Principles of Trauma Therapy (CH1) PDF

 ONE  WHAT IS TRAUMA?  T he Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association [APA], 2013) defines a trauma as: Exposure to actual or threatened death, serious injury, or s...

 ONE  WHAT IS TRAUMA?  T he Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association [APA], 2013) defines a trauma 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) (Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related). Although this definition is useful, some have criticized the requirement that trauma be limited to “exposure to actual or threatened death, serious injury, or sexual violence,” since many events may be traumatic even if life threat or injury is not an issue (Briere, 2004; Anders, Frazier, & Frankfurt, 2011). The earlier DSM-III-R (APA, 1987) definition also included threats to psychological integrity as valid forms of trauma. Because the DSM-5 does not consider events to be traumatic if they are merely highly upsetting but not life threatening—for example, extreme emotional abuse, major losses or separa- tions, degradation or humiliation, and coerced (but not physically violent) 9 10 PART 1 TRAUMA, EFFECTS, AND ASSESSMENT sexual experiences—it undoubtedly underestimates the extent of actual trauma in the general population. It also reduces the availability of a stress disorder diagnosis in some individuals who experience significant posttraumatic dis- tress, since Criterion A is a prerequisite for the diagnosis of posttraumatic stress disorder (PTSD) and acute stress disorder (ASD). The issue of whether an event should have to satisfy current diagnostic definitions of trauma in order to be, in fact, “traumatic” is an ongoing source of discussion in the field (for example, Kubany, Ralston, & Hill, 2010; O’Donnell, Creamer, McFarlane, Silove, & Bryant, 2010). Our own conclu- sion is that an event is traumatic if it is extremely upsetting, at least temporar- ily overwhelms the individual’s internal resources, and produces lasting psychological symptoms. This broader definition is used throughout this book, since people who experience major threats to psychological integrity can suf- fer as much as those traumatized by physical injury or life threat, and can respond equally well, we believe, to trauma-focused therapies. This is solely a treatment issue; however the DSM-5 version of trauma should be adhered to when making a formal stress disorder diagnosis. MAJOR TYPES OF TRAUMA Surveys of the general population indicate that more than half of adults in the United States have experienced at least one major trauma (Elliott, 1997; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Norris, 1992). Were threats to psychological integrity (for example, major losses and other very upsetting, but not physically harming, events) also included, this proportion would be even higher. Although traumatic stressors are common, their ability to produce significant psychological symptoms and disturbance varies as a function of a wide variety of other variables, as is discussed in Chapter 2. The following pages detail most of the major types of traumatic events potentially experienced by those seeking mental health services. There are myriad ways in which an individual can be psychologically hurt, of course, not all of which are easy for the client to disclose or express in an initial clinical interview. This is important to keep in mind—frequently, clients will not report events they have experienced unless they are specifically asked about those events in a nonjudgmental, supportive context (see Chapter 3). Each type of trauma is described only briefly here; the reader is referred to the Suggested Reading section at the end of the chapter for references to more detailed information. CHAPTER 1 What Is Trauma? 11 Child Abuse Childhood sexual and physical abuse, ranging from fondling to rape and from severe spankings to life-threatening beatings, is quite prevalent in North American society. Studies of retrospective child abuse reports in the United States suggest that approximately 25 to 35 percent of women and 10 to 20 per- cent of men, if asked, describe being sexually abused as children, and approxi- mately 10 to 20 percent of men and women report experiences congruent with definitions of physical abuse (Briere & Elliott, 2003; Finkelhor, Hotaling, Lewis, & Smith, 1990). Several studies suggest that 35 to 70 percent of female mental health patients self-report, if asked, a childhood history of sexual abuse (Briere, 1992). Many children are psychologically abused and/or neglected, as well, although these forms of maltreatment are harder to quantify in terms of incidence or