Reducing Shame, Promoting Dignity: A Model for the Primary Prevention of Complex Post-Traumatic Stress Disorder

Complex Posttraumatic Stress Disorder Links Trauma Exposure and Suicidal Behaviors Among Sexual Minority Populations: A New Target in Suicide Prevention?

Exposure to potentially traumatic events and posttraumatic stress are known risk factors for suicidal thoughts and behaviors (STB). Research suggests that sexual minorities are disproportionately exposed to traumatic events and experience greater STB than their heterosexual peers, although few studies have explored connections between these parallel disparities. Further, existing literature may implicate complex posttraumatic stress disorder (CPTSD) as a potential mechanism in the trauma-suicide connection among sexual minorities. This study uses a sample from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; n = 1351) to test structural equation models for associations between trauma exposure, heterosexist discrimination, and CPTSD with suicide attempt status. We found CPTSD mediated associations between exposure to traumatic events and presence of a lifetime suicide attempt among sexual minority male and female samples. Discrimination demonstrated a synergistic effect on the association between trauma exposure and CPTSD, but, among males, CPTSD did not fully explain associations between discrimination and suicide attempts. Our findings suggest that CPTSD should be considered an important mechanism in the trauma-suicide connection for sexual minorities and may be a potentially important target for suicide prevention and that interventions should address the influence of discrimination on traumatic stress in this high-risk population.

Shame, health literacy and consent

This paper is particularly concerned with shame, sometimes considered the 'master emotion', and its possible role in affecting the consent process, specifically where that shame relates to the issue of diminished health literacy. We suggest that the absence of exploration of affective issues in general during the consent process is problematic, as emotions commonly impact upon our decision-making process. Experiencing shame in the healthcare environment can have a significant influence on choices related to health and healthcare, and may lead to discussions of possibilities and alternatives being closed off. In the case of impaired health literacy we suggest that it obstructs the narrowing of the epistemic gap between clinician and patient normally achieved through communication and information provision. Health literacy shame prevents acknowledgement of this barrier. The consequence is that it may render consent less effective than it otherwise might have been in protecting the person's autonomy. We propose that the absence of consideration of health literacy shame during the consent process diminishes the possibility of the patient exerting full control over their choices, and thus bodily integrity.

Dissociation and misdiagnosis of schizophrenia in populations experiencing chronic discrimination and social defeat

As recently as the late 20th century, Schizophrenia, a category of mental illness with widely varying phenotypic symptoms, was believed by psychobiologists to be a genetically based disorder in which the environment played a limited etiological role. Yet a growing body of evidence indicates a strong correlation between schizophrenia and environmental factors. This theoretical paper explores the relationship between highly elevated rates of schizophrenia in some low-income minority communities worldwide and trauma-related dissociative symptoms that often mimic schizophrenia. Elevated rates of schizophrenia in racially and ethnically isolated, inner-city Black populations are well documented. This paper contains evidence proposing that this amplification in the rate of schizophrenia is mediated by childhood trauma, disorganized attachment, and social defeat. Further, evidence demonstrating how these three variables combine in early childhood to incubate dissociative disorders will also be conveyed. The misdiagnosis of dissociative disorders as schizophrenia is theorized to partially mediate the increased rate of schizophrenia in communities that experience high levels of racial/ethnic discrimination. It is argued that this misdiagnosis is often attributable to cultural misunderstanding and/or a lack of knowledge about dissociative disorders.

Can scent-detection dogs detect the stress associated with trauma cue exposure in people with trauma histories? A proof-of-concept study

Introduction

Post-traumatic stress disorder (PTSD) is an impairing mental health condition with high prevalence among military and general populations alike. PTSD service dogs are a complementary and alternative intervention needing scientific validation. We investigated whether dogs can detect putative stress-related volatile organic compounds (VOCs) in the breath of people with trauma histories (54% with PTSD) exposed to personalized trauma cues.

Methods

Breath samples were collected from 26 humans over 40 experimental sessions during a calm (control breath sample) and stressed state induced by trauma cue exposure (target breath sample). Two scent detection canines were presented with the samples in a two alternative forced choice (2AFC) discrimination and yes/no detection task. The 2AFC task assessed the dogs' ability to discriminate between the two states within the breath samples of one individual. The detection task determined their ability to generalize the target odour across different individuals and different stressful events of one individual. Signal Detection Theory was applied to assess dogs' sensitivity, specificity, precision, and response bias.

