Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. I Defining Trauma: Exploring frameworks, theories, and measurement with clinical psychologists A thesis presented in partial fulfilment of the requirements for the degree of Master of Arts In Psychology at Massey University, Manawatu, New Zealand Georgia Bishop-Matthews 2023 II Abstract Traumatic experiences are a devastating part of the human experience, with a significant percentage of the population experiencing at least one traumatic event in their lifetime. The way in which we are affected by these experiences dramatically differs from person to person, yet we are all assessed by the same standards and criteria. The present study aims to investigate the post-trauma presentations seen by psychologists in those seeking trauma treatment, how patients are affected by their experiences and whether this is reflected in quantitative measures designed to evaluate post-traumatic pathology. Most of the literature argues that psychometrics are accurate and effective due to their ability to identify the criteria assigned to a post-traumatic diagnosis. This study suggests that the criteria itself only fits a marginal proportion of those who have experienced trauma; therefore, those measures cannot be universally applicable. This is not an issue that has been examined in literature to date. Thematic data from interviews with practicing psychologists has been analysed to examine how trauma presents in their clients, their preferred methods of assessment and treatment, as well as how they determine progress. Contrary to what is often assumed, trauma presents in an unquantifiable manner, with significant variations between individuals. Post-traumatic pathology is influenced by every factor surrounding the event and everything that follows. While quantitative measures provide objectivity and ease of use, trauma is a deeply subjective experience. As such, a qualitative approach to diagnostics and treatment should be the standard in trauma care to give patients the best chance of recovery. This change would have far-reaching implications for those accessing and providing services, especially supplying agencies such as ACC that rely on objective measures to assess need. III Table of Contents Abstract ..................................................................................................................................... II Introduction ............................................................................................................................... 1 Defining Trauma ....................................................................................................................... 1 Theories ..................................................................................................................................... 2 Nachträglichkeit ........................................................................................................................................... 2 Constructivist Self-Development Theory....................................................................................................... 3 Conditioning.................................................................................................................................................. 4 Physiological ................................................................................................................................................. 6 Types of Trauma ....................................................................................................................... 8 Acute, Chronic and Complex Trauma ........................................................................................................... 8 Secondary Trauma ........................................................................................................................................ 9 Reactions to trauma ............................................................................................................... 13 Stress ...........................................................................................................................................................13 Acute Reactions ..........................................................................................................................................13 Post-Traumatic Stress Disorder ..................................................................................................................15 Complex-PTSD .............................................................................................................................................16 Treating Trauma ...................................................................................................................... 22 IV Trauma Focused - Cognitive Behavioural Therapy .....................................................................................23 Dialectical Behavioural Therapy .................................................................................................................24 Prolonged Exposure ....................................................................................................................................24 Eye Movement Desensitisation and Reprocessing .....................................................................................26 Measuring Trauma .................................................................................................................. 28 Quantitative Data .......................................................................................................................................28 Qualitative Data .........................................................................................................................................33 Method ..................................................................................................................................... 38 Participants .................................................................................................................................................40 Recruitment ................................................................................................................................................40 Procedure ....................................................................................................................................................41 Ethical considerations .................................................................................................................................42 Analysis .......................................................................................................................................................42 Summary .....................................................................................................................................................43 Analysis and Discussion ....................................................................................................... 44 Defining Trauma .........................................................................................................................................44 Responses to Trauma .................................................................................................................................48 V Culture and Spirituality ...............................................................................................................................57 Measurement (symptoms) .........................................................................................................................63 Progress Measurement...............................................................................................................................70 Data ............................................................................................................................................................72 Treatment ...................................................................................................................................................75 Key factors in treatment .............................................................................................................................78 Summary .....................................................................................................................................................80 Limitations ............................................................................................................................... 82 Strengths ................................................................................................................................. 83 Conclusion .............................................................................................................................. 83 References............................................................................................................................... 87 VI List of Tables Table 1 – Influences on Post-Trauma outcomes ............................................................ 57 Table 2 – Psychometric Use Frequency ........................................................................ 67 Table 3 – Progress Measurement Frequency ................................................................ 72 Table 4 – Treatment Method Frequency ........................................................................ 77 Appendices Appendix A WHO Mental Health Survey items ............................................................ 111 Appendix B Information Sheet ..................................................................................... 113 Appendix C Consent Form .......................................................................................... 115 Appendix D Interview Schedule (Phase I) .................................................................... 116 Appendix E Online Interview (Phase II) ....................................................................... 118 Appendix F Ethics Approval........................................................................................ 121 1 Introduction Traumatic experiences are a devastating part of the human experience. Despite our best efforts to avoid harm, trauma is commonplace. From natural disasters to intimate partner violence to child abuse, almost everyone will experience at least one traumatic event in their lifetime. The prevalence of trauma is well recognised in the current literature and in our society. Yet, even after decades of research, the way in which trauma can erode an individual or community’s entire livelihood is rarely reflected in the literature, and not at all consistent with the longstanding methods of evaluating post-traumatic pathology. Experiencing a traumatic event is one of the most deeply personal things we can go through, despite that, we are all assessed through evaluation of identical symptoms, representative of a diagnostic criteria that is supposably universally applicable. The present study asks how such a subjective experience could possibly be measured objectively, and questions the capability of a single, Westernised criteria in identifying those who are struggling in the aftermath of a traumatic event. This study acknowledges what we know about trauma and how our understanding has evolved over the decades, past and present theories of traumatic pathologies, recognised post-traumatic disorders, assessment and treatment, and how this knowledge compares to first-hand experiences of psychologists treating traumatised populations. This research aims to start a conversation around the discrepancies between how trauma affects us, and the guidelines by which it is evaluated. Defining Trauma Despite decades of research in the field, trauma remains a concept without a stipulated definition. Definitions vary depending on whether the writer views trauma as an event or a response. Some explanations