International Society for Traumatic Stress Studies

Cumulative Trauma Exposure, Emotion Regulation, and PTSD Among Incarcerated Women

08/02/2019
by Shannon M. Lynch, PhD
Women in prison experience high rates of traumatic exposures such as childhood physical and sexual abuse, sexual assault, and partner violence. Not surprisingly, research suggests this population has rates of PTSD that are three to five times that of women in the general population (Karlsson & Zielinski, 2018). While the research literature focused on this group is growing, comparatively few trauma focused treatments have been evaluated for their effectiveness with incarcerated women. Given the limited resources of many corrections facilities, it is critical that we identify strong potential targets of effective treatment for trauma exposed women in prison. In a previous study that assessed incarcerated women’s perceptions of their own treatment needs, women in prison identified emotion regulation as one their top five treatment needs (Lynch, Fritch, & Heath, 2012). For this article, we assessed trauma exposure, prevalence of PTSD, and the indirect effect of emotion regulation on the association between cumulative trauma and PTSD in 152 women in prison.

We know that not all individuals who experience traumatic events develop PTSD. Researchers continue to work to identify mechanisms that help us understand why some individuals develop PTSD while others do not. One mechanism receiving increasing attention is emotion regulation. Emotion regulation has been defined as a set of skills that include awareness and understanding of emotions, willingness to experience diverse emotions, the ability to inhibit impulsive behavioral tendencies and act in accordance with one’s values, and the ability to choose and implement strategies to modulate the experience of emotion in order to obtain desired goals (Gratz and Roemer, 2004).  This study examined associations among cumulative trauma exposure, emotion regulation difficulties, and current PTSD symptom severity in a randomly selected sample of 152 women in prison in the rural northwest.

The women in this study had been incarcerated an average of three years, primarily for nonviolent offenses. They ranged in age from 20 to 64 years old with an average age of 37. The women selected all ethnic identities that applied and identified themselves as White/Caucasian (58.6%), Multiethnic (22.4%), Hispanic (9.2%), Native American (7.2%), and African American (0.7%).

Similar to other studies with incarcerated women, the participants reported high rates of trauma exposure, indicating experiences of an average of about nine different types of traumatic events across their lifetime.  The most commonly reported traumatic exposures were forced intercourse (71.5%), being attacked without a weapon (69.1%), life threatening accident (59.2%), and witnessing another person being injured (55.9%). In their responses to the CAPS-5 (Weathers et al., 2013), a structured diagnostic interview for PTSD, about 40% of the women met DSM-5 criteria for PTSD in the past 30 days.

We examined the associations among cumulative trauma, emotion regulation and PTSD symptom severity using structural equation modeling. We found that cumulative trauma was significantly associated with the women’s emotion regulation difficulties and PTSD symptom severity. In addition, we identified a significant indirect effect of emotion regulation on the association between cumulative trauma exposure and severity of current PTSD symptoms.  These findings are consistent with previous research suggesting that emotion regulation is significantly affected by trauma exposure, and they support previously identified associations between emotion regulation difficulties and severity of PTSD.

There are evidence based trauma treatments that include an explicit focus on building emotion regulation skills such as Skills Training in Affect and Interpersonal Relationships (STAIR; Cloitre,  Koenen, Cohen, & Han, 2002), Dialectical Behavior Therapy (DBT; Linehan, 1993) and Seeking Safety (Najavits, 2002). However, there are relatively few treatment outcome studies that have assessed the effectiveness of these or other trauma focused interventions for incarcerated women. An important next step is to test the effectiveness of these types of interventions with this underserved population.

References

Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology70, 1067–1074. https://doi.org/10.1037//0022-006X.70.5.1067

Gratz, K. L. & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26, 41–54.  https://doi.org/10.1007/s10862-008-9102-4

Karlsson, M. E., & Zielinski, M. J. (2018). Sexual Victimization and Mental Illness Prevalence Rates Among Incarcerated Women: A Literature Review. Trauma, Violence, & Abuse, 1524838018767933. https://doi.org/10.1177/1524838018767933

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.

Lynch, S. M., Fritch, A., & Heath, N. M. (2012). Looking beneath the surface: The nature of incarcerated women’s experiences of interpersonal violence, treatment needs, and mental health. Feminist Criminology, 7(4), 381-400. https://doi.org/10.1177/1557085112439224

Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford Press.

Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keance, T. (2013). National Center for PTSD Clinician-Administered PTSD Scale for DSM-5.  Retrieved from www.ptsd.va.gov

Reference Article:

Konecky, E. M. and Lynch, S. M. (2019), Cumulative Trauma Exposure, Emotion Regulation, and Posttraumatic Stress Disorder Among Incarcerated Women. JOURNAL OF TRAUMATIC STRESS. doi:10.1002/jts.22435

Questions for Discussion:

  1. The women in this study report high rates of trauma exposure and PTSD. Yet there are comparatively few trauma focused treatment outcome studies with this population. Why do you think there are so few studies with incarcerated women and what interventions should be prioritized for evaluation in this population.
  2. Women in prison have identified difficulties with emotion regulation as one of their top treatment needs in prior studies (see Lynch et al, 2012). In this sample of incarcerated women, emotion regulation demonstrated an indirect effect on the association between trauma exposure and PTSD. Why do you think emotion regulation might be a strong potential treatment target for this population in particular?

About the Author:

Shannon Lynch, PhD is a clinical psychologist and professor in the Department of Psychology at Idaho State University. She and her students conduct research examining incarcerated women’s trauma exposure and mental health, treatment needs, and pathways to incarceration. 
 
 
 

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