Thesis advisor: Belle Liang / The study of treatments for complex posttraumatic stress disorder (CPTSD), especially in cases of chronic childhood abuse, has revealed that traditional trauma treatments often lack success due to the complexity of symptom presentation. CPTSD often manifests as a lack of integration between the self and the body. While certain coping strategies used by survivors during the trauma experiences, such as dissociation, may be adaptive in the short-term, prolonged use posttrauma comes at a cost--resulting in a loss of awareness of one's emotional and physical being in the present moment. Mindfulness-based interventions, such as hatha yoga, show promise as alternative or complementary treatments for CPTSD. Furthermore, current trauma treatments have been criticized for their primary focus on psychopathology. More recent conceptualizations of trauma recovery call for a paradigm shift that recognizes not only the need for symptom-reduction, but also the encouragement of positive development and personal growth (i.e., stronger sense of self, relationships with others, and perspective on life). This qualitative study explored the experiences of women with CPTSD in a 10-week, trauma-informed hatha yoga class, specifically examining perceived changes with regard to symptom reduction and personal growth. Six themes were identified through qualitative content analysis. Theme 1 describes the yoga practice and study design characteristics that influenced participants' experiences. Themes 2 through 6 reflect participants' increased feelings of Gratitude and compassion, Relatedness, Acceptance, Centeredness, and Empowerment (referred to as G.R.A.C.E. themes). Findings are discussed in the context of current literature. Limitations of the study are also presented along with recommendations for future research and clinical work. / Thesis (PhD) — Boston College, 2011. / Submitted to: Boston College. Lynch School of Education. / Discipline: Counseling, Developmental, and Educational Psychology.

The recent inclusion of complex posttraumatic stress disorder (CPTSD) within the International Classification of Diseases, eleventh edition (ICD-11) prompted scholars to re-evaluate treatment guidelines for traumatic disorders. The present study aimed to conceptualize dyadic, community, and systemic connections within the context of ICD-11 traumatic disorders and investigate unique associations between factors capturing relational quality. The current study additionally utilized a novel network modeling approach to explore the CPTSD symptom network structure using a college sample of trauma survivors. Consistent with generations of theory and research, relational quality factors associated with the disturbances in self-organization (DSO) symptom cluster, and anticipated discrimination associated with both relational disturbance and sense of threat. Affect dysregulation, re-experiencing, and relational engagement emerged as most central within the CPTSD symptom network, providing evidence towards the role of affect regulation in relational functioning, while intersectional discrimination associated with both the PTSD and DSO symptom clusters. Findings from the present study provide context to the potential application of a relational and systems focused intervention.

Background The effects of prolonged, interpersonal trauma have long been recognised. Such traumatic events can lead to the development of post-traumatic stress disorder (PTSD), but are also associated with a range of other psychological difficulties. The forthcoming ICD-11 has proposed the inclusion of a new diagnostic category to cover such trauma reactions, named complex-PTSD (CPTSD). CPTSD is conceptualised as including the core elements of PTSD with additional difficulties with affect regulation, self-concept, interpersonal relationships. This thesis presents a systematic review of the research into the proposed CPTSD diagnosis. In addition, this thesis investigates the association between difficulties with emotional regulation, interpersonal problems and PTSD symptoms in a group of male prisoners, and a male community sample. Aims This project aims to investigate whether the proposed CPTSD diagnosis accurately describes the difficulties seen following complex trauma, and examines whether it is best to view CPTSD is different from exiting disorders, including PTSD and borderline personality disorder (BPD). In addition, it aims to investigate the association between difficulties with emotional regulation, interpersonal problems and PTSD among men in prison. Methods We systematically assessed and synthesised the available research regarding the proposed ICD-11 CPTSD diagnosis. In the second paper, data regarding PTSD, emotional regulation, and interpersonal problems were collected from HMP Glenochil, a male-only prison in Scotland (n=51), and matched to an existing community data set (n=46). Results The results of the systematic review provide partial support for the factorial validity of CPTSD. In addition, they indicate that CPTSD can be conceptualised as distinct from both PTSD and BPD, and that CPTSD is more closely related to prolonged interpersonal trauma than PTSD. However, there is overlap between PTSD and CPTSD in terms of both symptomology and aetiology. The results also indicate high levels of PTSD among male prisoners. In addition, PTSD was found to be strongly associated difficulties with emotional regulation, but not interpersonal problems, in the forensic sample. In the community sample emotional regulation was a less strong predictor of PTSD symptoms, and both emotional regulation, and interpersonal problems were associated with the severity of PTSD. Conclusions This thesis supports the inclusion of CPTSD as a distinct diagnostic entity. Inclusion of CPTSD may allow survivors a better understanding of the aetiology of their difficulties, and may initiate research into effective ways of working with individuals who have experienced complex-trauma. I addition, they demonstrate the need for trauma-informed prison services, which prioritise the development of emotional regulation strategies in recovery and rehabilitation.