focus on occurrences that are collectively considered 2 traumatic, including war, natural disasters, accidents causing injury, violence and abuse, and death (Benjet et al., 2016; Kessler et al., 2017). Others attend to individual experiences and responses to a specific event or series of events (Wathen, Schmitt & MacGregor, 2021). These events are typically unexpected, uncontrollable, and involve actual or threatened death or injury to oneself or others, eliciting feelings of fear and helplessness (Bartoskova, 2015; Hesse, 2002). Pagel (2020) defined trauma as a catastrophic event in which individuals witnessed or were personally threatened with death, physical harm, or sexual violence. Other definitions of trauma are broader, using the term to explain the stress of a negative event that exceeds a critical level (Christiansen, Iversen, Ambrosi & Elklit, 2016). What is traumatic for one person may not be traumatic for another, and the impact of a trauma leaves a lasting imprint on an individual’s nervous system, emotions, behaviours, body, and relationships (de Thierry, Reeves & Music, 2020). Regardless of the exact definition, several types of trauma have been proposed, each with independent pathology, presentation, and necessary treatment. Theories Researchers and clinicians alike have long endeavoured to understand the mechanisms behind post-traumatic pathology. The following chapter explores a range of theories, from the early hypotheses of post-traumatic processes to some of the more recent circulating theories. Nachträglichkeit Early in the exploration of trauma theory, Freud introduced the concept of Nachträglichkeit, which roughly translates to "afterwardsness" or deferred action (Thöma & Chesire, 1991). Freud's original hypothesis was that individuals presenting with hysteria or obsessive-compulsive behaviour had experienced "physical seduction" (Breuer & Freud, 3 1957) in childhood or infancy when their minds were unable to interpret the sexual nature of the event. Nachträglichkeit was used to explain how sexual encounters in childhood may not be interpreted as traumatic at the time, but may later manifest in traumatic ways after puberty, when new meanings are ascribed to the memories resulting in feelings such as guilt and shame (Fletcher, 2013). Although Freud's theory was proposed in private and later abandoned, the concept was adopted by various scholars. The theory of Nachträglichkeit suggests that in some cases, the effects of a potentially traumatic event may be delayed by several years and require significant change, such as aging, to arise. This delayed onset of traumatic pathology may be logically determined. The theory has also been used to explain traumatic pathology in those who do not meet the traumatic event criterion of the DSM criteria for Post-Traumatic Stress, as the meaning of an event may change over time, resulting in traumatic symptomology (Bistoen, Vanhuele & Craps, 2014). While Freud's point of view relates Nachträglichkeit exclusively to the conversion of previously stagnant memories into sexual trauma, others suggest that the concept should be broader. They propose that every time we revisit our past, we are calling on Nachträglichkeit (Faimberg, 2007; Stern, 2011). This is based on the idea that every present and future experience continues to change how we understand our past experiences. Freud’s theory provides a possible explanation for a delayed onset of symptoms following a traumatic event. However, decades have passed since the conception of Nachträglichkeit, and many theories have been proposed in this time, mostly focusing on the human experience itself playing a role in the onset of pathology, such as Constructivist Self-Development Theory. Constructivist Self-Development Theory Constructivist Self-Development Theory (CSDT) is a more modern theory of post- 4 traumatic mechanisms. CSDT acknowledges a fundamental need we all possess: to believe that the world is safe and that we, personally, are safe (Baird & Kracen, 2006). In response to this belief, everyone develops cognitive schemas about themselves and the world around them, which serve as a guide and personal roadmap (McCormack & Adams, 2016). This theory suggests that changes that occur in the aftermath of traumatic events result from a disturbance in at least one of these schematic areas (Baird & Kracen, 2006). CSDT is an integrative personality theory that combines aspects of psychoanalytic, social learning, and cognitive developmental theories rooted in constructivist thinking, according to Saakvitne, Tennen, and Affleck (1998). The theory describes personality development as the interaction between core self-capacities (such as early relationships, secure attachments, and internal resources) and constructed beliefs and schemas built upon cumulative experience. This theory highlights the aspects of self that construct an individual's personality and are also the most likely to be affected by a traumatic event. These areas are perhaps the most vulnerable and susceptible to change, but they are also the areas that may be strengthened as an individual heals from trauma. Constructivist self- development theory emphasizes the influence of an individual's developmental, social, and cultural contexts on how they experience a traumatic event and its aftermath. Conditioning A further argument for how reminders of an event can trigger an emotional response is rooted in Pavlovian conditioning. One of the earliest and most well-known cases demonstrating the role of classical conditioning in anxiety disorders is that of Little Albert. Conducted by Watson and Rayner in 1920, the study aimed to condition a generalised fear of animals and objects in an 11-month-old infant. After repeatedly pairing a sound that was known to upset the child with a white rat over a short period of time, the child began to get upset at the sight of the rat in the absence of the sound (Watson & Rayner, 1920). This 5 emotional response was reported to be generalised to other white, fluffy animals and objects. The child also reacted to items that were not directly involved in the experiment but were in the environment at the time of conditioning. This study has become a point of contention amongst researchers due to ethical issues, confirmation bias, and limitations, as well as concerns for the health of the child (Digdon, 2020). Regardless, fear conditioning remains a common paradigm in the aetiology of anxiety disorders, including post-traumatic stress disorder (PTSD). It is proposed that during a traumatic event, an individual's surroundings and things that may have occurred shortly before the event, including sights, sounds, and smells, are encoded to memory alongside the event (De Houwer, 2020; Franke et al., 2021). Following the event, encountering those same sights, sounds, and smells in the absence of a threat can evoke memories, feelings, and physiological responses associated with the trauma (Franke et al., 2021). These cues that were present in the environment shortly before or during a traumatic event can become predictors of danger, sometimes on a purely subconscious level (Ehlers & Clark, 2000; Elzinga & Bremner, 2002). This means that someone may begin re- experiencing a trauma seemingly randomly, not realizing that something in the environment - a sight, sound, or smell - has triggered the activation of those memories. People may also experience emotional reactions without recollection of the memories (Ehlers & Clark, 2000), which can make it exceedingly difficult for them to identify their reaction as a trauma response, and even harder for the person to understand that there is no active threat. This association of environmental cues with danger is a survival mechanism and a normal response of fear memory (Johnson, McGuire, Lazarus & Palmer, 2014). However, in PTSD, these responses are often amplified and fail to extinguish over time, thus becoming 6 debilitating. The biological processes behind these mechanisms have been proposed as a separate theory, providing a neurological explanation for post-traumatic symptoms. Physiological Reactions to trauma can be understood on a physiological basis, as traumatic events take a toll on both the body and the mind. Post-traumatic stress disorder is marked by a significant increase in arousal, which is a result of autonomic nervous system activation (van der Kolk, 1994; Zaleski, Johnson & Klein, 2016). Hyperarousal of the autonomic nervous system typically occurs in response to a threat, leading to heart rate increase, cold sweats, rapid breathing, heart palpitations, hyper-vigilance, and an exaggerated startle response (Rothschild, 2000; Blechert et al., 2007). Although this state is typically short-lived, passing with the perceived threat, it can result in sleep disturbances, loss of appetite, sexual dysfunction, and difficulty concentrating if it becomes chronic, which are common symptoms of PTSD (Nixon et al., 2005). This is largely due to activation of the limbic system, located in the centre of the brain between the cerebral cortex and the brain stem, this system controls all arousal. Regulating survival behaviours such as eating, reproduction, and fight, flight or freeze responses (Tyler, 2012). It also influences emotional expression and memory processing (van der Kolk, 1994). The limbic system receives information and evaluates a situation, then feeds that information to the autonomic nervous system (ANS). When a threat is perceived, the ANS activates either the sympathetic nervous system (SNS) or the parasympathetic nervous system (PNS). The SNS is involved in the aggressive (fight) and avoidance (flight) response, while the PNS can trigger a dissociative (freeze) response (Tyler, 2012). The freeze response is also observed when the SNS and PNS are activated simultaneously, resulting in an altered state of consciousness in which fear and pain are minimised to provide the best chance of survival (van der Kolk, 1994). 7 During this process, several chemical changes take place, including the release of epinephrine and norepinephrine (van der Kolk, 1994). Once the threat has passed, cortisol is released to halt this chemical production, enabling the body to return to baseline functioning. People with PTSD may not have sufficient cortisol to stop the alarm reaction, resulting in chronic ANS arousal (Yehuda et al., 1990). ANS activation through the limbic system in reaction to a traumatic event is a healthy, adaptive survival response. However, when this arousal continues despite the threat having passed, it can result in PTSD symptoms. Studies investigating the correlation between this reaction and the onset of PTSD have discovered that those who experienced high levels of panic or dissociation (Bryant & Panasetis, 2001; Nixon & Bryant, 2003) and those with an elevated heart rate immediately, one week, one month, and four months following a traumatic event (Shalev et al., 1998) were more likely to develop post-traumatic pathology. Traumatic event processing also occurs within the limbic system, specifically the hippocampus and the amygdala. The amygdala is involved in the processing of emotionally charged memories, such as those surrounding a traumatic event (van der Kolk, 1994). The hippocampus processes events within our timeline, providing them with a beginning, middle, and end (Mujawar, Jaideep, Chaudhari & Saldanha, 2021). During traumatic events, this process is often suppressed, and the event is therefore not processed and stored correctly, leading it to continue invading the present (van der Kolk, 1994). The perception of the event being over, and the individual having survived is missed in memory consolidation. This mechanism is a possible cause of flashbacks in PTSD. Many in the field do not subscribe to any particular theory, rather seeing trauma as a point of intersection between emotional, physical, spiritual, cultural, and structural avenues (Buelens, Durrant & Eaglestone, 2013). Even so, there is a shared acknowledgement of various types of trauma. 