Journal of Family Violence

, Volume 29, Issue 7, pp 725–737 | Cite as

Trauma Severity, Poly-victimization, and Treatment Response: Adults in an Inpatient Trauma Program

  • Julie S. Cinamon
  • Robert T. Muller
  • Susan E. Rosenkranz
Outcomes for Survivors of Abuse


The goal of the current study was to evaluate the extent to which abuse history predicted change in treatment in an inpatient setting. Poly-victimization and trauma severity were examined as predictors of treatment response measured by the Trauma Symptom Checklist-40 and the Symptom Checklist-90-R at admission, discharge, and 6-months follow-up. Data from 161 clients of an inpatient trauma treatment program were analyzed using structural equation modeling. Results indicate that level of poly-victimization predicted treatment response from admission to discharge on two of four outcome variables; however, this relationship was not found at follow-up. Further analyses suggest that the difference in treatment response at discharge among clients with higher rates of poly-victimization was an artifact of scores at admission. Trauma severity analyses reveal that differing types of abusive experiences generally did not predict treatment response. Overall, results demonstrate that this inpatient treatment program is similarly effective for a broad array of patients, including those with a greater number, and higher severity, of victimizations.


Inpatient treatment Childhood trauma Poly-victimization Trauma severity Treatment response 



This research was funded by grants to the second author from the Homewood Foundation and the Social Sciences and Humanities Research Council of Canada. This research was also funded by grants to the first author from the Ontario Graduate Scholarship and the Lillian Wright Maternal-Child Health Graduate Scholarship. The authors wish to acknowledge the support of David Wright, Joanne Rappaport, Taryn Moss, and Robert A. Cribbie.

Author Note

Julie S. Cinamon, M.A., is a Doctoral candidate in the Department of Psychology in the Clinical-Developmental Area at York University in Toronto, Ontario, Canada. Her research focuses on the role of parental support for children following disclosure of abuse and over the course of trauma therapy. She also received a Master of Arts from Concordia University in the Clinical Stream in Montréal, Québec.

Robert T. Muller, Ph.D., is Professor of Psychology, Faculty of Health, York University; and Fellow of the International Society for the Study of Trauma & Dissociation. He is also the Founding Editor of The Trauma & Mental Health Report.

Susan Rosenkranz, Ph.D., C. Psych., is currently a psychologist at the Centre for Addiction and Mental Health in Toronto, Canada, where she engages in research and clinical work in the area of youth substance use problems and concurrent mental health concerns, with a specific interest in the role of trauma. She received her Ph.D. from York University in Toronto, Canada.


