Betrayal Trauma, APA, 11 August 2006

Transcription

1 Using Research to Inform Trauma Treatment: Insights from Trauma Studies Trauma Theory, Research, & Treatment Implications Overview of Trauma Theory Some Empirical Findings & Implications Jennifer J. Freyd, University of Oregon and Eileen Zurbriggen, University of California, Santa Cruz 11 August 26 Thank you Collaborators Special thanks to Carolyn Allard Pamela Birrell Kathy Becker-Blease Lisa Cromer Anne DePrince Melissa Foynes Lewis Goldberg Rachel Goldsmith Bridget Klest Eileen Zurbriggen Trauma Theory: Lets start with a question In order to be effective in helping trauma survivors, it is helpful to know what makes trauma harmful (and how trauma impacts victims). What aspects of traumatic events make them potentially psychologically harmful to people (and how do those aspects of trauma impact victims)? TRAUMA: What is psychologically harmful to people? Mainstream traumatic stress model: emphasis on lifethreat, fear and resulting anxiety But is this the only dimension of events that causes long-lasting distress or harm? What about interpersonal/social elements of events? Interpersonal Trauma What is it like? Not necessarily immediately life-threatening Not necessarily immediately horrifying or fear-inducing But nonetheless harmful Examples Chronic emotional abuse Childhood sexual abuse at the hands of a trusted other Societal oppression due to gender, ethnicity, class, etc. Copyright Jennifer J. Freyd, 26 Handout Page 1

2 Interpersonal Trauma Consider Frank Fitzpatrick Frank Fitzpatrick... began remembering having been sexually molested by a parish priest at age Mr. Fitzpatrick's retrieval of the repressed memories began, he said, when "I was feeling a great mental pain Mr. Fitzpatrick slowly realized that the mental pain was due to a "betrayal of some kind," and remembered the sound of heavy breathing. "Then I realized I had been sexually abused by someone I loved," said Mr. Fitzpatrick. Trauma Theory My initial research question Why and how would individuals remain unaware of (or forget) traumas they had experienced? Why are some traumas forgotten (and not others)? But it was not until two weeks later that he suddenly remembered the priest, the Rev. James R. Porter. The New York Times, 21 July 1992 Trauma Theory: 1. Consider our Sensitivity to We are repeatedly engaging in social contracts with others. I give you A if you give me B An ability to evaluate trustworthiness is highly important When empowered, we have exquisite sensitivity to cheating and betrayal Response: withdrawal or confrontation Trauma Theory: 2. Consider Human Dependence Humans, particularly children, are profoundly dependent on others Attachment system protects dependent person/child Baby has job to engage (love and be lovable) Trauma Theory: Blindness as a Survival Mechanism Trauma Theory Suggests Two Primary Dimensions of Traumatic Events What does a child do when caregiver betrays? conflict between sensitivity to betrayal and needs of attachment a child abused by a caregiver would risk further mistreatment if awareness caused withdrawal or conflict blindness occurs when awareness would threaten necessary (or apparently necessary) relationships Thus unawareness and forgetting are sometimes an adaptive response to betrayal Life threatening (physically terrorizing and fear inducing) Social betrayal ( Trauma ) Copyright Jennifer J. Freyd, 26 Handout Page 2

3 Trauma Research & Treatment Implications How does betrayal trauma impact the victim and what can be done to help? Some Empirical Findings & Implications 1. trauma, forgetting, & delayed disclosure 2. trauma, dissociation, attention, & memory 3. trauma, mental & physical health, & gender Research Question 1: trauma, forgetting, & delayed disclosure Focus on motivations trauma theory predicts that forgetting and unawareness will be greater for betrayal traumas than nonbetrayal traumas Motivation to Not Remember: A Specific Prediction Memory and Victim-Perpetrator Relationship (Freyd, DePrince, & Zurbriggen, 21) Childhood abuse perpetrated by a caregiver will lead to more memory impairment than will abuse perpetrated by a non-caregiver Memory Impairment Physical Abuse Emotional Abuse Sexual Abuse caretaker non-caretaker College student population of 22 participants. Abuse perpetrated by a caregiver is related to less persistent memories of abuse. Caretaker status significant for sexual and physical abuse. Follow-up regression analyses: Age and duration of abuse did not account for findings. Type of Abuse also related to disclosure delays Foynes, Freyd, & DePrince (26) The majority of abuse survivors reported substantial time lapses from abuse onset to disclosure. Survivors abused by very close perpetrators were significantly more likely to wait years to disclose their abuse, if it was disclosed at all. Clinical implications part 1: trauma, forgetting, & delayed disclosure Important to be aware that that closeness of victim-perpetrator likely leads to more forgetting and denial by the child or adult survivors Because the closeness of victim-perpetrator relates to outcome, this could mean longer treatment. Given the harm of betrayal trauma occurs in the context of relationships, healing human relationships are likely going to be crucial for some trauma survivors. Copyright Jennifer J. Freyd, 26 Handout Page 3