8 Types of Trauma Acute, Chronic and Complex Trauma Acute trauma is typically associated with a single event that endangers an individual's safety, such as a car accident or experiencing or witnessing violence. In contrast, incidents that occur repeatedly, such as long-term child abuse, domestic violence, or combat situations can lead to chronic trauma (Fullerton & Ursano, 2009). In certain circumstances, individuals who have experienced extensive, prolonged harm may be exposed to complex trauma. All traumatic events can have a profound impact on an individual's life, both immediately and in the long term. However, the longer someone is exposed to trauma, the greater the impact is likely to be (Bryant et al., 2017). There are several possible factors that may impede or facilitate healing from a traumatic event. With solitary traumatic events, for example, survivors can often seek safety once the event is over. On the other hand, complex trauma is ongoing or frequently repeated, offering very little time for people to recover. This may be because it often occurs in secrecy, preventing the person from talking about it and getting help, or due to the prolonged nature of chronic trauma. It is also worth acknowledging that many acute events, such as car accidents or natural disasters are shared experiences and are often made public. The collective nature of some singular events promotes awareness and builds connections within a community, potentially validating survivors and reducing shame. In most cases, complex trauma events are interpersonal and begin early in life (Briere & Scott, 2015; Wamser-Nanney & Vandenberg, 2013). Trauma in childhood can interrupt development, leading to difficulties with emotions, concentration, and memory, which can result in ongoing challenges maintaining safe relationships (Greenberg, 2020). The interpersonal nature of complex trauma means that it occurs within a relationship that is 9 meant to be safe, and survivors often feel as though they were unable to escape, leading to chronic feelings of helplessness (Greenberg, 2020). The discrepancies between how things should be and how they are create an inner conflict that results in survivors doubting themselves and feeling unsafe when they grow close to people outside of the trauma. Essentially, complex trauma changes the way people think, behave, and feel about themselves and others. It can lead to difficulties with thinking and concentration, struggling to feel present in one's own life, lack of attention, dissociation, problems with memory, and trouble with emotional regulation (Briere & Scott, 2015). These struggles can result in complex post-traumatic stress disorder, developmental trauma disorder, disorders of extreme stress not otherwise specified, or enduring personality changes (Briere & Scott, 2015; Wamser-Nanney & Vandenberg, 2013). Secondary Trauma It is possible to feel the effects of trauma without having experienced a traumatic event directly. The impact of trauma extends far beyond those directly involved and can have a significant effect on those who assist victims of trauma, such as mental health professionals (Jenkins & Baird, 2002). Professionals in these roles dedicate their practice to helping others in the wake of traumatic exposure. As a result, they have a multitude of traumatic narratives relayed to them on a regular basis, which in itself is a form of indirect trauma. Efforts to clarify the stress placed on those who work with survivors of trauma have produced a handful of terms, including burnout, compassion fatigue, secondary trauma, and vicarious trauma (Bride, 2007; Baugerud, Vangbaek & Melinder, 2018). These terms are often used interchangeably, although some clear differences have been identified. Burnout is a possible side effect across a range of professions and is not specific to trauma-related work. Symptoms of burnout include emotional exhaustion, physical fatigue, 10 depersonalization, and feelings of self-inefficacy, often in the context of chronic stress (Barrington & Shakespeare-Finch, 2014). Studies have suggested that burnout occurs when the demands of a job outweigh the resources, and that measurement of these factors can be predictive (Bakker, Demerouti & Euwema, 2005). The current central hypothesis follows a job demands-resources model, with the assumption that while every job is likely to have its own risk factors associated with stress or benefit, they can be classified as demands or resources, resulting in a format that can be applied to any role irrespective of field. Bakker, Demerouti and Euwema (2005) described job demands as any aspects of an individual’s role that require sustained physical or mental effort and therefore take a physiological and psychological toll. Job resources, on the other hand, include aspects such as social support from colleagues and supervisors, role autonomy, constructive feedback, and regular appraisal of good performance (Bakker, Demerouti & Euwema, 2005). Several job resources may buffer the impact of various job demands, including stress reactions such as burnout, although these interactions are also likely to differ between individuals and occupational characteristics. Burnout as an idea is far better developed and documented than trauma-specific concepts, as it relates to a wide range of occupational stress. Currently, it is conceptualized as a defensive response to prolonged occupational strain in situations that provide minimal support (Jenkins & Baird, 2002). The symptoms of which can be monitored with measures such as the Maslach Burnout Inventory (Maslach, Jackson & Leiter, 1997). Cases of burnout in those who work with trauma survivors can escalate and cause significant impairment if not addressed or mediated. A potential decompensation of burnout is compassion fatigue. Definitions of compassion fatigue vary, with many researchers using the term to describe secondary or vicarious trauma (Figley, 1995). A more inclusive definition is provided by Cocker and Joss (2016), who explain that the empathetic ability of the caregiver becomes compromised as a 11 result of prolonged exposure to overwhelming stress of others’ needs. Compassion fatigue often occurs due to burnout in those vulnerable to secondary trauma, such as those working with trauma survivors (Baird & Kracen, 2006). Although it can also occur after short instances of exposure, such as emergency responders assisting survivors of an accident (Baird & Kracen, 2006; Barrington & Shakespeare-Finch, 2014). Symptoms of compassion fatigue arise from an individual's inability to cope with their everyday environment due to a state of total physical and mental exhaustion. This concept is characterized by exhaustion, irritability, maladaptive coping behaviours, a reduced capacity for sympathy and empathy, loss of interest in work leading to absenteeism, and an impaired ability to make decisions about patient care (Cocker & Joss, 2016). While practicing mental health professionals are at risk of compassion fatigue, some have suggested that the satisfaction derived from their work is a protective factor. This has been posited as a buffering factor referred to as compassion satisfaction and could include any positive influence within an individual's profession or their beliefs about themselves (Hernandez-Wolfe, Killian, Engstrom & Gangsei, 2015). Despite the use of compassion fatigue to discuss vicarious or secondary trauma, the effects of compassion fatigue do not encompass the cognitive disruptions that occur because of traumatic exposure (Barrington & Shakespeare-Finch, 2014). The term vicarious trauma was coined by McCann and Pearlman in 1990, having been conceptualized within constructivist self-development theory, to describe the change that occurs within a trauma worker due to empathetic engagement (Pearlman & Mac Ian, 1995). Many believe that vicarious traumatization is an inevitable result of working with trauma survivors and hearing their narratives (Baird & Kracen, 2006; Barrington & Shakespeare-Finch, 2014; Finklestein et al., 2015). It carries a significant cost for the 12 professional, presenting with many of the same symptoms as post-traumatic stress disorder, the differentiating factor being that the sufferer has not experienced the trauma directly (Linley & Joseph, 2007). Vicarious trauma is most often seen in therapists and other mental health workers due to repeated empathetic engagement with trauma narratives, resulting in disrupted cognitive schemas, hyperarousal, avoidance of triggers and cues, and intrusive imagery related to trauma narratives they have heard (Baird & Kracen, 2006; Finklestein et al., 2015; Linley & Joseph, 2007). Changes within an individual that occur due to vicarious trauma, as with direct trauma, challenge their beliefs about themselves and the world around them. These changes are pervasive and permanent and may significantly impact the ability to do one's job, especially as a trauma worker (Baird & Kracen, 2006). It has been suggested that when a clinician is suffering, they struggle with increasingly negative thinking in five key areas: trust, safety, control, esteem, and intimacy (Barrington & Shakespeare- Finch, 2014). Mental health workers rely on their ability to form empathic bonds with their clients. Unfortunately, it is this empathy that creates a vulnerability to vicarious traumatization, as clinicians risk taking on the pain of their clients (Hernandez Wolfe et al., 2015). It is important to note that this outcome does not speak to the pathology of the clinician, nor is it the intention of clients. Several characteristics that may influence the development of vicarious trauma in therapists have been posited, including personal trauma history, the meaning of certain events to the therapist, their psychological and interpersonal style, their training, and current stressors and supports (Pearlman & Mac Ian, 1995). 13 Reactions to trauma Stress Stressors, whether positive or negative, are a constant part of life. They are essentially events or circumstances that require us to adapt to maintain our wellbeing. The demand placed on an individual’s physical and psychological resources to respond to these events is quantified as stress. Stress reactions are our emotional, physical, cognitive, and behavioural responses to stressors, designed to protect us from harm, achieve goals, or gain access to additional resources (Ford, Grasso, Elhai & Courtois, 2015). The overall goal of our biological stress response is to meet the demands of the stressor and maintain or return to our baseline health. However, resource allocation to a stressor that continues after the circumstance has passed depletes personal resources, and the system can become overwhelmed by the demands of ordinary day-to-day stressors. Ford et al. (2015) identified three features that consistently distinguished ordinary stressors from those that resulted in traumatic stress: severe life-altering injury, unpredictability, and uncontrollability. They theorized that when individuals are confronted with extreme violence or loss, it shatters their illusion of safety and invulnerability. In situations where events are highly unpredictable or uncontrollable, there is an increase in anticipatory anxiety, vigilance, dread, and a feeling of powerlessness. The resultant stress is higher than if the situation or circumstances were expected. This additional stress is due to having to exacerbate personal resources to regain balance and develop a plan immediately (Lovallo, 2005). Acute Reactions Acute reactions to traumatic stressors can occur during and immediately after exposure. These reactions include dissociation, intrusive symptoms, avoidance, hyperarousal, hypervigilance, and difficulties with concentration, memory, problem-solving, 14 and decision-making (Ford et al., 2015). These reactions