Domestic Violence Trauma 1. Running head: DOMESTIC VIOLENCE TRAUMA INTERVENTIONS

Domestic Violence Trauma 1 Running head: DOMESTIC VIOLENCE TRAUMA INTERVENTIONS The Trauma of Domestic Violence: A Counsellor s Guide to Effective Interventions Master of Counselling Project Letter of Intent Campus Alberta Graduate Program University of Calgary, Athabasca University, and Lethbridge University Francine Wilson-Symbaluk Supervisor: Paul Jerry July 17, 2006

Domestic Violence Trauma 2 The Trauma of Domestic Violence: A Counsellor s Guide to Effective Interventions The purpose of this project is to conduct a literature review to identify the current, effective interventions being applied to treat trauma symptomology due to domestic violence. Literature has identified the need for continued effort in research on the subject and the development of effective interventions to treat the detrimental psychological and physiological impact of trauma. The results of the literature review will be compiled as an intervention guide for counsellors working with women that have or are experiencing trauma due to domestic violence. Rationale and implications of the project provide a basis for its need including the high prevalence of domestic violence affecting women, the relationship of Post Traumatic Stress Disorder (PTSD) and Complex Post Traumatic Stress Disorder (CPTSD) to the experience of domestic violence, and the competency needs of counsellors required to meet the needs of this population. Overview Problem Statement This project is being conducted to identify the current interventions for the treatment of trauma symptomology related to the traumatic experience of domestic violence with a specific focus on the diagnosis of PTSD, and co-morbid CPTSD. The following questions will be addressed in this process: 1. What is the etiology of PTSD and of CPTSD? What are the contextual differences, complicating factors and differences in physiology between the diagnoses? 2. What led to the development of CPTSD and what are the current developments in the literature? 3. How is the development CPTSD, co-morbid to PTSD, related to the trauma of domestic violence and how are the separate diagnoses distinguished?

Domestic Violence Trauma 3 4. What types of traumatic events may lead to the development of CPTSD and how are they different from those leading to the development of PTSD. 5. How does trauma, related to domestic violence differ from that of other traumatic events? 6. What are the effective interventions supported by the literature for the treatment of PTSD and CPTSD resulting from the traumatic experience of domestic violence? What are the differences and are there common elements? Rationale Although numerous trauma interventions have been developed and are applied in treating its psychological and physiological impact, none demonstrate an empirically supported curative element specifically in cases of severe trauma symptoms resulting in PTSD (Foa, Keane, & Friedman, 2000). The nature of trauma impact is an important element in the development of effective trauma interventions. Based on clinical studies, an increasing number of psychologists consider PTSD to be the most accurate diagnosis for victims of domestic violence (Walker, 1994 as cited in Paul, 2004). It has also been argued that PTSD, as described in the DSM IV, does not fit all the reactions experienced by victims exposed to repeated and extensive abuse (Courtois, 2004). In response, researchers have proposed the existence of complex post-traumatic stress disorder (CPTSD), which addresses those symptoms that are not included in the diagnosis of PTSD. Currently 7% of women in Canada are subjected to domestic violence with 72,000 reported cases among women in Alberta in 2004 (Alberta Justice Communications, 2005). Based on the correlates between domestic violence and the development of PTSD, and more specifically, CPTSD, the prevalence of these disorders may be very high. Inquiry into the relationship between PTSD and CPTSD, and appropriate interventions for trauma resulting from domestic

Domestic Violence Trauma 4 violence is thus warranted. This information will be accessed and presented in the form of a guide for counsellors that aims to increase the effectiveness of treatment for trauma resulting from domestic violence among women. Conceptual Foundations According to a study by Norris (as cited in Keane, Weathers & Foa, 2000) 69% of adults experience one or more traumatic events in their lifetime. Of these individuals, 25% will develop acute psychiatric disorders including Acute Stress Disorder and/or Post-Traumatic Stress Disorder (Keane et al., 2000; National Institute for Clinical Excellence [NICE], 2005). Current trauma interventions are based on a diverse set of psychological theoretical assumptions of human behaviour, however, no one curative intervention exists for the treatment of trauma symptomology. Domestic violence. According to Robertiello (2006), studies focusing on the mental health effects of domestic violence are few, however, within those conducted, domestic violence has been strongly correlated with both physical and mental disorders including symptoms of depression, suicide ideation, and PTSD. It has been indicated that among women that have experienced domestic violence, 74% present with various forms of PTSD (Woods, 2000). Further, the existing research has demonstrated the correlation of psychological, behavioural, social/environmental, and biological factors to the development of PTSD among abused women (Morrell & Rubin, 2001; Robertiello, 2006; Yehuda, 1999). The severity and intensity of domestic violence has been positively correlated with the severity of PTSD symptoms experienced (Roberts, 2002 as cited in Robertiello, 2006). CPTSD. Complex trauma is a relatively new term that was created in response to the discovery that some trauma is as more pervasive and complicated than other trauma that

