Keywords

Overview of the Trauma

We all use the word “trauma” in everyday language to mean a highly stressful event. But the key to understanding traumatic events is that it refers to extreme stress that overwhelms a person’s ability to cope both psychologically and physiologically. Technically, trauma refers only to the event, not the reaction to it, and should be reserved for major events that are psychologically overwhelming for an individual. However, the term trauma for mental health practitioners refers both to negative events that produce distress and to the distress itself (Briere & Scott, 2006). The Diagnostic and Statistical Manual of Mental Disorders-5 (American Psychiatric Association, 2013) defines trauma with two necessary criterions:

  1. 1.

    Direct personal experience of an event that involves actual or threatened death or serious injury or other threat to one’s physical integrity; witnessing an event that involves death, injury, or threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or close associate.

  2. 2.

    The person’s response to the event must involve intense fear, helplessness, or horror (in children, the response must involve disorganized or agitated behavior).

The following is a list of the variety of potentially traumatic events a person may experience: combat, sexual and physical assault, robbery, being kidnapped or taken hostage, terrorist attacks, torture, natural disasters (i.e., earthquakes, tornadoes, etc.), severe vehicle accidents, life-threatening illnesses, witnessing serious death or serious injury, as well as childhood sexual and/or physical abuse (APA, 2013). Approximately one million cases of abuse and neglect are substantiated per year. Many thousands of children undergo traumatic medical or surgical procedures or are victims of community violence or suffer from system-induced trauma (multiple foster placements, separation from siblings, etc.).

Most research contends that the frequency, intensity, and duration of traumatic events are the main important factors in our assessment and treatment of trauma (Herman, 1992). Symptoms and diagnoses vary and depend on a person’s developmental level, sources of support, and temperament/coping resources. Early experiences of trauma and stress have an impact not only in the cognitive, behavioral, and emotional development of a child but also their adjustment and personality along his/her adulthood. As demonstrated in a systemic literature review (Carr, Martins, Stingel, Lemgruber, & Juruena, 2013), early stress and traumatic experiences such as physical, emotional, and sexual abuse, as well as neglect, are associated with several psychiatric disorders during adulthood. It is also important to consider that a traumatic experience can be acute, chronic, or complex. There are different presentations for clients with extensive histories of severe childhood maltreatment differing from those who had experienced a single traumatic event as a well-adjusted adult. As such, it is helpful to classify the trauma reactions as acute, chronic, or complex. Acute trauma is generally limited in time. An earthquake, a dog bite, and a motor vehicle accident are all examples of acute trauma (National Child Traumatic Stress Network, 2008, p. 6). Chronic trauma generally refers to the experience of multiple traumatic events. For example, living in an unsafe environment as a result of poverty, homelessness, domestic violence, or abuse or witnessing violence. As van der Kolk (2005) sustained, the concept known as complex trauma is used to describe the experience of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset. The length of treatment and the pace with which exposure is utilized should vary based on these types and several other factors to be discussed further in this chapter.

Impact of Culture

Laura Brown (2008) states “Trauma is trauma is trauma. The texture of pain, the color of fear, and the melody of cries are all human and shared. They are all, also, uniquely configured and ordered by human identities, cultures, heritages, and networks of relationships” (p. 258). Brown’s work is seminal in the area of culture and trauma because it provides us a multicultural/ecological framework to consider. First, it addresses what scholars interested in minority psychology have been researching, such as the implications of privilege and oppression, cultural literacy, and the importance of the therapeutic relationship, all of which can be easily ignored or superficially considered in our new press for evidence-based techniques. Orozco, Chin, Restrepo, and Tamayo (2001) suggested that to fully understand the complexity of and impact of culture on trauma reactions, one must consider an ecological framework, which holds that human development involves the interchange between an individual and his multilevel environments/systems. Some of these systems include the nuclear and extended family, peers, school, neighborhood, and community. The importance of understanding the social ecology and its relationship to trauma for a diverse group such as that of Latinos required an 80+ page document full of references and recommendations created by the NCTSN and the Chadwick Center , which is clearly an example of the complexity of culturally informed work (The Workgroup on Adapting Latino Services, 2008). Attempts to utilize treatment adaptations do not necessarily make a practice culturally competent because clinicians can easily miss cultural nuances and err by making concrete overgeneralizations. Even well-developed treatment adaptations cannot be appropriate for all individuals or groups. Therapists must possess the clinical skills to recognize this and continually evaluate the appropriateness and effectiveness of their treatments. Achieving cultural sensitivity requires a combination of cultural and systems awareness training, clinical consultation, reflection and treatment evaluation, and adaptation.

