자연주의적 탐구조사(Naturalistic Inquiry)

‘The Production of Space’, in: Frans Jacobi, Imagine, Space Poetry, Copenhagen, 1996, unpaginated.

The Production of Space

This paper suggests a conceptual framework for understanding the processes of help-seeking among survivors of intimate partner violence (IPV). A cognitive theory from general literature on help-seeking in "stigmatizing" situations suggests three relevant processes or stages of seeking help in the IPV context: defining the problem, deciding to seek help, and selecting a source of support. Individual, interpersonal, and sociocultural factors that influence decision-making at each of these stages are discussed and illustrated with case examples.

A Theoretical Framework for Understanding Help‐Seeking Processes Among Survivors of Intimate Partner Violence

Complex trauma events, or chronic interpersonal traumas that begin early in life, are thought to result in profound disruptions, well beyond the symptoms of PTSD. Complex trauma events may be especially toxic for children and adolescents, whose regulatory systems are more vulnerable. This study provides empirical support for the previously unexamined hypothesis that complex trauma events result in broad systemic difficulties, not simply higher levels of PTSD symptoms. This study also offers evidence for a dimensional conceptualization of traumatic events, with acute noninterpersonal trauma residing on one end of the spectrum and complex trauma on the other. 346 treatmentseeking children and adolescents who had experienced a traumatic event were included in this study. Results indicated that children exposed to a complex trauma event had significantly higher levels of trauma-related and generalized difficulties as compared to those exposed to other, less severe traumatic events. Children exposed to successively more severe traumatic events were also reported to have increasingly higher levels of difficulties. The evidence of including an impaired caregiving system, operationalized as the child being removed from the home following the onset of the traumatic event, into the definition of complex trauma was examined, but not supported. The results demonstrate the validity of the concept of complex trauma and point to the need for a diagnostic construct related to complex trauma for children and adolescents. Wamser, Rachel, UMSL, 2012 8 Complex Trauma in Children and Adolescents A substantial number of children and adolescents experience traumatic events such as sexual, physical, or emotional abuse, neglect, domestic violence, natural disasters, school or community violence and serious car accidents and other accidents. It is the unfortunate reality that some of these youth receive more than their fair share, experiencing severe, multiple, prolonged traumas. In fact, one nationally representative sample of over two thousand children found that 22% of surveyed children had experienced four or more different kinds of victimization within a single year (Finkelhor, Ormrod, & Turner, 2007). This suggests that the experience of extensive and repeated trauma is not all uncommon, yet this subset of survivors have not received little attention to their unique needs. Decades of research, however, have been devoted to examining the impact of single types of maltreatment (i.e., sexual or physical abuse) and consistently demonstrate the toxicity of various traumatic events. Childhood traumatic experiences have been linked to a variety of physical and mental health problems, risky and selfinjurious behaviors, negative parenting outcomes, revictimization, and perpetration of interpersonal violence (Abram, Teplin, Longworth, McClelland, & Dulcan, 2004; Anda, 2006; Banyard, Williams, & Siegel, 2003; Felitti et al., 1997; Walsh, Blaustein, Knight, Spinazzola, & van der Kolk, 2007; Whitfield, Dube, Anda, & Felitti, 2003). Clearly, these well-documented symptoms extend far beyond the confines of the diagnostic construct Posttraumatic Stress Disorder (PTSD) even for acute traumatic events. When considering the impact of poly-victimization, then PTSD may be insignificant. A diagnosis of PTSD requires the direct or indirect exposure to a traumatic event that involves an actual or perceived threat to the physical integrity of an individual or others (criterion A1; APA, 2000). Traumatic events commonly observed in childhood Wamser, Rachel, UMSL, 2012 9 include, but are not limited to: child sexual or physical abuse, neglect, domestic violence, life-threatening illness, school or community violence, unexpected death of a family member or close friend, natural disaster, motor vehicle accident or other serious accident. Thus, a wide range of events are captured under the heading of a traumatic event. But would the experience of learning of a friend's non-fatal car accident be expected to result in an identical symptom presentation as chronic sexual abuse perpetrated by one's biological father? According to the PTSD framework, yes. Despite qualitative differences in terms of the degree of involvement, severity, and chronicity of the traumatic event, with the diagnostic construct of PTSD, all traumatic events are assumed to potentially result in the same sequelae. Yet, common sense and clinical lore suggests that survivors of severe traumatic events will have a more complicated symptom presentation. This is affirmed by research. Researchers