Domestic Violence Trauma 5 generates complex reactions that are additional to those identified under PTSD (Courtois, 2004). Situations that may lead to complex trauma include acute/chronic illness that requires medical intervention, child abuse, and experiences of war (Courtois, 2004). Domestic violence, characterized as occurring over extended periods of time during which an individual is entrapped and conditioned in a number of ways, is also an identifiable situation that leads to the experience of complex trauma (Courtois, 2004). Currently, CPTSD falls under the categorization of disorders of extreme stress not otherwise specified (DESNOS; Pelcovitz et al., 1997 as cited in Courtois, 2004) and is co-morbid with PTSD. According to Courtois (2004) research of CPTSD interventions suggests many treatment strategies must be utilized from a variety of perspectives in order to address clients multiple concerns. CPTSD intervention has been deemed as transtheoretical in nature and based on biopsychosocial components that require an array of linked biopsychosocial treatment approaches (Courtois, 2004). Method The intention of this project is to provide a greater understanding of the current theoretical perspectives and psychological interventions for the treatment of trauma due to domestic violence. A review of the literature will be conducted to gather information focusing on these areas with from within both qualitative and quantitative studies. The findings will then be synthesized and organized to outline the main theoretical approaches and the current effective interventions, which will serve as a guide for counsellors. This guide will entail the conceptual understanding of each of the research questions posed within a 30-page document. This document will be available to counsellors whose clientele includes women that are experiencing, or have experienced, domestic violence.

Domestic Violence Trauma 6 Approach. The process of the literature review will be systematic following, Nine Building Blocks to the Literature Review (Campus Alberta Graduate Program, n.d.) (See Appendix A). Research on the topic of the impact of trauma, theoretical approaches and effective interventions related to domestic violence will be accessed. The identification of a set of potential articles and books relevant to these topics will involve searching the electronic databases of PsycInfo, PsycLit, PsycARTICLES, and Psychology and Behavioral Sciences Collection. This search will be augmented by reviewing the reference sections of each article and book obtained from the database search. Key words used in the search process will include trauma, domestic+violence+trauma, trauma+intervention, PTSD+domestic+violence, and CPSTD+domestic+violence. An Internet search will also be utilized to access educational and informational websites addressing trauma and related psychiatric disorders. To be included as viable sources, research articles must: (a) address domestic violence, trauma related symptoms, and psychiatric disorders, (b) have been applied to a population of 18 years and older, and (c) been published in the year 1995 or later. Excluded studies are those that involve treatment intervention for domestic violence for populations other than women and/or focus on a co-morbidity of disorders, gender, or cultural factors in trauma. Quantitatively designed research will include controlled randomized trials or a meta-analysis of existing data resulting in statistically significant results. Qualitative research will include the experiences and perspectives held by women experiencing domestic violence. The collection of studies will continue until the point of saturation has been reached. Once the sources of research have been obtained, they will be read and the retrieved information noted including: (a) the theoretical approach to trauma, (b) the intervention utilized, (c) the type of outcome measures (quantitative or qualitative), and (d) results of

Domestic Violence Trauma 7 efficacy. The research will be evaluated and findings regarding trauma interventions will be analyzed. A synthesis of these finding s will be organized and presented in the form of a guide for counsellors treating individuals that demonstrate trauma symptomology due to the experience of domestic violence. Implications This project has positive implications for a number of groups. Individuals in the fields of psychological and psychobiological trauma research and counsellors offering therapeutic interventions with individuals for the treatment of trauma related to domestic violence will benefit from a clear synthesis of literature and a guide to effective intervention. As well, clients within this population will benefit by receiving effective interventions to address their needs. Specifically, results of the project will offer a synthesis of the current literature focused on effective interventions for the treatment of trauma experienced due to domestic violence. Commonalities between the interventions will be provided that may offer a new perspective that bridges theoretical approaches. This is in contrast to the ongoing controversy and debate among current therapeutic trauma interventions (Bisson et al., 2000; Chemtob et al., 2000; Davidson & Parker, 2001; Ironson et. al., 2002; Lebow, 2003; McNally et al., 2003; Mitchell, 2003; Sikes & Sikes, 2003; Shapiro, 2002; Sykes Wylie, 2004). Counsellors will benefit from the project by gaining an overall orientation to the field of trauma research, as well as an understanding of the various treatment interventions that currently exist. The results will be presented in the form of a guide for appropriate, effective interventions for counsellors working with individuals from within this population. A correlation exists between experiencing domestic violence and the development of PTSD, and more recently, CPTSD. At the same time, a high prevalence of domestic violence in Canada exists. It is

Domestic Violence Trauma 8 therefore highly probable that counsellors will, at some time, be faced with clients requiring effective treatment of trauma related symptoms due to an experience of domestic violence. For the individual counsellor a greater understanding of the nature of trauma on humans, higher confidence in interventions gained through empirical studies showing support for specific treatments, and an increased sense of competency will benefit the counsellor s ability to offer sound therapeutic assistance to clients. As such, there is an increased likelihood that clients will benefit from the project through the application of the knowledge gained by counsellors. Lastly, through the completion of this project, it is intended to identify effective interventions and stimulate further research into the field of trauma to prevent or mitigate the detrimental symptoms of trauma exposure on the human mind and body. Conclusion At this time, many interventions exist under a number of philosophical assumptions of human nature and, while debate continues on the true nature of trauma impact, many clients continue to chronically suffer from the trauma of domestic violence. Insight into the relationship of PTSD and CPTSD and domestic violence and the current interventions offers the counselor knowledge into providing competent and effective counselling services to their clients.