The need for all of the abovementioned components of culturally sensitive practice is highlighted by the reports that several disparities in Hispanic mental health services have been noted in the literature. These include the underutilization of mental health services and very high dropout rates. Latinos with mental health disorders rarely seek services, and recent immigrants have even lower rates of service utilization (Acosta, 2006; Office of the Surgeon General, Center for Mental Health Services, & National Institute of Mental Health, 2001). Studies have indicated that almost 70% of Latinos who access mental health care services do not return after their first visit, thus indicating a possible lack of trust in the mental health care system (Aguilar-Gaxiola, 2005). In response to mental health disparities, several authors have indicated that the two most important issues that need to be addressed are inadequate/inappropriate sources of treatment and insufficient Latino or bilingual service providers (Acosta, 2006; National Council of La Raza, 2005; NCTSN, 2007). Additionally, some traumatic experiences may be related to the process of immigrating without proper documentation. For example, a growing body of research has demonstrated wide-ranging consequences of sudden caregiver-child separation, one of the most damaging outcomes of raids (Rodriguez & Hagan, 2004; Suárez-Orozco, Todorova, & Louie, 2002). Some documented consequences include, among others, fear and anxiety, depression, and posttraumatic stress symptoms and reactions (Capps, Castaneda, Chaudry, & Santos, 2007; Chaudry et al., 2010; Pumariega & Rothe, 2010). Additionally, there are many children who are separated from their parents very early in their development due to piece-meal migration which can intensify the child’s risk of exposure to other traumatic events as well as their general sense of safety (Suárez-Orozco et al., 2002).

Over 25 years of research studies has found that Hispanic adults are more likely than their non-Hispanic counterparts to experience severe symptoms of post-traumatic stress disorder (PTSD) (Escobar et al., 1983; Galea et al., 2004; Kulka et al., 1990; Lewis-Fernandez et al., 2008; Norris, Perilla, & Murphy, 2001; Pole et al., 2001; Schell & Marshall, 2008). Eisenman, Gelberg, Liu, and Shapiro (2003) mentioned that a third of the Latino population who have been exposed to traumatic experiences developed symptoms of depression and PTSD . A longitudinal study by Marshall, Schell, and Miles (2010) with over 600 participants replicated several study findings indicating that Hispanics tended to report higher levels of symptoms such as hypervigilance and flashbacks. In contrast, few differences were observed for symptoms characteristic of impaired psychological functioning such as difficulty concentrating or sleep difficulties (other than nightmares). This may suggest that the pattern of symptoms for Hispanics with PTSD may differ not only in prevalence and degree but also in the types of symptoms. A study by Pole, Best, Metzler, and Marmar (2005) comparing Hispanic police officers (n = 189) from their non-Hispanic Caucasian (n = 317) and Black (n = 162) counterparts found that greater peri-traumatic dissociation, greater wishful thinking and self-blame coping, lower social support, and greater perceived racism were important variables in explaining the elevated PTSD symptoms among Hispanics.