4 Clinical Implications Part 1 Continued Attachment It is assumed that in chaotic homes you're more likely to see disorganized attachment.. In the homes where kids are trying to maintain the appearance of normalcy, you may well see dissociative kids with secure or at least organized attachment styles. Clinical Implications Part 1 Continued Understand the dynamics of forgetting and nondisclosure While delayed disclosure, like forgetting, may allow the attachment relationship to be sustained, it may also prolong the abuse and prevent receipt of emotional, legal, or financial support. Also may interfere in later relationships and activities Therapists should be aware of their own reactions to disclosure, as prejudicial disbelief could result in further harm. Research Question 2: trauma, dissociation, attention, & memory Attention & Dissociation Interaction Focus on mechanisms High levels of dissociation are empirically associated with a history of trauma Dissociation is a lack of normal integration of thoughts, feelings, and experiences into the stream of consciousness and memory (Bernstein and Putnam, 1988) Dissociation involves cognitive processes of attention and memory Stroop Interference (ms.) Selective Dual Attention Condition Low DES High DES DePrince & Freyd (1999) High dissociators showed more Stroop interference in focused attention conditions and less in divided attention conditions, compared to low dissociators Suggests high dissociators more skilled at divided attention Memory Interaction: Dissociation and Forgetting Trauma Words Memory Interaction Replicated Low High DePrince & Freyd (1999) Free Recall High dissociators remember fewer trauma words than do low dissociators relative to neutral words % Correctly Recalled Neutral Trauma Word Category Low DES High DES DePrince & Freyd, 21 Item-Method Directed Forgetting Task; Divided Attention; Remember Condition High dissociators remember fewer trauma words than do low dissociators relative to neutral words Neutral Charged Example charged words: victim, incest, assault, rape DePrince & Freyd, Copyright Jennifer J. Freyd, 26 Handout Page 4

5 Memory Interaction Replicated Again Memory Interaction Found in Preschoolers % Correct Recall L Trauma Neutral Word Category Low DES High DES DePrince & Freyd (24) List Method Directed Forgetting Task; Divided Attention; Remember Condition High dissociators remember fewer trauma words than do low dissociators relative to neutral words Mean # Correct No Abuse Abuse Neutral Charged Becker-Blease, Freyd, & Pears (24) Picture Memory Task; Divided Attention Abused preschoolers remember fewer charged pictures than do non-abused preschoolers relative to noncharged words. Summary of Findings Part 2: trauma, dissociation, attention, & memory Trauma: High dissociators report significantly more trauma in their history. Attention Interaction: High dissociators show more Stroop interference in focused attention conditions and less in divided attention conditions. Memory Interaction: High dissociators remember fewer trauma words (and abused children remember fewer charged pictures) proportionally, especially in multi-task condition. Trauma interpretation: Keeping information about betrayal traumas out of awareness and memory may lead to high levels of dissociation. Dissociation may involve increased facility with divided attention, and dissociative individuals may seek or create cognitive environments that require divided attention. Clinical Implications Part 2 Dissociative adults and abused children may indeed forget trauma stimuli under some conditions divided attention (which is probably more like everyday life than usual lab context) and when stimuli inspire spontaneous forgetting Clinical Implications Part 2, Continued Certain cognitive environments and divided attention may help dissociative adults and abused children keep betrayal trauma information out of memory and awareness. When children or adults seem to create chaos in their lives, we may sometimes understand that chaos as an attempt to create a divided attention context an attempt to cope. We may help dissociative people take constructive advantage of their significant cognitive skills for certain employment contexts help them find the right cognitive environments Copyright Jennifer J. Freyd, 26 Handout Page 5

