Clinical Handbook of Mindfulness (85 page)

vivors of prolonged and extended trauma were reporting. In response to

these observations the diagnosis of Complex PTSD was developed to refer to

the symptomatology that follows “trauma that occurs repeatedly and cumula-

tively, usually over a period of time and within specific relationships and con-

texts”
(Courtois, 2004,
p. 412). The topic of complex trauma is the source of controversy within the field of traumatic stress. One important aspect of this

discussion is whether complex PTSD is sufficiently different from current

conceptualizations of PTSD, thereby warranting its own diagnostic criteria.

At the present time, complex PTSD has not been included as a separate cate-

gory in the DSM, but many clinicians and researchers find it useful to utilize

Chapter 16 Mindfulness for Trauma and Posttraumatic Stress Disorder

303

this construct in their work with trauma survivors. Complex trauma is typi-

cally observed in situations where the victim is trapped, such as in prolonged

instances of child abuse. In addition to the PTSD symptoms, complex PTSD

includes interpersonal ineffectiveness and emotion regulation problems that

are associated with survivors of prolonged trauma exposure. Follette, Iver-

son, & Ford (in press) note that complex trauma can influence the devel-

opment of personality characteristics or poor generalized coping skills in

survivors of early onset or long-term abuse. One of the distinguishing fea-

tures of a complex PTSD diagnosis is interpersonal and emotion regulation

difficulties. These difficulties can make it extremely difficult for the client to

engage in exposure treatments in a safe manner
(Ford, 1999).
Further, some researchers suggest that there may be the possibility of iatrogenic effects if

exposure is implemented with this population prior to mastering emotion

regulation skills that would allow them to more fully engage in the treatment

(Ford & Kidd, 1998).

Trauma symptomatology can result from a range of stressors and both clin-

icians and researchers are increasingly aware of clients presenting with mul-

tiple trauma experiences. Additionally, the salience of contextual factors on

trauma-related symptoms, as well as resiliency, is now clearly documented in

the literature. The context can moderate the outcomes associated with trau-

matic experiences and it is therefore important for clinicians and researchers

to be aware of some of the more common environmental factors that may

impact treatment. For our purposes, we will discuss the environmental fac-

tors associated with trauma by examining three frequently observed cate-

gories: interpersonal violence, combat, and natural disasters.

Interpersonal violence
. The term interpersonal violence refers to forms

of violence that are perpetrated by one individual toward another with the

specific intent of causing harm or injury. Interpersonal violence includes

physical or sexual abuse, sexual trauma or victimization. Child abuse (physi-

cal/sexual abuse or neglect) is a problem throughout the world and the con-

sequences of the maltreatment and abuse of children is extensive. A child is

vulnerable to abuse simply because they are dependent on adults for their

overall safety and well-being. Further, when a child exists in an abusive envi-

ronment, frequently there are other factors present (e.g., lack of adequate

financial resources, lack of appropriate supervision) that are associated with

poor psychological outcomes. One distinctive feature of childhood trauma is

that it can be detrimental to a child’s developmental trajectory in that he/she

is denied access to variety of age appropriate learning experiences (Cloitre

et al.,
2006).
When a child does not have the opportunity to access developmentally appropriate learning experiences it can lead to difficulties later

in life such as attachment difficulties. Specifically, when the child did not

develop in an environment in which the caretaker was safe, reliable and emo-

tionally validating, difficulty with trust, intimacy, and boundaries can occur.

Attachment problems have also been related to difficulties with affect reg-

ulation, emotion regulation, accurate expression and general psychological

distress
(Cloitre et al., 2006)

Sexual victimization and sexual revictimization are forms of interpersonal

violence that impact a significant proportion of the population. Revictimiza-

tion is one of the more frequently observed outcomes associated with child

victimization
(Polusny & Follette, 1995).
There are several factors thought
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Victoria M. Follette and Aditi Vijay

to be associated with increased rates of revictimization. Child sexual abuse

(CSA) and adolescent sexual abuse (ASA) seem to be the most robust risk

factors for future victimization
(Classen, Palesh & Aggarwal, 2005;
Desai, Arias, Thompson & Basile,
2002;
Marx, Heidt & Gold, 2005).
The severity, frequency and age at the time of the first incident, relationship to the per-petrator and the duration of the abuse all serve to increase the risk of revic-

timization. The nature of sexual contact also impacts future risk; the more

invasive the sexual contact was in childhood, the greater the risk of revictim-

ization. The extant literature indicates that woman who are revictimized are

significantly more likely than women who have experienced a single incident

of sexual assault to exhibit PTSD symptoms or suffer from anxiety disorders

(Classen et al., 2005;
Arata, 2002).
In addition to experiencing psychological distress, women who are the victims of sexual abuse at any time during

their lifespan tend to experience more health problems (Buckley, Green &

Schnurr,
2004).
If PTSD develops following the first incident of victimization, it greatly increases the possibility of further distress and revictimization

(Chu, 1992).
Victimization and revictimization put individuals with a trauma history at risk for affect regulation problems, interpersonal and intrapersonal

difficulties and general forms of psychological distress
(Cloitre & Rosenberg,

2006).