Domestic Violence Trauma 9 References Alberta Justice Communications. (2005). Domestic violence handbook for police and crown prosecutors in Alberta. Edmonton, AB: Author. Bisson, J. I., McFarlane, A. C., & Rose, S. (2000). Psychological Debriefing. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds). Effective treatments for PTSD (pp.18-38). New York, NY: Guilford Press. Campus Alberta Graduate Program (n.d.). Nine building blocks to a literature review. Retrieved November 23, 2005 from http://www.abcounsellored.net/courseware/caap617lesson2presentation2.ppt Chemtob, C. M., Tolen, D. F., van der Kolk, B. A., & Pitman, R. K. (2000). Eye Movement Desensitization and Reprocessing. In E.B. Foa, T.M. Keane, & M.J. Friedman (Eds). Effective New York, NY: The Guilford Press. Courtois, C. (2004). The psychological impact of trauma: Theory, research, assessment and intervention. Psychotherapy: Theory, Research, Practice and Training, 41(4), 412-425. Davidson, P. R., & Parker, K. C. H. (2001). Eye Movement Desensitization and Reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305-316. Foa, E. B., Keane, T. M., & Friedman, M.J. (Eds). (2000). Effective treatments for PTSD. New York, NY: Guilford Press. Ironson, G. I., Freund, B., Strauss, J. L., & Williams, J. (2002). A comparison of two treatments for traumatic stress: A community based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58, 113-128.

Domestic Violence Trauma 10 Keane, T. M., Weathers, F. W., and Foa, E. B. (2000). Diagnosis and assessment. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds), Effective treatments for PTSD (pp.18-38). New York, NY: Guilford Press. Lebow, J. (2003). War of the worlds: Researchers and practitioners collide on EMDR and CISD. Psychotherapy Networker, 27(5). Retrieved April 12, 2006 from http://pqasb.pqarchiver.com/psychotherapynetworker/679023071.html?did=679023071&fm T=ABS&FMTS=FT&date=Sep%2FOct+2003&author=Jay+Lebow&pub=Psychotherapy+Ne tworker&desc=war+of+the+worlds McNally, R. J., Bryant, R. A., & Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 2, 45-79. Mitchell, J.T., & Everly, G.S. (2003). Critical incident stress management (CISM): Group crisis intervention, (Rev. ed.). Ellicott City, MD: International Critical Incident Stress Foundation, Inc. Morrell, J. S., & Rubin, L. J. (2001). The Minnesota Multiphasic Personality Inventory-2, posttraumatic stress disorder, and women domestic violence survivors. Professional Psychology: Research and Practice, 32(2), 151-156. National Institute of Clinical Excellence. (2005). Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care. Retrieved April 11, 2006 from http://www.nice.org.uk/pdf/cg026niceguideline.pdf Paul, M. (2004). Clinical implications in healing from domestic violence: A case study. American Psychologist, 59(8), 809-816.

Domestic Violence Trauma 11 Robertiello, G. (2006). Common mental health correlates of domestic violence. Brief Treatment and Crisis Intervention, 6, 111-121. Shapiro, F. (2002). EMDR 12 years after its introduction: Past and future research. Journal of Clinical Psychology, 58(1), 1-22. Sikes, C., & Sikes, V. (2003). EMDR: Why the controversy. Traumatology, 9(3). Retrieved April 12, 2006 from http://www.fsu.edu/~trauma/v6i3/v6i3a3.html Sykes Wylie, M. (2004). The limits of talk: Bessel van der Kolk wants to transform the treatment of trauma. Psychotherapy Networker, 28(1), 30-41. Retrieved April 12, 2006 from http://www.traumacenter.org/networker.pdf Woods, S. J. (2000). Prevalence and patterns of posttraumatic stress disorder in abused and postabused women. Issues in Mental Health Nursing, 21, 309-324. Yehuda, R. (1998). Psychoendocrinology of post-traumatic stress disorder. Psychiatric Clinics of North America, 21(2), 359-379.

Domestic Violence Trauma 12 1. Identify the research topic/focus. 2. Review secondary sources. 3. Develop a search strategy. 4. Conduct search. Appendix A: Nine Blocks to a Literature Review 5. Read and prepare bibliographic information and summary notes. 6. Critically review (evaluate) research literature. 7. Obtain and read primary sources and note and summarize the key points in the sources. 8. Synthesize main themes from the literature to develop conceptual/theoretical framework, research questions, and/or hypothesis, 9. Write several drafts to the literature review (get feedback).