Case Example Jen was a 19-year-old college student who had experienced a sexual assault in her dorm room the previous semester. The perpetrator, another student, had been cleared of charges in a mishandled case. Jen took the semester off and returned to her home to manage her ongoing PTSD symptoms. When she would try to fall asleep at night, she would find herself lying awake for hours, ruminating on her anger and resentment toward the unjust system that had allowed her perpetrator to walk free. Jen’s assault happened in the dark of her dorm room, and now she would leave the light on all night long, which affected the quality of Relational Violence Individuals with PTSD are not specifically violent, and most do not perpetrate relational violence. It is important to provide a disclaimer against this stigma. However, practitioners should be aware of trauma-related symptoms (e.g., information-processing deficits, impulsivity, or heightened reactivity) that may increase the risk for relational violence, such as intimate partner violence (IPV) and parental abuse. Men with severe PTSD symptoms show an increased prevalence of IPV perpetration (Hahn et al., 2015). Arousal symptoms of PTSD are positively correlated with aggressive behaviors, impaired attention, impulsivity, and a lack of emotional control (Cole et al., 2021; Hahn et al., 2015). The information-processing model posits that individuals with trauma histories may develop an amplified sense of threat perception, causing them to misinterpret benign interpersonal interactions as overly hostile or negative and respond with aggression (Gilbar et al., 2020). Some researchers consider the intermediary role of shame to describe the increased risk for IPV perpetration. According to this explanation, some individuals develop intense feelings of shame following trauma and, in a maladaptive effort to avoid the feelings of weakness associated with shame, respond with expressions of rage (Lawrence & Taft, 2013). Conclusion Trauma is insidious and can contribute to a multitude of clinical symptoms and psychological suffering beyond PTSD. Professionals need to be aware of the high rates of comorbidities that can appear alongside PTSD. This chapter analyzed six major comorbidities—depression, substance use, TBI, suicidality, insomnia, and relational violence— and highlighted the propensity for symptom overlap and misdiagnosis or false positives. Professionals should rely on the theoretical and explanatory models that attempt
her sleep. Jen also frequently had nightmares about the incident, which interrupted her sleep throughout the night. While Jen’s PTSD symptoms were eventually alleviated, her insomnia persisted, primarily due to her new sleep patterns. Though she was not plagued by fear or avoidance, she still kept her light on out of habit. She also would spend time on her phone while lying in bed before falling asleep. Jen’s sleep hygiene was targeted with behavioral interventions (e.g., using the bed only for sleep, not electronics) that ended the insomnia. PTSD within parents has been associated with higher parental stress, reduced parenting satisfaction, damage to the parent–child relationship, and more negative parenting practices (Christie et al., 2019) as well as child abuse potential (Cross et al., 2018). When parents experience active trauma symptoms, they may be more emotionally unavailable, avoidant, or hostile and controlling with their children (van Ee et al., 2016). Adults with persistent trauma symptoms may behave in frightening or threatening ways with their children (van Ee et al., 2016). Furthermore, they may be parenting with depleted psychological and emotional resources and may be susceptible to impulsive reactions, such as violence as a form of punishment (van Ee et al., 2016). The risk of child abuse within a home appears to increase if PTSD is present for both parents and relational conflict between the parents (Christie et al., 2019; Fredman et al., 2019). Service providers should consider the interaction between certain trauma symptoms and the potential risk for violence within relationships. Contextualizing trauma treatment within the larger relational/family system will attune practitioners to potential areas of risk. Additionally, trauma-informed care (described in greater detail later in the course) with perpetrators can target certain aspects of PTSD as a means of preventing future abuse (Hahn et al., 2015).
to reconcile how and why two disorders may co-occur. PTSD can mediate the relationship between trauma and another disorder (e.g., trauma can lead to PTSD, which can lead to insomnia, which causes and is symptomatic of depression). A co-occurring disorder and PTSD can share the same etiology, as is the case when combat trauma results in both a TBI and PTSD. It is also possible that PTSD and another disorder influence one another in a reciprocal manner (e.g., PTSD can lead to substance use for self-medication; substance withdrawal exacerbates PTSD symptoms, resulting in increased self-medication and relapse). Finally, the symptoms of some disorders (e.g., depression, obsessive compulsive disorder) simply overlap. Professionals aware of the common PTSD comorbidities and the underlying mechanisms contributing to these relationships will be able to diagnose more accurately, thus enabling better interventions. THE THERAPEUTIC RELATIONSHIP: THE ESSENCE OF TRAUMA TREATMENT The information contained in the previous chapters provides
trauma survivors is stated in the first general principle of the APA Ethics Code (2017b), “psychologists strive to benefit those with whom they work and take care to do no harm (2017b).” The first priority is to make certain that a clinician's intervention choices, actions during a session, wording and tone of voice, and overall manner of engagement do not cause undue distress for the client. Given the sometimes- fragile nature of individuals who have experienced trauma, clinicians need to have a sound understanding of the nature of trauma and trauma response.
a framework for understanding the nature of trauma. This chapter continues with attention to the therapeutic relationship, which provides the holding environment, or a container for the work, and a treatment matrix. Within this matrix, traumatized individuals are able to move from living in the “never-never land” of past trauma to living in present time, having a sound sense of self and the ability to live with hope, joy, and good relationships. The paramount value when engaging in the assessment and treatment of
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Book Code: SWPA1525
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