  1. Allen, J. G., Coyne, L., & Console, D. A. (2000). Course of illness following specialized inpatient treatment for women with trauma-related psychopathology. Bulletin of the Menninger Clinic, 64(2), 235–56.PubMedGoogle Scholar
  2. Bills, L. J., & Bloom, S. L. (1998). From chaos to sanctuary: Trauma–based treatment for women in a state hospital system. In B. L. Lubotsky, A. K. Blanch, & A. Jennings (Eds.), Women’s health services: A public health perspective (pp. 348–367). Thousand Oaks: Sage.Google Scholar
  3. Blake, D. D., Weathers, F., Nagy, L. M., Kaloupek, D. G., Klauminzer, G., Charney, D. S., & Keane, T. M. (1990). A clinician rating scale for assessing current and lifetime PTSD: the CAPS-1. The Behavior Therapist, 13(8), 187–188. doi: 10.1002/jts.2490080106.Google Scholar
  4. Bloom, S. L. (1997). Creating sanctuary: Toward the evolution of sane societies. New York: Routledge.Google Scholar
  5. Bloom, S. L., & Farragher, B. (2011). Destroying sanctuary: The crisis in human service delivery systems. New York: Oxford University Press, Inc.Google Scholar
  6. Briere, J., & Elliott, D. M. (1993). Sexual abuse, family environment, and psychological symptoms: on the validity of statistical control. Journal of Consulting and Clinical Psychology, 61(2), 284–288. doi: 10.1037/0022-006X.61.2.284.PubMedCrossRefGoogle Scholar
  7. Briere, J., & Runtz, M. (1989). The trauma symptom checklist (TSC-33): early data on a new scale. Journal of Interpersonal Violence, 4(1), 151–163. doi: 10.1177/088626089004002002.CrossRefGoogle Scholar
  8. Brown, C. H., Wang, W., Kellam, S. G., Muthén, B. O., Petras, H., Toyinbo, P., & Windham, A. (2008). Methods for testing theory and evaluating impact in randomized field trials: intent-to-treat analyses for integrating the perspectives of person, place, and time. Drug and Alcohol Dependence, 95(Suppl.1), S74–S104. doi: 10.1016/j.drugalcdep.2007.11.013.
  9. Collishaw, S., Pickles, A., Messer, S., Rutter, M., Shearer, C., & Maughan, B. (2007). Resilience to adult psychopathology following childhood maltreatment: evidence from a community sample. Child Abuse and Neglect, 31(3), 211–229. doi: 10.1016/j.chiabu.2007.02.004.PubMedCrossRefGoogle Scholar
  10. Courtois, C. A., & Bloom, S. L. (2000). Inpatient treatment. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD (pp. 199–223). New York, NY: Guilford.Google Scholar
  11. Derogatis, L. R. (1994). SCL-90-R symptom checklist-90-R: Administration, scoring and procedures manual. Minneapolis: National Computer Systems Pearson, Inc.Google Scholar
  12. DiLillo, D., Peugh, J., Walsh, K., Panuzio, J., Trask, E., & Evans, S. (2009). Child maltreatment history among newlywed couples: a longitudinal study of marital outcomes and mediating pathways. Journal of Consulting and Clinical Psychology, 77(4), 680–692. doi: 10.1037/a0015708.PubMedCrossRefGoogle Scholar
  13. Dougherty, M. J. (2002). Client satisfaction survey of inpatient trauma and dissociative disorders program. Journal of Trauma and Dissociation, 3(2), 97–105. doi: 10.1300/J229v03n02_06.CrossRefGoogle Scholar
  14. Edwards, V. J., Anda, R. F., Felitti, V. J., & Dube, S. R. (2004). Adverse childhood experiences and health-related quality of life as an adult. In K. A. Kendall-Tackett (Ed.), Health consequences of abuse in the family: A clinical guide for evidence-based practice (pp. 81–94). Washington: American Psychological Association.Google Scholar
  15. Ellason, J. W., & Ross, C. A. (1997). Two-year follow-up of inpatients with dissociative identity disorder. The American Journal of Psychiatry, 154(6), 832–839.PubMedGoogle Scholar
  16. Elliott, D. M., & Briere, J. (1992). Sexual abuse trauma among professional women: validating the trauma symptom checklist- 40 (TSC-40). Child Abuse and Neglect, 16(3), 391–398. doi: 10.1016/0145-2134(92)90048-V.PubMedCrossRefGoogle Scholar
  17. Falsetti, S. A. (1992). Causal attributions, depression, and post-traumatic stress disorder in victims of crime. (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses. (9236142).Google Scholar
  18. Ferguson, K. S., & Dacey, C. M. (1997). Anxiety, depression, and dissociation in women health care providers reporting a history of childhood psychological abuse. Child Abuse and Neglect, 21(10), 941–952. doi: 10.1016/S0145-2134(97)00055-0.PubMedCrossRefGoogle Scholar
  19. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007a). Poly-victimization: a neglected component in child victimization. Child Abuse and Neglect, 31(1), 7–26. doi: 10.1016/j.chiabu.2006.06.008.PubMedCrossRefGoogle Scholar