prevalence (Briere, Godbout, & Runtz, 2012; Hart et al., 2011). As is described later in this and following chapters, child abuse and neglect not only produces significant, sometimes enduring, psychological dysfunction, it is also associated with a greater likelihood of being sexually or physically assaulted later in life, often referred to as revictimization (Classen, Palesh, & Aggarwal, 2005; Duckworth & Follette, 2011). Because it occurs early in life, when the child’s neurobiology may be especially vulnerable (Pechtel & Pizzagalli, 2011; Pratchett & Yehuda, 2011) and enduring cognitive models about self, others, the world, and the future are being formed (Messman-Moore & Coates, 2007), child abuse and neglect is likely to consti- tute one of the greatest risk factors for later psychological difficulties of all traumatic events. Mass Interpersonal Violence Intentional violence that involves high numbers of injuries or casualties— but does not occur in the context of war—is a newer category in the trauma field. The Oklahoma City bombing on April 19, 1995 (North et al., 1999), the terrorist attacks on the World Trade Center and the Pentagon on September 11, 2001 (Galea et al., 2002), and the July 7, 2005, attacks on the London mass transit system (Salib & Cortina-Borja, 2009) are obvious cases of mass trauma in Western society. There is an unfortunately large number of other examples, however, including terrorist attacks throughout the world and mass human rights abuses (Hoffman et al., 2007; Johnson et al., 2010; Pfefferbaum et al., 2001). The September 11 attacks stimulated a dramatic increase in North 12 PART 1 TRAUMA, EFFECTS, AND ASSESSMENT American research on the effective short-term treatment of mass trauma, as described in Chapter 11. As noted later, this research suggests that it is as important to know what not to do as it is to know what to do when working acutely with victims of mass trauma. It is a goal of international groups like the International Society for Traumatic Stress Studies (http://www.istss.org) to disseminate this information worldwide, since there is little reason to believe that terrorist attacks or other mass casualty events will decrease in the foresee- able future. Natural Disasters Natural disasters can be defined as large-scale, not directly human- caused, injury- or death-producing environmental events that adversely affect a significant number of people. Disasters are relatively common in the United States; surveys suggest that between 13 and 30 percent of individuals have been exposed to one or more natural disasters in their lifetimes (Briere & Elliott, 2000; Green & Solomon, 1995). Typical disasters include earthquakes, large fires, floods, tsunamis, avalanches, hurricanes, tornadoes, and volcanic eruptions. Although some disaster-exposed individuals either are initially unaffected or recover relatively rapidly, a significant proportion suffer signifi- cant long-term effects (for example, Briere & Elliott, 2000; Holgersen, Klöckner, Boe, Weisæth, & Holen, 2011). The extent of physical injury, fear of death, death of loved ones, and property loss during disasters appear to be the most traumatizing aspects of these events (Briere & Elliott, 2000; Maida, Gordon, Steinberg, & Gordon, 1989; Shear et al., 2011; Ursano, Fullerton, & McCaughey, 1994). When mental health workers are involved in assisting disaster victims, it is usually within the context of governmental (for example, the Federal Emergency Management Agency) or quasi-governmental agencies (for example, the Red Cross) that have been mobilized relatively soon after the event. At such times, as described in Chapter 11, the clinician’s initial job usu- ally involves triage and providing support, comfort, and psychological “first aid,” as opposed to trauma therapy, per se. Large-Scale Transportation Accidents Transportation accidents include events such as airplane crashes, train derailments, and maritime (for example, ship) accidents. These events often involve multiple victims and high fatality rates (Maeda & Higa, 2006). CHAPTER 1 What Is Trauma? 