DSM that best describes the childhood version of complex trauma, and its inclusion in the new Trauma-and-Stressor-Related Disorders section affirms that perspective.
Complex trauma clients are also frequently seen in non-mental health settings. Findings from the Adverse Childhood Experiences (ACE) study which tracks rates of experiences within the CT paradigm indicate that as the number of such adverse experiences go to above one, there are statistically higher rates of chronic obstructive pulmonary disease, pregnancy complications, including adolescent pregnancy, unintended pregnancy at all ages, and fetal death, ischemic heart disease, liver disease, and sexually transmitted diseases (http://www.acestudy.org/). Adolescents with complex trauma histories are more likely to enter early into self-described consensual sex, often having been sexually abused earlier in life, but to have more difficulty with sexual safety, accounting for the higher STD rage. They are also more likely to begin drug and alcohol use as adolescents, frequently to self-medicate for problems of emotion-regulation, and to start early use of cigarettes, frequently to regulate anxiety. Attempts to intervene in these problematic behaviors to reduce the risk of their longer-term consequences in adults with CT must take the possibility of trauma exposure into account.
Persons with CT can also have other trauma-related symptoms, including a full PTSD profile. What is most important to understand about this paradigm is how CT presents, not simply as PTSD, but as a range of symptoms reflecting the biological, psychological, psychosocial, and existential difficulties engendered by chronic, repetitive, inescapable early trauma exposure, frequently in the presence of neglect and disorganized or anxious attachment experiences. It is very likely that the development of CT de novo in adults who are subjected to torture and other forms of extreme and inescapable violence has to do with the marked power differentials between perpetrators and victims in those instances, leading to a regression to younger levels of functioning in the traumatized person.
I have referred on a number of occasions to trauma as a biopsychosocial-spiritual/existential phenomenon. It can be particularly helpful for psychotherapists, who have a good understanding of the last three components but not as clear a picture about the biology of trauma, to have sufficient comprehension of the impacts of trauma on brain and bodily functioning in order to effectively conceptualize the biological substrate of the psychosocial and existential challenges presented by their clients. Knowledge of this material can also assist the clinician to psychoeducate clients about the reality that they are not stupid, lazy, or weak; rather, they are dealing with a whole body/brain experience that requires compassion and some time to remediate, and whose long-term consequences for health are not entirely within the conscious control of the adult survivor. Additionally, understanding the biology of trauma allows for the development of better integration of psychopharmacological and other somatic interventions with psychotherapeutic treatment strategies.
In traumatized children, brain development becomes shaped around survival in response to repeated activation of the stress response system. Ford (2009) refers to this as the brain changing from a “learning brain” to a “survival brain,” with both structure and function optimized to respond to anticipated or present threat. This, in turn, has cascading effects on brain functioning, with underdevelopment of neural networks that privilege openness to experience and relational capacities. Instead, neural networks are strengthened that privilege avoidance of harm, detachment from relationships, and quick reactivity, e.g., emotion dysregulation. Ford (2009) argues that many of the psychosocial difficulties experienced by survivors of childhood trauma stem from the manner in which brain development is distorted to respond to the demands of a traumagenic early environment.
In adults as well, several brain structures appear to be affected by exposure to trauma. These include the hippocampus, which is responsible for integration of cognitive and affective experiences in memory, and Broca’s area, which is responsible for speech and language. Brain systems implicated in the trauma response include the limbic system, particularly the amygdala, which is implicated in fear response, and the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system, which are components of the stress response system, and involve the remainder of the body as well as the brain.
One striking finding in these studies was the performance of Broca’s area in trauma survivors; consistently, this brain structure was deactivated, with reduced electrical activity. This finding offers a biological explanation about the difficulties that trauma-exposed persons may have in finding language to describe their experiences and emotions, and may account for the observed alexithymia (inability to know and speak to emotion) in many trauma survivors.
The second most common finding in the neuroimaging literature has been of reduced hippocampal volume. This change to brain structure may affect the capacities of trauma-exposed persons not only to consolidate information inputs across a range of sensory systems, and integrate and effectively store new information, but also to distinguish between threatening and non-threatening stimuli in their post-trauma environments. This may help explain the degree to which some traumatized persons, particularly those with CT, appear to engage in trauma reenactments, manifesting what Kluft (1990) called “sitting duck syndrome” in which interpersonal revictimization is common.
Chronic activation of the stress response system in traumatized individuals has neurochemical, endocrine, and immune system correlates. Kendall-Tackett (2007) reported that trauma survivors have decreased immune functioning, higher levels of systemic inflammation, and are more likely to have auto-immune disorders, even when trauma exposure has occurred primarily in adulthood. These findings help to make sense of the result of the ACE study, as a number of the conditions for which trauma survivors demonstrate excess morbidity and mortality can be partially due to immune dysfunction or systemic inflammation. In fact, the latter phenomenon is now being seen as a sort of uber-pathology underlying a wide range of biological illness, including cancer and cardiovascular disease.
Activation of the HPA axis appears to result in compromised levels of the neurohormone cortisol, whose expression is necessary for bringing brain and body back to resting state after anxious activation. The chronically elevated levels of anxiety experienced by trauma survivors, as well as their frequent difficulties in returning to their own baseline after an episode of heightened activation, is most likely due to these impairments in cortisol production. Some authors have also hypothesized that the reductions in hippocampal volumes found in neuroimaging studies of trauma survivors may be a degenerative process in response to cortisol toxicity arising from over-activation of the HPA axis. While this particular relationship remains speculative due to the retrospective nature of the data on hippocampal volume, the effects of disrupted cortisol levels on functioning for trauma survivors have, at the very least, an impact on anxiety levels, reactivity, and the capacity to effectively self-regulate.
More recently, Porges (2011) has proposed his Polyvagal Theory, which describes ways in which central nervous system regulation of organ systems is affected by trauma. Porges has postulated that the various common trauma responses (Fight, Flight, Freeze, and Collapse) are indicative of different vagus nerve responses, activating or de-activating different organ systems during varying kinds of traumatic stress. While the Flight/Fight paradigm is well-known to most mental health professionals, the trauma-specific responses of Freeze and Collapse are better understood through application of Porges’s model.
The essential first step in trauma-informed psychotherapy is a thorough understanding of the wide variety of ways in which trauma is experienced, and its aftermath is expressed biologically, behaviorally, and emotionally. When a clinician has a solid grasp of the many ways in which life can become subjectively traumatizing, he is more likely to engage in assessment and treatment strategies that are effective. When the clinician also comprehends the manner in which trauma of all kinds affects the entire person, biologically as well as psychologically, it may become possible to conceptualize that individual’s difficulties in a more holistic manner.
As the preceding discussion makes clear, exposure to trauma does not ipso facto lead to the development of Post-traumatic stress disorder (PTSD). One thinking error made by some clinicians goes as follows – if only 20 percent of trauma exposed individuals go on to develop PTSD, then the other 80 percent are fine. A related thinking error suggests that if only 20 percent get PTSD, then in any given group of people experiencing a similar trauma, only 20 percent of them should become eligible to receive a diagnosis of PTSD. While PTSD symptoms generally mean that a person has been exposed to a trauma as broadly defined in the first section, the converse is not true.
Trauma-aware clinical practice avoids both of these thinking errors. Instead, a psychotherapist needs to consider the range of possible diagnostic presentations for which trauma is a known risk factor, and then consider how to carefully assess for the presence of trauma-specific symptoms in those clients. In this discussion, I assume a model for symptoms called the “diathesis-stress” paradigm. To understand this construct, consider three bridges, each of which is being driven over.