Ce travail de thèse raconte un cheminement de clinicienne, avec des allers retours entre une pratique psychothérapeutique et une réflexion conceptuelle, tentant de cheminer vers une démarche intégrative permettant d’aborder les situations psychotraumatologiques complexes. Guidée par l’envie d’apprendre, mais aussi par la mise à l’épreuve du terrain, nous avons élargi pas à pas notre démarche psychotraumatologique, pour aboutir à la proposition d’un modèle intervention intégratif et original. Nous espérons que ce modèle puisse permettre au clinicien de s’adapter, sans se perdre, à la réalité complexe des personnes souffrant de traumatisations complexes et chroniques. La présentation de différentes publications et de cas cliniques illustrera ce cheminement de pensée et de pratiques pour arriver à un modèle rigoureux pouvant être soumis à l’épreuve scientifique et au terrain. / This thesis tells a journey of a clinician, with back and forth between a psychotherapeutic practice and conceptual thinking, trying to move towards an integrative approach for addressing complex situations in psychotraumatology. Guided by the desire to learn, but also examining field practice, we have expanded, step by step, our psychotraumatologic approach, coming to a proposal of an integrative and original treatment model. We hope this model may allow clinicians to adapt to the complex reality of complex and chronic traumatized persons, without getting lost. The presentation of different publications and clinical cases illustrate this line of thought and practices in order to achieve a rigorous model that can be subjected to scientific testing as well as put to the proof of the psychotherapy field.

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This dissertation consists of two studies designed to broaden our understanding of the impact of complex trauma on symptom profiles and outcomes of children in the child welfare system through the lenses of gender, development, and placement permanency. Data for both were obtained using the Child and Adolescent Strengths and Needs Comprehensive Assessment tool (CANS; Lyons, Gawron, & Kisiel, 2005) for youth ages 6 -17 years involved in the child welfare system. In Study 1, I examined symptom profiles of 3,446 youth to determine the ability of gender, age, ethnicity, trauma type, and other adversity variables to predict the following CANS domains: posttraumatic stress symptoms (PTSS), emotional/ behavioral needs, risk behaviors, life domain functioning, and child strengths. Findings supported the hypothesis that males and females would exhibit a similar number and severity of PTSS subsequent to exposure to maltreatment, including complex trauma. Unique gender-specific developmental profiles of trauma exposure and symptomatology emerged. I concluded that the complex and dynamic interactions among gender, age, trauma experience, and psychosocial functioning are more complicated than can be elucidated in main effect or two-way interactions. It is therefore recommended that trauma researchers disaggregate analyses by gender in trauma research because the dynamics of trauma are different for males and females. In Study 2, I employed survival analyses to examine the ability of child characteristics, complex trauma exposure, and placement-related variables to predict placement disruption in a sample of 4,822 youth at high-risk for placement disruption. Older age, female gender, higher levels of externalizing behavior, and more prior placements increased risk for placement disruption, whereas longer time in care and type of out-of-home placement decreased risk for placement disruption in the sample. It is recommended that placement stability be directly targeted for those at higher risk through provision of intensive support to youth and their foster caregivers. Caseworkers should receive training about those subgroups most at-risk for placement disruption. Externalizing behavior and attachment, but not PTSS, mediated the relation between complex trauma and placement disruption. Intervention for youth with a history of complex trauma should focus on both attachment and externalizing behaviors.

To assess a wide range of stressors and traumas, we developed a trauma and stressors exposure checklist for adults to capture a wide variety of potential trauma exposure. This study details the extensive development and validation process of the Comprehensive Trauma and Stressors Checklist (CTSC). Study 1 consisted of item pool generation, review of existing trauma measures, content analysis, and expert review and input. Study 2 analyzed reliability and validity of the updated checklist. Participants were recruited from college and community samples (N = 200) and completed the CTSC along with five additional measures. The CTSC demonstrated high internal consistency (α =.96). Good temporal stability was established with a subset of participants (n = 28) who completed the survey twice for test-retest reliability (r = 0.86, p < .001). Significant correlations between scores on the CTSC and the Stressful Life Events Screening Questionnaire, Life Events Checklist for the DSM-5, Intersectional Discrimination Index, and Spiritual Abuse Questionnaire are evidence of strong convergent validity. Finally, the lack of significant correlations between CTSC scores and theoretically unrelated constructs supported the discriminant validity of the CTSC. This study provides preliminary evidence that the CTSC is a reliable and valid measure of exposure to traumas and stressors. Future studies with the CTSC will examine measurement invariance, exploratory and confirmatory factor analysis, and reading level.

