Trauma Counseling: Theories and Interventions 9780826106834, 9780826106841, 9780826109569, 2012003171

Citation preview

COUNSELING

LEVERS

TRAUMA THEORIES AND INTERVENTIONS

P h D, P C C - S, L P C, C R C, N C C EDITOR

T

rauma Counseling is a comprehensive, multidisciplinary guide to the theory and treatment of survivors of a broad spectrum of traumatic events, including interpersonal violence, hate crimes, school violence, community violence, natural disasters, and war and terrorism. The book is edited by a Fulbright scholar who is internationally recognized for her work with traumatized populations in Rwanda, several southern African countries, Russia, and the United States, and includes the contributions of researchers from around the world. The guide discusses evidence-based trauma assessment and intervention techniques and integrates the latest findings from neuropsychology and psychopharmacology. It focuses on issues of loss and grief, survivorship and disability, genocide, natural disasters, the impact of war on civilians and veterans, and the distinct effects of trauma in early childhood, childhood, and adolescence. Also addressed are ethical perspectives and methods of self-care for counselors who work with this population. The text will be of value to graduate counseling students and professional counselors, as well as social workers, psychologists, psychiatric nurses, and other human service providers. The content of Trauma Counseling not only fulfills but exceed the requirements of The Council of Accreditation and Counseling and Related Educational Program (CACREP) standards. K E Y F E AT U R E S :

• Addresses the theory and treatment of trauma survivors of interpersonal violence, hate crimes, school violence, community violence, natural disasters, and war and terrorism • Provides a multidisciplinary approach to treatment that integrates findings from neuropsychology and psychopharmacology • Includes evidence-based counseling techniques • Illuminates the intersections of trauma, crisis, and disaster issues, exceeding related requirements of CACREP standards

TRAUMA COUNSELING THEORIES AND INTERVENTIONS

LISA LOPEZ LEVERS

• Offers topic-relevant resources at the end of each chapter ISBN 978-0-8261-0683-4

11 W. 42nd Street New York, NY 10036-8002 www.springerpub.com

TRAUMA COUNSELING

LISA LOPEZ LEVERS,

9 780826 106834

EDITOR

Trauma Counseling

Lisa Lopez Levers, PhD, PCC-S, LPC, CRC, NCC is a professor of Counselor Education and Supervision in the Department of Counseling, Psychology and Special Education at Duquesne University, Pittsburgh, PA. She is a licensed professional clinical counselor (endorsed supervisor, Ohio), licensed professional counselor (Pennsylvania), certified rehabilitation counselor, and national certified counselor. She has worked clinically with survivors of trauma and offered crisis intervention counseling since 1974. She has taught several trauma-related graduate courses over the last two decades, and she has provided crisis intervention training to such diverse groups as police officers and medical personnel. Levers is a Fulbright scholar with international recognition for her work with traumatized populations. She has done extensive trauma counseling, training, and research throughout the southern region of Africa and in Rwanda following the genocide, through a commission by the Rwandan Ministry of Health. She also worked with a team of mental health professionals in Russia, shortly after the end of the Soviet era, to initiate and develop a system of community-based foster care for vulnerable children there.

Trauma Counseling Theories and Interventions

LISA LOPEZ LEVERS, PhD, PCC-S, LPC, CRC, NCC Editor

Copyright © 2012 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Jennifer Perillo Composition: Absolute Service, Inc. ISBN: 978-0-8261-0683-4 E-book ISBN: 978-0-8261-0684-1 Instructor’s Manual: 978-0-8261-0956-9 Qualified instructors may request supplements by emailing [email protected] 12 13 14 15/ 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet Web sites referred to in this publication and does not guarantee that any content on such Web sites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Levers, Lisa Lopez. Trauma counseling : theories and interventions / Lisa Lopez Levers. — 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8261-0683-4 — ISBN 978-0-8261-0684-1 (e-book) I. Title. [DNLM: 1. Counseling—methods. 2. Psychological Theory. 3. Stress Disorders, Traumatic— psychology. 4. Stress Disorders, Traumatic—therapy. 5. Stress, Psychological. 6. Survivors— psychology. WM 55] 362.1’04256—dc23 2012003171 Special discounts on bulk quantities of our books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. If you are interested in a custom book, including chapters from more than one of our titles, we can provide that service as well. For details, please contact: Special Sales Department, Springer Publishing Company, LLC 11 West 42nd Street, 15th Floor, New York, NY 10036-8002s Phone: 877-687-7476 or 212-431-4370 Fax: 212-941-7842 Email: [email protected] Printed in the United States of America by Hamilton Printing

This book is dedicated to the lives and memories of

Robert Elwood Levers Born 1 January 1925, Died 9 April 2011 [Dad, you remain my lifelong hero.] and Manuel Vicente Lopez Born 24 June 1898, Killed 24 December 1955 [One bullet dramatically changed the lives of two sets of families forever.]