are an instinctual response to psychologically overwhelming or potentially life-threatening situations. Acute reactions are survival mechanisms and are expected to resolve within hours or days following traumatic exposure. However, if symptoms persist or worsen within the first month, it may indicate Acute Stress Disorder (ASD). According to Ford et al., ASD occurs when these reactions are "destabilizing rather than a source of helpful physical and psychological readjustment" (2015, p.54). Acute stress disorder (ASD) was introduced in the DSM-IV as an acute response characterized by dissociative, reexperiencing, avoidance, and hyperarousal symptoms occurring two days to one month following a traumatic event (American Psychological Association, 1994). This allowed for identification of those struggling in the immediate post- trauma phase and presented an opportunity for intervention for those who may be developing symptoms of post-traumatic stress disorder. A diagnosis of ASD initially required at least three of five possible dissociative symptoms, with the rationale that a dissociative response to an event limits emotional processing, contributing to post-traumatic pathology (Bryant, 2021). However, reviews noted that although most people who met the criteria for ASD did go on to develop PTSD, the majority of those with PTSD did not initially meet the criteria for ASD. They suggested that most people experienced acute stress reactions but not in the way the criteria defined (Bryant, 2021). It was proposed that the inclusion of dissociative symptoms limited the ability of the ASD diagnosis to predict PTSD. As such, it became a measure to identify those in need of intervention from mental health services rather than a predictive tool. The DSM-5 revised the criteria, requiring that at least 9 out of a possible 14 symptoms be present at least three days following traumatic exposure. Additionally, only two of the original five dissociative symptoms are listed (American Psychological Association, 2013). 15 There is increasing evidence that elevated sympathetic nervous system activation in the acute trauma phase may increase the likelihood of subsequent development of PTSD (Bryant, Harvey, Guthrie & Moulds, 2000; Salev et al., 1998). Post-Traumatic Stress Disorder The World Health Organization conducted a study across 24 countries to evaluate the association between lifetime traumatic events and post-traumatic stress disorder (Kessler et al., 2017). Of the respondents, 70.4% reported experiencing at least one of the 29 identified traumatic events outlined in the study (see Appendix A). However, the prevalence rate for PTSD sits between 6.1-9.2% depending on the event (Pagel, 2020). This disparity suggests that the development of PTSD is determined by more than just a traumatic event. It is worth noting that any statistics regarding the prevalence of PTSD are likely underestimations, as people may not seek help for their symptoms due to shame, guilt, and other internal and environmental factors (Pagel, 2020). Psychological responses to trauma were historically viewed as variations of the normal grieving process up to six months after an event. More recently, this timeframe has been changed from six months to one month, after which individuals still experiencing psychological symptoms should be evaluated for PTSD (American Psychological Association, 2013). Diagnostic criteria have changed extensively since the first publication in 1980, with some requirements being tightened and others made more lenient (Pagel, 2020). As per the current criteria, a diagnosis of PTSD requires a history of exposure to major trauma (Criterion A) and pervasive symptoms belonging to each of the following clusters: avoidance, intrusion, negative alterations in cognitions and mood, and alterations in arousal and reactivity (American Psychological Association, 2013). The symptoms must have been 16 present for more than one month and cause significant functional impairment. Symptoms cannot be secondary to medication, substance use, or other medical illness. Although a diagnosis calls for measurable functional impairment in more than one area of life, there are those who, even with severe symptoms of PTSD, can function to a high level. When quantifiable impairment is used to define the presence or absence of a psychiatric disorder, there is a significant risk of overlooking those who mask their symptoms around others. Research has identified multiple groups that appear to be more susceptible to PTSD following traumatic events. It is more frequently reported in adolescents and young adults than other age groups, more common in women, those in lower socioeconomic classes, living in rural areas, those with lower IQs, and people with a family history of PTSD. It has also been suggested that specific themes within the traumatic event, such as betrayal by a trusted person, sexual violence, and acts of human atrocity increase the likelihood of post- traumatic pathology developing (Layne et al., 2008). Complex-PTSD The diagnostic formulation of PTSD is primarily based on the experiences of survivors of singular traumatic events. However, this approach may fail to capture the full range of difficulties faced by those who have experienced prolonged, repeated trauma. The concept of a concomitant diagnosis arose in an effort to explain the complex symptomology seen in the realms of emotional dysregulation, interpersonal difficulties, and negative self- perception. Early descriptions of a complicated presentation of PTSD came from clinicians working with survivors of childhood sexual assault (Briere, 1988). Many reported a post- 17 traumatic presentation disguised by chronic depression, dissociative symptoms, substance abuse, impulsivity, self-injury, and suicidality (Herman, 1992). Similar observations were made in instances where individuals were unable to escape the traumatic situation and were in complete control of the perpetrator, establishing an environment of prolonged, repeated trauma. These included people who had spent time in prison, concentration and slave labour camps, and domestic abuse situations. Herman (1992) identified a common theme of coercive control within traumatic events that predated the development of complex symptomology, noting that those held captive by physical, social, economic, or psychological means had similarities in presentation. The symptomatic observations that differentiate disorders of prolonged trauma from so-called simple PTSD are threefold: symptoms are more complex; characterological changes are evident; and vulnerability is increased (Herman, 1992). Regarding the complicated symptomology, somatisation, dissociation, and affect dysregulation have been observed as being amplified in cases of complex trauma (Briere, 1988; Herman, 1992; Taylor, Asmundson & Carleton, 2006; Palgi et al., 2021). People who have suffered long- term, interpersonal trauma have shown to be at a higher risk of developing chronic health conditions and chronic pain than those without traumatic histories and those who experienced acute events (Sachs-Ericsson, Kendall-Tackett & Hernandez, 2007; Tsur, 2022). The interpretation of pain can be mediated by a variety of factors, and several theories have been put forth to explain the higher rate of pain and illness associated with trauma. Due to the biopsychosocial nature of pain, it can be altered by a multitude of factors including an individual's understanding and beliefs around pain, lifestyle, and support system (Turner & Dworkin, 2004; Hinrichs-Rocker et al., 2012). Some have suggested that an increased vulnerability to stressors, hypervigilance, and distorted beliefs around bodily sensations culminate in an amplified pain response (Sachs-Ericsson et al., 2007). Others 18 have posited that chronic trauma, especially childhood abuse, produces pathophysiological responses that make individuals more vulnerable to pain, particularly when hypervigilant or in times of high stress (Meagher, 2004). This has also been suggested as a possible causal factor in the development of autoimmune diseases and other chronic pain conditions (Macarenco, Opariuc-Dan & Nedelcea, 2022). Dissociation has been identified as a central construct in the aftermath of complex trauma, with devastating consequences on functioning (Dorahy et al, 2013). People who suffer from prolonged trauma, especially those who are unable to escape the situation they are in, become adept at avoidance. This avoidance can manifest in the ability to alter one's own consciousness to cope with an unbearable reality, resulting in disturbances in time, senses, and memory (Herman, 1992). Dissociation is often conceptualised as a defensive mechanism and serves to separate an individual's mind from their body, senses, and environment (de Thierry, Reeves & Music, 2020). While dissociation can be an effective method of protection during a traumatic event, it can significantly impact an individual's quality of life if it continues. Once someone becomes adept at dissociation, this kind of cognitive separation can be triggered as a result of any kind of stress and can vary within hours or last days at a time. People exposed to complex trauma suffer from various difficulties in affect regulation alongside dissociation. Affect dysregulation covers problems in “managing or recovering from extreme states of affect, including both under regulation of heightened affect states and maladaptive overregulation of affect” (van Dijke, Hopman & Ford, 2018, p.2). Under regulation refers to the inability to access or implement strategies to cope with intense emotional states, resulting in struggles with impulse control and goal-driven behaviour (Gross, 2013; van Dijke et al., 2018). For example, anxiety that escalates into full-blown terror and anger that manifests into unmanageable rage. Overregulation describes total 19 suppression and minimal awareness of emotional states resulting in numbness and detachment (Pat-Horenczyk et al., 2015). Dissociation could therefore be considered an extreme form of overregulation, although the most common understanding views it as a failed attempt to regulate emotion (Hébert, Langevin & Oussaïd, 2018). Herman (1992) reported chronic depression as being the most common finding in repeatedly traumatised populations. Other studies have resulted in similar findings, with depression severity directly correlating with the disturbances in self-organisation seen in complex PTSD, having no significant relationship with other symptoms (Haselgruber et al., 2021; Fung et al., 2022). This depression is often exacerbated by other aspects of affect dysregulation and chronic trauma, including insomnia, nightmares, concentration difficulties, helplessness, apathy, isolation, hopelessness, and guilt (Herman, 1992). The conceptualization of Complex PTSD as a Disorder of Extreme Stress not otherwise specified (DESNOS) has resulted in further diagnostic markers, described as disturbances in self-organisation (DSO). DSO includes the aforementioned affect dysregulation, which can present as somatisation, dissociation, and mood disorders. This domain also covers negative self-concept and difficulties in relationships. The characterological changes witnessed in DESNOS or Complex PTSD include personality changes, the loss of a sense of self, and difficulties in relating to others (Landy, Wagner, Brown-Bowers & Monson, 2015). It is common for a victim of a singular traumatic event to feel as though they are not themselves in the immediate aftermath. However, a victim of chronic trauma may lose their sense of self entirely and may not see themselves as a person at all (Cox, Resnick & Kilpatrick, 2014). Just as our past experiences influence how we interpret future events and situations, these processes are thought to establish our continual sense of self over time 20 (Lanius, Terpou & McKinnon, 2020). Insights we develop about our own