The Supporting Transformation and Resilience (STAR) program is a groundbreaking doctoral project in the field of occupational therapy designed to enhance the resilience, quality of life, and overall well-being of adult survivors of childhood trauma who are raising a child with a disability. Childhood trauma can profoundly impact an individual's life, and caring for a child with a disability can introduce additional challenges, making it essential to develop a comprehensive support program tailored to this specific population. STAR uses a mixed-method experimental design with a waitlist control group. The STAR program leverages a hybrid approach, combining psychoeducational and experiential components underpinned by a peer mentor model. The in-person sessions are proposed to be held at the YMCA, spanning a 12-week period with weekly in-person gatherings. Furthermore, participants will engage in a once-weekly asynchronous email support group and have access to online modules available around the clock. The waitlist control group will be granted access to the online modules, offering a basis for comparison with the participants actively engaging in the in-person and online aspects of the program. The aim of the STAR program is not only to gather critical data but also to offer support and resources for survivors of childhood trauma, creating a holistic approach that addresses their unique needs and circumstances. The STAR program holds the potential to shed light on the impact of a novel occupational therapy health promotion initiative on the resilience, quality of life, and overall well-being of its participants. This project anticipates significantly contributing to the occupational therapy and trauma fields. It has the potential to enhance the lives of those who face the challenges of both childhood trauma and caring for a child with a disability.

Female survivors of multiple forms of trauma are increasingly found to be a significant portion of the university population (Briere, Kaltman, & Green 2008). While there is a strong literature base for understanding the effects of individual trauma on psychological functioning (e.g., Briere, 1992; Kaltman, Krumnick, Stockton, Hooper, & Green, 2005), little is known about specific symptom constellations for those who have experienced multiple traumas (Rich, Gingerich, & Roseìn, 1997). Using a clinical population of 500 female university students, this study explored the rates of multiple interpersonal traumatic experiences, the connection between multiple traumas and symptom severity, and the association of specific constellations of multiple types of traumas with specific constellations of trauma symptoms. The Trauma Symptom Inventory-Alternate (Briere, 1995) and self-report measures of demographic data and abuse histories were used to collect data, which was analyzed with frequencies, Multivariate Analysis of Variance, and a Canonical Correlation to explore the interrelationships of abuse and trauma symptoms. Multiple abuse was common, with 81% of participants experiencing two or more types of abuse. Multiple trauma generally predicted more severe trauma-related symptoms than those with no trauma or single traumas. A Canonical Correlation revealed a moderately significant relationship between participants with aggressive types of abuse (e.g., childhood physical, adult physical, and adult sexual abuse) with higher symptoms of intrusive experiences, defensive-avoidance, and dissociation. These findings suggest a differential model of trauma effects, particularly for trauma types characterized by aggression. Implications for future research and clinical practice are addressed.