  20. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007b). Re-victimization patterns in a national longitudinal sample of children and youth. Child Abuse and Neglect, 31(5), 479–502. doi: 10.1016/j.chiabu.2006.03.012.PubMedCrossRefGoogle Scholar
  21. Follette, V. M., Alexander, P. C., & Follette, W. C. (1991). Individual predictors of outcome in group treatment for incest survivors. Journal of Consulting and Clinical Psychology, 59(1), 150–155. doi: 10.1037/0022-006X.59.1.150.PubMedCrossRefGoogle Scholar
  22. Follette, V. M., Polusny, M. A., Bechtle, A. E., & Naugle, A. E. (1996). Cumulative trauma: the impact of child sexual abuse, adult sexual assault, and spouse abuse. Journal of Traumatic Stress, 9(1), 25–35. doi: 10.1002/jts.2490090104.PubMedCrossRefGoogle Scholar
  23. Glaser, D. (2002). Emotional abuse and neglect (psychological maltreatment): a conceptual framework. Child Abuse and Neglect, 26(6–7), 697–714. doi: 10.1016/S0145-2134(02)00342-3.PubMedCrossRefGoogle Scholar
  24. Glaser, J. P., van Os, J., Portegijs, P. J. M., & Myin-Germeys, I. (2006). Childhood trauma and emotional reactivity to daily life stress in adult frequent attenders of general practitioners. Journal of Psychosomatic Research, 61(2), 229–236. doi: 10.1016/j.jpsychores.2006.04.014.PubMedCrossRefGoogle Scholar
  25. Gold, S. R., Milan, L. D., Mayall, A., & Johnson, A. E. (1994). A cross-validation study of the trauma symptom checklist: the role of mediating variables. Journal of Interpersonal Violence, 9(1), 12–26. doi: 10.1177/088626094009001002.CrossRefGoogle Scholar
  26. Henning, K., Leitenberg, H., Coffey, P., Turner, T., & Bennett, R. T. (1996). Long-term psychological and social impact of witnessing physical conflict between parents. Journal of Interpersonal Violence, 11(1), 35–51. doi: 10.1177/088626096011001003.CrossRefGoogle Scholar
  27. Herman, J. L. (1992). Trauma and recovery. New York: Basic Books.Google Scholar
  28. Hogan, M. F. (2002). Spending too much on mental illness in all the wrong places. Psychiatric Services, 53(10), 1251–1252. doi: 10.1176/ Scholar
  29. Hornsey, M. J., Dwyer, L., & Oei, T. P. S. (2007). Beyond cohesiveness: reconceptualizing the link between group processes and outcomes in group psychotherapy. Small Group Research, 38(5), 567–592. doi: 10.1177/1046496407304336.CrossRefGoogle Scholar
  30. Insel, T. R. (2008). Assessing economic costs of serious mental health. American Journal of Psychiatry, 165(6), 663–665. doi: 10.1176/appi.ajp.2008.08030366.PubMedCrossRefGoogle Scholar
  31. Jepsen, E. K. K., Svagaard, T., Thelle, M. I., McCullough, L., & Martinsen, E. W. (2009). Inpatient treatment of adult survivors of childhood sexual abuse: a preliminary outcome study. Journal of Trauma and Dissociation, 10(3), 315–333. doi: 10.1080/15299730902956812.PubMedCrossRefGoogle Scholar
  32. Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychological Bulletin, 113(1), 164–180. doi: 10.1037/0033-2909.113.1.164.PubMedCrossRefGoogle Scholar
  33. Kessler, R. C., Herringa, S., Lakoma, M. D., Petukhova, M., Rupp, A. E., Schoenbaum, M., & Zaslavsky, A. M. (2008). Individual and societal effects of mental disorders on earnings in the United States: results from the national comorbidity survey replication. American Journal of Psychiatry, 165(6), 703–711. doi: 10.1176/appi.ajp.2008.08010126.PubMedCrossRefPubMedCentralGoogle Scholar
  34. Mara, C. A., Cribbie, R. A., Flora, D. B., LaBrish, C., Mills, L., & Fiksenbaum, L. (2011). An improved model for evaluating change in randomized pretest, posttest, follow-up designs. Methodology: European Journal of Research Methods for the Behavioral and Social Sciences, 8(3), 97–103. doi: 10.1027/1614-2241/a000041.Google Scholar
  35. McArdle, J. J. (2009). Latent variable modeling of differences and changes with longitudinal data. Annual Review of Psychology, 60, 577–605. doi: 10.1146/annurev.psych.60.110707. 163612.PubMedCrossRefGoogle Scholar
  36. Meagher, M. A. (2004). Links between traumatic family violence and chronic pain: biopsychosocial pathways and treatment implication. In K. A. Kendall-Tackett (Ed.), Health consequences of abuse in the family: A clinical guide for evidence-based practice (pp. 155–177). Washington: American Psychological Association.Google Scholar
  37. Muller, R. T., & Rosenkranz, S. E. (2009). Attachment and treatment response among adults in inpatient treatment for posttraumatic stress disorder. Psychotherapy: Theory, Research, Practice, Training, 46(1), 82–96. doi: 10.1037/a0015137.CrossRefGoogle Scholar