6 Clinical Implications Part 2 Continued Use caution in assuming that kids might be doing well--it might be that they are just as impacted as other kids who are more obviously distressed, but that they are dissociating or selective remembering. Research Question 3: trauma, mental & physical health, & gender Focus on consequences of betrayal trauma Is betrayal related to mental & physical health? Is betrayal risk related to gender? Are Physical and Mental Health Symptoms Also Related to Traumas? Goldsmith, Freyd, & DePrince (24), 185 college students, BBTS We assessed betrayal traumas and physical and mental health symptoms 185 college students (Goldsmith, Freyd, & DePrince, 24) 99 adult community members with health/pain problems (Freyd, Klest, & Allard, 25) Days Sick Number of physician visits Anxiety Depression Dissociation Exposure to Trauma with Less *.18* Exposure to Trauma with More.24**.26**.38**.35**.39** More betrayal is a significant predictor of both anxiety and depression. When we add less betrayal into the model (using multiple regression), R- square statistics change very little, and these changes are not significant. Freyd, Klest, and Allard (25), 99 Individuals From the Community with Chronic Illness and/or Pain, BBTS Gender and Traumatic Events Depression Anxiety Exposure to traumas with less betrayal.31**.39** Exposure to traumas with more betrayal.45**.49** More betrayal is a significant predictor of both anxiety and depression. When we add less betrayal into the model (using multiple regression), R-square statistics change very little, and these changes are not significant. Depression, anxiety, and dissociation are associated with exposure to betrayal traumas Other research suggests that women have higher rates of these sorts of mental health problems This raises the question: Is gender predictive of exposure to betrayal traumas? Dissociation.4**.46** Physical Illness Symptoms.31**.37** Copyright Jennifer J. Freyd, 26 Handout Page 6

7 What about Gender and Traumatic Events? Goldberg & Freyd (26) -- Lots of Gender Differences for Different Types of Event Occurrences Goldberg and Freyd (26) asked 75 homeowners about their trauma experiences Traumatic event rates were quite high for both males and females (as has been found by other researchers) But, specific event categories tend to show highly significant gender differences Violet indicates women report more; blue indicates men report more. Significant gender effects in bold. *** p <.1 Eugene-Springfield community sample: 422 women; 34 men Before 18 After 18 Earthquake, fire, flood Automobile, bike accident *** Witness...close...killed Witness...not close...killed.***.*** Witness...close...attack family member *** Attacked...close.6219.*** Attacked...not close.***.2*** Sex abuse...close.***.31*** Sex abuse...not close.***.1*** Emotionally mistreated.1***.*** Death of own child n too small.1454 Other traumatic event Observed Gender Differences Categorized by Degree of Goldberg & Freyd (26) A specific comparison.. Gender and Exposure to Physical Abuse: Close versus Not-close Attacks High Items (6 items) Medium Items (12 items) Low Items (6 items) Men Under Age 18 Men Over Age 18 Emotional Abuse Adult*** Report Emotional Abuse Adult*** More of Close Sex Abuse Child*** This Emotional Abuse Child*** Trauma Close Sex Abuse Adult*** (p<.1) Men Report More of This Trauma (p<.1) Not-close Sex Abuse Child*** Not-close Sex Abuse Adult*** Witness someone close attack family member Adult *** Not-close Attack Child*** Not-close Attack Adult*** Witnessed Not-close Death Adult*** Accident Adult*** Witness Not-close Attack Child*** Percentage reporting 2% 18% 16% 14% 12% 1% 8% 6% 4% 2% % Attacked by Attacked by someone someone not-close close Percentage reporting 2% 18% 16% 14% 12% 1% 8% 6% 4% 2% % Attacked by someone notclose Attacked by someone close Goldberg & Freyd (26) % of women and men reporting at least one high- and low-betrayal trauma Clinical Implications Part At Least One Traumatic Event Categorized High At Least One Traumatic Event Categorized Low Men is associated with dissociation, depression, anxiety & physical health symptoms is also highly associated with gender The majority of women experience betrayal traumas more likely to feel and be told they are crazy How clinicians provide education to clients, label them, etc., is important in this context At Least One Traumatic Event Categorized High At Least One Traumatic Event Categorized Low Men Copyright Jennifer J. Freyd, 26 Handout Page 7

8 Clinical Implications Part 3 Continued Close relationships and family are supposed to be safe places. Why is this accepted wisdom so different from the empirical reality for so many people? Are betrayal traumas disbelieved & discounted because they are disproportionately experienced by women? Issues of believeability and (in) validation are going to be important to your clients. General Clinical Implications of Trauma Theory & Research Therapist should be aware that the harm of trauma may often be betrayal (rather than or in addition to fear) May need to address trust and betrayal directly in therapy And once again Given the harm of betrayal trauma occurs in the context of relationships, healing human relationships are likely going to be crucial for some trauma survivors. Thank you! For full text articles and more info: Copyright Jennifer J. Freyd, 26 Handout Page 8