PostTraumatic Stress Disorder Intimate Partner Violence Stephanie Gimenez

Post-Traumatic Stress Disorder & Intimate Partner Violence Stephanie Gimenez Wake Forest University Department of Counseling ABSTRACT METHODS Victims of intimate partner violence (IPV) with posttraumatic stress disorder (PTSD) - one of the largest traumatized populations in North America (Johnson et al. , 2006; Kubany et al. , 2004). PTSD - most prevalent disorder among victims of IPV (Bennice et al. , 2003; Johnson et al. , 2006; Krause et al. , 2008). • • Psych. Info (most results) • Pub. Med (no relevant results) • Prolonged Exposure Therapy (PE) Stress Inoculation Training (SIT) Cognitive Processing Therapy (CPT) Cognitive Trauma Therapy for Battered Women (CTT-BW) Helping to Overcome PTSD through Empowerment (HOPE) • PTSD affects 10. 4% of American women twice as much as men (Kubany et al. , 2004). • 1 in 4 women were raped or assaulted in their lifetime - National Violence Against Women Survey (Tjaden & Thoennes, 2000). (American Psychological Association, 2003; Krause et al. , 2008; Bennice et al. , 2003) PHYSICAL ASSAULT ANXIETY (APA, 2003). TENSION BUILDING • IPV may be conceptualized via the “Vortex of Violence” (Carrington, AVOIDAN T COPING SYMPTO MS 2014). • PTSD & IPV have been found to be chronic conditions that appear to be mutually aggravating factors (Krause et al. , 2008; Johnson et al. , 2009). Chronicity of PTSD Symptoms Re-experiencing Avoidant coping Negative/distorted cognitions, moods & emotions Social estrangement Irritability, Anger, Aggression Recklessness, Self-destructive behavior Cyclical Nature of IPV Re-victimization Avoidance, denial, wishful thinking Negative/distorted cognitions, moods, & emotions Isolation Fear, Anger, Aggression Recklessness, Self-destructive behavior • IPV CONTEXTUAL FACTORS: v Ongoing safety issues v Legal family issues v Homelessness v Substance abuse v Physical & mental illness v Victim & abuser share children → Barriers to leaving abuser → Continuous source of stress → May complicate treatment (Johnson et al. , 2008) • AGGRAVATING IMPACT OF PTSD SYMPTOMS: MUTIMODAL IMPAIRMENT (APA, 2013) v Interpersonal & Social (i. e. social estrangement, anger, aggression) v Developmental & Educational (i. e. distorted cognitions) v Medical (i. e. self-destructiveness, recklessness) v Occupational impairment → Barriers to leaving abuser → Re-victimization → May complicate treatment Myth Buster: The BATTERED WOMEN’S SYNDROME - “That a battered women’s mental health problems, such as PTSD, or other contextual factors (…) will dissolve once they are safely out of an abusive relationship” (Johnson et al. , 2008; Kubany et al. , 2004; Resick et al. , 2002). RESEARCH POSTER PRESENTATION DESIGN © 2011 www. Poster. Presentations. com Ø Ø • • Published in English Years of publication: 2000 -2015 ü PTSD - a comorbid condition, which may develop after primary or secondary exposure to a traumatic event (TE) — actual or threatened death, serious injury, or sexual violence. • Prevalence of PTSD among women in domestic violence shelters range from 45% to 84% (Kubany et al. , 2004). • IPV & Sexual Violence (SV) severity → PTSD likelihood & severity HONEYMOON Phase Ø Psychology (2 articles) Professional Psychology: Research and Practice (1 article) Journal of Traumatic Stress (1 article) Sociological Inquiry (1 article) British Journal of Social Work (1 article) Violence & Victims (1 article) v OTHER SOURCES: • Background information: Ø DSM-V • Websites visited: Ø US & Canada government • Websites of interest: Ø National Coalition Against DV Ø National Coalition Against SA Ø NC Coalition Against DV Ø NC Coalition Against SA RESULTS FOUNDATIONS • PTSD is often a chronic condition v JOURNALS: Ø Journal of Consulting and Clinical EBSCO (most results) Google Scholar v KEY WORDS & PHRASES in Advanced Search: • “posttraumatic stress disorder” • “domestic violence” • “treatments” • “effective therapies” v LIMITS: • Scholarly journals • Female population • Peer-reviewed • Link to full text WHAT PTSD TREATMENTS HAVE BEEN TESTED & FOUND EFFECTIVE