The first bridge was built with particularly strong materials and extra bracing, ready to withstand an earthquake or high winds. The second is an average bridge, well-constructed, and adequate for a place where the earth never shakes. The third bridge was built by a shoddy contractor; the concrete was mixed with the wrong proportions of sand and cement, and reinforcing rebar has been left out of several key sections of the bridge. It, nevertheless, stands under most circumstances. The first bridge represents a low level of diathesis, or biological vulnerability; it does not, however, represent zero vulnerability. The third bridge represents a high level of diathesis. The first bridge is less likely to fall down, e.g., become symptomatic, except in the case of more severe, extreme, or repeated stressors. Thus, the Bay Bridge, which went down in the 1989 Loma Prieta earthquake, was built to withstand seismic disruptions, but partially collapsed in that quake because of both the severity of the quake and its specific location that undermined the bridge’s stability. The third bridge is more likely to fall down with less stressors, and its particular diathesis to become more visible more easily.
In exploring the gene/environment interactions that lead to a wide range of human difficulties, we can see that individuals carry a variety of diatheses for psychological distress. In persons with a weak diathesis for certain kinds of expressions of distress, traumatic stressors may be necessary to evoke expression of that genetic predisposition. In persons with a very strong diathesis, stressors can be less and still lead to a more potent and difficult to treat expression of the predisposition. When trauma-caused epigenetic changes to a parent have been transmitted to the offspring, that diathesis, and vulnerability to a stress response, would be further accentuated. I would argue that each of us has a biological response to both traumatic and non-traumatic stressors that we likely share with first-degree relatives, and that we can recognize easily on reflection. Some of us become more anxious; others experience depressive symptoms. Some people experience their stress more somatically. Some cannot sleep; others cannot wake up. Some get confused; some are obsessively focused in non-productive directions. Others are just plain “cranky” or irritable.
Trauma survivors, like everyone else, have these preferential modes of stress response. It is not yet known which, if any, kinds of biology predispose people to the development of PTSD. However, some studies have found that the presence of a depressive disorder in a first-degree relative is a risk factor for the development of PTSD in adults with single-episode trauma. While this is an intriguing connection, it begs an important question. That is, were those relatives manifesting post-traumatic symptoms as depression? Or is a diathesis for depression implicated in the development of PTSD? Because most research on depression fails to take trauma into account as the etiological variable that it is known to be, its presence in those first-degree relatives is invisible to the research.
Trauma has also recently been demonstrated to be a likely epigenetic phenomenon. What does this mean? Epigenetic phenomena are anything other than the DNA sequence that influences which genes are expressed in the development and maintenance of an organism. In the case of trauma, hippocampal changes are posited to be epigenetic in nature. Epigenetic changes have now been found to be heritable in two studied human populations: offspring of Holocaust survivors, and offspring of indigenous Canadians who were forced into abusive residential schools. It is also likely that these epigenetic phenomena have an additional, more indirect effect on risk for development of a post-traumatic symptom picture, through mediating effects on the functioning of caregivers who have been trauma-exposed and themselves experienced trauma’s epigenetic effects.
With this in mind, let us consider the range of psychological disorders for which trauma has been implicated as a risk factor. Remember that a risk factor is not a cause but rather, an experience raising the probability of the development of that disorder. Going back to our three bridges, we can see that a poorly built bridge has a stronger risk factor for falling down. Nonetheless, unless subjected to the particular stressors that would lead to its collapse, it may stand for decades.
Depressive symptoms are the affective presentation most commonly associated with trauma exposure. National studies of non-patient populations have found that depression is three to five times more common in those exposed to a Criterion A stressor than those not so exposed. If we then take into account exposures to the other types of trauma described earlier in this course, it is likely that some kind of subjectively experienced trauma is implicated in significant numbers of cases of depression.
It is likely that depression is such a common post-traumatic symptom because trauma has effects on the biological and psychosocial environments that are similar to those factors leading to depression when trauma is not present. Trauma may serve as the stressor for people with a biological diathesis for depression. In addition, some of trauma’s effects on brain functioning appear to include a lowering of levels of serotonin and dopamine, both neurotransmitters implicated in the occurrence of depression. Trauma is often psychosocially isolating; reduced social support is a known psychosocial risk factor for depression. Trauma frequently involves loss and grief, which when prolonged can increase risk of moving from non-complicated bereavement to depressed mood.
PTSD and depression are also commonly comorbid and share symptoms. Clusters C and D of PTSD include symptoms of social withdrawal, emotional numbness, negative self-cognitions, and hopelessness (sense of a foreshortened future), and the hyperarousal symptoms of Cluster E may create difficulties in sleep and concentration similar to those seen in depression. PTSD itself may predispose to the expression of a weak diathesis for depression by becoming its own biopsychosocial stressor; living with nightmares and flashbacks tends to be objectively depressing and stressful.
Trauma exposure has not been directly implicated in the development of manic episodes or bipolar disorder. However, for a number of people, manic episodes or initial psychotic breaks are themselves traumatic and frightening, and a person with a history of bipolar manic episodes may present with trauma-related symptoms arising from these experiences. Because current thinking about bipolar disorders is that they are primarily biological in their etiology, psychotherapists often overlook how the person who has experienced a manic episode may find that experience the cause of additional symptoms that may be overlooked given the narrow lens placed on persons with this diagnosis by current etiological paradigms.
Additionally, persons with a trauma history may receive a bipolar diagnosis in error when a simplistic set of criteria is used to arrive at a diagnosis. It is not uncommon for trauma survivors to non-manically meet several of the criteria for a manic episode, including long episodes of little sleep, compulsive behaviors such as over-spending or sexual compulsivity, and pressured speech, all arising from extremely heightened anxiety stemming from trauma exposure. Careful attention to the affective flavor of these episodes is useful in distinguishing post-traumatic from manic symptoms. Because anecdotal evidence suggests that in many parts of the U.S. today bipolar disorder has become a default diagnosis by psychopharmacologists, trauma-aware assessment is essential to making the careful differential diagnosis.
PTSD, as noted earlier, contains components of several anxiety disorders, including generalized high levels of anxiety and phobic avoidant responses. Due to the biological substrate of trauma response in which the HPA axis is over-activated, many survivors of trauma have persistent high levels of biological activation arising from deficits in cortisol functioning. Trauma-informed assessment will assist in determining the degree to which symptoms may reflect traumagenic activation as versus other more primary anxiety symptoms.
Some components of obsessive-compulsive disorder and PTSD also resemble one another, and these disorders may co-occur as well. A useful differential is that PTSD leads to intrusive images and thoughts of what has already happened and could recur, while OCD is more likely to lead to intrusive images and thoughts of what might happen and what could have but didn’t happen.
A prior personal or family history of anxiety disorder constitutes a risk factor for PTSD in trauma-exposed individuals. As is true with depression, a diathesis for anxiety under stress may express itself as PTSD in a trauma-exposed person, and also as other anxiety disorders.
Persons presenting to therapy with anxiety symptoms other than PTSD should be carefully screened for the presence of trauma in their histories because of important implications for treatment, especially in the case of complex trauma. A number of the empirically supported treatments for anxiety disorders, including exposure therapies and cognitive behavioral treatments, can be effective with some forms of PTSD as well (a topic to be discussed in the next course in this series, Treating Trauma: Basic Skills and Specific Treatments. However, for individuals with a complex trauma picture, employing such therapies without prior work to create stabilization and containment for the client, as well as to build resilience and capacities for the high level of responsibility that such treatment places on the client, may lead to decompensation and treatment failures resulting from the pervasive hopelessness, helplessness, and feelings of absence of personal agency that are common in complex trauma survivors.