consistently find that characteristics of the traumatic event are related to a more complicated symptom presentationtypically with non-PTSD symptoms. For example, interpersonal traumas, such as abuse and domestic violence, appear to be particularly harmful, resulting in long-lasting, severe, and more generalized symptoms than non-interpersonal traumas such as motor vehicle accidenets (Briere & Jordan, 2004; Briere, Kaltman, & Green, 2008; Ford, Stockton, Kaltman, & Green, 2006; van der Kolk, 2005). Interpersonal traumas are partly so toxic as they are intentionally perpetrated by another person, thus, the victim’s views regarding safety, intimacy, and trustworthiness are vulnerable to unhelpful or inaccurate alterations (Janoff-Bullman, 1992). The duration and the number of instances of the traumatic event are also related to outcome. Duration and number of incidents are linked together as traumatic events that are chronic, by their nature, have occurred more than once and conversely, multiple incidents of a Wamser, Rachel, UMSL, 2012 10 traumatic event often occur over an extended period of time. Unsurprisingly, the longer and more frequently the trauma occurs, the more severe and varied the post-traumatic sequelae (Blaauw, Winkel, Arensman, Sheridan, & Freeve, 2002; Mechanic, Uhlmansiek, Weaver, & Resick, 2000). Both of these characteristics may contribute to the survivor feeling overwhelmed, helpless, or that the trauma is inescapable. The age of the victim when the trauma begins is important. Traumatic events that begin in childhood result in a more severe symptom presentation compared to those which begin in adulthood (Cloitre, Scarvalone, & Difede, 1997; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). In sum, all traumatic events are not created equal. Taken together, research would suggest that traumatic events which are interpersonal in nature, chronic or multiple, or begin at an early age are related to a more complex symptom presentation (Herman, 1992; Terr, 1991). Within the current PTSD construct, these differences are not acknowledged and instead are subsumed under a single diagnostic category. PTSD also takes a one-size-fits-all approach to trauma-related symptoms, which is tragic as PTSD is fails to capture the full span of trauma-related sequelae. PTSD is classified as an anxiety disorder and consequently, PTSD describes symptoms of anxiety. Trauma survivors unfortunately have problems beyond that of anxiety. Survivors of childhood sexual abuse, for example, have difficulties in a broad range of domains including serious impairments in affect regulation, self-concept, and interpersonal problems, sexualized behavior, and somatic complaints (Cloitre, Stovall-McClough, Zorbas, & Charuvastra, 2003; Spinazzola, 2005; Stovall-McClough & Cloitre, 2006; Zucker, Spinazzola, Blaustein, & van der Kolk, 2006). These symptoms are notably absent from the list of acceptable symptoms of PTSD. As an anxiety disorder, the construct PTSD is unable to capture these difficulties without violating the organization Wamser, Rachel, UMSL, 2012 11 of the DSM. The non-anxiety symptoms which do not fit are relegated to a variety of “comorbid” conditions, which ostensibly are thought to be unrelated to the trauma. This would be acceptable if few traumatized individuals presented with non-PTSD diagnoses. Unfortunately, non-PTSD symptoms are ubiquitous, with more than 80% of individuals diagnosed with PTSD also receiving a comorbid diagnosis (Foa, Freidman & Keane, 2000). PTSD has one of the highest rates of comorbidity of any DSM diagnostic category (Kessler, Chiu, Demier, Merikangas, & Walters, 2005). This may be problematic, it is implied that some, but not all, of the patient's symptoms may be ascribed to the traumatic experience. Conceptualizing other potential effects of trauma as merely “co-morbid,” as opposed to the “real” trauma disorder may also limit the validity of trauma research; as such co-morbid conditions are often excluded from traumafocused research. In fact, a review of the treatment outcome studies demonstrated that the typical presenting client would be screened out of PTSD studies because of comorbid conditions (Spinazzola, Blaustein, & van der Kolk, 2005). Thus, much of PTSD research may not be even applicable to the typical client. PTSD is, instead, more useful in capturing the effects of single-episode, acute traumas occurring in adulthood (Cloitre, Scarvalone, & Difede, 1997; van der Kolk, 2005). In fact, PTSD is diagnosed more frequently following single instances of trauma than after multiple or chronic traumatic events (Green et al., 2000). Clearly, this does not indicate that individuals who have experienced repeated and severe traumatic events do not present with trauma-related difficulties, but rather, that the PTSD criteria may be insufficient in describing reactions to more severe traumatic events. Since its inception into the DSM in 1980, leaders in the field of traumatic stress have argued that PTSD does not accurately capture the presentation of victims of child abuse, concentration camps, Wamser, Rachel, UMSL, 2012 12 refugee camps, domestic violence, or those that have experienced other repeated and extensive trauma (Herman, 1992; Cook et al., 2005; Courtois, 2004). The shortcomings of PTSD are too great for the most serious of traumas. Diagnostic issues tend to be magnifie