IN TREATING PTSD IN IPV VICTIMS? • • • v DATABASES: DISCUSSION ü Recklessness/self-destructiveness ü Hypervigilance ü Attention & sleep problems DSM-V SYMPTOMS (APA, 2013): ü Re-experiencing ü Distressing dreams, memories ü Reminding ex-/internal stimuli ü Avoidant coping ü Negative & distorted cognitions, mood, & emotions ü Dissociative amnesia ü Low self-efficacy ü Diminished interest ü Social estrangement ü Irritability, anger, aggression PROLONGED EXPOSURE THERAPY (PE) - Empirical support used in (Resick, Nishith, Weaver, Astin, & Feuer, 2002) • Designed to treat PTSD in victims of non-reoccurring trauma (i. e. natural disasters, accidents, crime victims), not for IPV victims with ongoing threat of re-victimization & safety concerns (Krause et al. , 2008) • EDUCATION • RELAXATION • BEHAVIORAL EXPOSURE to feared external reminders of the trauma • IMAGINAL EXPOSURE: trauma memory STRESS INOCULATION TRAINING (SIT) - Empirical support used in (Resick, Nishith, Weaver, Astin, & Feuer, 2002) • Coping skills treatment protocol • EDUCATION • RELAXATION SKILL BUILDING • COGNITIVE RESTRUCTURING • BEHAVIORAL REHEARSAL Ø Overt modeling Ø Role playing Ø Behavioral exposure to reduce avoidance of feared stimuli COGNTITVE PROCESSING THERAPY (CPT) – A Comparative study by (Resick, Nishith, Weaver, Astin, & Feuer, 2002) • Designed to treat PTSD in sexual violence victims • Excludes women: Ø Currently in abusive relationship, or being stalked Ø Who were raped in the last 3 months Ø Who experienced marital rape in the last 6 months • COGNITIVE COMPONENT Ø Socratic questioning: distorted beliefs (i. e. denial, self-blame, guilt, & overgeneralized beliefs about self & the world • Homework assignments Ø Goals: identify “stuck points, ” contradictions, flawed logic, assumptions • EXPOSURE COMPONENT Ø Client Distress Ratings & Hierarchy (in vivo & imaginal exposure) Ø Writing & reading about the TE, associated meanings, thoughts, emotions, & sensory details • THEORY TO PRACTICE Ø Explore a second trauma to turn dysfunctional cognitions into narratives of safety, trust, power-control, esteem, & intimacy Ø Rewrite impact statements Ø Evaluate treatment gains COGNITIVE TRAUMA THERAPY for BATTERED WOMEN (CTT-BW) – Two controlled experiments by (Kubany, Hill, Owens, Lannce-Spencer, Mc. Caig, Tremayne, & Williams, 2004) • Excluding women with recent incidence of IPV & SV • GUILT: key factor in PTSD assessment & treatment Ø TRAUMA HISTORY Ø PTSD EDUCATION Ø STRESS MANAGEMENT TRAINING Ø EXPOSURE TO ABUSE & abuser reminders Ø SELF-MONITORING negative self-talk Ø COGNITIVE APPROACH to guilt Ø SELF-ADVOCACY, ASSERTIVENESS & how to IDENTIFY PERPETRATORS HELPING to OVERCOME PTSD through EMPOWERMENT (HOPE) – A pilot study by (Johnson & Zlotnick, 2006); & a randomized trial (Johnson & Zlotnick, 2008) • Individually administered, short-term cognitive-behavioral therapy to treat PTSD in battered women in crisis, & with ongoing safety concerns • Securing safety & resources: key determinant in treating PTSD • “PRIME TIME” to intervene: Ø As soon as a victim is committed to leaving her abuser regardless of recentness of last IPV incident, & PTSD symptoms are identified • STABILIZATION: Collaboration with shelter, formal & informal support Ø Crisis intervention, exit planning, & case management (i. e. advocacy, social services referral system, transitional housing, occupational & financial needs) • PSYCHOEDUCATION: IPV & PTSD, long-term safety planning, empowerment “tool box, ” independence, self-care, self-efficacy • COGNITIVE-BEHAVIORAL SKILLS: Safety, trust, power/control, esteem, & intimacy, reducing & managing PTSD symptoms & interpersonal dysfunction (i. e. internalized abuser’s beliefs), depression, anxiety • CO-OCCURRING PROBLEMS: Securing resources, PTSD-caused impairments, substance abuse, grief (of relationship or family unit) • REINTEGRATION SILENT & UNDERSERVED WITH “INVISIBLE WOUNDS” Ø THE CYCLE OF PTSD & IPV: Do PTSD symptoms interfere with decision-making pertaining to self-preservation or survival instincts? The longer a woman stays, the greater the safety