The dissociative disorders represent a category of diagnoses about which many clinicians are unfamiliar, and with which many clinicians appear to be very uncomfortable. These diagnoses are currently considered to have chronic childhood traumatization in a context of disorganized attachment as their most common etiology, and are considered by many trauma-informed psychotherapists to be on a continuum with other trauma-based disorders. Individuals with dissociative symptoms, particularly those with Dissociative Identity Disorder (DID), Other Specified Dissociative Disorder, and Unspecific Dissociative Disorder (two new diagnostic categories which appear to overlap with the now-extinct diagnosis of DDNOS) report multiple experiences of misdiagnosis of their conditions at the hands of well-meaning clinicians who either do not know how to differentiate between the symptoms of DID and similar non-dissociative phenomena, or have been trained to “not believe” in dissociative disorders.
The non-belief stance is not a scientifically supportable one given the large body of empirical research documenting both the reality of dissociation and its biological manifestations. The Dutch researcher Ellert Nijenhuis and his colleagues (1999) have demonstrated the physiological correlates of changes in personalities or ego states of individuals diagnosed with DID. These clear biological markers of the condition, in which EEG tracings, blood flow rates, and other physiological measures change with changes in personalities, offer what should be unequivocal evidence that at least some individuals diagnosed with DID are not exhibiting an iatrogenic phenomenon, as the “non-belief” school has argued, but rather a biologically documented one that appears to be traumagenic in origin. As noted earlier, dissociative symptoms that would now be diagnosed as DID or other dissociative disorders were described by Janet over a century ago, well before the publicity about dissociation that has been posited by some of the “non-belief” authors as the cause of DID.
Persons rarely present to a general psychotherapist with a known diagnosis of DID or other disociative disorders. Dissociative individuals who have an awareness of their condition almost always seek out a therapist with some prior knowledge and experience when available, due to having frequently had negative experiences with non trauma-aware practitioners. When a dissociative person is not aware of her or his condition, s/he is more likely to present for therapy with other symptoms, frequently including depression that has been intractable to treatment, severe anxiety, or Schneiderian first-rank symptoms of hearing voices. Additionally, the more florid symptoms of these dissociative disorders, particular blackouts, time loss, and fugue, may also be found in persons with severe substance abuse disorders. Like all of the other disorders with their roots in trauma, persons with DID or other dissociative disorders can also have comorbid psychological problems, including any or all of the affective and anxiety disorders, primary substance abuse disorders, and characterological pathologies.
With all of this in mind, what is the naïve beginning-to-be-trauma-informed therapist to do? First, importantly, therapists should be open to the possibility that they may encounter a person with severe dissociative symptoms in their practice. The bulk of clinicians who have entered the dissociative disorders field have done so as generalists confronted with their first highly dissociative client who were not scared too badly by the experience to seek further education and become open to continuing to work with this population.
Being open to the possibility of dissociation in one’s clients means attending to small clues being offered, and then engaging in more formal differential diagnosis. The use of specific instruments and structured interviews to assess for the presence of dissociative pathologies will be discussed at greater length in this course. Clinically, psychotherapists should be attentive to reports of time loss or fugue not attributable to substance use; reports of voices arguing with one another, as well as observations of such arguments occurring in the office in front of the therapist; reports of severe headaches preceding lost time; other Somatic symptom and related presentations such as so-called pseudo-seizures; rapid changes in mood, vocabulary, and posture during sessions; and persistent, non-organic problems with memory for significant portions of current day life not attributable to substance use.
Persons with DID or other dissociative disorders also frequently have a complex trauma presentation; in fact, some scholars in the fields of trauma and dissociation argue that the dissociative disorders are simply one form of complex trauma occurring in individuals with a strong diathesis to dissociate (van der Hart, Steele, & Nijenhuis, 2006, Steele, Boon, & van der Hart, 2016). The therapist taking on the care of individuals with complex trauma is consequently more likely than a generalist to encounter dissociative symptoms.
Dissociative phenomena also occur outside of the chronically traumatized population. As noted earlier in the discussion of ASD, dissociative symptoms are the hallmark of ASD, and represent the forms in which peritraumatic dissociation is most likely to manifest: depersonalization, derealization, confusion and fugue. For some recently traumatized individuals, such ASD dissociative symptoms can themselves be more frightening than the trauma itself, which is perceived as evidence of going crazy. Psychoeducation for clients about the normative nature of peritraumatic dissociative symptoms can be an important component of working with this population.
Finally, evidence suggests that some cases of primary depersonalization and derealization are not traumagenic in nature. Clinicians should be cautious not to infer the presence of trauma in a client’s history from these symptoms just as they should be attentive to the possibility of dissociation and trauma in clients presenting initially with non-dissociative problems. While treatment for dissociative disorders will be briefly discussed in a later course in this series, psychotherapists working for the first time with this population require additional focused training in dissociative disorders treatment, and should seek that as well as consultation, upon confirming that a client has DID or another dissociative disorder.
Along with depression, substance abuse disorders, including nicotine dependence, are the most common co-morbid diagnoses for people with a history of trauma exposure. Persons with a history of trauma exposure in childhood are likely to start using substances earlier in life, use more substances, and have more difficulties with becoming and remaining substance-free than individuals with no trauma history. Development of substance abuse problems in the aftermath of adult-onset trauma exposure is also common. Clients presenting with a substance abuse problem are more likely than not to have a trauma history.
Substances are used by trauma survivors as forms of emotion regulation and self-medication. In addition, a percentage of substance abusing trauma survivors have a strong diathesis for substance abuse that would have likely led to a primary substance abuse problem absent the trauma exposure. Finally, some unknown percentage of persons who present for substance abuse treatment become aware of and symptomatic from previously unrecalled or chemically dulled trauma exposures upon achieving abstinence. Untreated post-trauma symptoms are frequently implicated in relapse for individuals with co-occurring post-traumatic symptoms and substance abuse.
Somatic symptom and related disorders have tended to occupy an orphan position with psychotherapists, conceived of as evidence of less psychological mindedness, or more charitably as culture-specific manifestations of distress. However, the evidence is strong that Somatic symptom and related disorders can better be conceptualized as somatoform dissociation constituting a response to trauma exposure. They thus constitute a category of disorders like dissociation for which trauma is a known strong risk factor, but which has not been grouped with trauma in the DSM. However, in DSM-5 the introduction to this section notes that their appearance is commonly associated with early trauma experiences. Van der Hart, Steele, & Nijenhuis (2006) note that first descriptions of these phenomena were authored by Janet and Freud, both of whom ascribed them to histories of sexual abuse; while Freud went on to repudiate that paradigm, Janet’s research, and as importantly work done in the late 20th century with individuals with somatoform presentations, indicate that the link between trauma exposure and somatic symptom and related disorders is a robust one. The ICD-10 contains a category, “Dissociative disorders of movement and sensation,” which includes dissociative seizures, paralysis, anesthesias, and other motor disorders (WHO, 1992), providing a clinician with a more trauma-informed framework for working with clients who present with these problems.
Both the diagnosis of Somatic symptom disorder and that of Conversion disorder, the two DSM diagnoses for somatoform syndromes, are empirically associated with a history of trauma exposure, commonly complex trauma exposure. Other somatoform presentations for which trauma exposure is a known risk factor include chronic pelvic pain and other chronic pain. Some research has suggested that individuals with a history of trauma exposure develop chronic pain syndromes because they have a post-traumatic response to the pain that proceeds to set up a priming of neural networks for pain, creating a spiral of pain, post-traumatic response to pain, and more pain, all of which remains refractory to standard treatments.
Psychotherapists working with individuals presenting with Somatic symptom and related disorders should thus consider the possibility of a trauma history. Because of the dissociative nature of many somatoform presentations, clients may initially deny such a history as they have no conscious available memory of such experiences at the outset of treatment.