identity rely heavily on our autobiographical memories; trauma can result in extremely negative self-beliefs and distorted thoughts about oneself. As such, it is common for those with Complex PTSD to view themselves as an object rather than a person. They often report feeling as though they have been changed on a cellular level by events and like they will never feel normal again (van Dijke et al., 2018). This negative self-concept has previously been operationally defined as “persistent negative beliefs about the self, and feelings of guilt and shame related to the event” (Melegkovits et al., 2022, p.12) and is a hallmark of Complex PTSD. The loss of a sense of self has been directly linked to pathological changes and difficulties in relationships (Herman, 1992). In cases of chronic trauma, victims often develop beliefs about themselves and the world instilled by the perpetrator. Victims of abusive relationships often become completely cut off from all social ties and come to rely solely on the perpetrator (Hinde, Finkenauer, & Auhagen, 2001). Even after escaping an abusive situation, survivors can find it hard to trust other people and suffer from a learned helplessness that developed due to their inability to engage with the outside world (Lanius et al., 2020). It should also be reiterated that many survivors of repeated trauma struggle to understand that the abuse has ended, changing how people feel able to engage in their own lives. In childhood abuse, this can result in significant attachment difficulties, while adults often enter unstable and sometimes further abusive relationships, in fear of both abandonment and domination (Hébert et al., 2018). Finding oneself in serial abusive relationships has been found to be a common repetitive phenomenon following prolonged trauma. It has been estimated that survivors of childhood abuse are twice as likely as the general population to be harmed again (Herman, 1992). The risk of repeated trauma is similar for those who have suffered sexual or physical violence at the hands of others. The increased risk of harm following complex trauma also 21 covers self-harm, which is rarely witnessed after acute trauma (Courtois, 2008). Dyer, Dorahy, Shannon and Corry (2013) identified pervasive self-injurious behaviour within a Complex PTSD population. Altered self-perception, including guilt, shame and an inherent sense of badness were suggested as a “significant predictor of self-destructive behaviour” (p.58). Self-harming behaviours have been correlated with self-hatred and extreme shame (Gilbert et al., 2010). This may explain the high rates of self-injury and self-destructive behaviours in those who have suffered chronic trauma. The fifth edition of the DSM altered the diagnostic criteria for PTSD, expanding the symptoms to include negative self-concept and changes in belief about the world and others, and elaborated on the avoidance criteria, attempting to capture the symptoms seen in Complex PTSD (American Psychiatric Association, 2013). While the ICD-11 includes Complex PTSD as an illness separate to PTSD (World Health Organisation, 2022). These changes provide an alternative for those who would otherwise be diagnosed with PTSD and a multitude of comorbidities to explain their symptoms, notably those marked by emotional dysregulation, dissociation, disinhibition, identity struggles and addiction (Cloitre et al., 2014). Prior to the acknowledgement of Complex PTSD as a distinguished diagnosis, many people were misdiagnosed with Borderline Personality Disorder (BPD) in an effort to explain the presenting constellation of symptoms (Nestgaard Rød & Schmidt, 2021). BPD is well known for the associated stigma; the presenting behavioural and internalised symptoms can make it a challenging illness to treat (Ring & Lawn, 2019). This can result in practitioners distancing themselves from those with a diagnosis of BPD, and impact how they tolerate and treat these individuals (Aviram, Brodkey & Stanley, 2006). A misdiagnosis of this magnitude can result in patients feeling labelled, stigmatized, and misunderstood, as well as making it difficult for them to access appropriate care. Not only does it negatively impact the people 22 suffering, but it becomes a struggle for clinicians to decide on sufficient treatment methods, given the misinformation around what they are treating. Treating Trauma The treatment of trauma is dependent on the individuals’ needs and the experience and favoured methodology of the clinician. Several treatment methods have been developed over the years, including Relational Trauma Psychotherapy, Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), Prolonged Exposure (PE) and Eye Movement Reprocessing and Desensitisation (EMDR). These therapies can be used alone but are often combined or altered to focus on trauma processing and recovery. Relational Trauma Psychotherapy is based on Herman’s triphasic model of recovery, established in 1992. It is an entirely client focused method of talk therapy that prioritises the therapeutic relationship and is based on enabling clients to reclaim their sense of empowerment and connection to themselves and the people around them (Zaleski, Johnson & Klein, 2016). As the name suggests, the model has three phases: safety, remembrance and mourning, and reconnection (Herman, 1992a). The safety phase focuses on the nervous system, educating clients on the dysregulation of the autonomic nervous system that can result from trauma. Assisting clients in regulating their autonomic nervous system results in normalizing biological functions that often become dysfunctional following trauma, such as eating and sleeping cycles, as well as hyperarousal and intrusion symptoms, difficulties concentrating and executive dysfunction (Cahill, 1997). Managing these symptoms and allowing an individual to regain control over these aspects of their life allows them to begin to feel safe within themselves. Once this has been completed and the clinician is confident that their client can cope, the remembrance and mourning phase is initiated. This involves 23 retelling the story of their trauma, allowing them to reintegrate the narrative and facilitate hippocampal memory reprocessing. After processing the trauma, the client is encouraged to reconnect with their life. Allowing them to reengage with all aspects of their life and learn how to regulate their nervous system in different settings and social interactions. This process is the basis for trauma-focused talk therapy, although most clinicians now tend to train in more specific treatment modalities. Trauma Focused - Cognitive Behavioural Therapy Trauma focused – Cognitive Behavioural therapy (TF-CBT) was developed specifically for children and adolescents, and has rapidly become one of the leading treatments for trauma and PTSD (Cary & McMillen, 2012). TF-CBT involves prolonged and/or narrative exposure through imaginal reliving with rescripting and cognitive restructuring (Melegkovits et al., 2022). Cognitive restructuring is used to change negative thinking patterns about the self and the world, including negative thinking biases and dysfunctional core beliefs (Ehlers et al., 2005). Practice involves the use of trauma-sensitive interventions alongside essential CBT protocols over 12-16 weeks. The acronym PRACTICE is used to outline each step of therapy: Psychoeducation regarding trauma responses; Relaxation training such as mindfulness and breathing techniques; Affective coping skills; Cognitive reframing to enable clients to differentiate between thoughts, emotions and behaviours; Trauma narration to overcome avoidance, identify cognitive distortions and view the trauma in context of their life; In-vivo exposure in cases where specific places or activities are being avoided; Conjoint child and parent sessions to assist in increasing communication between family members, and; Enhancement of future safety involving additional education as needed (Melegkovits et al., 2022). Meta-analysis evaluating the efficacy of TF-CBT in decreasing symptoms of PTSD and co-occurring depression indicated that TF-CBT was “exceptionally superior to no treatment or wait-list comparisons and 24 moderately superior to alternative treatments” (Lenz & Hollenbaugh, 2015, p.28). Although TF-CBT is favoured for use in cases of child and adolescent treatment, the principles of gradual trauma exposure and cognitive restructuring have proven to be effective in cases regardless of age, ethnicity, type of trauma and location (Ehlers et al., 2005). Dialectical Behavioural Therapy Dialectical Behavioural therapy (DBT) was conceptualised by Marsha Linehan and first published as a method to treat borderline personality disorder in 1993 (Linehan, 1993). Earlier treatment methods had proven ineffective in treating complex cases characterised by emotion dysregulation, interpersonal difficulties, negative self-concept, and self-destructive behaviours (Chapman & Dixon-Gordon, 2020). DBT is a phase-based treatment with modules focusing on emotion regulation, interpersonal effectiveness, and distress tolerance, along with integrated mindfulness practices (Linehan & Wilks, 2015). The majority of those completing DBT have a pervasive history of trauma, incentivising the development of a trauma protocol created to work alongside DBT. DBT-Prolonged Exposure was established by Melanie Harned with the goal of “providing effective PTSD treatment to high-risk, complex, and severely impaired clients who are typically unable to access these treatments” (Harned, 2022, p.4). Studies of the efficacy of DBT-PE have shown significant symptom improvement, with 71-80% of participants no longer meeting criteria for PTSD following treatment (Harned, Schmidt, Korslund, & Gallop, 2021). Prolonged Exposure Exposure-based treatments have been used effectively to reduce fear and avoidance in anxiety-based disorders (Feske & Chambless, 1995; Foa, Riggs, Massie & Yarczower, 1995). In these cases, individuals are gradually exposed to the thing that frightens them in a 25 controlled environment. In PTSD, anxiety is typically linked to memories of the traumatic experiences. Therefore, exposure therapy for PTSD focuses on retelling of the trauma, and repeated reliving of the experience through imagination. Tarrier et al. reported exposure therapy as “the most studied and supported treatment technique for PTSD” (1999, p.13). Therapy involves psychoeducation, breathing retraining, behavioural exposures, and imaginal exposures (Resick et al., 2002). After being educated about the symptoms of PTSD and the rationale behind exposure, clients are asked to create a list of things that scare them, from least to most anxiety-inducing. This hierarchy is based on the Subjective Unit of Distress (SUDs) associated with each item, rated on a scale from 0-100. In-vivo exposure tasks involve physical, behavioural exposures such as being in certain places or around people associated with past trauma. Imaginal exposure requires clients to retell the story of their trauma for at least 45 minutes, this is recorded in session. Clients are then asked to listen to the recording each day between sessions and engage in behavioural exposures wherever possible. Exposure to the memory continues until the emotional reactions decrease. Bryant et al. explained that this therapy is based “on the premise that imaginal exposure to the feared stimulus (e.g., traumatic memories or feared situations) leads to symptom reduction because prolonged activation of the traumatic memories leads to emotional processing of the affective information, habituation of anxiety, and integration of corrective information.” (2003, p.706) As such, a study evaluating the efficacy of PE in treating chronic PTSD discovered that those who had the most severe PTSD pathology and reacted with the most fear during imaginal exposure benefitted more than those with milder pathology and distress during treatment (Foa et al., 1995). 