Results

The dogs performed at ∼90% accuracy across all sample sets in the discrimination experiment, and at 74% and 81% accuracy, respectively, in the detection experiment. Further analysis of dog olfactory performance in relation to human donor self-reported emotional responses to trauma cue exposure suggested the dogs may have been detecting distinct endocrine stress markers. One dog's performance correlated with the human donors' self-reported fear responses and the other dog's performance correlated with the human donors' self-reported shame responses. Based on these correlations between dog performance and donor self-report measures, we speculate that the VOCs each dog was detecting likely originated from the sympathetico-adreno-medullary axis (SAM; adrenaline, noradrenaline) in the case of the first dog and the hypothalamo-pituitary-adrenal axis (HPA; glucocorticoids) in the case of the second dog.

Conclusion

Our proof-of-concept study is the first to demonstrate that some dogs can detect putative VOCs emitted by people with trauma histories when experiencing distress theoretically associated with the intrusion and arousal/reactivity symptoms of PTSD. Results have potential to improve the effectiveness and training protocol of PTSD service dogs with a focus on enhancing their alert function.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

Trauma-Related Shame and Guilt as Prospective Predictors of Daily Mental Contamination and PTSD Symptoms in Survivors of Sexual Trauma

Mental contamination (MC), the experience of dirtiness in the absence of a physical contaminant, has established links with posttraumatic stress disorder (PTSD). Shame and guilt have well-documented relationships with symptoms of PTSD and may play a role in the development and maintenance of MC. The present study examined whether trauma-related shame and guilt prospectively predicted daily MC and symptoms of PTSD among 41 women with a history of sexual trauma. Women completed baseline and twice-daily assessments of MC and symptoms of PTSD over a 2-week period and baseline measures of trauma-related shame and guilt. Two sets of hierarchical mixed linear regression models examined individual and combined fixed effects of baseline trauma-related guilt (guilt cognitions and global guilt) and shame in predicting daily trauma-related MC and symptoms of PTSD. Trauma-related shame positively predicted both daily MC and PTSD. This association remained robust even when accounting for the experience of trauma-related guilt. Neither trauma-related guilt cognitions nor global guilt predicted daily MC or PTSD. While other studies have addressed shame related to sexual assault, this is the first study to demonstrate a positive prospective relationship between shame and trauma-related MC. Findings regarding PTSD and shame are consistent with a growing literature. Further research is needed to better understand the temporal relationships between trauma-related shame, MC, and symptoms of PTSD, including how these variables interact and change over the course of PTSD treatment. A better understanding of the factors influencing the development and maintenance of MC can inform efforts to more easily target and improve MC, and subsequently PTSD.

The truth project- paper two- using staff training and consultation to inculcate a testimonial sensibility in non-specialist staff teams working with survivors of child sexual abuse

This paper explores how trauma informed training and consultation for non-specialist staff at the Independent Inquiry into Child Sexual Abuse in England and Wales enabled them to work with survivors of non-recent child sexual abuse in the Truth Project and other areas of the Inquiry. The paper draws on data gathered from 32 semi-structured interviews with a range of Inquiry staff, including civil servants, legal professionals, senior operational managers, and researchers. The interview questions mapped on to the trauma informed principles embedded in the Inquiry and considered the efficacy and implementation of this training for engaging with survivors' voices, working with challenging testimonies and materials, and contributing to epistemic change. Findings included all staff having an awareness of what it meant to be trauma informed in an Inquiry context, talking about the principles in terms of value-based positions. Staff described an awareness of needing to attend to the idiosyncratic experiences of the individual survivor, and there was recognition that previous damage to survivor trust, through institutional failure, meant that demonstrating trustworthiness was a central task. Staff talked about the impacts of participation on some survivors, and the impacts it had on them to be exposed to trauma-related materials. There was acknowledgment of the limitations of the trauma informed approach but also recognition of the wider applications of this learning for other areas of their personal and professional lives. There is some support for the therapeutic culture developed at the Inquiry leading to what Fricker refers to as a testimonial sensibility, a quality of listening necessary for the establishment of epistemic justice. The discussion focuses on how this way of working can be applied to other public service settings and how epistemic justice concepts can be included in more traditional trauma informed care models to encourage an ethic of listening that has political and social, in addition to therapeutic, outcomes.

