Positive Approaches Journal, Volume 13, Issue 1
Reinhardt & Campagnolio | 24-32
Volume 13 ► Issue 1 ► June 2024
Understanding Complexity: The Convergence of Disability and Trauma in Clinical Practice
Jessica S. Reinhardt & Aidan Campagnolio
The incidence of trauma has seen a notable rise across both the general populace and among those with disabilities. This paper is rooted in an understanding of the concurrent presence of disabilities and trauma, aiming to enhance practitioners' work. This overview provides practitioners with concise guidelines on diagnosing trauma, implementing trauma-informed care, and selecting trauma-specific treatments appropriate for individuals with disabilities. It is important to note, however, that a comprehensive review of these complex and interwoven topics is beyond the scope of this paper. Nonetheless, we highlight the critical need for more extensive research to further our understanding and to guide the development of more evidence-based interventions in this area.
Individuals with intellectual disabilities (IDD) are more vulnerable to psychological trauma compared with the general population 1 . Similarly, research indicates that children diagnosed with IDD2 and autism spectrum disorders3 (ASD) are more susceptible to repeated instances of maltreatment, including bullying, abuse, and sexual assault. Exploring the intersection of various disabilities and trauma/trauma-related disorders such as Post-Traumatic Stress Disorder (PTSD), presents a significant challenge for professionals in selecting the most suitable clinical intervention strategies. Mehtar and Mukaddes 4 found that there was a 26% overlap in the incidence of autism and potentially traumatic experiences, with 17% of the individuals fulfilling the diagnostic criteria for both PTSD and autism. That said, differentiating between symptoms of trauma, and IDD and/or ASD, presents a challenge to clinicians, as there are several shared characteristics between autism/IDD and PTSD, and other stressor related disorders 5 6 . Research suggests that those who reported experiencing traumatic life events, in both child and adulthood, had a significantly higher risk of aggression, self-injurious behavior, in addition to symptoms of psychological distress 7. Problematic and aggressive behaviors in individuals with IDD are thought to be mediated by past traumatic experiences and mental health 8 9. The overlap or mediation of externalizing symptoms of trauma, internalizing symptoms are difficult to distinguish. More specifically, Kildahl and colleagues 10 found that altered arousal was easily observable, but symptoms of avoidance present differently, and symptoms of re-experiencing were difficult to recognize (unless the clinician knew of the person’s trauma). Challenges with diagnosis are likely exacerbated by the lack of instrument designed specifically for populations with disabilities. Of note, the recently published Diagnostic Interview Trauma and Stressors – Intellectual Disability (DITS–ID), has shown promising psychometrics 11. Given the multifaceted challenges inherent in accurately diagnosing trauma within populations with disabilities, it becomes imperative to pivot focus towards developing an understanding of trauma-informed care and interventions that are specifically designed to address the unique needs of these individuals.
Trauma-Informed Approaches (TIA) and trauma-specific treatments are two complementary, yet distinct approaches in mental health care. TIA is an organizational framework that pervades the policies, practices, and culture of an institution. A key underlying belief guides TIA: any individual may have experienced trauma at some point in their lives. Thus, TIA aims to minimize re-traumatization, promote safety, and support healing by adjusting the overall environment and interactions. TIA does not directly treat trauma but creates a supportive setting that acknowledges the prevalence and impact of trauma on individuals’ lives. Substance Abuse and Mental Health Services Administration’s (SAMSHA) guidance around TIA speaks of the four Rs, namely: 12
1. Realize the profound and pervasive consequences of trauma, acknowledging the pathways toward recuperation and resilience for individuals, as well as the collective within communities, organizations, and beyond.
2. Recognize the signs and symptoms of trauma, which may vary across gender, age, and setting, in everyone from service recipients to staff members, fostering an environment where these signs are understood as survival mechanisms in response to past or current adversities.