26 According to Foa and Meadows, PE works through four systems, “promoting symptom reduction by allowing patients to realise the contrary to their mistaken ideas: a) Being in objectively safe situations that remind one of the trauma is not dangerous; b) Remembering the trauma is not equivalent to experiencing it again; c) Anxiety does not remain indefinitely in the presence of feared situations or memories, but rather it decreases even without avoidance or escape; and d) Experiencing anxiety or PTSD symptoms does not lead to loss of control” (1997, p.462). This gradual exposure to fear and anxiety allows for emotional processing with excellent results. Post-treatment assessments have indicated a success rate of up to 53%, with those clients no longer meeting criteria for PTSD after receiving PE (Resick et al., 2002). Eye Movement Desensitisation and Reprocessing Eye Movement Desensitisation and Reprocessing (EMDR) is a form of exposure accompanied by saccadic eye movements (Foa & Meadows, 1997). Clients are required to attend to traumatic memories and associations while simultaneously engaging in bilateral physical stimulation such as tapping, eye movements or auditory input (Melegkovits, 2022). EMDR utilises an entirely subjective approach to treatment, focusing on the traumatic events and associated beliefs that are the most damaging to clients. The benefits of eye movement in relation to memory processing was discovered incidentally by Francine Shapiro in 1989, after noticing she felt less stressed and anxious following a walk in the park, during which she moved her eyes back and forth (Luber & Shapiro, 2009). In 1995, EMDR was recognised as an effective psychotherapy capturing a 27 total trauma history, focusing on target memories and associations, and processing those memories to resolution (Shapiro, 1989; Hill, 2020). This therapy provides assessment and treatment in the three realms that are affected by trauma: cognitive, emotional, and somatosensory (Hill, 2020; Van der Kolk, 2014). Following the success of EMDR in trauma treatment, the Adaptive Information- Processing (AIP) model was established to provide a theoretical underpinning for the treatment and so the mechanism of change could be understood (Hill, 2020). The model described how memories are processed and stored in the brain: either adaptively with typical memories or maladaptively in the case of traumatic memories. In essence, highly emotional memories receive little to no logical processing, resulting in some of the information around the event being lost and leaving the emotional memories scattered and not consolidated. AIP hypothesises that the bilateral stimulation occurring in EMDR activates all parts of the brain, increasing communication between structures (Siegel, 2002; Shapiro & Laliotis, 2011). When the brain is completely activated and all structures are focused on an event, all parts of the memory can be located and integrated to be processed in the same way as typical, non-traumatic memories. Hill explained that “AIP theory is built on a model of removing obstacles to the brain’s typical processing, rather than on changing or fixing the brain or its processes” (2020, p.322). Controlled research found that 85-100% of those who have experienced a single- event trauma can be effectively treated for PTSD in three 90-minute sessions of EMDR or the equivalent (Shapiro, 2002). Practice of EMDR has grown considerably since its conception and is now used to treat all forms of PTSD, a wide range of anxiety and mood disorders, addictions, eating disorders and chronic pain (Hill, 2020). The overwhelming benefit of EMDR lies within the entirely subjective approach to treatment, and many have 28 found it even more effective when combined with trauma focused CBT or DBT (Melegkovits, 2022). All of the aforementioned therapeutic practices have yielded positive results, individually and combined. The approach taken depends on both the qualifications and experience of the therapist and needs of the client. The clients presenting problems and their individual needs must be assessed to decide on an effective treatment plan. The following chapter discusses how the clients’ needs are most often determined. Measuring Trauma Following a traumatic event, people are affected in a myriad of ways. Despite the recognised criteria that has been established for the diagnosis of a post-traumatic syndrome, presentation varies from person to person. As with any illness, many guidelines and accompanying measures have been produced to objectively gauge distress and inform diagnosis. Assessing psychological trauma often consists of a mixture of clinical interviews, standardised measures, and behavioural observations. The following section organises these methods based on the way in which data is collected, either quantitatively or qualitatively, the benefits and potential downfalls are discussed. Quantitative Data Quantitative data refers to data represented numerically: anything that can be counted, measured, or given a numerical value. Quantitative measures in psychology refer to psychometrics designed to assess a specific pathology, containing a variety of items that represent known symptoms, and measurement of latent constructs using a numerical scoring system (Michell, 1997). Each item asks the individual to score the symptom on a 29 scale, often representing the severity or frequency of each over a certain timeframe. Scores are tallied and interpreted based on the corresponding clinical cut off values for each symptom and/or total pathology. All psychometrics undergo rigorous testing and scrutiny to examine their reliability and the accuracy of each item in detecting the focus pathology, as well as the strength of the correlation between items (Edenborough, 1999). Selecting a measure requires several considerations, including the time available, the health of the client and the goal of the assessment. Psychometrics take time to complete, typically this could be anywhere from 5 to 50 minutes, or longer depending on the length of the measure, the administrator, and the capacity of the client. If a client has a limited attention span, a shorter measure is likely to be more plausible and capture more accurate responses than one with more items. Similarly, if someone is severely unwell and has a significant impairment, the chosen measure might need to be short, with simple, easy to understand wording and directions. The goal of the assessment is crucial in deciding which measure to administer. The administrator needs to know which symptoms they aim to assess, and if there are multiple potential diagnoses to tease apart, this needs to be considered as well (Markon, 2013). The assessor must also decide if they need to understand the individual’s current symptoms, their struggles over the preceding months, or their lifelong difficulties. There are a handful of measures that have been developed with the goal of quantifying trauma, the most used psychometrics are discussed below. The Post-Traumatic Checklist (PCL) was developed at the National Center for PTSD in 1990 and is now reported as one of the most widely used self-report measures (Blevins et al., 2015). The PCL has been adapted for the changes made to the PTSD criteria in the DSM-5, producing the PCL-5. Consisting of 20-items, the PCL is a relatively short measure that asks the client to rate the frequency of their symptoms over the last month. Symptoms cover intrusions, avoidance, negative alterations in cognitions and mood, and marked 30 alterations in arousal and reactivity, scoring each item based on how they have been affected on a scale that ranges from 0 (not at all) to 4 (extremely) (Stanley et al., 2023). The PCL-5 is an especially valuable measure in that it can be personalised to better suit the person completing it. The measure generally requires identification of the traumatic event and refers to the trauma in relation to each test item. The required score for diagnosis of PTSD ranges from 30-60, depending on the population of the individual completing the measure, the setting in which the assessment is conducted and the purpose of the assessment. The ability to alter the assessment allows for a more subjective approach and takes individual experiences into account, resulting in a more accurate and considerate diagnosis. Tailoring the items to a specific event also makes the items more relevant to the individual doing the measure, making it easier to understand and complete. The National Center for PTSD also developed the Clinician Administered PTSD Scale (CAPS). Initially formulated in 1989, the scale has now been altered to account for the criteria changes and additions introduced in the DSM-5 and ICD-11 (Weathers et al., 2018). The CAPS is a 30-item structured interview that includes the assessment of the following: • All PTSD criteria including associated features such as dissociation • Global ratings of distress, impairment, response validity, symptom severity, and measured comparison to prior assessments • Dichotomous and continuous ratings for individual symptoms and overall disorder • Separate assessment of symptom frequency and intensity • Behaviourally anchored prompts and rating scales • Assessment of trauma-relatedness for symptoms not exclusively linked to trauma such as low mood, isolation, and concentration difficulties 31 (Weathers et al., 2018). The CAPS has three different versions corresponding to various time periods. Depending on the timeframe the assessor wants to examine, they can administer a measure that covers the past week, the past month, or the individual’s worst month. There is often an addition to this measure that aims to identify specific traumatic events, the Life Events Checklist (LEC). The LEC is a 17-item self-report measure of exposure to various events that potentially fulfil the DSM-5 Criterion A for PTSD. Each item asks the individual if that event has happened to them, if they’ve witnessed it, learned about it, been exposed to it because of their job or if it doesn’t apply (Weathers et al., 2013). There is also an option to add in any events that are not listed. The use of the LEC alongside the CAPS allows for more specific answers, similar to the PCL-5. Another simple and popular measure is the International Trauma Questionnaire (ITQ). The ITQ contains 18 items focusing on core symptoms of both PTSD and Complex PTSD as according to the ICD-11 (Cloitre et al., 2018). The questionnaire has two major subscales with three symptom clusters in each. PTSD related items cover the symptoms of re-experiencing, avoidance, and sense of threat, while the C-PTSD focused items cover affect dysregulation, negative self-concept, and disturbances in relationships, consistent with the disturbances in self-organisation seen in C-PTSD (Schnurr, Vielhauer, Weathers & Findler, 2012). An obvious benefit of the ITQ is the ability to identify symptoms of C-PTSD, allowing for a wider range of assessment and accuracy in diagnosis. There is also a version for children and adolescents, containing 22-items pertaining to the same symptom clusters and subscales as the adult version. 