There are several other running theories for these differences such as the idea that there is a culturally based propensity to exaggerate or overreport mental health symptoms (Ruef, Litz, & Schlenger, 2000; Ortega & Rosenheck, 2000), a disposition toward acquiescent responding (Ortega & Rosenheck, 2000), and the tendency of Latinos to manifest suffering in physical rather than psychological form (Hough, Canino, Abueg, & Gusman, 1996). Some of the other explanations include disparity in the experience of traumatic life events (Frueh, Brady, & de Arellano, 1998), ethnic discrimination (Loo et al., 2001; Marsella, Friedman, & Spain, 1996), differences in coping resources following trauma exposure (Pole et al., 2005), and/or sociodemographic disadvantage (Pole, Gone, & Kulkarni, 2008). All of these studies warrant future research. At this point stating that Latinos experience a greater risk for PTSD does not need as much further study as it provides very little clinical utility. Future research will be required to disentangle the many constructs within Hispanic ethnicity that may contribute to the observed differences in reactions to trauma. Examples of these factors include education, income, culture, religiosity, family composition, employment type, self-concept, discrimination, and its historical link to colonialism (Brown, 2008). Additionally, understanding that symptom presentation may differ, it is important that these symptoms be directly assessed in this population. In general, many general psychological screening measures do not focus much attention on hypervigilance, flashbacks, and dissociation. As such, clients’ symptoms may be misdiagnosed as bizarre or thought disorder related which increases the risk of misdiagnosis. Further studies may consider how to incorporate these factors into general screening assessments.

Symptoms/Diagnoses

For the purposes of this chapter, we will mainly focus on the diagnoses of post-traumatic stress disorder (PTSD) and acute stress disorder acknowledging that there is likely to be other comorbidity involved in chronic and complex trauma responses. The DSM-5 (APA, 2013) lists the following categories as the ones necessary for a PTSD diagnoses: traumatic event/stressor, intrusion symptoms, persistent avoidance of stimuli associated with the trauma, negative alterations in cognitions and mood that are associated with the traumatic event, and alterations in arousal and reactivity that are associated with the traumatic event. Examples of intrusion symptoms include flashbacks, nightmares, and frightening thoughts. Flashbacks are when one is reliving the trauma over and over, and this includes physical symptoms like a racing heart or sweating. Reexperiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger reexperiencing symptoms ; therefore, clinicians would need to help a client identify these triggers. Avoidance symptoms include staying away from places, events, or objects that are reminders of the traumatic experience, as well as avoiding thoughts or feelings related to the traumatic event. These symptoms may cause a person to change his or her personal routine. Arousal and reactivity symptoms include an increased startle response, feeling tense or “on edge,” difficulty sleeping, and angry outbursts. Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to perform daily tasks, such as sleeping, eating, or concentrating. Additionally, there are thought- and mood-related symptoms such as trouble remembering key features of the traumatic event; negative thoughts about oneself or the world; distorted feelings like guilt, shame, or blame; and loss of interest in enjoyable activities.

The National Institute of Mental Health (n.d.) emphasizes that children and teens can have extreme reactions to trauma, but their symptoms may not be the same as adults. In very young children (less than 6 years of age), these symptoms can include wetting the bed after having learned to use the toilet, forgetting how to or being unable to talk (regression), acting out the scary event or related themes during playtime, and/or becoming unusually clingy with a parent or other adult. Older children and teens are more likely to show symptoms similar to those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. They may also have thoughts of revenge.

A diagnosis of acute stress disorder is given within the first month after a traumatic event. Symptoms are also classified into categories: intrusion, negative mood, dissociation, avoidance, and arousal. It involves the reexperience of the event in the present, which varies by individual, but commonly includes recurrent memories that include a sensory, emotional, or physiological component (APA, 2013). Acute stress disorder and PTSD differ in two fundamental ways. The first difference is that the diagnosis of acute stress disorder can be given only within the first month following a traumatic event. If posttraumatic symptoms were to persist beyond a month, the clinician would assess for the presence of PTSD. The acute stress disorder diagnosis would no longer apply. Acute stress disorder also differs from PTSD in that it includes a greater emphasis on dissociative symptoms. An acute stress disorder diagnosis requires that a person experience three symptoms of dissociation (e.g., numbing, reduced awareness, depersonalization, derealization, or amnesia), while the PTSD diagnosis does not include a dissociative symptom cluster. Problems with sleep onset and maintenance, as well as panic attacks, are also often reported (Harvey & Bryant, 1998). After a month, it may also progress to PTSD.

