Stress & Trauma Toolkit

for Treating Women in a Changing Political and Social Environment

Bias against women has been documented for centuries around the globe, including in American culture specifically. Women have been denied opportunities to vote, pursue an education or a career, make choices about participation in sexual encounters and their own reproductive options. At the same time, traditional institutions and workplaces have largely ignored or minimized women’s unique biologic needs. These inequities continue to have harmful effects on women’s mental health, and both men and women have been working to correct them.

The current political and social environment has given rise to fear and anxiety among women. In an August 2016 national survey, 52% of women reported that the presidential election was a significant source of stress for them. The high-profile media coverage of sexual assault allegations during the 2016 presidential campaign triggered many survivors of sexual assault or longstanding sexual abuse to relive their painful experiences. The 2018 coverage of the testimony during Senate committee nomination process of a Supreme Court justice who was accused of sexual assault was also triggering.

Women who are racial/ethnic minorities and/or immigrants may face additional stress from real and perceived threats of deportation, targeted hostility, and/or lost services. For many women, these stressors have disrupted their ability to function, work, and feel safe.

The emergence of the #MeToo movement in 2017 and 2018 has publicly exposed the widespread private abuse and mistreatment of women in the U.S. Women who have been sexually harassed, assaulted, or denied equal work opportunities are rejecting the centuries-old status quo and are speaking out, inspired by current national conversations.

Clinical Vignette

Susan, 46 years old

Susan is a 46-year-old white female and mother of two children, with a history of depression and post-traumatic stress disorder (PTSD) following a sexual assault during adolescence, who returns to the clinic for follow-up appointment. She has a history of mental health treatment for which she responded well to medication and weekly therapy.

During the 2016 presidential campaign, media attention about past sexually assaultive behavior of one of the candidates came to light. This triggered Susan to experience anxiety symptoms and flashbacks of her assault. She also developed depressive symptoms. She requested a female therapist; during the assessment session she explored her rationale for this request and discussed her symptoms. Re-entering therapy with a female therapist, she expressed shame for allowing herself to be victimized as an adolescent. At the same time, she cautiously explored what it would mean for her to share her story outside of therapy.

Unique Risks for Women with Mental Health Problems

The World Health Organization reports that depression is twice as common in women as in men and is predicted to be the second leading cause of global disability burden by 2020.

WHO identifies the following risk factors for common mental health disorders that disproportionately affect women:

  • Gender-based violence
  • >Socioeconomic disadvantage
  • >Low income/income inequality
  • >Low social status and rank
  • >Status of being the primary caregiver to others

Some of these are discussed in more detail below.

  • Gender-Related and Intimate-partner Violence. Sexual and physical assaults against women are widespread and occurs at a disturbing frequency. Women account for 91% of rape and sexual assault victims in the U.S. The Centers for Disease Control and Prevention (CDC) estimates that one in five women will experience a rape or an attempted rape during her lifetime. CDC data from 2017 also indicates that nearly 1 in 4 adult women report having experienced severe physical violence from an intimate partner in their lifetime. More than 50% of female rape victims reported being raped by an intimate partner. Adverse mental health outcomes of intimate partner violence (IPV) include depressive disorders, suicidal behaviors, anxiety, and post-traumatic stress disorder (PTSD). Research shows that 30% to 80% of sexual assault survivors go on to develop PTSD.
  • Psychological Violence. Intentional coercion, threats, and verbal abuse can seriously impair another person’s psychological integrity and be detrimental to a woman’s mental health. Psychological violence may contribute to increased rates of depressive disorders, anxiety, PTSD, and suicide attempts.
  • Objectification. Based on Fredrickson and Roberts’ objectification theory, the lived experiences of girls/women includes sexual objectification that may increase rates of mental illness, particularly depression, sexual dysfunction, and eating disorders. The internalization of interpersonal or media-driven sexual objectification may lead a girl/woman to feel body shame, to hyper focus on herself, and to learn to relate to others mainly as a sexual object. This results in ineffective or inadequate coping strategies and disproportionately increases a woman’s mental health risk.
  • Sexual Harassment. A national Quinnipiac University poll done in November 2017 revealed that 60% of women report they have been sexually harassed. A 2016 survey of women in academic medicine published in JAMA, found that 30% of respondents have experienced some form of sexual harassment in the workplace. Of those women, 59% perceived a negative effect on their confidence, and 47% reported that the experiences negatively affected their career advancement. Medical literature shows that chronic harassment and repeated microaggressions (subtle and sometimes unintentional or unconscious incidents of discrimination) can lead to mental health problems such as depression, anxiety, withdrawal, rage, fears, and a diminishment of self-esteem.