32 The aforementioned measures are relatively short, which can be beneficial when time or client capacity is limited. However, when a detailed symptom analysis is required, large measures such as the Trauma Symptom Inventory (TSI) are used. The TSI is a complex measure describing 100 trauma-related symptoms, rated on a 4-point scale of frequency over the preceding six months (Fernandez & Gebart-Eaglemont, 2001). These symptoms cover ten domains: anxious arousal, depression, anger/irritability, intrusive experiences, defensive avoidance, dissociation, sexual concerns, dysfunctional sexual behaviour, impaired self-reference, and tension reduction behaviour (Briere, 1995). The measure also contains built in validity scales, designed to identify under- and over- endorsement and inconsistent responding. There is a shorter version of this measure designed for those under 18, the Trauma Symptom Checklist for Children (TSCC). The full screening contains 54 items, possessing symptoms from six clinical domains: anxiety, depression, anger, posttraumatic stress, dissociation, and sexual concerns (Boyle & Viswesvaran, 2003). There is also an adjusted version that has 44 items and no reference to sexual issues, and a shorter version that only contains 20-items covering general trauma symptoms and sexual concerns. The use of these measures ultimately depends on the age and capacity of the client, and their presenting concerns. The use of quantitative data in assessing and navigating trauma and other psychological difficulties can provide valuable information in an easily understandable format. Standardised measures allow for simple comparison over time and can provide answers for clinicians and patients who may be struggling to understand or separate symptoms. They are straight forward, user-friendly, and can assist in confirming clinical diagnoses. However, regardless of how expansive these measures are, there are some 33 phenomena that can never be completely quantifiable by nature. Qualitative Data Trauma is an entirely subjective experience, how it is perceived and the way in which it affects a person is unique. How we are impacted by a traumatic event is dependent on everything that has come before, how we understand and make meaning of what has happened, and our personal and sociocultural context surrounding the event. By definition, these factors cannot be measured with numbers or understood based on a rating scale. While a standardised measure can allow us to understand what symptoms a person is struggling with, they cannot tell us how those symptoms present or how they are experienced. The nature of quantitative measures allows for generalisation of findings, while this can be beneficial in strictly empirical scientific settings, it could be argued that nothing about individual trauma responses can be generalised. A study investigating the use of various trauma measures within a population of women with a history of sexual trauma found that personal interviews were more beneficial and resulted in less discomfort than anonymous questionnaires and psychometrics (Schwerdtfeger, 2009). Stating that while both were reasonably well tolerated, women reported “significantly higher personal benefit” (p.39) from personal interviews. Earlier investigations had similar results, finding that participants who reported the most emotional engagement in the process benefitted the most (DePrince & Chu, 2008; Schwerdtfeger & Nelson Goff, 2008). One of these studies gave participants the choice between personal, face-to-face interviews and individual questionnaires; 92.7% of participants opted for interviews (Schwerdtfeger & Nelson Goff, 2008). These researchers believed that this choice and the high benefit-to-cost ratio associated to the interviews was based on “the creation of a context in which the experience is likely to result in insight and feelings of well-being” 34 (p.66). Qualitative interviews allow for a personal connection, reciprocation of emotion and familiar language. They also help researchers and therapists to understand the patient’s internal beliefs and experiences, and the context of their trauma. This level of insight may also help patients in understanding more about themselves. DePrince and Chu (2008) acknowledged possible hesitancy in conducting personal interviews within traumatised populations, for the fear that these methods come with a greater risk. The perceived risk is focused on patient experience, given that typically more in- depth information is shared in these settings, and the relational context might increase the risk of shame or embarrassment. However, this risk may be mitigated by the benefits, notably that interviews “might actually create more opportunities for personal meaning- making compared to questionnaires, thus actually increasing participants’ perceived benefits” (p.36). Researchers discussed a long-standing argument initiated by female scholars, stating that interview and narrative methods are especially important when investigating the experiences of women and oppressed groups because narrative allows participants to communicate context. DePrince and Chu concluded that “interview procedures may provide participants with more extensive opportunities for reflection, perspective-taking and meaning-making than questionnaires” (2008, p.45), suggesting that qualitative interviews have greater benefit and result in more meaningful information being shared than quantitative measures alone. The use of qualitative measures in assessing trauma allows for a wide range of exploration and understanding. They provide an opportunity to discuss the context of an event and the aftereffects, and allow individuals to express exactly how their experiences have made them feel. It creates space for connection and trust within a therapeutic relationship, assisting with the recovery process. A focus on qualitative data might also mean that less people fall through the cracks regarding PTSD diagnoses and treatment. 35 Criterion A of the PTSD criteria has the potential to be problematic in that it excludes many events that may be deeply upsetting but are non-lethal, such as emotional abuse and discrimination. It has also been noted that “the criteria do not address the complicated, severe symptoms of individuals with multiple or recurring traumas” (Hill, 2020, p.318). This is despite the knowledge that repeated traumatic exposures create an “increased vulnerability” to further trauma (Hill, 2020, p.318). A reliance on the hard and fast expected symptoms and causes of PTSD as seen in quantitative measures risks those outside of that box missing out on treatment entirely. It is common for people to meet some but not all of the PTSD, despite significant difficulties in functioning (Dickstein, Walter, Schumm & Chard, 2013). Without a detailed understanding of the presenting problems and the context of the event(s), many people would miss out on a diagnosis and subsequent treatment. This is especially poignant in the case of government funded care. For example, the Accident Compensation Corporation (ACC) provides funding for therapy and counselling under specific conditions. To qualify, one must have suffered either a sexual trauma or have lasting psychological difficulties following an accidental, physical injury (ACC, n.d.). Further, sustained funding is reliant on the diagnosis of a mental injury resulting directly from the event, as per the guidelines presented to registered providers, meaning that if an individual is experiencing symptoms on a subclinical level, they may not have continued access to treatment. Despite the benefits of quantitative measures, namely the ability to objectively and quickly assess symptoms across the board, access definitive and verified diagnoses and compare specific measures of functioning over time, trauma is far from an objective experience. It should also be considered that these positive aspects of quantitative measures rely on the assumption that psychological attributes can be measured numerically to begin with. Some researchers have drawn attention to the fact that the use of quantitative measures is based on a hypothesis that has not been tested in psychology today (Essex & 36 Smythe, 1999; Michell, 2000; Michell, 2010; Toomela, 2010). Essex and Smythe (1999) repeatedly refer to psychometrics as “mathematical machinery”. They discuss the conversion of intensive variables, such as subjective judgements and psychological states, into extensive variables that can be measured. While there are appropriate ways to conduct this translation, including the use of memory and perceptual tasks to transform variables, the writers state that “the more common practice is to proceed unthinkingly from the intensive to the extensive, as in summing the numerical responses to distinct items on a Likert scale to measure the overall ‘strength’ of an attitude” (Essex & Smythe, 1999, p.747). Michell (2000; 2010) shared a similar understanding, explaining that the attributes that psychometrics aim to measure are not directly observable, rather responses to test items are measured and inferences are made. Michell also expressed concern that psychometrics are assumed to be accurate for the ease of use, specifically that “it is not reasonable to infer that psychological attributes must be quantitative just from the fact that quantification offers simpler forms of explanation” (2010, p.64). Despite the overwhelming assumption that psychological factors can be measured numerically, it has been stated repeatedly that there is no evidence to support this. Some researchers have gone as far as to say that these measures are “useless for answering questions about structures and processes that underlie observed behaviours” (Toomela, 2010, p.1). A reliance on quantitative measures suggests a focus on external behaviours, and it needs to be understood that these behaviours may represent different internal processes across the board. Toomela explained that “no quantitative procedure can distinguish qualitatively different mechanisms that may underlie externally the same behaviour” (2010, p.15). Essentially, even if psychologically driven behaviours could be quantified effectively, these behaviours may have different underlying processes from person to person. Given the variations in internal behaviours across individuals, the potential differences between cultures also needs to be considered. 37 The perceived universality and accuracy of quantitative measures and therefore the criteria they are assessed on generates even more concern across populations. In this case, quantitative measurements of trauma are assumed to accurately identify post-traumatic pathology across the board. Yet, concerns have been raised around the applicability of DSM criteria (Ruchkin et al., 2005) and the use of the PTSD criteria specifically (Bracken, Giller and Summerfield, 1995) within non-westernised cultures. Bracken and colleagues (1995) argued the used of PTSD criteria universally, stating that the idea of individuality and sense of self differs in non-Western cultures, rendering the recognised symptoms of PTSD unreliable in collectivist cultures. There are dangers in expecting universality within psychology, simply because the same symptoms are witnessed across cultures, they do not necessarily mean the same thing. A behaviour that may be considered a symptom of some underlying pathology in one culture, might be an entirely normal experience in another. The genuine internal processes behind any behaviour cannot be understood without trying to truly understand the individual exhibiting the behaviour, and experiencing the thoughts and feelings that go along with it. While it should be noted that receiving only qualitative information risks the chance of observer bias, given that the information gathered is more open to interpretation than that acquired via standardised measures. It could be argued that this risk is mitigated by the benefits of a personal approach, and pales in comparison to the danger of assuming psychological attributes and behaviours represent an identical pathology in every person. The present study aims to understand the varying post-traumatic presentations observed in psychological practice, and the perceived efficacy and accuracy of measures psychologists choose to employ. 