13 Although the incidence of such events is not easily determined, large-scale transportation accidents can be especially traumatic to survivors (Lundin, 1995; Maeda & Higa, 2006), since such events frequently occur over a rela- tively extended period of time, during which the victims are exposed to ongo- ing terror and fear of death. Immediate response to airplane accidents in the United States is controlled primarily by the Federal Aviation Administration and the National Transportation Safety Board, who work in concert with local emergency services, the relevant airline company, and others in providing assistance to traumatized survivors and their families. Fire and Burns Although large-scale fires are often listed as disasters in the trauma litera- ture, a significant number of survivors seen by trauma clinicians have been injured by smaller fires. These include house fires, often caused by smoking in bed, electrical short circuits, or leaking/malfunctioning propane tanks, stoves, or heaters. In other cases, serious burns may result from automobile accidents, industrial fires, fireworks, barbeque accidents, or even intentional burning by others. Physical injuries from fire can be particularly traumatic. The lasting physical effects of serious burns—extreme pain, a long recovery period, multiple surgeries, the presence and persistence of visible and/or pain- ful scars, disfigurement, amputation, and reduced mobility—mean that the traumatic event, in some ways, continues and repeats over time (Gilboa, Friedman, Tsur, & Fauerbach, 1994), often leading to severe and chronic psy- chological outcomes (Browne, Andrews, Schug, & Wood, 2011; Davydow, Katon, & Zatzick, 2009; Fauerbach et al., 2009). Motor Vehicle Accidents Approximately 20 percent of individuals in the United States have expe- rienced a serious motor vehicle accident (MVA; Blanchard & Hickling, 1997), and more than half of American adults will have a car accident by age 30 (Hickling, Blanchard, & Hickling, 2006). A substantial number of these people go on to develop significant psychological symptoms, especially if the acci- dent involved major injury or resulted in the death of others. In the latter case, grief and self-blame may increase subsequent psychological effects. In addition, as noted in Chapter 2, survivors of major MVAs may sustain traumatic brain injury, which can further complicate assessment and treatment (Harvey & 14 PART 1 TRAUMA, EFFECTS, AND ASSESSMENT Bryant, 2002; Hickling, Gillen, Blanchard, Buckley, & Taylor, 1998; Kim et al., 2007). Despite the fact that serious MVAs are more likely than some other noninterpersonal traumas to produce PTSD and other forms of dysfunc- tion, clinicians often inappropriately overlook such traumas when interview- ing clients about negative life events. Rape and Sexual Assault Rape can be defined as nonconsensual oral, anal, or vaginal sexual pen- etration of an adolescent or adult (if the victim is a child, see “Child Abuse”) with a body part or object, through the use of threat or physical force, or when the victim is incapable of giving consent (for example, when under the influ- ence of drugs or alcohol, or when otherwise cognitively impaired). The term sexual assault sometimes denotes any forced sexual contact short of rape, although we will define it more broadly as any forced sexual contact, includ- ing rape. Using definitions similar to these, the prevalence of rape against women in the United States is reported to be 14 to 20 percent (Black et al., 2010; Kilpatrick & Resnick, 1993; Tjaden & Thoennes, 2000; White, Koss, & Kazdin, 2011). Peer sexual assault against adolescent women is quite common; Singer, Anglin, Song, and Lunghofer (1995) found that, among students in six geo- graphically and economically diverse high schools, 12 to 17 percent of women reported having been made to engage in at least one sexual act against their wishes. Similarly, the National Survey of Adolescents suggests that approxi- mately 12 to 13 percent of female adolescents in America has experienced sexual assault or rape (Elwood et al., 2011). Sexual assault rates for males are less clear, due in part to only recent social awareness that men can be sexually victimized, but are estimated to range between 2 and 5 percent (Black et al., 2010; Elliott, Mok, & Briere, 2004; Tjaden & Thoennes, 2000). Recently, clinicians and researchers have examined the phenomenon of military sexual trauma (MST), referring to sexual coercion, sexual harass- ment, and sexual assaults against active service people by their peers or supe- riors in the military. Such events are much more common than had previously been assumed: One study of returning Operation Enduring Freedom and Operation Iraqi Freedom veterans, for example, indicated that 15 percent of women and 1 percent of men had experienced MST while on active duty (Kimerling et al., 2010). CHAPTER 1 What Is Trauma? 