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Assessment and Suggested Treatment Recommendations

  • Take a history with all patients. Assess emotional, physical, verbal and sexual violence, and trauma with all patients. Always include a question as to whether they feel safe in their current home and work environment.
  • Screen and assess:
    • Consider the use of validated measures to assess trauma and PTSD. (See Resources list below.)
    • Be familiar with the patient’s cultural background to better provide culturally competent/sensitive services, including translation if needed.
    • Validate and listen to the experience of the patient and encourage conversation.
    • Recognize that the experience of trauma may be affected by the patient’s cultural group. Anticipate barriers to obtaining an accurate trauma history when patients belong to cultures that resist recognition of psychological consequences of trauma.
    • Be aware of possible accompanying medical problems and physical symptoms, such as fibromyalgia, chronic pelvic pain, or functional gastrointestinal disorders.
    • Assess for psychological violence and offer clinical attention and treatment as appropriate.
  • Incorporate the strengths of patients
    • Encourage support from immediate and extended family, friends, and/or community when appropriate.
    • Incorporate religious or spiritual values of patients into the treatment plan when appropriate.
  • Provide supportive and trauma-informed care
    • Refer to trauma-informed care guidelines published by Substance Abuse and Mental Health Services Administration (SAMHSA).
    • Refer patient to trauma resources and/or specialists in your area as appropriate. Contact the National Alliance on Mental Illness HELPLINE (800-950-NAMI) for assistance in locating local trauma-specific programs/providers.
    • Provide psychoeducation, as appropriate, about the role that violence and victimization play in the lives of women. (See Resources list below.)
    • Offer medication, if clinically indicated.
    • Consider becoming involved in advocacy to directly change policy that affects patients. (See Resources list below.)
    • Consider the evolving public narrative about women’s trauma when evaluating a patient’s trauma-related symptoms.

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Resources

The American Psychiatric Association Political Action Committee (APAPAC) offers resources for advocating for policy change at https://www.psychiatry.org/psychiatrists/advocacy

Centers for Disease Control offers information about intimate partner violence (survey data, educational materials, and resources for healthcare professionals) at https://www.cdc.gov/violenceprevention/nisvs/index.html

The National Center for PTSD offers a list of clinical evaluation measures at https://www.ptsd.va.gov/professional/assessment/all_measures.asp

The National Center for Trauma-Informed Care offers information about trauma specific interventions at https://www.samhsa.gov/nctic/trauma-interventions

References

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Authors

  • Jorien Campbell, M.D.
  • Christina Mangurian, M.D., M.A.S.
  • Louisa Olushoga, M.D.
  • Maureen Sayres Van Niel, M.D.

About the Toolkit

Disclaimer: This toolkit is intended to provide general medical advice or recommendations. Each clinician is responsible for using his or her own medical judgement as to how to best diagnose and treat patients.

This introductory guide offers an array of topics that will be essential in understanding how to work with special populations experiencing stress and trauma in today's changing political environment. It provides basic information to raise awareness of the needs of special population patients and strategies to incorporate in care in psychiatric practices. This toolkit does not represent official APA policy, but offers a perspective from physicians that work with this community on a regular basis. The objective of this toolkit is to help a broader range of psychiatrists become familiar with best practices for treating special populations experiencing stress and trauma. Psychiatrists can consult Resources & References section on each page for further reading.