This category includes non-substance based compulsions such as disordered eating, sexual compulsivity, compulsive over-work, compulsive over-exercise, shoplifting, compulsive spending, and compulsive gambling. Each of these behaviors, like substance abuse, appears in high rates in trauma-exposed individuals, although no statistics are available about rates in the more general patient population. These behaviors appear most commonly in individuals with a complex trauma presentation, although they can also emerge in those individuals with an adult onset trauma experience who have a strong diathesis for being affected by these forms of self-soothing. These behaviors can be seen as forms of dissociative avoidance as well, in which the person distracts themselves from painful emotions or images by becoming lost in the compulsive behavior. For some individuals with a history of childhood sexual abuse, compulsive sexual behavior appears to be a reenactment of the experience of abuse, an adult version of the compulsive masturbation and inappropriate sexual touching in which some sexually abused children engage.
While psychosis is generally assumed to have a primarily biological cause, some evidence exists to suggest that trauma can be the stressor in individuals with only a moderate diathesis to thought disorder. Brief reactive psychosis with a strong dissociative element, which has been referred to in some research as dissociative psychosis has been observed in some individuals known to have been recently exposed to an extreme traumatic stressor. Individuals with DID are frequently misdiagnosed as psychotic due to the combination of Schneiderian first rank symptoms and their belief in the separateness of their ego states or personalities. However, it is also possible for such persons to have parts that are themselves primarily psychotic and manifest as such.
Finally, research indicates that persons who are chronically psychotic are more likely to be exposed to traumatic stressors in the aftermath of their diagnosis (Gold & Elhai, 2007). Thus, individuals may be comorbid for primary psychosis and acquired post-traumatic symptoms, which, because it mimics psychosis, may not be treated. The traumas experienced by persistently mentally ill individuals may also meet with disbelief when reported, and thus not be taken seriously by clinicians. The possibility of misdiagnosed DID, and comorbidities of either complex trauma serving as the stressor for the psychotic diathesis, or trauma exposure arising from life as a psychotic person, should thus always be considered.
While we are speaking here of adult trauma survivors, one of the more useful ways in which to make sense of both the symptoms that a person manifests and the difficulties they experience in engaging in treatment for them has to do with a developmental analysis of their trauma. Think of trauma response as a matrix in which biological diatheses interact with several other factors.
Another very important factor has to do with the internal resources available to the person at the time or times of trauma. Intuitively, a therapist knows that a two-year-old child has different cognitive, affective, and self-soothing capacities than does a 12-year-old adolescent, or a 40-year-old adult. Humans respond to trauma with the capacities available to them, and encode the traumatic experience in manners reflective of those capacities.
One of the challenges for the individual traumatized earlier in life is that the disruption of normal developmental processes resulting from trauma will then distort, sideswipe, or otherwise impair the capacity to move forward through other developmental steps in a normative fashion. Thus, the person traumatized at two has the remaining steps of child, adolescent, and adult development interfered with in some manner, as she approaches those subsequent developmental milestones with capacities already affected by the trauma. The adult survivor of trauma who has had few significant disruptions to development is more likely to be able to recruit capacities that have formed in a developmental normative sequence.
Evidence of age of trauma can often be seen through the nature of coping strategies marshaled. Children at younger ages are more likely to use more passive, fantasy-based coping strategies; more easily rendered helpless; and more likely to engage in the sort of developmentally normative self-focused attributions for events occurring in their lives. Shame is likely to be a prominent component of developmental earlier trauma responses, as the younger child has not yet acquired the cognitive capacities to differentiate self from actions. Early trauma is also more likely to occur within caregiving relationships, leading to more profound and enduring impairments to relational capacities and a more anxious or disorganized relational style that will play itself out in the therapy relationship.
Older children and adolescents will develop increasingly more sophisticated coping strategies in response to trauma. Interestingly, there appears to be a resurgence of self-blame for being a victim of interpersonal violence emerging in adolescence, as the developmental realities of that age group lead to the illusory belief that one is old enough to be able to successfully resist, run from, or otherwise effectively turn away exploitation and victimization, despite the real restrictions on adolescents’ freedoms of choice regarding where they reside and with whom they associate. Guilt, particularly survivor guilt, is more likely to be observed in the symptom picture of survivors whose trauma occurred at later points in their childhood and adolescent developments.
Adults’ responses to trauma are marked by existential challenges and crises, usually in the form of having existing “just world” beliefs badly damaged. Patterns of coping style are likely to become visible in adult-onset traumas, with differential capacities becoming visible for problem-focused versus emotion-focused copers. Depending on options available to the adult-onset trauma survivor, different coping styles may lead to different proximal and distal symptom sets in the face of trauma.
Consideration of developmental issues informing the creation of the post-traumatic response picture for an individual client is an important component of making treatment choices as well. Core beliefs about self that are forged in very early childhood trauma, at times when rational thinking is not part of the child’s cognitive capacities, are extremely unlikely to be responsive to straightforward cognitive behavioral approaches to treatment. Individuals not traumatized in a relationship of care and trust are more likely to have developed the kinds of self and relational capacities that lend them the resilience necessary to do well with exposure therapies, while persons with complex trauma and many relational wounds may become decompensated by such treatment approaches. Non-verbal therapy techniques, such as Eye Movement Desensitization Reprocessing (EMDR) or Somatic Experiencing (SE) may be more effective for those clients whose verbal capacities were poorly developed at the time of the trauma. Thinking developmentally about the experience of trauma lends a subtlety and precision to the diagnostic formulation that can enhance therapy.
Something for which psychotherapists rarely formally assess, but which is an important component of general assessment concerns in the field of trauma, is resilience. Despite having lived through difficulties that have left a mark on body, mind, and spirit, many trauma survivors are also capable and functional in a number of life domains. Even when they are not highly functional, they have employed what resources are available to them in such a manner that they are alive and acting as decent human beings despite the free tickets offered them by life to behave otherwise.
The general literature on resilience can be helpful here; we know that people who have certain personal and psychosocial resources do better with the vicissitudes of life, trauma or not. For some trauma survivors, standard markers of resilience, such as intelligence, talent, conventional attractiveness, spirituality, or access to financial resources, are sources of guilt and shame, which makes a therapist’s attention to them potentially problematic. Therapists working with trauma survivors should, at the very least, note such markers of resilience; questions such as “What are the things you’ve done in life to help yourself?” or “What about you feels like more of a success?” can be useful probes during general intake.
Trauma-aware therapists also credit our clients’ attempts to solve the problems of their distress, which reflects a competency-based stance on our clients (Bertolino & O’Hanlon, 2001). This standpoint sees people as problem-solvers, and thus symptoms as evidence of less-than-perfect attempts to have solved the problem of trauma exposure. Gilfus (1999) refers to this stance as a “survivor-centered epistemology,” which she defines as “first and foremost the acknowledgment of the survivor as a complete human being with a cultural and historical context, capable of expert knowledge in her or his own right, to be viewed through the lens of a loving perception” (p. 1253).
Some of these strategies for responding to the unbearable pains of trauma will have succeeded magnificently for varying periods until they didn’t work any longer. Overwork is one of the most obvious of these, as is dissociative amnesia. Some of these problem-solving strategies will have succeeded poorly if at all; phobic avoidance is an example of this kind of strategy, as it keeps the person away from traumagenic stimuli, but makes the rest of life very difficult. Some will have success, but at a price; self-inflicted violence, which powerfully changes the inner state but draws unwanted negative attention and judgment, is a good example of this sort of strategy. All of these strategies are evidence of the survivor’s intentions and desires to deal with what trauma has invited into his life. Trauma-informed practice respects and honors the diversity of attempts that trauma survivors have made to solve the problems of distress and disruption that trauma has brought into their lives, and mark them as evidence of resilience.