Repeated and prolonged victimization experiences increases the probabil-

ity of developing more serious psychopathology and detracts from function-

ing in other domains. Moreover, some data suggests that the effects of trauma

are cumulative; with increases in exposure to trauma increasing the like-

lihood of developing trauma symptomatology (Follette, Polusny, Bechtle &

Naugle,
1996;
Kaysen, Resick & Wise, 2003).
Interpersonal violence has a different impact on the victim than other traumatic events (e.g., combat or

natural disaster) as a function of the relational factors associated with the

assault. For many survivors of childhood interpersonal violence, they have

been perpetrated against by someone they knew and/or trusted and these

are cases where it is likely that difficulty with affect regulation, emotion reg-

ulation and sense of self are a part of the presenting symptoms. A complex

PTSD conceptualization may be especially appropriate and useful in these

cases. Another salient construct to this population is betrayal, which sug-

gests that outcomes such as amnesia are an adaptive response to childhood

abuse because the child remains dependent on the caretaker for their basic

needs and the resulting amnesia allows them to forget the betrayal of the

abuse
(Freyd, 1994).
It is not in a child’s best interest to behave in a way that would negatively impact attachment to their caregiver. This type of amnesia is in the service of maintaining this relationship in order to allow them

to survive. Factors associated with interpersonal trauma, such as problems

with trust and memory, have implications for the therapeutic relationship.

Survivors of these experiences may not have had the opportunity to engage

in safe and appropriate relationships. Thus, problems may arise in develop-

ing a therapeutic alliance. On the other hand, the benefits of the therapeutic

relationship may be especially essential to this population, presenting clients

with a model for healthy interpersonal relationships in the future.

Combat
. Sadly, war and armed conflicts are a central part of both the cur-

rent and historical, political and social landscape. Involvement in a combat

situation has been cited as one factor that is very likely to lead to trauma

Chapter 16 Mindfulness for Trauma and Posttraumatic Stress Disorder

305

symptoms, psychological distress, and/or PTSD
(Fairbank et al., 2001).
Veterans of war are different from other survivors of trauma due to the num-

ber and type of traumatic events they may have been exposed to such as a

function of living in combat zones
(Keane, Zimering & Caddell, 1985).
The constellation of symptoms that are now recognized as PTSD were originally

studied because of the psychological distress returning soldiers were report-

ing
(Wilson, 2004).
The lifetime prevalence of PTSD in military personnel is estimated to be 30.9 percent for men and 26.9 percent for women (Breslau

et al.,
1998).
However, these numbers remain in question, and may be serious underestimates, because of the stigma of seeking mental health services

and the potential career ramifications for military personnel.

The duration of time in a combat zone and the environment (e.g., living on

the front line) were associated with higher rates of trauma symptomatology

(Kaysen et al., 2003).
In addition to the duration of time, soldiers who are in combat frequently remain hypervigilant as a result of exposure to chronic

and unpredictable danger. This constant stress can be related to cognitive and

biological changes that are frequently associated with later psychological dis-

tress. Moreover, combat veterans report the difficulty in returning to civilian

life related to transitioning from “battlemind” thinking and a sense of discon-

nection from the normalcy of daily life. Epidemiological studies indicate that

a significant proportion of military personnel are experiencing psychological

distress
(Fairbank et al., 2001).
At the present time in the United States, there continue to be large numbers of military personnel who are returning from

multiple deployments in Iraq and/or Afghanistan, who have served extended

terms of duty and may be at significant risk for developing PTSD (Hoge, Cas-

tro & Messer,
2004).
Finally, in a somewhat related vein, it should also be noted that exposure to the risk of terrorist activity remains a rather chronic

stressor for both civilians and military personnel.
Bonanno (2005)
provides data on the impact of the events of September 11th which indicates that the

US population was impacted by these attacks.

Natural disasters
. Disasters such as earthquakes, fires, floods, hurricanes,

and tornadoes are large-scale events that adversely affect a significant num-

ber of people throughout the world
(Briere & Elliott, 2000).
As with other extreme stressors, the psychological symptoms that have been associated

with natural disasters include PTSD, depression, anxiety, anger, dissocia-

tion, aggression and antisocial behavior, somatic complaints, and substance

abuse problems
(Briere & Elliott, 2000).
In addition to the distress resulting from the disaster, including injury and loss of loved ones, there is

often stress associated with the loss of resources such as property and shel-

ter. This can interfere with employment, school, and accessing necessary

resources to rebuild their lives. Hurricane Katrina, which affected the south-

east region of the United States in 2005, provides an iconic example of a

natural disaster that resulted in extensive property loss with far reaching con-

sequences for both individuals and the community at large. The conservation

of resources model, which asserts that people attempt to keep, protect and

build resources when there is imminent threat, is demonstrated in some of

the impacts of Hurricane Katrina
(Hobfoll, 1989;
Hobfoll, Johnson, Ennis & Jackson,
2000).
In the example of Hurricane Katrina survivors reported that the trauma of the hurricane was compounded by the loss of loved ones, the

loss of their homes and the chaotic environment that resulted when people

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Victoria M. Follette and Aditi Vijay

in the area were unable to access resources to replace the ones they had

recently lost. Moreover, many survivors of that event were displaced and lost

a variety of sources of social support as well as the more general sense of

support that belonging to a community can provide.

Functional Analytic Assessment of PTSD

As we have stated several times, the contextual elements of trauma-related

exposure are critical for analysis when assessing for trauma-related out-

comes. Multiple factors affect the course of the disorder by exacerbating,

maintaining, or improving the symptoms and overall course of the disor-

der
(Wilson, 2004;
Follette & Naugle, 2006).
Therefore, a range of factors beyond the trauma per se becomes significant in treatment planning. A functional analytic clinical assessment is a process that identifies potentially rel-