38 Method The present study is driven by the position that qualitative data and research methods should be used over quantitative methods in psychology whenever possible. This is due to the flexibility and inclusivity allowed for within a qualitative approach, and the afforded ability to examine all of the available information, rather than focusing on data that suits preconceived notions. As such, thematic analysis has been chosen to fully assess all information provided within the appropriate context. Employing qualitative content analysis was considered, however this focuses on predetermined key words or concepts (Bengtsson, 2016). Compared to thematic analysis, which focuses on the provided data and makes inferences based solely on the available content, content analysis has the potential to increase the risk of misinterpretation. The use of predetermined key words to form a conclusion also runs a high chance of instilling bias throughout the analysis. Thematic analysis allows for flexibility in approach and interpretation that is somewhat limited in other methods of qualitative analysis (Braun & Clarke, 2006). The nature of this approach allows participants to speak freely and express their own beliefs, opinions, and knowledge on the subject matter, as well as enabling reflexive interpretation. Due to the subjectivity involved in interpreting qualitative data, my role as the researcher is undoubtedly coloured by my own experiences and understanding of the given field. I am a 27 year old cis-gender female of British and New Zealand descent. I lived in Cambridgeshire, England before emigrating to New Zealand just prior to my ninth birthday. The culture shock and dramatic differences in how people interacted with one another and their surroundings fostered an early interest in how environment and cultural ties impact the kind of people we become. 39 I have been living with Complex-PTSD since I was 16 years old. After completing trauma therapy, I went on to work with ACC sensitive claim providers for two years, before becoming a mental health support worker at an adolescent inpatient facility. Despite the circumstances, I consider myself fortunate to have experience within the mental health system both as a patient and a provider. It is this experience that lead to my frustration around the gaps within the mental health system, especially in addressing trauma. Having been significantly affected by trauma, and seeing first-hand the way in which it can manifest in others, I hold a firm position that this is not something that can be measured objectively. As far as I am concerned, the idea that something as personal and life-altering as trauma can be understood based on ratings of predetermined symptoms would be laughable if it wasn’t so devastating. Given my strong feelings about the subject matter, it has been crucial that I remain open and reflexive throughout this process. In conducting qualitative research, I am acutely aware that the information I receive is open to interpretation. With my own beliefs in mind, I have been careful in assuring that the information I discuss throughout the present study is directly from the participants and verifiable academic research. I have also been sure to include information and opinions that do not necessarily align with my position, to provide a complete picture and allow readers to form their own conclusion. In addition, beyond this section, I will refer to myself only as “the researcher” in order to ensure the focus is largely on the contribution of participants. The risk of imparting bias is greater in qualitative research than quantitative, given the reliance on discussion and interpretation over standardised numerical values. However, the process of reflexivity and the ability to recognise my own emotions, motives and reactions in response to this research allows for a deeper understanding of the material. One that enables me to reflect on my influence and the influence of others, and broaden my own 40 dynamic acumen. While this is a complex, progressive process, I struggle to see how we can sufficiently investigate any aspect of psychology without accounting for our humanity, the experiences that have shaped us, and the beliefs that we hold. Participants Eight psychologists volunteered to participate in the present study, including six females and two males. Of the participants, seven identified as NZ European and one identified as South African. The ages of participants ranged from 35 to 64 years at the time of the interview. Participants had been working as psychologists for between five and 27 years, with a combined total experience of 145 years in practice. Participants were asked to identify the percentage of trauma-related cases in their workload at the time of the interview. Answers ranged from 50 to 100%, with an average of 82.75%. Participants held either a Doctorate, Master’s degree or Post Graduate Diploma in Clinical Psychology or Applied Psychology and all possess active registrations on the NZ Psychological Board. Recruitment Participants were recruited via snowball sampling, using pre-existing personal networks to circulate information about the research. Massey University Psychology Clinics were also contacted and asked to pass on the study information to psychologists on staff. Potential participants were asked to contact the researcher if interested or to ask any questions. The only inclusion criteria were that they were registered as a psychologist and had professional experience with a traumatised population. Those who met these criteria were emailed an information sheet (Appendix B) and a written informed consent (Appendix C), the interviews were then scheduled. Only eight participants were sought due to the depth of the topic and limited timeframe. 41 Procedure Four participants were interviewed over Zoom, with interviews ranging from 20 to 75 minutes based on the responses provided and resulting discussion. Other participants were unable to find an hour to put aside for Zoom interviews, which resulted in Phase Two of interviews, completed in a written format online. Prior to commencing interviews, written informed consent was collected. The consent form also asked participants if they wanted to receive a copy of their transcript for review and editing, and a copy of the thematic analysis once completed. In cases wherein participants had not filled out and returned the consent form, verbal consent was obtained. In Phase One, the interview schedule was designed with open-ended questions to guide the conversation with a focus on how clinicians understood trauma, the presentations they had seen and their use of psychometrics in diagnostics and treatment (Appendix D). All Zoom interviews were digitally recorded and stored on a secure flash drive for transcription and thematic analysis. If participants indicated that they wanted a copy of their transcript, it was sent to them within 24 hours, after which they had two weeks to advise of any changes they wanted made. Transcription was completed via Otter.ai, a confidential online service. They were then reviewed by the researcher alongside the recorded audio to make any amendments. Phase Two interviews were conducted through SurveyMonkey, with questions formulated based on prior literature reviews and interviews (Appendix E). Questions were designed to elicit thoughtful, thorough responses without the need for conversation and follow-up questioning allowed in face-to-face interviews. Participants were automatically sent a copy of their responses and were advised to make contact if they required any changes to be made. 42 Ethical considerations Ethical approval for this study was obtained through Massey University Human Ethics Committee: Southern B (Application SOB 22/03; Appendix F). Due to the nature of the interviews, there was potential (bearing in mind the literature on secondary trauma) for participants to become distressed or emotional when discussing their experiences. This was acknowledged in the information sheet provided, and participants were encouraged to discuss any difficulties they were having during the interview or contact their own supervisor to debrief. Participants were also provided a list of available helplines and counselling resources as well as contact information for the researcher and supervisor if needed. No participants appeared distressed or emotional during the interviews, and no one has reached out to the researcher or supervisors with concerns. The researcher had a prior relationship with two of the participants, as they used to work with ACC Sensitive Claim providers. There was potential for bias, as the participants may have felt obligated to agree with the researcher’s point of view. There was also a risk that the conversation would turn casual, rather than focusing on the matter at hand. This relationship was acknowledged and did not appear to hinder the interviews in any way, all participants were very outspoken, and the discussion remained on task. If anything, the shared experiences allowed for more free-flowing conversation, thus providing more information. Analysis The data collected for analysis consisted of verbatim transcripts from the participants' interviews. Recorded interviews and transcripts were stored on an external password- protected drive. Participant names were replaced with numerical codes for confidentiality. Transcription was completed via online software, Otter.ai. The researcher listened back to each interview alongside the completed transcript to ensure accuracy. A few amendments 43 were needed due to diminished sound quality in some areas of the recordings, making it difficult for the automatic software to identify the words accurately. Written responses were reviewed and analysed without any changes being made. Thematic analysis was used to identify commonalities and differences in how professionals have seen trauma present in practice and their favoured treatment protocols. Analysis was completed through a semantic approach in which coding and theme development was designed to explicitly reflect the qualitative data (Braun & Clarke, 2022). This involved familiarizing the researcher with the data by listening to and reading transcripts and responses, developing codes that reflected the key information, and using these to generate the broader themes of the data. Initially, raw data was organised according to the question; all responses regarding trauma definition were compiled, as were those in reference to presentation, treatment and so on. Commonalities within these sections were identified as themes and interpreted individually as well as in collation with other responses. Outlying responses were also marked for investigation and discussion. Upon development and review of the themes, participant responses were collated to discuss each area of investigation. Summary This study aimed to explore how psychologists understand trauma and their use of psychometrics in diagnostics and treatment. Eight psychologists with experience in working with a traumatized population were recruited via snowball sampling. Interviews were conducted over Zoom or in a written format online. Thematic analysis was used to identify commonalities and differences in how professionals have seen trauma present in practice and their favoured treatment protocols. 44 Analysis and Discussion The following chapter discusses the main themes that arose during spoken and written interviews. The themes cover how participants defined trauma, the responses they have seen to trauma, the importance of cultural and spiritual awareness in trauma treatment, and a variety of measurement and treatment methods. All names used in this chapter are pseudonyms to protect participant confidentiality. Defining Trauma As expected, participants had varying definitions of trauma, including what causes it and its effects on a person. The most cited definition was in line with the traumatic event criterion outlined in the DSM: witnessing or experiencing an event where you feel like your life is threatened, events recognised as "Big T" traumas: “I guess I have been influenced by the DSM definition of trauma, which is around kind of, you know, being party to or witnessing an event where you feel like your life is threatened, or your wellbeing threatened. I guess a