15 Women who are refugees or live in war-torn countries often have experi- enced rape as well, partially because sexual violence may be used by invading forces as a way to humiliate civilians, devastate morale, foster “ethnic cleans- ing,” or reward soldiers (Berman, Girón, & Marroguín, 2006; Human Rights Watch, 2009; Turner, Yuksel, & Silove, 2003; Stiglmayer, 1994). In addition, significant numbers of women and children are raped or sexually assaulted during illegal immigration, for example, by coyotes (human traffickers) who rape women and children as they smuggle them across the Mexican border (Amnesty International, 2010; Segura & Zavella, 2007). Stranger Physical Assault Stranger physical assault refers to muggings, beatings, stabbings, shoot- ings, attempted strangulations, and other violent actions against a person not well known to the assailant. The motive for such aggression is often robbery or the expression of anger, although in gang and “drive-by” situations the intent may also be to define or protect turf or to otherwise assert dominance. Although many acts of violence in relationships are directed more toward women than men, the reverse appears true for stranger physical assaults (Amstadter et al., 2011). In one study of urban psychiatric emergency room patients, for example, 64 percent of men reported having experienced at least one nonintimate physical assault, as opposed to 14 percent of women (Currier & Briere, 2000). Similarly, Singer et al. (1995) found that, depending on the research site, 3 to 33 percent of male adolescents described being shot at or shot, and 6 to 16 percent reported being attacked or stabbed with a knife. Intimate Partner Violence Also known as wife battering, spousal abuse, or domestic violence, inti- mate partner violence is usually defined as physically or sexually assaultive behavior by one adult against another in an intimate and often (but not inevi- tably) cohabiting relationship. In the vast majority of cases, there is emotional abuse as well, including humiliation, degradation, extreme criticism, stalking, and/or threats toward or violence against children, pets, and/or property (Black et al., 2010; Kendall-Tackett, 2009; D. K. O’Leary, 1999; Straus & Gelles, 1990). In a large-sample survey of individuals in the United States who were married or living with a partner, 25 percent reported at least one incident of 16 PART 1 TRAUMA, EFFECTS, AND ASSESSMENT physical aggression in a domestic context, while 12 percent reported incidents of severe physical violence such as punching, kicking, or choking (Straus & Gelles, 1990). Similarly, the results of the National Violence Against Women Survey suggest that 20 percent of women in the general population have been physically assaulted by their current or former partner, as compared to 7 per- cent of men (Tjaden & Thoennes, 2000). Rates of sexual assault of women by partners or spouses—irrespective of their history of physical battering—range from 9 to 17 percent (Black et al., 2010; Elliott & Briere, 2003; Finkelhor & Yllö, 1985). Among women who are physically assaulted by a partner, concomitant rates of sexual assault as high as 45 percent have been reported (Campbell & Soeken, 1999). According to the National Center for Injury Prevention and Control’s National Intimate Partner and Sexual Violence Survey (Black et al., 2010), when all forms of intimate violence are considered simultaneously, 36 percent of women and 28 percent of men in the United States have experienced rape, physical violence, and/or stalking by an intimate partner. The prevalence of intimate partner vio- lence among women who have psychiatric disorders or requesting psycho- logical services is even higher, sometimes exceeding 50 percent (for example, Chang et al., 2011). As might be expected, the impacts of such violence are significant, both medically and psychologically (Black et al., 2010; Okuda et al., 2011; see Hien & Ruglass, 2009, for a review). Sex Trafficking Sex trafficking can be defined as the forced or coerced recruitment, trans- portation, transfer, harboring, or receipt of individuals for the purposes of commercial sexual exploitation (The Protection Project, 2011). Although exact numbers are impossible to determine, it is estimated that 600,000 to 800,000 people are trafficked for sex or forced labor across international bor- ders each year, with 14,500 to 17,500 trafficked into the United States (U.S. Department of State, 2005). Once trafficked, women and girls (as well as, less frequently, boys) are forced into a variety of activities, including prostitution (in brothels, “out calls,” and on the streets), pornography, strip shows, massage parlors, escort services, mail-order bride networks, and sex tourism. It can be argued that local prostitution, when coerced or forced by a pimp or brothel, is also a form of sex trafficking, albeit one not involving physical relocation (for example, Leidholdt, 2003). CHAPTER 1 What Is Trauma? 