Nonetheless, every trauma survivor that we encounter will have created some sort of self-help strategy – avoidance; dissociation; over-work; abuse of substances, food, or exercise; prayer; art; petting the dog; giving birth; or being celibate, to name a few. They have arrived at our offices alive, if sometimes only barely so. Frequently the strategies that they have utilized reflect an intersection of their identities in the world and their developmental capacities at the time of the trauma, and may shape their identities in the world as they go forward. Similar to Carl Rogers’s thesis that all humans are possessed of the drive to self-actualize, so I find useful the notion that humans have the will to solve the problems of their lives. Taking this perspective assists the trauma-aware therapist to become attuned to how his clients have been resilient.
One final word of caution. Therapists have been known to frequently assume that being high-functioning is isomorphic with being resilient, and have plunged into doing more exposure-based trauma work with the belief that their client will tolerate this painful material well. Resilience and functional capacities are not the same; a person may be low in functional capacity, but have stores of resilience from repeated experiences of surviving trauma exposure. As discussed in the section above on “just world” trauma, individuals who are high-functioning and have had little experience in flexing the emotional muscles necessary for dealing with trauma may be surprisingly not resilient – surprising to themselves and those around them. A trauma-aware therapist should not be surprised. Assume that all traumatized individuals have some forms of resilience, and may lack others; assess for what those are when planning how to proceed with treatment.
Trauma-informed psychotherapy means that all intake histories should include questions about exposures to a range of traumatic stressors, phrased in such a way as to increase the likelihood that clients will share these experiences where it is available, as well as questions about the range of experience of distress, given the previous discussion of trauma as a risk factor for such a broad range of problems. Because clients will frequently not divulge this information early in therapy, trauma-informed clinicians should consider intake to be a continuous process, rather than something done in the first one or two sessions. I have had the experience of clients taking many years to disclose a trauma, the revelation of which changed the course of treatment by illuminating the post-traumatic meaning of certain symptoms.
Many trauma survivors find it painful and difficult to talk about their trauma in the early stages of treatment, even at the level of responding “yes” or “no” to questions about whether they have experienced some particular variety of trauma exposure. For that reason, I also consider intake checklists on which clients are asked to tick off the kinds of trauma that they have experienced to be potentially problematic for the development of a therapeutic alliance, although they can be useful when a clinician’s job is focused assessment and not psychotherapy.
If specific questions about types of trauma are asked, the language should be such as to increase a client’s ability to give us the information we are seeking. For example, research on sexual assault trauma, particularly at the hands of known others, has shown that if women are asked if they were “raped,” many who are survivors of acquaintance rape will respond in the negative, as the term “rape” is coded conceptually as representing a violent act perpetrated by a stranger, what some authors have called “real rape.” However, asking the same group of women if they have experienced sex that was unwanted, coerced, or occurred while they were asleep or drugged, yields more accurate information about a type of trauma that may indeed have long-lasting psychological consequences (Koss, 1988). Asking about any kind of trauma that evokes shame, which includes all sexual trauma, is helpfully prefaced by the clinician’s acknowledgement that these are intrusive questions, and that the client is free to defer responding until they feel more able to do so should the material be too painful or the clinician not yet trusted.
Questions about trauma thus need to be phrased in neutral and behaviorally descriptive manners, with verbal shorthand and clinical jargon, e.g., “were you ever a victim of interpersonal violence” avoided. Instead, a question such as “when you were growing up did anyone ever do anything with you sexually that was confusing or frightening or painful,” “have you ever been on the receiving end of someone else’s violent behavior,” or “have you ever behaved in ways that other people experienced as frightening” are all more likely to elicit information. Even a disaster is not just a disaster. Asking about an experience in which one’s life was disrupted by such events of nature as storms, earthquakes, fires, or mudslides will more likely evoke the narrative exposing what was traumatic as well as what was simply annoying.
At times, people will be unsure if something qualifies for the label “traumatic.” Utilizing such words as “painful,” “scary,” or “humiliating,” all affects commonly associated with trauma, or describing the types of responses people frequently have when traumatized, e.g., “sometimes people feel as if they’re watching themselves in a movie, or from a great distance, during some kinds of confusing, painful or scary events – have you ever had experiences like that?” can be effective in both normalizing the experience of trauma and letting clients know that you are not unfamiliar with what they have suffered. This may, in turn, increase clients’ abilities to talk about their traumas even very early in the therapy process. Since it is common for trauma survivors, particularly those afflicted with florid symptoms such as flashbacks or dissociative episodes, to wonder if they are crazy, this normalizing process in which common symptoms are identified by a psychotherapist as within the range of usual post-trauma response, allows for trauma-informed intake to occur.
Clinicians need to also be aware at intake of how variables of culture and identities may affect gathering information. Cultural considerations that stand in the way of answering questions about certain kinds of experience must be taken into account. If, for instance, one’s family is shamed by one’s experiences, then one may not tell of them unless and until the questioner has earned sufficient trust. Often, information about a trauma history can be best elicited by asking open-ended questions such as “I wondering if you can tell me about the life experiences you’ve had that you would consider painful, humiliating or frightening,” which can then be followed up with clarifying questions as to specific experiences of trauma. Cultural sensitivity leads to other considerations, such as whether the psychotherapist potentially represents the source of the trauma. When psychotherapists are themselves reminders of a trauma, simply asking the client about painful or humiliating experiences may not be sufficient to elicit the information, as the client may be unwilling to disclose her experience to someone who is themselves unwittingly triggering her symptoms.
The Clinician Administered PTSD Scale (CAPS) has long been considered a gold standard for structured interviews for the diagnosis of PTSD. While it has not been commonly used in clinical practice outside of the Veteran’s Affairs treatment programs where it was first developed, and now primarily emerges in clinical research settings, it offers clinicians a well-validated, and comprehensive structured interview for ruling in or out the diagnosis of PTSD. The CAPS offers the possibility of scoring each variable both dichotomously and continuously, giving the clinician a sense of not only whether a client has a particular symptom, but also to what degree of severity. Use of the CAPS requires specific training in its administration and scoring in order to achieve fidelity; information about that training can be found at http://www.ptsd.va.gov, where there is also a link for ordering the scale and scoring manual.
The Structured Clinical Interview for the DSM-IV (SCID) contains a PTSD module that can be administered separately from the remainder of the SCID, or in conjunction with modules assessing the common comorbid disorders described above. The SCID PTSD module can function as a brief screening device, but is likely to miss subtleties in presentation and to lack information about symptom severity. However, the SCID-D, the Structured Clinical Interview for the DSM-IV Dissociative Disorders (Steinberg, 1994), is extremely useful, not only in the diagnosis of dissociative disorders, but also in differential diagnosis of dissociation and other similar and co-morbid presentations. As is the case with the CAPS, both the SCID and SCID-D are more commonly used in research or forensic settings than in clinical practice, and require extensive training to be utilized with fidelity to the assessment protocol. A SCID for the DSM-5 is not available at the time of writing of this course.
The Structured Interview for Disorders of Extreme Stress (SIDES) was developed as a companion to the CAPS and similar non-complex trauma measures. Again, it has largely been utilized in research settings, and does not appear to have a great deal of clinical usage.
Not all psychotherapists will wish to include formal psychological assessment in their clinical repertoire, having incorrectly learned that assessment can be inimical to treatment. Finn’s excellent work on Therapeutic Assessment (1996, 2007) has demonstrated to the contrary; assessment done in a manner that is focused on empowering the client with assessment findings so as to enhance their self-awareness, can be especially helpful with trauma survivors. The potential for assessment to serve a normalizing function for the client, and to assist the therapist in seeing difficulties that a client has more ease disclosing to a test than to the therapist, highlight its value as an integrated component of trauma treatment. Below I will discuss both trauma-specific instruments and trauma response patterns on ones that are more general. The trauma-specific instruments described below can be purchased and used by all mental health professionals, making them particularly useful for non-psychologists.
