Unraveling the Incidence of Interpersonal Trauma: Integrating Trauma-Informed Care in Behavioral Health
The Substance Abuse and Mental Health Services Administration (SAMHSA) has called to bring a trauma-informed care approach within behavioral facilities.[1] At its core, this approach advocates for a shift in clinicians’ perspective towards patients, from “What’s wrong with you?” to “What happened to you?”
Indeed, interpersonal type traumas, encompassing physical, sexual, or psychological abuse, affect a substantial portion—30-50%—of individuals with severe mental illnesses[2][3]. Often rooted in childhood, these traumas, marked by their repetitive and severe nature, yield more profound consequences than non-interpersonal traumas, such as natural disasters.[4] Exposure to interpersonal trauma is suggested to negatively shape self-concept, beliefs about others, and perceptions of the world, manifesting in various negative emotional and cognitive impacts. [5]
Personal histories marked by interpersonal trauma emerge as non-specific risk factors for various mental disorders.[6] Even in the absence of specific syndromes associated with trauma like post-traumatic stress disorder (PTSD), a history of interpersonal trauma is associated with a poorer prognosis and treatment trajectory for individuals with severe mental illnesses.[7][8]
With the aim to assess the incidence of interpersonal trauma in patients with mental illnesses, we analyzed MHO data from 367,744 episodes of care across all ages and care levels (inpatient, PHP, IOP) using diagnosis codes that indicate childhood and adulthood interpersonal trauma. For a subset of patients where facilities submit more detailed data to MHO on traumatic life events, we examined 6,551 episodes of care with the purpose of analyzing these variations of trauma events.
Diagnosis data
First, data from recorded diagnoses align with previous studies, revealing that almost 1 in 3 patients (27.8%) has a history of interpersonal trauma, with higher prevalence in females (34.7%) than males (19.8%). Childhood sexual and physical abuse emerged as the most prevalent forms of interpersonal trauma in patients, followed by childhood psychological abuse.
Notably, 9% of all patients have experienced more than one type of trauma. Across races, females consistently had higher rates of trauma and a primary or secondary PTSD diagnosis. Patients of American Indian or Alaskan Native descent seem to be especially marked by a trauma history, with almost 1 in 2 females and 1 in 3 males having a history of interpersonal trauma, followed closely by a diagnosis of PTSD. Smaller variations in the average number of types of traumas were observed, with most groups having an average of 1.5 trauma types.
Incidence of interpersonal trauma and secondary PTSD across mental disorders
Continuing, we examined the incidence of interpersonal trauma alongside secondary diagnoses of PTSD across various mental disorders. Personality disorders exhibited the highest rates of both interpersonal trauma history and the likelihood to experience more than one trauma, with 1 in 2 patients reporting at least one traumatic life experience. While a history of interpersonal trauma doesn’t necessarily lead to a formal PTSD diagnosis, our data indicate a correlation between trauma exposure history and secondary PTSD diagnoses. This trend may be inflated by clinicians being more likely to document trauma history once a patient presents with PTSD. Intriguingly, patients with eating disorders show a discrepancy between low interpersonal trauma exposure rates (4.8%) and higher PTSD diagnoses (17.8%), hinting at potential documentation issues within eating disorder units in behavioral health facilities.
Patient self-report interpersonal trauma history
Approximately 62% of patients with psychosocial data self-reported some form of lifetime trauma, encompassing both interpersonal and non-interpersonal events, while nearly 53% reported experiencing at least one interpersonal trauma.
A noteworthy observation is that self-reported data show a higher incidence of trauma history compared to official diagnosis records. It’s important to note that the subset of self-reported data may not be fully representative across various demographics, such as age, race, treatment types, and diagnoses. Therefore, perfect alignment in rates between self-report and diagnosis data is not expected. Furthermore, the types of trauma examined in the psychosocial differ significantly from those represented by diagnosis codes. Clinicians, for instance, may document diagnoses such as parent-child conflict, while the self-reported survey captures data on witnessing victimization. Additionally, diagnosis codes may lump together various types of trauma (e.g., physical and sexual trauma), whereas the psychosocial categorizes them separately.
The following table illustrates the percentage of patients self-reporting specific trauma types, including only those types where at least 1% of patients endorsed them. Like diagnosis data, there’s a trend where more patients reported some form of childhood physical and sexual related traumas. Additionally, 20% of all patients self-reported non-interpersonal trauma types. Among patients with any self-reported trauma history, a quarter reported psychosocial loss, such as traumatic death, in adulthood. While these non-interpersonal traumas are beyond the scope of this blog, a further attention to this topic is imperative.
Treatment implications
The adoption of trauma-informed care implies a cultural shift at the organizational level, emphasizing a commitment to the following principles: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice, and consideration of cultural, historical, and gender issues.[1] In the context of patient treatment, trauma-informed care underscores the importance of assessing trauma and its impact, as well as addressing any symptomatology associated with trauma.
Upon examining available patient experience data, we evaluated patient emotional safety upon discharge. Importantly, our analysis revealed no significant differences in emotional safety between patients with and without a history of interpersonal trauma, regardless of whether they had received a PTSD diagnosis. This finding suggests that, at least based on the assessed criterion, emotional safety upon discharge appears to be consistent across both groups.
Concluding words
In summary, our analysis underscores that interpersonal trauma is prevalent across diverse patient populations, and clinicians should expect, on average, that at least one in three patients has a history of such trauma. However, our data also reveals disparities as certain groups, particularly American Indian or Alaskan Native descents, females, and specific diagnostic categories, experience a higher incidence of interpersonal trauma. This insight emphasizes the need for targeted interventions and the importance of implementing trauma-informed care strategies. Furthermore, evidence suggests that addressing traumatic experiences in therapy, regardless of formal diagnoses, can yield benefits by enhancing overall self-perception, altering beliefs about others, and perception of the world.[1]
In conclusion, the implications of our findings extend beyond the mere identification of trauma incidence, urging a reevaluation of treatment approaches to better cater to the unique needs of individuals with a history of interpersonal trauma.