Determinants of Care Pathways for C-PTSD Patients in French Psychotrauma Centers: A Qualitative Study

In 2018, the International Classification of Diseases (ICD-11) established a novel nosographic category within the stress-specific disorders known as complex post-traumatic stress disorder (C-PTSD). Characterized by distinctive clinical attributes and a limited response to conventional PTSD treatments, C-PTSD has prompted the reconsideration of care methods. Our study's purpose was to explore the intricate factors shaping the care pathways for individuals suffering from C-PTSD. We used a grounded theorization technique involving professionals across a range of specialized French psychotraumatology institutions. The resulting comprehensive theoretical model offers valuable insights into the constitution mechanisms of these pathways, helping elucidate the varying care options. Interestingly, we found that differences in clinical perspectives were determined by the care provider's viewpoint on clinical guidelines, screening tools, and treatment options, but also by structural and organizational factors. The distinctive dynamics and interrelationships identified in our research reveal potential areas of focus for incorporating C-PTSD care more effectively into specialized French trauma centers. This investigation offers a path toward improved understanding and management of C-PTSD, ultimately advancing patient outcomes.

The Lived Experiences of Female Relatives of Child Sexual Abuse Material (CSAM) Offenders in Ireland and the United Kingdom

There is a limited understanding about how an association with those that download Child Sexual Abuse Material (CSAM), a highly stigmatized crime, impacts the lives of their innocent family members. Non-offending family members are often considered a valuable protective resource for offender desistance and in safeguarding children from abuse. Therefore, the present study aimed to explore the lived experiences of female family members of CSAM offenders in Ireland and the United Kingdom to both identify and target areas for intervention thus ameliorating their ability to protect. A qualitative research design was adopted, and data analyzed via reflexive thematic analysis. Fifteen individuals self-selected for participation and interviews resulted in the identification of three key themes: Shattered Worldview, The Injured Self; Contamination by Association. The analysis highlighted how non-offending family members experienced considerable shame, trauma, and stigma with consequences that reached into every aspect of their lives. The findings are discussed in the context of the limited available literature along with research implications and recommendations for both policy and practice.

The truth project paper one-how did victims and survivors experience participation? Addressing epistemic relational inequality in the field of child sexual abuse

The last 30 years has seen an exponential increase in Historical Institutional Abuse Inquiries. One feature of these has been to place adult survivor voices at the center of Inquiry work, meaning that child abuse victims and survivors are engaging with Inquiries, sharing their experiences, with this participation often presented as empowering and healing. This initiative challenges long held beliefs that child sexual abuse survivors are unreliable witnesses, which has led to epistemic injustice and a hermeneutical lacunae in survivor testimony. However to date there has been limited research on what survivors say about their experiences of participation. The Truth Project was one area of work of the Independent Inquiry into Child Sexual Abuse in England and Wales. It invited survivors of Child Sexual Abuse to share their experiences including the impacts of abuse and their recommendations for change. The Truth Project concluded in 2021 and heard from more than 6,000 victims of child sexual abuse. The evaluation of the Trauma Informed Approach designed to support survivors through their engagement with the project was a mixed methods, two phase methodology. A total of 66 survey responses were received. Follow-up interviews were conducted with seven survey respondents. The Trauma Informed Approach was found to be predominantly helpful in attending to victim needs and minimizing harm. However, a small number of participants reported harmful effects post-session. The positive impacts reported about taking part in the Truth Project as a one-off engagement challenges beliefs that survivors of child sexual abuse cannot safely talk about their experiences. It also provides evidence of the central role survivors should have in designing services for trauma victims. This study contributes to the epistemic justice literature which emphasizes the central role of relational ethics in the politics of knowing, and the importance of developing a testimonial sensibility when listening to marginalized groups.