3. Respond by infusing the principles of a trauma-informed approach throughout the entire organizational structure, altering language, behavior, and policies to honor the traumatic experiences of both service users and providers, and embedding this understanding into the fabric of organizational culture.
4. Resist re-traumatization by consciously creating a safe, supportive environment that avoids replicating the dynamics of trauma, ensuring that the organization's practices promote recovery and do not inadvertently contribute to stress or trauma.
To achieve these, SAMSHA’s model is centered around six key principles summarized below12 13.
1. Safety: Ensuring physical and emotional safety for all in a space (clients and staff.) This involves creating spaces and interactions that foster a sense of security, reducing potential stimuli that can lead to re-traumatization.
2. Trustworthiness and Transparency: Building trust with clients through consistent, transparent practices and policies. This principle emphasizes the importance of clarity, integrity, and openness in operations and interactions, helping clients to rebuild trust in systems and individuals.
3. Peer Support: Recognizing the critical role that peer support plays in recovery and healing. This principle champions the inclusion of individuals with lived experiences of trauma in the healing process, providing mutual support and shared learning opportunities.
4. Collaboration and Mutuality: Promoting equality and democratization in the therapeutic relationship. This involves breaking down hierarchical dynamics between professionals and clients, fostering a more collaborative and participatory approach to care and decision-making.
5. Empowerment, Voice, and Choice: Empowering clients by prioritizing their voices and choices throughout their care. This principle stresses the importance of highlighting individuals' strengths, ensuring that clients have a say in their treatment plans, and are supported in their recovery journey.
6. Cultural, Historical, and Gender Issues: Acknowledging the impact of cultural, historical, and gender issues on trauma and recovery. This principle requires an awareness and responsiveness to the diverse experiences of trauma among different populations, incorporating practices that are respectful of and relevant to individuals’ cultural, historical, and gender identities.
The present authors argue that cultural, historical and gender issues should not be treated as a separate principle. Rather we advocate that attunement to cultural context is a critical overarching concept which informs the other five principles in trauma informed care. Readers interested in adopting a trauma-informed framework are encouraged to view: SAMSHA’s Practical Guide for Implementing and Trauma-Informed Approach. 13
Many different fields have begun adopting TIA, including, but not limited to, education, counseling, nursing, social work, and yoga. In addition to systemic TIA , there is a great need for trauma-specific treatments designed for individuals with disabilities. A dual approach using both TIA and specific treatments is critical. Trauma-specific treatments refer to research-supported clinical interventions specifically designed to address the consequences of trauma. Examples include: Cognitive Behavioral Therapy (CBT) for PTSD, Eye Movement Desensitization and Reprocessing (EMDR), and trauma-focused cognitive-behavioral therapy (TF-CBT), among others. Individuals with intellectual disabilities, autism, and other developmental disabilities, are often lacking in trauma-specific treatment research. Specifically, there is a gap in the current literature containing randomized, controlled trails (RCTs) to further support the effectiveness of many treatment modalities 16 . That said, the early stages of research show promise.
A recent systematic review investigates the literature on EMDR and CBT interventions for children and adults with an intellectual disability presenting with PTSD or trauma-like symptoms16 . EMDR has capacity for producing meaningful therapeutic outcomes in adults with ID 14, 15, 16. There is specific support for EMDR as a useful and effective intervention for people with ID, noting EMDR’s applicability with non-speaking clients and its efficient treatment timeline compared to alternatives16. CBT informed treatments and TF-CBT also show promising evidence, although the research has been limited 16 . While it is recognized that considerable methodological limitations persist in much of the current research, these studies nevertheless offer practitioners a foundation of hope. This research paves the way for more inclusive and effective therapeutic interventions. Indeed, it is essential to tailor these methodologies to the nuanced needs of individuals with disabilities. The burgeoning body of early-stage research offers a beacon of hope, illuminating the path toward a future where all individuals, irrespective of their abilities, receive the compassionate and specialized care they deserve for trauma recovery.