The PDS is more of a screening instrument in that it asks relatively straightforward questions about types of trauma exposed to, whether the person experienced fear, horror, or helplessness, and then allows the test-taker to say how much, on a continuum from 0-3, they have been affected by any of the symptoms in the DSM-IV criteria set for PTSD. It is very short and easy to administer. However, in keeping with the discussion of intake, it can also be activating and distressing for clients to be asked to complete it early in treatment. A version updated for the new DSM-5 diagnostic criteria is not yet available.
The IES was one of the first screening instruments for PTSD symptoms, and has been revised to bring it into closer harmony with the DSM-IV definitions and criteria. The original version was the most widely used measure of PTSD, and it focuses on the assessment of Criterion B intrusive symptoms and Criterion E hyperarousal symptoms; however, even the revised version does not do a thorough job of assessing for Criterion C or D or dissociative symptoms. Like the PDS, the IES and IES-R are both very brief. Also like the PDS, these instruments can be activating for clients who are not yet prepared to disclose or discuss trauma experiences or symptoms.
All three of these measures were developed by John Briere to assess trauma-specific symptoms. Each measure also includes validity scales, which allow a clinician to determine response style, e.g., over-report or under-report, and are normed separately for African American and Latino test-takers, consistent with research findings. The DAPS allows the test-taker to identify an index trauma and respond to questions about it that match to DSM-IV criterion clusters for PTSD, while both the TSI and the more recent TSI-II have scales measuring clients’ endorsement on a range of well-known post-traumatic symptoms. The TSI-II, published in 2010, has expanded the scales for the measurement of complex trauma symptoms, making it a more comprehensive trauma assessment instrument. All three of these tests are relatively brief, requiring little time to administer and score, and yield reliable and valid information about a range of trauma symptoms, with the TSIs going beyond PTSD. The TSI-II also offers change scores, allowing a clinician and client to track changes in symptom pictures over time.
The DES, originally developed as a research instrument, became the most widely used tool for the assessment of dissociation because of its ease of administration and scoring. Questions have arisen, however, about its face validity, as the DES asks test-takers to respond on a continuum as to how much they have been affected by a wide range of dissociative symptoms, allowing for easy faking either of dissociative pathology (a common occurrence in criminal forensic contexts) or the absence of such pathology (a more common occurrence in clinical settings where a dissociative client is unwilling or unable to yet disclose such material). In the later 1990’s, evidence of a subset of items which more reliably diagnosed the presence of DID or DDNOS versus dissociation in the context of other disorders was developed. The DES is simple to administer, and can serve as a baseline screening instrument to rule the presence of dissociation in or out; however, its reliability for doing so is not strong, and the absence of any validity scales makes it impossible to assess an over-or-under-report response style.
The MDI, also developed by Briere, assesses all aspects of dissociation separately, allowing the clinician to differentiate between DID and other forms of dissociative presentation. The scale measuring Identity Disturbance, which is used to rule in or out the presence of DID, has very strong sensitivity and specificity. A brief test requiring little time to administer and score, it is the most accessible and reliable means of establishing the presence and nature of dissociative symptoms. This test is now free and available from Dr. Briere’s professional website.
These measures may be of interest to clinicians exploring the ramifications of complex trauma with clients. While they are not generally included in discussions of assessment of PTSD, Briere & Spinnazola (2009) suggest that assessment of complex trauma include measures of these variables, which constitute a significant portion of the distress and problematic behaviors that complex trauma survivors present to treatment.
The AAI was developed as a research instrument to explore early attachment experiences, separation, loss, trauma, and rejection, and to study relationships between early attachment experiences and subsequent “adult mental representations of attachment.” Responses allow the client to be categorized as being Autonomous, Dismissing, Preoccupied, or Unresolved/Disorganized. While this kind of information about a client’s attachment style would likely be a very useful adjunct to treatment, its application to psychotherapy with adults who have experienced problematic attachment experiences has not been well-studied, and its use has primarily been in research settings. The AAI requires training for its use, and takes around an hour to administer.
Several other instruments have been developed to assess attachment style in peer romantic relationships. These include the Relationship Questionnaire (RV-CQ) and the Experiences in Close Relationships (ECR) questionnaire and the Experiences in Close Relationships - Revised (ECR-R) questionnaire. All of these instruments yield information about attachment style that might be useful for a clinician working with complex trauma survivors. The ECR-R can be found and taken on-line at http://www.web-research-design.net/cgi-bin/crq/crq.pl in about 10 minutes, and yields information about attachment style that could be useful for a therapist working with a trauma survivor.
Also developed by Briere, the IASC provides a brief objective measure of capacities in the domains of relatedness, identity, and affect regulation. It maps onto variables that are otherwise best assessed using projective instruments. Since so few clinicians are well-trained in the use of projective measures, the IASC allows clinicians to quickly gather information about particular areas of struggle or challenge for a client in these realms.
The TABS measures cognitive schemata that are commonly affected by trauma exposure on the variables of Safety, Trust, Esteem, Intimacy, and Control. Each domain assessed yields subscales indicative of a client’s belief about self and others. This instrument, which was developed in a trauma-focused clinical setting, can be a useful strategy for uncovering relational dynamics between therapist and client.
While the MMPI-2 and PAI were both developed as more general measures of psychological distress, each of them can be useful in the assessment of post-traumatic symptoms. The PAI is more specifically designed to do so, with a scale measuring post-traumatic intrusive and avoidant symptoms (ARD-T), as well as research evidence regarding how PTSD manifests on the test. Some more recent research has found evidence of a specific response pattern for victims of intimate partner violence on the PAI.
The MMPI-2, while better known and more widely used, is more problematic in the assessment of post-traumatic phenomenon. The P-K scale, developed by Keane, reliably assesses for combat trauma, but is more problematic in measuring civilian PTSD symptoms. Additionally, the most common symptom patterns for individuals with PTSD, complex trauma, or dissociation on the MMPI-2 are generally misdiagnosed by computerized interpretations as evidence of psychosis. Research on MMPI-2 profiles of survivors of intimate partner violence and childhood sexual abuse is available and relatively well known in the field of trauma assessment, but has not yet been integrated into standard texts on the MMPI-2. Research is also available regarding common markers of dissociation on the MMPI-2. No research is available to date on trauma survivor profiles on the MMPI-RF, which organizes responses to the MMPI-2 question set into a different set of scales. While an assessor who is very familiar with both scoring systems may be able to extrapolate a trauma presentation on the MMPI-RF from their knowledge base, clinicians unfamiliar with these tests should not attempt to do so in the absence of formal data about trauma profiles on the RF version.
The Millon Inventories
The Millon Inventories, in particular the Millon Clinical Multiaxial Inventory-2 (MCMI-3) have not been found useful in the assessment of post-traumatic phenomena. Elevations on the Self-defeating personality disorder scale are usually consistent with the presence of complex trauma; however, the use of this terminology has problematic effects on how clients are perceived. The PTSD scale in the Axis I segment of the test has weak sensitivity and specificity, and is not considered a good measure of PTSD. A revision of this instrument to reflect the end of the multiaxial diagnosis structure in the DSM-5 is not yet available.
The Rorschach, while used more infrequently today than in the past, can be a helpful adjunct to work with trauma survivors. A very small yet growing body of information exists regarding projective assessment of post-traumatic and dissociative symptoms that allows an experienced user of the test to interpret findings through the trauma lens using the Exner scoring system (Andronikof, 2002). The sensitivity of such instruments to individual differences makes them particularly valuable in assessment of subtle post-traumatic phenomena. Rorschach users who are interested in becoming more trauma-aware and attuned to manifestations of trauma-related content are referred to the special issue of the journal Rorschachiana on trauma assessment (Andronikof, 2002) referenced above. Because of its relative newness, information about trauma profiles using the RPAS scoring system is not available at the time this course was prepared.