Contents

Contributors xi Foreword Susan Herman, JD Preface xvii Acknowledgments xxiii

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SECTION I: TRAUMA AND CONTEXT 1. An Introduction to Counseling Survivors of Trauma: Beginning to Understand the Context of Trauma 1 Lisa Lopez Levers Appendix, Deirdre Stoelzle Graves 2. Historical Contexts of Trauma 23 Debra Hyatt-Burkhart and Lisa Lopez Levers 3. Theoretical Contexts of Trauma Counseling Martin F. Lynch

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4. Neurobiological Effects of Trauma and Psychopharmacology John R. Tomko

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SECTION II: TRAUMA OF LOSS, VULNERABILITY, AND INTERPERSONAL VIOLENCE 5. Issues of Loss and Grief 77 Judith L. M. McCoyd, Carolyn Ambler Walter, and Lisa Lopez Levers 6. Trauma Survivorship and Disability 98 Eboneé T. Johnson, Jessica M. Brooks, Elias Mpofu, Jasim Anwer, Kaye Brock, Evadne Ngazimbi, and Fambaineni Innocent Magweva 7. Sexual Trauma: An Ecological Approach to Conceptualization and Treatment 116 Laura Hensley Choate 8. Trauma Experienced in Early Childhood Staci Perlman and Andrea Doyle

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9. Trauma Experienced in Adolescence Andrea Doyle and Staci Perlman 10. Treating Adult Trauma Survivors Barbara Peck

146 161

11. Intimate Partner Violence 178 Nancy N. Fair and Frank M. Ochberg 12. Elder Abuse Erika Falk

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13. Addiction and Psychological Trauma: Implications for Counseling Strategies 214 Patricia A. Burke and Bruce Carruth Appendix, Maureen Keating 14. Criminal Victimization Laurence Miller

231

15. Traumatic Aftermath of Homicide and Suicide Tumani Malinga-Musamba and Tapologo Maundeni

249

SECTION III: INTOLERANCE AND THE TRAUMA OF HATE 16. Existential Perspectives on the Psychology of Evil 264 Alison L. DuBois, Lisa Lopez Levers, and Charles P. Esposito 17. Racial and Ethnic Intolerance: A Framework for Violence and Trauma Emma Mosley

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18. Understanding and Responding to Sexual and Gender Prejudice and Victimization 297 Kathleen M. Fallon and Susan Rachael Seem

SECTION IV: COMMUNITY VIOLENCE, CRISIS INTERVENTION, AND LARGE-SCALE DISASTER 19. Contextual Issues of Community-Based Violence, Violence-Specific Crisis and Disaster, and Institutional Response 317 Lisa Lopez Levers and Roger P. Buck 20. School Violence and Trauma 335 Jeffrey A. Daniels and Jenni Haist 21. Workplace and Campus Violence Eric W. Owens

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22. Natural Disasters and First Responder Mental Health Scott Tracy 23. Genocide, Ethnic Conflict, and Political Violence Kirrily Pells and Karen Treisman

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Contents 24. The Impact of War on Civilians Elaine Hanson and Gwen Vogel

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25. The Impact of War on Military Veterans Roger P. Buck

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26. Disaster Behavioral Health: Counselors Responding to Terrorism June Ann Smith and Jo Ann Jankoski

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SECTION V: CLINICAL ASSESSMENT AND TREATMENT ISSUES 27. Assessment in Psychological Trauma: Methods and Intervention F. Barton Evans

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28. Models for Trauma Intervention: Integrative Approaches to Therapy Lisa Lopez Levers, Elizabeth M. Ventura, and Demond E. Bledsoe 29. Strategies and Techniques for Counseling Survivors of Trauma Elizabeth M. Ventura