17 The effects of sex trafficking are often severe. Involvement in prostitu- tion, and the associated effects of the trafficking process (being kidnapped or coerced into slavery; raped and beaten as punishment for noncompliance; and transported illegally to another country without documents, where a different language may be spoken and isolation is severe) have been associated with high rates of depression, posttraumatic stress, substance abuse, and other symptoms and disorders (Farley, 2004; Freed, 2003; Reid & Jones, 2011). Torture The United Nations Convention Against Torture defines torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him [sic] or a third person information or confession, punishing him for an act he has committed or is suspected of having committed, or intimidating him or a third person” (United Nations Treaty Collection, 1984). The current U.S. Code (Title 18, Part I, Chapter 113C, Section 2340) defines it as “an act committed by a person acting under the color of law specifically intended to inflict severe physical or mental pain or suffering (other than pain or suffering incidental to lawful sanctions) upon another person within his [sic] custody or physical control.” Regardless of function or context, methods of torture involve both physi- cal and psychological techniques, including beatings, near strangulation, elec- trical shock, various forms of sexual assault and rape, crushing or breaking of bones and joints, water-boarding, sensory deprivation, threats of death or mutilation, mock executions, being made to feel responsible for the death or injury of others, sleep deprivation, exposure to extreme cold or heat, stress positions, mutilation, and being forced to engage in grotesque or humiliating acts (Hooberman, Rosenfeld, Lhewa, Rasmussen, & Keller, 2007; Punamäki, Qouta, & El Sarraj, 2010; Wilson & Droždek, 2004). Most politically based torture involves police officers following arrest or violence at the hands of military forces. The incidence of torture is not known, although Amnesty International (2008) estimates that more than 81 nations currently sanction the use of—or at least tacitly allow—torture. Further: some of the measures that governments have taken in response to the attacks of 11 September 2001, as well as attacks or the threat of attacks in other countries since then, have amounted to a serious assault on the framework of human rights protection. States have used torture and other ill-treatment and 18 PART 1 TRAUMA, EFFECTS, AND ASSESSMENT have tried to justify this in the name of security, and to conferring impunity on the perpetrators. (Amnesty International, 2012, para. 4) Torture victims are dramatically overrepresented among refugees (Baker, 1992). It is estimated that 500,000 torture survivors from Africa, Eastern Europe, the Middle East, South America, and Southeast Asia currently live in the United States (U.S. Department of Health and Human Services, 2012), although such individuals are rarely questioned about a potential torture his- tory when they come in contact with North American mental health systems. War War is a common and relatively powerful source of trauma and enduring psychological disturbance. Posttraumatic difficulties have been described by veterans of a number of modern wars, including both world wars; those in African countries such as Angola, Somalia, and Rwanda; as well as wars in Afghanistan, Korea, Vietnam, Cambodia, the Persian Gulf (including Iraq), Israel, Armenia, Northern Ireland, the Falklands, and Bosnia. Combat involves a very wide range of violent and traumatic experiences, including immediate threat of death and/or disfigurement, physical injury, witnessing injury and/or death of others, and involvement in injuring or killing others (Kulka et al., 1988; Weathers, Litz, & Keane, 1995). For some, war includes witnessing or participating in atrocities, as well as undergoing rape, capture, or prisoner-of- war experiences such as confinement, torture, and extreme physical depriva- tion. These traumas, in turn, can produce a variety of symptoms and disorders (Institute of Medicine, 2010; Pizarro, Silver, & Prause, 2006). The majority of North American war veterans who seek psychological services today were combatants or support personnel in Afghanistan, Iraq, Vietnam, or Korea. Although the Veterans’ Administration (VA) provides care for many U.S. war veterans with service-connected injuries or disabilities in the United States, others may not qualify for such treatment, and it is not uncommon for veterans to present to non-VA mental health centers and clinicians. War can also profoundly affect the people indigenous to where it takes place. A number of studies indicate that living in a war-torn area (or armed- conflict zone) is associated with significant and lasting anxiety, depression, PTSD, and other—sometimes culture-specific—adverse outcomes, for both children and noncombatant adults (Bracken, Giller, & Summerfield, 1995; CHAPTER 1 What Is Trauma? 