Editor’s note: For more information on this topic, see ISTSS’ free webinar recording, Trauma from an Intersectional Perspective, and scroll down for additional resources from the presenters.
A burgeoning body of trauma research has emerged over the past few decades. In particular, we as a field have developed an understanding of the sequelae of trauma exposure, including medical (e.g., cardiovascular health) and mental health (e.g., posttraumatic stress disorder [PTSD], depression) multimorbidity (Breslau, 2009; Schnurr et al., 2007). Furthermore, several evidence-based treatments have been established, facilitating recovery among trauma survivors (Beck & Sloan, 2020).
To date, the field of traumatology has largely operated through a diagnostic lens focused on PTSD. This approach has facilitated understanding of diagnosis, assessment and treatment; however, it has potentially hampered the conceptualization of trauma survivors’ lived experiences due to its emphasis on presence and severity of PTSD symptoms. In doing so, it has limited the understanding of the contribution of concurrent factors that impact individuals’ clinical presentations. Specifically, trauma rarely occurs in a vacuum, with trauma-exposed individuals often experiencing pre- (e.g., risky behaviors increasing likelihood of traumatization), peri- (e.g., loss of trust in support systems or institutions) and post-trauma (e.g., secondary traumatization by hospitals or legal entities) impacts on their psychosocial functioning.
The often-co-occurring adverse social determinants of health are an important aspect of understanding trauma and its impact. For example, a number of psychosocial stressors, such as unemployment, homelessness and justice involvement, are associated with notably high rates of trauma exposure (Deck & Platt, 2015; Dierkhising et al., 2013; Hartwell et al., 2015). Often these histories of trauma exposure begin in early childhood and involve chronic victimization. Indeed, across the socioecological levels with which survivors interact (e.g., intra- and interpersonal systems, community and systemic levels), there are a number of factors that can increase risk for traumatization (Campbell et al., 2009; Harvey, 1996). For instance, individuals experiencing homelessness report higher rates of trauma exposure than housed individuals (Bender et al., 2013). Similarly, rates of physical and sexual assault during incarceration are notably high (Wolff & Shi, 2009).
As such, a sole focus on the PTSD diagnosis may not fully capture the complex needs of trauma survivors. Psychosocial stressors are often incorporated into conceptualizations of trauma and associated psychiatric diagnoses (Tsai & Rosenheck, 2015), however, many common stressors (e.g., homelessness) cannot be sufficiently addressed through existing frameworks and instead often require stand-alone assessment and treatment. For instance, although trauma-focused evidence-based treatments, such as cognitive processing therapy and prolonged exposure therapy, have strong empirical support as a treatment for PTSD (see Watts et al., 2013), these interventions do not explicitly address needs related to these social determinants (e.g., criminal justice involvement; unemployment) and may in fact overlook these factors in order to prioritize addressing PTSD symptoms. Although PTSD recovery via trauma-focused treatment may generalize to other domains, thus resulting in more global improvement (e.g., reduced avoidance promotes pursuit of employment; improved sleep quality facilitates social and family engagement), in the absence of tailored interventions (e.g., interpersonal skills training, vocational rehabilitation) to address complex needs, these individuals may continue to find themselves in environments that perpetuate post-trauma or additional trauma exposure, thus creating a ceiling for the global effectiveness of a trauma-focused episode of care.
This disconnect is likely further exacerbated when considering additional sociocultural factors. It is well established that trauma exposure and adverse social determinants of health are overrepresented in subsets of the general population (e.g., trauma exposure among veterans; homelessness among LGBTQIA youth; criminal justice involvement among certain racial/ethnic groups). Nonetheless, a dearth of research examining trauma exposure among marginalized populations limits our understanding of these populations’ needs, clinical presentations and means of increasing treatment access and engagement. Furthermore, existing interventions have largely been validated upon White, non-Hispanic individuals of high socioeconomic status. Although several initiatives have sought to tailor treatment to diverse populations who are disproportionately impacted by social determinants of health, additional research remains necessary to fully understand the therapeutic response to existing interventions and methods as well as frameworks for adapting care for optimal response (Rathod et al., 2018).
As such, we implore the field to continue to expand the lens of assessing and treating trauma exposure among those experiencing complex, co-occurring psychosocial stressors. In particular, we assert that a bidirectional relationship between trauma and social determinants is well established, and we identify a need to continue to grow our conceptualization of common factors driving risk for traumatization and decreased psychosocial functioning among these populations. By understanding the elements that drive risk for re-traumatization and decreased psychosocial functioning, we can design protocols that are tailored to such at-risk populations (e.g., those with PTSD who experience housing and employment instability). Moreover, this examination can also elucidate specific elements necessary to augment existing treatment as a stand-alone intervention (e.g., addition of problem-solving skills to address financial or occupational difficulties to standardized trauma-focused care). Finally, given unique risk among several subsets of the general population, a comprehensive lens remains necessary to conceptualize a holistic, patient-centered model. Only then can we, as a field, fully understand the needs of all our patients and address them optimally.
About the Authors
Ryan Holliday, PhD, is a clinical research psychologist at the Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention and assistant professor at the University of Colorado Anschutz Medical Campus. His clinical and research interests focus on understanding the intersection of trauma, psychosocial stressors (such as homelessness and justice involvement) and mental health. He is further interested in translating these findings into evidence-based practice.
Alisha Desai, MS, is a clinical psychology doctoral candidate at Drexel University and a predoctoral psychology intern at Rocky Mountain Regional VA Medical Center. Her clinical and research interests focus on the intersection of trauma, justice involvement and substance use disorders among veterans, with an emphasis on the responsive delivery of evidence-based practice to address complex comorbidities and psychosocial stressors.
References
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