Kristine Burkman

Constellations of Interpersonal Trauma and Symptoms in Child Welfare: Implications for a Developmental Trauma Framework

Patterns of trauma exposure and symptoms were examined in a sample of 16,212 children in Illinois child welfare. Data were collected on trauma histories, child and caregiver needs and strengths, and analyzed in light of the proposed Developmental Trauma Disorder diagnostic criteria. Youth exposed to both interpersonal violence and attachment-based (“non-violent”) traumas within the caregiving system had significantly higher levels of affective/physiological, attentional/behavioral, and self/relational dysregulation in addition to posttraumatic stress symptoms compared to youth with either type of trauma alone or in relation to other trauma experiences. These complexly traumatized children exhibited higher levels of functional impairment and were more likely to have placement disruptions and psychiatric hospitalizations. Findings suggest a developmental trauma framework can more adequately capture the spectrum of needs of these multiply traumatized youth than existing diagnostic formulations. Utilizing this framework for assessment, treatment planning, and intervention can lead to more targeted and effective services for these children.

Treating Complex Trauma Among Veterans: Three Stage‐Based Treatment Models

This article addresses the issue of complex trauma in veterans and treatments for symptom presentations resulting from complex trauma exposure. While various definitions have been proposed for complex trauma, the clinical issues related to it are relevant for veterans as they are at risk for cumulative trauma exposures such as multiple combat deployments and military sexual trauma. Several treatments were either developed to address and/or implemented with complex trauma. This article discusses three of these treatments that share a stage-based approach, focusing on the present (e.g., skills training and psychoeducation), which can then be followed, if needed, with a past-focused (e.g., exposure-based) treatment: Dialectical Behavior Therapy (Linehan, 1993), Seeking Safety (Najavits, 2002), Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy (Cloitre, Cohen, & Koenen, 2006). This article also discusses what is currently being done to address symptom presentations resulting from complex trauma exposure and challenges and possible solutions to implementing this care.

Impact of Killing in War: A Randomized, Controlled Pilot Trial

OBJECTIVEnThe purpose of this pilot study was to test the effectiveness of Impact of Killing (IOK), a novel, cognitive-behavioral treatment (CBT) aimed at reducing mental health symptoms and functional impairment.nnnMETHODnParticipants were 33 combat Veterans with a posttraumatic stress disorder (PTSD) diagnosis who had completed trauma-focused psychotherapy and reported distress regarding killing or feeling responsible for the deaths of others in war. Veterans were randomized to either IOK treatment or a 6-week waitlist condition, after which Veterans could receive IOK. IOK is a 6- to 8-session, weekly, individual, CBT, lasting 60-90 minutes, and focused on key themes, including physiology of killing responses, moral injury, self-forgiveness, spirituality, making amends, and improved functioning.nnnRESULTSnWe found that compared to controls (N = 16), the IOK group (N = 17) experienced a significant improvement in PTSD symptoms, general psychiatric symptoms, and quality of life functional measures. Veterans who received IOK reported that the treatment was acceptable and feasible.nnnCONCLUSIONnThese results provide preliminary evidence that Veterans can benefit from a treatment focused on the impact of killing after initial trauma therapy.

Healing from Moral Injury: A Qualitative Evaluation of the Impact of Killing Treatment for Combat Veterans

ABSTRACT This paper evaluates the Impact of Killing (IOK) treatment—a psychological intervention designed to address moral injury and trauma associated with killing in war. Using qualitative data from interviews with 28 combat veterans, we examine IOK’s impact, how it differs from other trauma-focused treatments, and how it can be improved to better meet veterans’ needs. We found that many veterans processed their killing experiences for the first time in IOK, even though all had previously completed evidence-based treatments for posttraumatic stress disorder. Several described killing in war as the most distressing and transformative trauma of their lives, and all affirmed the value of an intervention focused directly and explicitly on moral injury and killing. IOK helped veterans to acknowledge their grief, shame, and distress; gently but critically examine their thoughts and beliefs about killing in war; and make strides toward acceptance, reconciliation, and forgiveness.

Treating Complex Trauma Among Veterans: Three Stage-Based Treatment Models: Complex Trauma

This article addresses the issue of complex trauma in veterans and treatments for symptom presentations resulting from complex trauma exposure. While various definitions have been proposed for complex trauma, the clinical issues related to it are relevant for veterans as they are at risk for cumulative trauma exposures such as multiple combat deployments and military sexual trauma. Several treatments were either developed to address and/or implemented with complex trauma. This article discusses three of these treatments that share a stage-based approach, focusing on the present (e.g., skills training and psychoeducation), which can then be followed, if needed, with a past-focused (e.g., exposure-based) treatment: Dialectical Behavior Therapy (Linehan, 1993), Seeking Safety (Najavits, 2002), Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy (Cloitre, Cohen, & Koenen, 2006). This article also discusses what is currently being done to address symptom presentations resulting from complex trauma exposure and challenges and possible solutions to implementing this care.