Introducing the Neuroplastic Narrative: a non-pathologizing biological foundation for trauma-informed and adverse childhood experience aware approaches

Most people accessing mental health services have adverse childhood experiences (ACEs) and/or histories of complex trauma. In recognition of this, there are calls to move away from medical model approaches and move toward trauma-informed approaches which privilege the impact of life experience over underlying pathology in the etiology of emotional and psychological suffering. Trauma-informed approaches lack a biological narrative linking trauma and adversity to later suffering. In its absence, this suffering is diagnosed and treated as a mental illness. This study articulates the Neuroplastic Narrative, a neuroecological theory that fills this gap, conceptualizing emotional and psychological suffering as the cost of surviving and adapting to the impinging environments of trauma and adversity. The Neuroplastic Narrative privileges lived experience and recognizes that our experiences become embedded in our biology through evolved mechanisms that ultimately act to preserve survival in the service of reproduction. Neuroplasticity refers to the capacity of neural systems to adapt and change. Our many evolved neuroplastic mechanisms including epigenetics, neurogenesis, synaptic plasticity, and white matter plasticity allow us to learn from, and adapt to, past experiences. This learning and adaption in turn allows us to better anticipate and physiologically prepare for future experiences that (nature assumes) are likely to occur, based on past experiences. However, neuroplastic mechanisms cannot discriminate between experiences; they function to embed experience regardless of the quality of that experience, generating vicious or virtuous cycles of psychobiological anticipation, to help us survive or thrive in futures that resemble our privileged or traumatic pasts. The etiology of suffering that arises from this process is not a pathology (a healthy brain is a brain that can adapt to experience) but is the evolutionary cost of surviving traumatizing environments. Misidentifying this suffering as a pathology and responding with diagnosis and medication is not trauma-informed and may cause iatrogenic harm, in part through perpetuating stigma and exacerbating the shame which attends complex trauma and ACEs. As an alternative, this study introduces the Neuroplastic Narrative, which is situated within an evolutionary framework. The Neuroplastic Narrative complements both Life History and Attachment Theory and provides a non-pathologizing, biological foundation for trauma-informed and Adverse Childhood Experience aware approaches.

Shame anxiety, stigma and clinical encounters

Stigma has been associated with delays in seeking treatment, avoiding clinical encounters, prolonged risk of transmission, poor adherence to treatment, mental distress, mental ill health and an increased risk of the recurrence of health problems, among many other factors that negatively impact on health outcomes. While the burdens and consequences of stigma have long been recognized in the health literature, there remains some ambiguity about how stigma is experienced by individuals who live with it. The aim of this paper is to elucidate the phenomenology of stigma, or to describe how it is that stigma shows up in the first-person experience of individuals who live with stigma and its burdens. Exploring the relationship between shame and stigma, I argue that shame anxiety, or the chronic anticipation of shame, best characterises the experience of living with a health-related, or health-relevant, stigma. Understanding the experiential features, or phenomenology, of shame anxiety will give healthcare professionals a greater sensitivity to stigma and its impacts in clinical settings and encounters. I will conclude by suggesting that 'shame-sensitive' practice would be beneficial in healthcare.

Beyond a trauma-informed approach and towards shame-sensitive practice

In this article, we outline and define for the first time the concept of shame-sensitivity and principles for shame-sensitive practice. We argue that shame-sensitive practice is essential for the trauma-informed approach. Experiences of trauma are widespread, and there exists a wealth of evidence directly correlating trauma to a range of poor social and health outcomes which incur substantial costs to individuals and to society. As such, trauma has been positioned as a significant public health issue which many argue necessitates a trauma-informed approach to health, care and social services along with public health. Shame is key emotional after effect of experiences of trauma, and an emerging literature argues that we may 'have failed to see the obvious' by neglecting to acknowledge the influence of shame on posttrauma states. We argue that the trauma-informed approach fails to adequately theorise and address shame, and that many of the aims of the trauma-informed are more effectively addressed through the concept and practice of shame-sensitivity. We begin by giving an overview of the trauma-informed paradigm, then consider shame as part of trauma, looking particularly at how shame manifests in post-trauma states in a chronic form. We explore how shame becomes a barrier to successful engagement with services, and finally conclude with a definition of the shame-sensitive concept and the principles for its practice.