In synthesizing the literature on trauma within populations with disabilities, the imperative becomes clear: We must continue to evolve our clinical practices to better understand and address the complex layers of trauma experienced by individuals with disabilities. The convergence of trauma-informed approaches and trauma-specific interventions offers a promising horizon for practitioners. Advancing this dual approach will not only deepen our grasp of trauma's multifaceted nature, but also enhance the healing and empowerment of those who have been historically marginalized in our health care narratives.
References
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7. MasonRoberts, S., Bradley, A., Karatzias, T., Brown, M., Paterson, D., Walley, R., Truesdale, M., Taggart, L., and Sirisena, C. (2018) Multiple traumatization and subsequent psychopathology in people with intellectual disabilities and DSM-5 PTSD: a preliminary study. Journal of Intellectual Disability Research, 62: 730–736. Temple University.
8. Clark M, Crocker AG, Morin D. Victimization History and Aggressive Behavior among adults with intellectual disabilities: the mediating role of mental health. International Journal of Forensic Mental Health 2016; 14(4) 303-311. Temple University.
9. Rittmannsberger D, Kocman A, Weber G, Lueger-Schuster B. Trauma exposure and post‐traumatic stress disorder in people with intellectual disabilities: A Delphi expert rating. Journal of applied research in intellectual disabilities, 2019; 32 (3), 558-567 doi: 10.1111/jar.12549.
10. Kildahl, A. N., & Jørstad, I. (2022). Post-traumatic stress disorder symptom manifestations in an autistic man with severe intellectual disability following coercion and scalding. Journal of Intellectual & Developmental Disability, 47(2), 190–194. Temple University.
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12. Substance Abuse and Mental Health Services Administration. SAMHSA'S Concept of Trauma and Guidance for a Trauma-Informed Approach 2014. Department of Health and Human Services, Rockville, MD.
13. Substance Abuse and Mental Health Services Administration (2014) Practical Guide for Implementing a Trauma-Informed Approach, 2023. Department of Health and Human Services, Rockville, MD.
14. Penninx Quevedo R, de Jongh A, Bouwmeester S, Didden R. EMDR therapy for PTSD symptoms in patients with mild intellectual disability or borderline intellectual functioning and comorbid psychotic disorder: A case series. Research in Developmental Disabilities 2021; 117 doi: 10.1016/j.ridd.2021.104044.
15. Verhagen, I., van der Heijden, R., de Jongh, A., Korzilius, H., Mevissen, L., & Didden, R. (2023). Safety, Feasibility, and Efficacy of EMDR Therapy in Adults with PTSD and Mild Intellectual Disability or Borderline Intellectual Functioning and Mental Health Problems: A Multiple Baseline Study. Journal of Mental Health Research in Intellectual Disabilities, 16(4), 291–313. Temple University.
16. Byrne G A Systematic Review of Treatment Interventions for Individuals With Intellectual Disability and Trauma Symptoms: A Review of the Recent Literature. Trauma, Violence & Abuse. 2020; 43(2) Temple University.
Biographies
Dr. Jessica S. Reinhardt (she/her), is a nationally certified school psychologist and licensed psychologist. She is the Coordinator of the School Psychology Program at Temple University. Her overarching professional interests include mental health of children and adolescents, culturally-responsive counseling, trauma-conscious practices, and assessment of neurodevelopmental disorders.
Aidan Campagnolio (he/him), is a PhD student in the school psychology program and research assistant at the Institute on Disabilities (IOD) at Temple University. After completing his undergraduate studies at Temple, Aidan matriculated into the school psychology program to further his understanding of children's and adolescents' psychopathology. Aidan also worked toward this goal by securing a position at the IOD and was soon promoted to research assistant, where he immersed himself in the rigorous research projects at the Institute. Today, Aidan is a key part of the Health Equity and Research and Evaluation teams that serve Pennsylvanians with disabilities.