concerns, the threats of re-victimization (Carrington, 2014), the dangers of serious injury or death, & the more severe the PTSD symptoms (i. e. anger, aggression, self-destructiveness). The more severe the symptoms, the greater the impairments (i. e. interpersonal, developmental). Ø According to the “Vortex of Violence” conceptualization (Carrington, 2014), the “prime time” to intervene in terms of a victim’s commitment to leave her abuser is right after an explosive incident. Ø In a sample of 18 battered women, 60% still met PTSD diagnostic criteria, AND reported re-occurring domestic abuse one-week postshelter. Therefore, there is a grave need for timely PTSD treatment tailored to the victim’s unique needs (Johnson et al. , 2006). Ø Re-exposure interventions & techniques may not only be ineffective, they may re-traumatize women, further limit their ability to safely re-stabilize, & increase risks of further victimization, therefore: are contraindicated for battered & raped women (Kubany et al. , 2004; Krause et al. , 2008; Johnson et al. , 2006; 2008). Ø Effective treatments may need to place less emphasis on “encouraging the victim to leave or have no contact with her abuser” (Johnson et al. , 2008, 240), & more on safety, reducing & managing PTSD symptoms, decision-making & commitment to selfcare, & stabilization (Johnson et al. , 2006; 2008; Kubany et al. , 2004). RECOMMENDATIONS FOR FUTURE RESEARCH Ø More rigorous empirical studies (e. g. larger samples of randomly selected & assigned women to treatment & control groups) — regardless of IPV or SV recentness — that include factors of ongoing threats of re-victimization, safety concerns, & resource loss (Johnson et al. , 2006; 2008; Krause et al. , 2008), & measures the extent to which PTSD interferes with these factors; as well as HOPE’s effectiveness in supporting women with safely re-stabilizing, committing to self, & preventing re-victimization, in addition to treating their PTSD. REFERENCES American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5 th ed. ). Washington, DC: Author. Bennice, J. A. , Resick, P. A. , Mechanic, M. B. , & Astin, M. C. (2003). The relative effects of intimate partner physical and sexual violence on post-traumatic stress disorder symptomatology. Violence & Victims, 18(1), 87 -94. Carrington, A. M. (2014) The vortex of violence: Moving beyond the cycle and engaging clients in change. British Journal of Social Work, 44(2), 451– 68. Duluth (1984/2011) ‘Duluth Model: Power and control wheels’, available online at www. theduluthmodel. org/wheelgallery. php Dunn, J. L. (2005). Victims’ and ‘Survivors’: Emerging Vocabularies of Motive for ‘Battered Women Who Stay’. Sociological Inquiry 75(1), 1– 30. Government of Newfoundland, & Labrador. (2014). Wheels of power and control and equality. (publication no). Newfoundland, Canada: Violence Prevention Initiative. Retrieved from http: //www. gov. nl. ca/VPI/types/wheelsofpower. html. Johnson, D. M. , & Zlotnick, C. (2006). A cognitive-behavioral treatment for battered women with PTSD in shelters: Findings from a Pilot Study. Journal of Traumatic Stress, 19(4), 559– 64. Johnson, D. M. , & Zlotnick, C. (2008). HOPE for battered women with PTSD in domestic violence shelters. Professional Psychology: Research and Practice, 40(3), 234– 41. Krause, E. D. , Kaltman, S. , Goodman, L. A. , & Dutton, M. A. (2008) Avoidant coping and PTSD symptoms related to domestic violence exposure: A longitudinal study. Journal of Traumatic Stress 21(1), 83– 90. Kubany, E. S. , Hill, E. E. , Owens, J. A. , Lannce-Spencer, C. , Mc. Caig, M. A. , Tremayne, K. J. , & Williams, P. L. (2004). Cognitive Trauma Therapy for Battered Women with PTSD (CTT-BW). Journal of Consulting and Clinical Psychology, 72(1), 3– 18. Resick, P. A. , Nishith, P. , Weaver, T. L. , Astin, M. C. , & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867– 79. Tjaden, P. , & Thoennes, N. (2000). Extent, Nature, and Consequences of Intimate Partner Violence: Findings from the National Violence against Women Survey. Washington, DC: U. S. National Institute of Justice.