19 Eytan, Guthmiller, Durieux-Pailard, Loutan, & Gex-Fabry, 2011; Heidenreich, Ruiz-Casares, & Rousseau, 2009; Krippner & McIntyre, 2003). Excepting clinicians who travel on humanitarian missions to war-involved areas, the vast majority of survivors of war are seen clinically as refugees and/or torture sur- vivors who have immigrated to safer environments (for example, Baker, 1992; Wilson & Drožðek, 2004). Witnessing or Being Confronted With the Homicide or Suicide of Another Person As described in the DSM-5 criteria for PTSD and ASD, trauma can involve witnessing or “learning about” death or serious injury of another per- son. Witnessing such events can produce significant psychological distress and symptomatology, especially when, as noted later, the injured or deceased person is a friend, relation, or otherwise loved one, and the death or injury is intentional. Perhaps two of the most disturbing of such events are murder and suicide of significant others. Murder The Federal Bureau of Investigation (2010) estimates that there were 14,748 homicides in the United States in 2010 alone, a rate of 4.8 per 100,000 people. In such cases, multiple closely associated individuals (for example, friends, spouses, parents, offspring) are typically affected by the crime, either by directly witnessing it or learning of it soon after it occurs, resulting in a significant proportion of homicide survivors in the general population. For example, in a study of 1,753 American young adults reached in a telephone survey, 15 percent had experienced the loss by homicide of a family member or close friend (Zinzow, Rheingold, Hawkins, Saunders, & Kilpatrick, 2009). The psychological effects of murder on others are wide, including posttrau- matic stress, extended grief, depression, anger, and substance abuse (Zinzow et al., 2009). Homicide survivors frequently experience not only the impacts that accrue from any relational loss, but also the results of sometimes intense media coverage, the level of violence implicit in the crime, the possibility that the survivor was the one to find the deceased victim, feelings of anger and desire for revenge, and, in some cases, prolonged involvement with law enforcement and judicial systems. 20 PART 1 TRAUMA, EFFECTS, AND ASSESSMENT Suicide Witnessing or being confronted with the suicidal death of a family mem- ber or close friend can be a highly traumatic event, particularly for children or youth exposed to suicide of a parent (Brent, Melhem, Donohoe, & Walker, 2009; Hung & Rabin, 2009; Wilcox et al., 2010), as well as for those whose partner or family member has committed suicide (Kaltman & Bonnano, 2003; K. Ogata, Ishikawa, Michiue, Nishi, & Maeda, 2011; Melhem, Walker, Moritz, & Brent, 2008). In addition to responses associated with loss and trauma (see Complicated or Traumatic Grief in Chapter 2), there also may be feelings of anger or betrayal directed at the deceased, and preoccupation with the possibility that the survivor somehow could have prevented the suicide. Such responses are often accompanied by corresponding guilt and shame. Life-Threatening Medical Conditions Although not always listed as such in the literature, illnesses and inva- sive medical procedures associated with overwhelming pain and/or poten- tial life threat can be very traumatic events. Examples of traumatic illnesses or events include heart attacks, cancer, HIV/AIDS, stroke or brain hemor- rhage, and miscarriage. Potentially traumatic medical procedures include heart surgery, treatment in intensive care units, surgery and nursing care for severe burns, major dental surgery, and other medical interventions that produce significant pain or fear (for example, O’Donnell, Creamer, Holmes, et al., 2010). Recently, the phenomenon of unexpected awareness or awakening under general anesthesia during surgery also has been discussed as a medical trauma (for example, Leslie, Chan, Myles, Forbes, & McCulloch, 2010). Those individuals with life-threatening illnesses often undergo invasive medical procedures; this can make it difficult to ascertain which aspect of the person’s illness or treatment is responsible for his or her posttraumatic diffi- culties. Regardless of its source, there is a growing recognition that trauma is not uncommon among those with major medical problems, and clinicians are increasingly advised to screen patients undergoing major medical procedures for possible posttraumatic stress, depression, or severe anxiety (for example, S. Lee, Brasel, & Lee, 2004). CHAPTER 1 What Is Trauma? 