An excellent in-depth discussion of this topic can be found in Briere (2004). The APA Division of Trauma Psychology is also in the process of developing material guiding assessors of trauma, which will be found on its website, http://www.apatraumadivision.org.
Several studies have found a link between PTSD and reduced performance on tests of cognitive function such as attention and memory (Vasterling & Brewin, 2005). Clients presenting to assessment for possible diagnosis of Attention Deficit-Hyperactivity Disorder, specific learning disabilities, or nonspecific problems of memory and concentration may be manifesting post-traumatic symptoms instead of, or in addition to, a more neurologically-based cognitive problem.
Consequently, assessment for and treatment of cognitive problems should always include inquiry into and assessment for possible trauma-based sources either of specific symptoms, or difficulties with treatment. Prior assessments of an individual to determine the presence or absence of a cognitive or attentional problem should be utilized with caution as information for current assessment and treatment when no evidence can be found that possible post-trauma symptoms were taken into account in arriving at diagnoses or recommendations. Note the importance of taking a “both/and” instead of an “either/or” approach.
A clinical example illustrates this well. The client, a mid-twenties Euro-American woman, presented to our clinic requesting an evaluation for accommodations for learning disabilities, stating that she had been diagnosed with these in middle school and needed to update her testing for community college. The assessment uncovered a history of sexual abuse by the coach of her soccer team in the context of family disruption due to divorce, all of which had happened in the client’s last year of elementary school. She reported that she had not told anyone of the abuse, was in fact telling it to the psychologist for the first time ever, and that she had been depressed, distracted, and anxious beginning with that period of her life. Her performance in school had suffered, leading to the earlier evaluation by a school psychologist for learning disabilities. Our clinic obtained a copy of that assessment, and found that no screening for affective, anxiety, or dissociative problems had been part of it, nor had there been any evidence of inquiry into abuse in the home, which was, despite the divorce-engendered chaos, a middle class one.
After the intake, the client was administered a range of cognitive assessments, including the WAIS, the Woodcock Johnson, the Rey Complex Figures Test, the Wisconsin Card Sort, the Wechsler Memory Scale – and also the PAI and the Trauma Symptom Inventory. Behavioral observations during testing were that she appeared highly anxious and engaged, engaging out loud in self-critical self-talk. PAI and TSI findings indicated that she suffered from a range of post-traumatic symptoms, including intrusive images, dissociative coping strategies, and persistent heightened levels of anxiety.
Findings from the cognitive assessment did indicate that she had problems of visual and auditory coding, and would continue to qualify for the diagnosis of a non-specific learning disability. However, the evaluator suggested that these difficulties, which had only emerged in the context of unreported and previously unaddressed trauma exposure, might be due, in whole or in part, to post-traumatic symptoms. She suggested two things to the client in addition to making accommodation recommendations for the community college. First, she suggested that the client engage in a course of trauma-focused treatment, including both psychotherapy and somatic interventions. Second, she suggested that after a year of therapy the client be reassessed.
The client was very surprised to learn that her academic difficulties might be due, not to some immutable characteristic of her brain and its capacities, but possibly to some combination of brain and trauma, or even completely to trauma. She took the recommendation for treatment and a return evaluation.
At one-year follow up, she continued to show some visual memory processing difficulties on testing, although in a standard deviation below where she had previously tested. Discrepancy scores between the WAIS and WJR no longer qualified her for a diagnosis of a learning disability. Scores on measures of post-traumatic stress, anxiety, and depression had all changed markedly. The client reported that she found herself not always asking for all of her accommodations, as her capacities to concentrate and remember things, particularly those she heard in class, had improved as she had processed her trauma in therapy.
In this instance, a child who had a mild deficit in visual learning but normative auditory learning capacities had had all of that undermined by the emotional distress arising from sexual abuse. The identity of the perpetrator, a coach who was connected to her academic environment, made school a more anxiety-provoking and threatening place. This was combined with family disruption due to divorce, which left both of her otherwise engaged parents distracted and less attentive, and the increased academic demands of middle school. A learning disability was the most parsimonious explanation of her difficulties. A trauma-aware cognitive assessment uncovered a combination of learning problems that were greatly reduced by treatment of the post-traumatic symptoms.
Malingering is of less concern in the purely clinical context. Clients entering psychotherapy of their own volition are likely to downplay rather than exaggerate symptoms, largely due to shame over the nature of post-traumatic distress, as well as fears that therapists will abandon them if the extent of symptoms becomes known.
There are very few specific situations in which malingering needs to be considered. These are 1. Forensic settings and 2. Compensation settings. Clients in each of those contexts have clear motive to malinger due to the presence of powerful secondary gain. A discussion of malingering assessment is beyond the scope of this course. However, trauma-informed practice means attention to the possibility that a client’s fear of loss of disability funding may become an impediment to recovery. Directly addressing this topic in a compassionate, empathic manner in therapy will be more effective and appropriate than subjecting such a therapy client to a formal malingering assessment, which is likely to undermine the therapeutic relationship to an extent that might make continued progress in treatment impossible.
In the next course in this series, Treating Trauma: Basic Skills and Specific Treatments, you will learn more about applying this knowledge to your psychotherapy practice.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC: American Psychiatric Press.
Andronikof, A. (Ed.) (2002). Rorschachiana: Yearbook of the International Rorschach Society. Cambridge MA: Hogrefe & Huber.
Bertolino, B., & O’Hanlon, W. (2001). Collaborative, competency-based counseling and psychotherapy. Boston MA: Allyn & Bacon.
Birrell, P.J. & Freyd, J.J. (2006). Betrayal trauma: Relational models of harm and healing. Journal of Trauma Practice, 5, 49-63.
Briere, J. (2004) Psychological assessment of adult post-traumatic states: Phenomenology, diagnosis, and measurement (2nd ed.). Washington DC: American Psychological Association.
Briere, J. & Scott, C. (2012) Principles of trauma therapy: A guide to symptoms, evaluation, and treatment, Second Edition. Thousand Oaks CA: Sage Publications.
Briere, J. & Spinazzola, J. (2009). Assessment of the sequelae of complex trauma: Evidence-based measures. In C. A. Courtois & J.D. Ford (Eds.). Treating complex traumatic stress disorders: An evidence-based guide. New York NY: Guilford.
Brown, L.S. (2009). Cultural competence in trauma therapy: Beyond the flashback. Washington DC: American Psychological Association.
Brown, L.S. & Freyd, J. J. (2008). PTSD Criterion A and betrayal trauma: A modest proposal for a new look at what constitutes a danger to self. Trauma Psychology Newsletter, 3(1), pp. 11-15.
Cook, J. M., Newman, E., & the New Haven Trauma Competency Group. (2014). A consensus statement on trauma mental health: The New Haven Competency Conference process and major findings. Psychological Trauma: Theory, Research, Practice and Policy, 6, 300-307.
Courtois, C. A. & Ford, J. D. (Eds.) (2009). Treating complex traumatic stress disorders. New York: Guilford.
Courtois, C.A. & Ford, J.D. (2013). Treatment of complex trauma: A sequenced, relationship-based approach. New York NY: Guilford.
Danieli, Y. (Ed.) (1998). Intergenerational handbook of multigenerational legacies of trauma. New York NY: Plenum.
Davidson, J. R. T. & Foa, E. (Eds.) (1993). Post-traumatic stress disorder: DSM IV and beyond. Washington DC: American Psychiatric Press.