Abstract : Complex Trauma (CT) refers to the exposure to chronic or prolonged experiences of maltreatment that often occur in the context of a caregiving relationship. This concept also refers to the numerous sequelae that CT can have on the child’s functioning, including dissociation. Dissociation reflects a continuum of behaviours and processes that range from normative (e.g., daydreaming) to pathological (e.g., amnesia). The majority of children in the child welfare system have been victim to experiences of chronic maltreatment, which represents an important precursor in the development of disorganized attachment (DA). As such, many authors highlight the importance of assessing for CT exposure and associated sequelae given the pathological trajectories that are associated to these, including DA and the development of dissociative symptoms. The MacArthur Story Stem Battery (MSSB; Bretherton, Oppenheim, Buschbaum, Emde, & the MacArthur Narrative Group, 1990) is a narrative task whose purpose is to activate children’s attachment representations. The Attachment-Focused Coding System for Story Stems (AFCS; Reiner & Splaun, 2008) is a valid coding system which uses four stories (out of the 14 available) from the MSSB that are considered more likely to activate the child’s attachment system. However, this system differs in that it is quicker to administer and to code, making it more accessible to researchers and clinicians. The AFCS screens for the majority of sequelae associated to CT but does not consider dissociation. The first theoretical article outlines the current state of knowledge surrounding child dissociation, as well as how this concept relates to DA and exposure to CT. This article also explores difficulties related to the assessment of dissociation symptoms in maltreated children and argues the relevance of using a narrative task like the MSSB to do so. The second empirical article aims to develop a child dissociation assessment system which examines   the verbal and non-verbal manifestations of children that emerge during the MSSB stories selected for use with the AFCS. The Child Dissociation Assessment System (CDAS) is composed of two complementary measures, the Child Dissociation Code (CDC), which screens for dissociative symptoms, and the Child Dissociation Tool (CDT), which then assesses how these symptoms affect several domains of functioning, should this be necessary. The CDAS is a response to the current lack of child dissociation instruments available and takes limitations identified amongst existing measures into account. Through this exploratory study, the authors sought to obtain interrater agreement, with an intraclass correlation coefficient (ICC) of 0.75. To achieve this, 20 MSSB protocols of children between 6 and 12 years old (10 from a clinical sample and 10 from a non-clinical sample) were scored using the CDAS. The Mann-Whitney statistical test was then applied to the CDC to compare the average scores obtained on this measure by both groups of children to verify whether it discriminated between a clinical and non-clinical population. Preliminary results indicated that the CDAS possesses adequate to excellent inter-reliability and that the CDC discriminated between a clinical and non-clinical sample of children, highlighting the relevance of using the CDAS and of pursuing a validation study. / Les traumatismes complexes (TC) décrivent l’exposition à de multiples événements de vie traumatiques qui se produisent de manière répétée et prolongée et dont la figure parentale est souvent l’auteur. Cette nomenclature réfère également aux multiples impacts des TC sur le fonctionnement de l’enfant, dont la dissociation. La dissociation reflète une gamme de comportements et de processus allant de normaux (p. ex., rêverie) à pathologiques (p. ex., amnésie). La majorité des enfants suivis par la protection de la jeunesse (PJ) ont été victimes de maltraitance chronique, qui constitue l’un des principaux précurseurs de l’attachement désorganisé (AD). Ainsi, plusieurs auteurs notent l’importance d’évaluer l’exposition aux TC et leurs séquelles compte tenu des trajectoires pathologiques qui y sont associées, dont l’AD et le développement de symptômes dissociatifs. Le MacArthur Story Stem Battery (MSSB; Bretherton, Oppenheim, Buschbaum, Emde, & the MacArthur Narrative Group, 1990) est une tâche narrative qui vise à activer les représentations d’attachement chez les enfants. L’Attachment-Focused Coding System for Story Stems (AFCS; Reiner & Splaun, 2008) est un système de codage se voulant simple et accessible pour les chercheurs et les cliniciens, qui est appliqué à quatre histoires du MSSB (sur 14) jugées plus susceptibles d’activer l’attachement de l’enfant. L’AFCS tient compte d’indices reflétant la majorité des séquelles engendrées par les TC mais ne considère pas la dissociation. Le premier article théorique vise à dresser un portrait de l’état des connaissances au sujet de la dissociation telle qu’elle se manifeste chez les enfants, son lien avec l’AD et avec l’exposition aux TC. L’article explore également les difficultés liées à l’évaluation des symptômes de dissociation chez les enfants et discute de la pertinence d’évaluer ceux-ci en utilisant une tâche narrative telle que le MSSB. Le deuxième article empirique vise à développer un système d’évaluation de la   dissociation chez l’enfant à partir des manifestations verbales et non-verbales de la dissociation qui émergent lors des histoires du MSSB sélectionnées par l’AFCS. Le Child Dissociation Assessment System (CDAS) est composé de deux outils complémentaires, soit le Child Dissociation Code (CDC), qui permet un dépistage de symptômes dissociatifs, et le Child Dissociation Tool (CDT) qui dans un deuxième temps précise les domaines de fonctionnement atteints par ces symptômes, le cas échéant. Le CDAS répond à un manque actuel d’instruments pour évaluer la dissociation infantile et comble les limites identifiées parmi ceux qui existent. À travers cette étude exploratoire, les auteurs visent un accord inter juges satisfaisant pour le CDAS, soit un coefficient de corrélation interclasse (CIC) de 0,75 ou plus. Pour ce faire, 20 protocoles du MSSB d’enfants âgés de 6 à 12 ans (10 issus d’une population clinique et 10 d’une population non-clinique) ont été codés à l’aide de ce nouveau système de dissociation. Ensuite, le test statistique de Mann-Whitney a été appliqué au CDC afin de comparer la moyenne des scores de dissociation obtenus par les deux groupes d’enfants pour vérifier si cet outil discrimine entre la population clinique et non-clinique. Les résultats préliminaires indiquent que le CDAS possède un taux d’accord inter juges adéquat à excellent et que le CDC discrimine entre des enfants issus d’une population clinique et non-clinique. Ces résultats soulignent la pertinence du CDAS et justifient la poursuite d’un travail de validation.