Gender Differences in Sleep and War Zone-Related Post-traumatic Stress Disorder

As women’s role in combat operations continue to expand, a larger number of female military personnel will be exposed to traumatic events in the war zone. Exposure to combat and other deployment stressors place both men and women at higher rates for developing PTSD and other mental health problems. Findings among male and female service members suggest minimal differences in overall rates of PTSD; however, results are mixed. Evidence suggests that men are more likely than women to endorse substance abuse following deployment whereas women are more likely than men to endorse depressive symptoms. To date, no studies examine gender differences in symptoms profiles of PTSD among combat veterans. However, studies among civilian samples (e.g., motor vehicle accidents, natural disasters, terrorist attacks) suggest that women report higher levels of overall post-traumatic stress disorder symptoms and a higher level of peritraumatic dissociation immediately following trauma events. While both men and women with PTSD experience significant problems with sleep quality, it appears there are some initial gender differences in types of problems experienced. Differences between reexperiencing, avoidant, and arousal symptoms are mixed, and it is unclear whether studies of post-traumatic stress disorder symptoms following civilian trauma can generalize to a military population. Cognitive, biological, and affective factors that influence the development and maintenance of PTSD are discussed in order to explore potential explanations for the observed gender differences in the symptomatology of PTSD. Implications for PTSD treatment are discussed.

Provider perspectives on a novel moral injury treatment for veterans: Initial assessment of acceptability and feasibility of the Impact of Killing treatment materials: BURKMAN et al.

OBJECTIVEnWe assessed whether treatment providers specializing in evidence-based treatment for posttraumatic stress disorder found the Impact of Killing (IOK), a novel treatment for moral injury among combat veterans, acceptable, and feasible.nnnMETHODSnTen providers from a large veterans administration (VA) medical center were provided with materials from IOK. We audio-recorded a semistructured interview with each provider where we elicited open-ended feedback as well as asked five structured questions about the relative advantage, compatibility, complexity/simplicity, trialability, and observability of IOK.nnnRESULTSnAll providers found IOK feasible, acceptable, and something they could incorporate into their existing practice. Providers reported that the spiritual and moral concerns addressed in IOK were novel, and that self-forgiveness and making amends were critical components promoting healing from moral injury not emphasized in other treatments.nnnCONCLUSIONSnAmong trauma providers, IOK was found acceptable and feasible, offering a novel approach to addressing moral injury among combat veterans.

“Opening a door to a new life”: The role of forgiveness in healing from moral injury

For military veterans struggling with moral injury, forgiveness can become both an animating concern and a potential path to healing. In this perspective piece, we draw on our clinical work and research findings to examine why forgiveness matters to veterans who feel guilt and shame about their actions in war, what type of forgiveness is attainable and meaningful, and what role clinicians can play in facilitating forgiveness. We conclude by reflecting on the potential, as well as the limits and tensions, of forgiveness work in the context of military moral injury.

Measuring Use of Evidence Based Psychotherapy for Posttraumatic Stress Disorder in a Large National Healthcare System

To derive a method of identifying use of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD), we used clinical note text from national Veterans Health Administration (VHA) medical records. Using natural language processing, we developed machine-learning algorithms to classify note text on a large scale in an observational study of Iraq and Afghanistan veterans with PTSD and one post-deployment psychotherapy visit by 8/5/15 (Nu2009=u2009255,968). PTSD visits were linked to 8.1xa0million psychotherapy notes. Annotators labeled 3467 randomly-selected psychotherapy notes (kappau2009=u20090.88) to indicate receipt of EBP. We met our performance targets of overall classification accuracy (0.92); 20.2% of veterans receivedu2009≥u2009one session of EBP over the study period. Our method can assist with identifying EBP use and studying EBP-associated outcomes in routine clinical practice.

Erratum to Constellations of Interpersonal Trauma and Symptoms in Child Welfare: Implications for a Developmental Trauma Framework (J Fam Viol, (2014), 29, (1-4), 10.1007/s10896-013-9559-0)

The original version of this article unfortunately contained a mistake. The fourth paragraph under the subsection Symptom Clusters and Outcomes in the Results section is corrected as follows: Further, in addition to showing an increased likelihood of developmental trauma symptom patterns, the complexly (violent/non-violent) traumatized youth in this sample, experienced significantly worse child welfare placement outcomes than did those with either violent or non-violent trauma exposure alone. Based on Zero-inflated Poisson regression analyses and Incident Rate Ratios, youth exposed to both violent and nonviolent interpersonal trauma experienced 1.26 times (or 26%)more placement disruptions in the 2 years following entry into care compared to those youth with other types of trauma (p <.001). In comparison, youth exposed to non-violent trauma alone also experienced significantly more placement disruptions (by 1.15 times or 15%) during this time frame (p<.001); yet there was no significantly increased likelihood of placement changes for youth who had been exposed to violent trauma alone. The pattern is different for psychiatric hospitalization: the incident rate was 1.7 times higher for youth with violent/non-violent trauma (p <.001) and 1.37 times higher for youth with violent trauma (p <.001) compared to youth with other types of trauma.