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Complex Trauma in Children and Adolescents

Two studies explored how domestic violence may be implicitly or explicitly sanctioned and reinforced in cultures where honor is a salient organizing theme. Three general predictions were supported: (a) female infidelity damages a man's reputation, particularly in honor cultures; (b) this reputation can be partially restored through the use of violence; and (c) women in honor cultures are expected to remain loyal in the face of jealousy-related violence. Study 1 involved participants from Brazil (an honor culture) and the United States responding to written vignettes involving infidelity and violence in response to infidelity. Study 2 involved southern Anglo, Latino, and northern Anglo participants witnessing a "live" incident of aggression against a woman (actually a confederate) and subsequently interacting with her.

Male honor and female fidelity: implicit cultural scripts that perpetuate domestic violence.

Two community-based group therapies, emotion focused versus goal oriented, are compared among women exposed to intimate partner violence (n = 46) and their children ( n = 48) aged between 6 and 12 years. A series of repeated measures analyses are employed to evaluate the effects of time from baseline to postintervention following random assignment. Main and treatment effects for women provide support for the relative effectiveness in increasing quality of social support in the emotion-focused intervention and in the reduction of both family conflict and alcohol use for the goal-oriented intervention.

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Differential Therapeutic Outcomes of Community-Based Group Interventions for Women and Children Exposed to Intimate Partner Violence:

La violencia privada domestic violence in chile

A meta-analysis on domestic violence interventions was conducted to determine overall effectiveness of mental health programs involving women and children in joint treatment. These interventions were further analyzed to determine whether outcomes are differentially affected based on the outcome measure employed. To date, no meta-analyses have been published on domestic violence victim intervention efficacy. The 17 investigations that met study criteria yielded findings indicating that domestic violence interventions have a large effect size (d = .812), which decreases to a medium effect size when compared to control groups (d = .518). Effect sizes were assessed to determine whether treatment differed according to the focus of the outcome measure employed: (a) external stress (behavioral problems, aggression, or alcohol use); (b) psychological adjustment (depression, anxiety, or happiness); (c) self-concept (self-esteem, perceived competence, or internal locus of control); (d) social adjustment (popularity, loneliness, or cooperativeness); (e) family relations (mother-child relations, affection, or quality of interaction); and (f) maltreatment events (reoccurrence of violence, return to partner). Results reveal that domestic violence interventions across all outcome categories yield effects in the medium to large range for both internalized and externalized symptomatology. Implications for greater awareness and support for domestic violence treatment and programming are discussed.

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The Therapeutic Efficacy of Domestic Violence Victim Interventions

Exploring risk factors and profiles of intimate partner violence in other countries provides information about whether existing theories of this phenomenon hold consistent in different cultural settings. This study will present results of a regression analysis involving domestic violence among Mexican women (n = 83,159). Significant predictors of domestic violence among Mexican women included age, number of children in the household, income, education, self-esteem, family history of abuse, and controlling behavior of the husband. Women's employment status was not a significant predictor when all variables were included in the model; however, when controlling behavior of the husband was withdrawn from the model, women's employment status was a significant predictor of domestic violence toward women. Results from this research indicate that spousal controlling behavior may serve as a mediator of the predictive relationship between women's employment status and domestic violence among Mexican women. Findings provide support for continued exploration of the factors that mediate experiences of domestic violence among women worldwide.

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Employment Status and Intimate Partner Violence Among Mexican Women

Trends in adolescent drug use are encouraging and suggest the importance of preventative programs for youth. Yet, among those who become involved with illicit substances and seek treatment, only a fraction report positive outcomes. This article describes an approach to enhance adolescent participation in substance abuse treatment. Aspects of the transtheoretical model are integrated into a treatment program designed to meet the unique developmental needs of adolescent alcohol and marijuana abusers. The result is a treatment that better engages adolescents in participation, thereby increasing the likelihood for treatment success.

Paula T. McWhirter

Papers

Differential Therapeutic Outcomes of Community-Based Group Interventions for Women and Children Exposed to Intimate Partner Violence:

La violencia privada domestic violence in chile

The Therapeutic Efficacy of Domestic Violence Victim Interventions

Employment Status and Intimate Partner Violence Among Mexican Women

Enhancing Adolescent Substance Abuse Treatment Engagement