Idioms of Distress

Nitcher (1981) defines idioms of distress as the ways in which distress is experienced and expressed in a certain culture, considering its values, norms, and health concerns. Hinton and Lewis-Fernández (2010) mentioned the ataque de nervios or “attack of nerves” as an example of idioms within the Caribbean-Latino populations that at times can be considered as a normal reaction to a stressful or traumatic event. Originally ataque de nervios was a pejorative label developed by US military psychiatrists in the 1950s and 1960s in regard to Puerto Rican military males. It was not viewed as a response to trauma but rather focused attention on the disturbing idea that there was some inherent defect in being Puerto Rican. These psychiatrists failed to analyze local cultural meanings and the social and political context of these expressions. Additionally they ignored the broader colonial process of treating Puerto Ricans as “others” (Guarnaccia, 2014). Nowadays it appears that the prevalence is higher in Puerto Rican females, although it is found in other Latino ethnic groups (Guarnaccia et al., 2010). Clinical knowledge of cultural idioms of distress is necessary in order to provide a culturally sensitive diagnosis and a treatment that fits the patient’s beliefs and practices. This becomes more salient considering that Latinos comprise the largest minority group in the United States and 17.6% of the population in the United States (US Census Bureau, 2015). Latinos constitute a diverse population from 20+ countries with distinct ethnic and racial compositions, as well as unique histories of migration to the United States.

Ataque de nervios has the following commonly reported symptoms: shouting uncontrollably, crying “attacks,” trembling, and becoming verbally or physically aggressive. Dissociative experiences, seizure-like or fainting episodes, and suicidal gestures are prominent in some ataques but absent from others. A central feature of an ataque de nervios is a sense of being out of control. Ataques de nervios frequently occur as a direct result of a stressful event relating to the family, such as news of a death of a close kin, a separation or divorce from a spouse, conflicts with family, or witnessing an accident involving a family member. After the ataque, people often experience amnesia of what occurred. However, they otherwise rapidly return to their usual level of functioning. Ataques de nervios have been shown to be associated with a range of affective, anxiety, conduct, and dissociative disorders in several epidemiological and clinical studies, as well as to be normative forms of expressing deep sadness and strong anger in stressful social situations (Guarnaccia et al., 2010).

While many people have associated ataque de nervios with anxiety disorders such as panic disorder, it should be noted that while trauma has been acknowledged to be a risk factor in the development of panic disorder, as well as many other anxiety disorders (e.g., Creamer, McFarlane, & Burgess, 2005; Goodwin, Fergusson, & Horwood, 2005; Lubit, Rovine, Defrancisci, & Eth, 2003), a distressing event is almost always a precipitant for ataques de nervios. However, previous studies that have examined this link between trauma and ataques de nervios have been mixed (Lewis-Fernandez et al., 2002; Schechter et al., 2000). Treatment manuals or even solid treatment guidelines that are specific to the ataque de nervios symptom presentation have not been found.

Trauma-Informed Care and Evidence-Based Techniques

Trauma-informed care refers to treatment that incorporates a thorough understanding of the profound neurological, biological, psychological, and social effects of trauma and violence on the individual, and care that addresses these effects is collaborative, supportive, and skill based (Jennings, 2004). While we teach specific techniques, there is much more involvedness to the treatment than the specific evidence-based treatments we utilize especially when considering complex trauma. The gold standard treatments for trauma-related disorders are somewhat different for children/adolescents (CPP, TF-CBT, etc.) and adults (CPT, EMDR, exposure therapy), but it is also important to conceptualize treatment model and length of treatment based on type of trauma (acute, chronic, or complex). Several random clinical trials have confirmed that exposure therapies and to a lesser extent other cognitive behavioral techniques, such as cognitive processing therapy (CPT ) , have been effective in the treatment of PTSD in adults (Keane, Kaloupek, & Kolb, 1998; Suris, Linl-Malcom, Chard, & North, 2013). The greatest number of studies has been conducted on exposure-based treatments, which involve having survivors repeatedly reexperience their traumatic event. There is strong evidence for exposure and of the various approaches; prolonged exposure (PE) has received the most attention although many clinicians report preferring titrated, gradual exposure or the “relationship as exposure” (Briere & Lanktree, 2008). PE includes both imaginal exposure and in vivo exposure to safe situations that have been avoided because they elicit traumatic reminders (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). Nonetheless, the outcomes of such approaches leave room for improvement, with approximately 20–50% of treatment completers continuing to be diagnosed with PTSD after treatment (Resick, Nishith, Weaver, Astin, & Feuer, 2002; Schnurr et al., 2007). This may be related to the experience of complex trauma and the need for more sessions than allotted for in manualized treatments or phase-oriented treatment for these individuals.