Duran, E., Duran, B., Brave Heart, M., & Yellow Horse-Davis, S. (1998). Post colonial syndrome. In Y. Danieli (Ed.) Intergenerational handbook of multigenerational legacies of trauma (pp. 341-354). New York NY: Plenum.
Essed, P. (1991). Everyday racism: Reports from women of two cultures. New York NY: Hunter House.
Farley, F. (1991). The Type T personality. Chapter in L.P. Lipsett & L.L Mitnick (Eds.), Self-regulatory behavior and risk taking: Causes and consequences. Norwood, NJ: Ablex Publishers.
Finn, S. E. (1996). Manual for using the MMPI-2 as a therapeutic intervention. Minneapolis: University of Minnesota Press.
Finn, S. E. (2007). In Our Clients’ Shoes: Theory and Techniques of Therapeutic Assessment. Mahwah, NJ: Earlbaum.
Fitzgerald, L.F. (1993). Sexual harassment: Violence against women in the workplace. American Psychologist, 48.
Ford, J. D. (2009). Neurobiological and developmental research: Clinical implications. In C.A. Courtois & J.D. Ford, (Eds.). Treating complex traumatic stress disorders (pp. 31-58). New York: Guilford.
Freyd, J. J. & Birrell, P. (2013). Blind to betrayal: Why we fool ourselves we aren’t being fooled. New York NY: Wiley.
Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting abuse. Cambridge MA: Harvard University Press.
Freyd, J.J., DePrince, A.P., & Zurbriggen, E.L. (2001). Self-reported memory for abuse depends upon victim-perpetrator relationship. Journal of Trauma & Dissociation 2, 5-17
Gilfus, M.E. (1999). The price of the ticket: A survivor-centered appraisal of trauma theory. Violence Against Women, 5, 1238-1257.
Gold, S. N. & Elhai, J.D. (Eds.) (2007). Trauma and serious mental illness. Binghampton NY: Haworth Press.
Herman, J. L. (1992). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York NY: Basic Books.
Herman, J.L. (2009). Forward. In C.A. Courtois & J.D. Ford, (Eds.). Treating complex traumatic stress disorders (pp. xii-xvii). New York: Guilford.
Hobfoll, S. E. (2001). The influence of culture, community, and the nested-self in the stress process: Advancing Conservation of Resources Theory. Applied Psychology, 50, 337-370.
Janoff-Bulman, R. (1992). Shattered assumptions. New York: Free Press.
Kelley, L. (2009). A Comparison of Life Threat and Betrayal as Risk Factors for Post-traumatic Stress Disorder. Unpublished Doctoral Dissertation, Auburn University.
Kendall-Tackett, K. (2007). Inflammation, cardiovascular disease, and metabolic syndrome as sequelae of violence against women: The role of depression, hostility, and sleep disturbance. Trauma, violence and abuse, 8, 117-126.
Kluft, R. P. (1990). Incest and subsequent revictimization: The case of therapist-patient sexual exploitation, with a description of the Sitting duck syndrome. In R.P Kluft (Ed.). Incest-related syndromes of adult psychopathology (pp. 263-288). Washington DC: American Psychiatric Press.
Koss, M.P. (1988). Hidden rape: Sexual aggression and victimization in the national sample of students in higher education. In M.A. Pirog-Good & J.E. Stets (Eds.), Violence in dating relationships: Emerging social issues (pp. 145168). New York, NY: Praeger.
Langer, E.J. (1975). The illusion of control. Journal of Personality and Social Psychology, 32, 311-328.
Lazarus, R. & Folkman, S. (1984). Stress, appraisal and coping. New York: Springer Publishing.
Lerner, M.J. (1980). The belief in a just world. New York: Plenum.
Main, M. and Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M. Greenberg, D. Cicchetti and E. Cummings (Eds.) Attachment in the preschool years: Theory, research and intervention, (pp. 121-160). Chicago: University of Chicago Press.
Marmar, C., Weiss, D., & Metzler, T. (1998). Peritraumatic dissociation and Post-traumatic stress disorder. In J.D. Bremner & C. Marmar (Eds.). Trauma, memory, and dissociation (pp. 229-246). Washington DC: American Psychiatric Press.
Millon, T. & Davis, C. (2001). Personality disorders in modern life. New York NY: Wiley.
Nijenhuis, E. R. S., Quak, J., Reinders, S., Korf, J., Vos, H. & Marinkelle, A. B. (1999) Identity dependent processing of traumatic memories in dissociative identity disorder: Converging regional blood flow, physiological and psychological evidence. Proceedings of the Sixth European Conference on Traumatic Stress. Istanbul, Turkey: ESTSS.
Pope, K.S. (1989). Therapist-patient sex syndrome: a guide for attorneys and subsequent therapists to assessing damage. In G. Gabbard (Ed.) Sexual exploitation in professional relationships (pp. 39-55).Washington, D.C.: American Psychiatric Press.
Pope, K.S. & Bouhoutsos, J.C. (1986). Sexual intimacy between therapists and patients. New York: Praeger.
Porges SW (2011). The Polyvagal Theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York NY: WW Norton.
Root, M. P. P. (1992). Reconstructing the impact of trauma on personality. In L. S. Brown & M. Ballou (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 229-265). New York: Guilford.
Russell, G. M. (2004a). The dangers of a same-sex marriage referendum for community and individual well-being: A summary of research findings. Angles Amherst MA: Institute for Gay and Lesbian Strategic Studies.
Russell, G. M. (2004b). Surviving and thriving in the face of anti-gay politics. . Angles Amherst MA: Institute for Gay and Lesbian Strategic Studies.
Russell, G. M. & Richards, J. A. (2003). Stressor and resilience factors for lesbians, gay men and bisexuals confronting anti-gay politics. American Journal of Community Psychology, 31, 313-328.
Sauro, M. D., Jorgensen, R. S., & Pedlow, C. T. (2003). Stress, glucocorticoids, and memory: A meta-analytic Review. Stress: The International Journal on the Biology of Stress, 6, 235-245.
Shays, J. (1995). Achilles in Viet Nam: Combat trauma and the undoing of character. New York NY: Scribner Touchstone Editions.
Smith, C.P. & Freyd, J.J. (2013). Dangerous Safe Havens: Institutional Betrayal Exacerbates Sexual Trauma. Journal of Traumatic Stress, 26, 119-124.
Smith, C.P. & Freyd, J.J. (2014). Institutional betrayal. American Psychologist, 69, 575-587.
Steinberg, M. (1994). Structured clinical interview for the DSM-IV dissociative disorders. Washington DC: American Psychiatric Press.
Sue, D. S. (2010) Microagressions in everyday life: Race, gender and sexual orientation. New York NY: Wiley.
Sue, D. W. (2003). Overcoming our racism: The journey to liberation. San Francisco CA: Jossey-Bass.
Sue, D. W., Bucceri, J., Lin, A., Nadal, K. L & Torino, G. C. (2007). Racial microaggressions and the Asian American experience. Cultural Diversity and Ethnic Minority Psychology, 13, 72-81.
Steele, K., Boon, S., & van der Hart (2016). Treating trauma-related dissociation: A practical integrative approach. New York NY: W.W. Norton.
van der Hart, O, Steele, K, & Nijenhuis, E. R. S. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York NY: W.W. Norton.
Vasterling, J.J. & Brewin, C. (Eds.) (2005). Neuropsychology of PTSD: Cognitive and clinical perspectives. New York NY Guilford.
van der Kolk, B. A. (2005). Developmental trauma disorder. Psychiatric Annals, 35, 401-408.
World Health Organization (1992). ICD-10: The IDC-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. Geneva Switzerland: Author.
|© Copyright 2004-2018 by SocialWorkCoursesOnline.com, Inc. All rights reserved.|