  38. Mun, E. Y., von Eye, A., & White, H. R. (2009). An SEM approach for the evaluation of intervention effects using pre-post-post designs. Structural Equation Modeling, 16(2), 315–337. doi: 10.1080/10705510902751358.PubMedCrossRefPubMedCentralGoogle Scholar
  39. Resnick, H. S. (1996). Psychometric review of Trauma Assessment for Adults (TAA). In B. H. Stamm (Ed.), Measurement of stress, trauma and adaptation. Lutherville: Sidran Press.Google Scholar
  40. Resnick, H. S., Best, C. L., Kilpatrick, D. G., Freedy, J. R. & Falsetti, S. A. (1993). Trauma Assessment for Adults – Self-Report. Charleston, Medical University of South Carolina: National Crime Victims Research and Treatment Center.Google Scholar
  41. Rosenkranz, S. E., & Muller, R. T. (2011). Outcome following inpatient trauma treatment: differential response based on pre-treatment symptom severity. Psychological Trauma: Theory, Research, Practice, and Policy, 3(4), 453–461. doi: 10.1037/a0021778.CrossRefGoogle Scholar
  42. Russ, M. J., Shearin, E. N., Clarkin, J. F., Harrison, K., & Hull, J. W. (1993). Subtypes of self-injurious patients with borderline personality disorder. American Journal of Psychiatry, 150(12), 1869–1871.PubMedGoogle Scholar
  43. Savalei, V., & Bentler, P. M. (2006). Structural equation modeling. In R. Grover & M. Vriens (Eds.), The handbook of marketing research: Uses, misuses, and future advances (pp. 330–364). Thousand Oaks: Sage Publications.CrossRefGoogle Scholar
  44. Schmitz, N., Hartkamp, N., Brinschwitz, C., Michalek, S., & Tress, W. (2000). Comparison of the standard and the computerized versions of the Symptom Check List (SCL-90-R): a randomized trial. Acta Psychiatrica Scandinavica, 102(2), 147–152. doi: 10.1034/j.1600-0447.2000.102002147.x.PubMedCrossRefGoogle Scholar
  45. Shapiro, S. S., & Wilk, M. B. (1965). An analysis of variance test for normality (complete samples). Biometrika, 52(3/4), 591–611. doi: 10.2307/2333709.CrossRefGoogle Scholar
  46. Shirk, S. R., & Eltz, M. (2008). Multiple victimization and the process and outcome of child psychotherapy. Journal of Aggression, Maltreatment, and Trauma, 2(1), 233–251. doi: 10.1300/J146v02n01_13.CrossRefGoogle Scholar
  47. Stalker, C. A., Palmer, S. E., Wright, D. C., & Gebotys, R. (2005). Specialized in-patient trauma treatment for adults abused as children: a follow-up study. American Journal of Psychiatry, 162(3), 552–559. doi: 10.1176/appi.ajp.162.3.552.PubMedCrossRefGoogle Scholar
  48. Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.). New York: Pearson, Education, Inc.Google Scholar
  49. Tarrier, N., Sommerfield, C., Pilgrim, H., & Faragher, B. (2000). Factors associated with outcome of cognitive-behavioural treatment of post-traumatic stress disorder. Behavior Research and Therapy, 38(2), 191–202. doi: 10.1016/S0005-7967(99)00030-3.CrossRefGoogle Scholar
  50. van Minnen, A., Arntz, A., & Keijsers, G. P. J. (2002). Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout. Behaviour Research and Therapy, 40(4), 439–457. doi: 10.1016/S0005-7967(01)00024-9.PubMedCrossRefGoogle Scholar
  51. Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Clinician-administered PTSD scale: a review of the first ten years of research. Depression and Anxiety, 13(3), 132–156. doi: 10.1002/da.1029.PubMedCrossRefGoogle Scholar
  52. Wind, T. W., & Silvern, L. E. (1992). Type and extent of child abuse as predictors of adult functioning. Journal of Family Violence, 7(4), 261–281. doi: 10.1007/BF00994618.CrossRefGoogle Scholar
  53. Wolfe, D. A., & McGee, R. (1994). Dimensions of child maltreatment and their relationship to adolescent adjustment. Development and Psychopathology, 6(1), 165–181.CrossRefGoogle Scholar
  54. Wright, D. C., & Woo, W. L. (2000). Treating post–traumatic stress disorder in a therapeutic community: the experience of a Canadian psychiatric hospital. Therapeutic Communities, 21(2), 105–118.Google Scholar
  55. Wright, D. C., Woo, W. L., Muller, R. T., Fernandes, C. B., & Kraftcheck, E. R. (2003). An investigation of trauma-centered inpatient treatment for adult survivors of abuse. Child Abuse and Neglect, 27(4), 393–406. doi: 10.1016/S0145-2134(03)00026-7.PubMedCrossRefGoogle Scholar
  56. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Julie S. Cinamon
    • 1
  • Robert T. Muller
    • 1
  • Susan E. Rosenkranz
    • 1
  1. 1.York UniversityTorontoCanada

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