The International Society for Traumatic Stress Studies (ISTSS) suggested that a phase-oriented or sequential treatment is needed in order to provide a hierarchy of treatment needs that go beyond addressing the standard PTSD symptoms (Cloitre et al., 2012). Phase 1 would be stabilization and skills strengthening. This phase is focused on safety and reduction of symptom acuity. Interventions in this phase include psychoeducation about trauma, assessment of harm to self/others, and the introduction of emotion regulation techniques. The next phase, Phase 2, would directly focus on the review and reappraisal of trauma memories. This is where the exposure and processing techniques come into play. The purpose is to maintain emotional engagement with the distressing memory while simultaneously remaining physically, emotionally, and psychologically intact. This is where you would experience reorganization and integration of the traumas into the memory (Cloitre et al., 2012).

There are two primary mechanisms of change hypothesized for efficacious treatment of post-traumatic stress disorder (PTSD): (1) Improvement occurs through emotional processing of the trauma memory by way of repeated exposure, and/or (2) improvement occurs because the meaning of the event changes (Brewin, Dalgleish, & Joseph, 1996; Ehlers & Clark, 2000; Foa & Jaycox, 1999; Keane & Barlow, 2002; Resick, 2001). The main issues that need to be addressed in treatment are psychoeducation regarding trauma symptoms, trigger identification, and body awareness. Useful bilingual tools to enhance clinician’s ability to work on the trauma symptoms such as extreme stress and flashbacks are included in this chapter. Some useful techniques for the treatment of PTSD are flashback halting, relaxation exercises, grounding, body scanning, and tracking of emotional intensity. However, these should not be considered more important than the therapist’s skills and relationship with the client.

The therapeutic alliance has been said to be the main ingredient for successful treatment more than any evidence-based intervention (Cabaniss, 2012, May 31). As the therapeutic relationship (relationship as exposure) can be a key corrective experience in cases of interpersonal abuse, it is very important to establish a strong, positive relationship with these potential trauma victims (Briere & Lanktree, 2008). Furthermore, the significance of the therapeutic relationship is paramount in Latino cultures, as suggested by the concept of personalismo, and the documented evidence that Latinos often do not return after their initial visits perceiving their therapists as “cold,” (Aguilar-Gaxiola, 2005, February 16; Añez, Paris, Bedregal, Davidson, Grilo, 2005). Three meta-analyses (Benish, Quintana, & Wampold, 2011; Griner & Smith, 2006; Smith, Domenech-Rodriguez, & Bernal, 2011) have found culturally adapted treatments to be superior to unadapted control and bona fide treatments. Therapist-patient negotiation of cultural meaning accounts for the superiority of cultural adaptation which may reduce the benefit of fidelity to “techniques” in certain populations. The authors refer to this as the “illness myth.” The fact that it is proven that Hispanics differ in rates and type of symptoms of PTSD warrants consideration for more specialized treatment. Additionally, more work needs to be done in providing guidelines for people who present with and/or report having “ataque de nervios,” as the neurological component is a distinct presentation as well.

As illustrated above, Latinos experience high levels of PTSD-related disorders and may have culturally variable presentations. Despite this high prevalence rate, Latinos underutilize mental health services which is unfortunate as trauma-related disorders can be effectively treated. Also there are limited resources available to clinicians who work with this population (specifically Spanish-speakers). The purpose of this chapter was threefold. First, we provided an overview of trauma-related disorders as they pertain to Latinos. Second, we discussed evidence-based treatments that can be used with Latinos. Finally, we have created a series of handouts and tools (all based on evidence-based principles and derived from empirically supported treatments) that can be used with Spanish speakers who present with a trauma-related disorder. A detailed index of these handouts and tools follows proceeded by the tools and handouts themselves.