21 Emergency Worker Exposure to Trauma Because emergency workers often encounter potentially traumatic phenom- ena, including fatal injury, traumatic amputation, disembowelment, severe burns, and extreme victim distress, it is not surprising that those who help the traumatized can become traumatized themselves. In fact, the DSM-5 trauma definition includes reference to “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).” Among those known to be at risk for such work-related stress are firefighters, rescue workers, paramedics and other emergency medical personnel, individuals involved in the identification and handling of deceased trauma victims, emer- gency mental health and crisis intervention workers, and law enforcement per- sonnel (Benedek, Fullerton, & Ursano, 2007; Fullerton, Ursano, & Wang, 2004; LaFauci Schutt & Marotta, 2011; Rivard, Dietz, Martell, & Widawski, 2002). Psychotherapists who treat trauma survivors may also develop a form of vicari- ous traumatization (Dalenberg, 2000; Goin, 2002; Pearlman & Saakvitne, 1995). THE PROBLEM OF COMBINED AND CUMULATIVE TRAUMAS This list of separately described traumas may give the erroneous impression that such events are independent of one another—in other words, that under- going one trauma does not necessarily increase the likelihood of experiencing another. This is generally true of noninterpersonal traumas such as disasters or fires. However, a number of studies demonstrate that victims of interpersonal traumas are at statistically greater risk of additional interpersonal traumas (for example, Rees et al., 2011). This is especially true in what was described ear- lier as revictimization: Those who have experienced childhood abuse are considerably more likely to be victimized again as adolescents or adults (Amstadter et al., 2011; Classen et al., 2002; Tjaden & Thoennes, 2000; see a detailed review by Duckworth & Follette, 2011). In addition, many clini- cians have noticed that some clients seem to have more than their normal share of adult traumas: Environmental, social, and behavioral issues appear to increase the likelihood of the individual being repeatedly victimized, as described next. 22 PART 1 TRAUMA, EFFECTS, AND ASSESSMENT The relationships among different traumas—and the symptoms and dif- ficulties they cause in a given individual’s life history—can be complex. Childhood abuse and/or neglect may produce various symptoms and maladap- tive behaviors in adolescence and adulthood (for example, substance abuse, running away from home, indiscriminate sexual behavior, attachment issues, and reduced danger awareness via dissociation or denial) that, in turn, increase the likelihood of later interpersonal victimization (Dietrich, 2007; Hetzel & McCanne, 2005; McCauley, Calhoun, & Gidycz, 2010; McIntyre & Widom, 2011; Messman-Moore, Walsh, & DiLillo, 2010; Reese-Weber & Smith, 2011). These later traumas may then lead to further behaviors and responses that are additional risk factors for further trauma and subsequent, potentially even more complex mental health outcomes. Because both childhood and adult traumas can produce psychological difficulties, current symptomatology in adult interpersonal trauma survivors may represent (1) the effects of child- hood trauma that have lasted into adulthood, (2) the effects of more recent sexual or physical assaults, (3) the additive effects of childhood trauma and adult assaults (for example, flashbacks to both childhood and adult victimiza- tion experiences), and/or (4) the exacerbating interaction of childhood trauma and adult assault, such as especially severe, regressed, dissociated, or self- destructive responses to the adult trauma. This mixture of multiple traumas and multiple symptomatic responses is well known to trauma-focused clinicians, who sometimes find it difficult to connect certain symptoms to certain traumas, and other symptoms to other traumas, or, in fact, to discriminate trauma-related symptoms from less trauma-specific symptoms. Although this task is often daunting, the remaining chapters of this book describe assessment and treatment approaches that clar- ify these various trauma-symptom connections and, in some cases, provide alternative ways of approaching multitrauma-multisymptom presentations. SUGGESTED READING Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. L. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216–222. Duckworth, M. P., & Follette, V. M. (Eds.). (2011). Retraumatization: Assessment, treatment, and prevention. London, UK: Routledge.