SECTION VI: COLLABORATIVE WORK IN THE AREA OF TRAUMA COUNSELING 30. Ethical Perspectives on Trauma Work Vilia Tarvydas and Helena K. Y. Ng 31. Vicarious Traumatization Jo Ann Jankoski

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32. Therapist Self-Care: Being a Healing Counselor Rather Than a Wounded Healer 554 Cynthia Diane Rudick 33. Trauma and Supervision Demond E. Bledsoe

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34. Conclusion: An Integrative Systemic Approach to Trauma Lisa Lopez Levers Index

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Contributors

Jasim Anwer, MBBS, MAppSc Provincial Hospital Coordinator (DEWS) and Epidemiologist, World Health Organization, Peshawar, Pakistan Demond E. Bledsoe, MS, LPC, NCC Doctoral Candidate, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania, and Clinical Consultant, Wesley Spectrum Services, Pittsburgh, Pennsylvania Kaye Brock, PhD Senior Lecturer, Epidemiology and Research Methods, The University of Sydney, Sydney, Australia Jessica M. Brooks, MS, CRC Doctoral Student, Rehabilitation Psychology, Department of Rehabilitation Psychology and Special Education University of Wisconsin-Madison, Madison, Wisconsin Roger P. Buck, PhD, LPCC, DAC Ohio

Director, Counseling Center, Hocking College, Nelsonville,

Patricia A. Burke, MSW, LCSW, BCD, C-CATODSW Affiliated Faculty, Psychology and Addiction Studies, Union Institute & University, Montpelier, Vermont Bruce Carruth, PhD, LCSW

Private Practice, San Miguel de Allende, GTO, Mexico

Laura Hensley Choate, EdD, LPC, NCC Associate Professor, Counselor Education, Louisiana State University, Baton Rouge, Louisiana Jeffrey A. Daniels, PhD Associate Professor, Counseling Psychology, West Virginia University, Morgantown, West Virginia Andrea Doyle, PhD Assistant Professor, School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania Alison L. DuBois, PhD Assistant Professor of Education, Westminster College, New Wilmington, Pennsylvania Rev. Charles P. Esposito, MDiv, STL, MEd Catholic Priest, Pastor, and Counselor with Grief and Other Spiritually Focused Issues, Church of the Good Shepherd, Kent, Pennsylvania F. Barton Evans, PhD Clinical Professor of Psychiatry, George Washington University Medical School, Washington, District of Columbia, Clinical and Forensic Psychology, and Charles George VA Medical Center, Asheville, North Carolina

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Contributors

Nancy N. Fair, MA Doctoral Candidate, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania, and Supervisor of Adult Counseling Services, Pittsburgh Action Against Rape, Pittsburgh, Pennsylvania Erika Falk, PsyD California

Director, Geriatric Assessment Services, Institute on Aging, San Francisco,

Kathleen M. Fallon, PhD Assistant Professor, Department of Counselor Education, The College at Brockport: State University of New York, Brockport, New York Deirdre Stoelzle Graves

Executive Director, The Dart Society, Kaycee, Wyoming

Jenni Haist, MEd Doctoral Student, Counseling Psychology, West Virginia University, Morgantown, West Virginia Elaine Hanson, PsyD, JD

Executive Director, SalusWorld, Denver, Colorado

Debra Hyatt-Burkhart, PhD Instructor, Counseling and Development, Slippery Rock University, Slippery Rock, Pennsylvania Jo Ann Jankoski, EdD, LCSW, MS Assistant Professor, Human Development and Family Studies, Penn State University, The Eberly Campus, Uniontown, Pennsylvania Eboneé T. Johnson, MS, CRC Doctoral Candidate, Rehabilitation Psychology and Special Education, University of Wisconsin-Madison, Madison, Wisconsin Maureen A. Keating, MEd PCC-S LICDC Community Health Center, Akron, Ohio

Director of Women and Family Services,

Lisa Lopez Levers, PhD, PCC-S, LPC, CRC, NCC Professor, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania Martin F. Lynch, PhD, NCC Assistant Professor, Counseling and Human Development, Warner School of Education, University of Rochester, Rochester, New York Fambaineni Innocent Magweva, MTech, MSc Disability Adviser, National Association of Societies for the Care of the Handicapped, Harare, Zimbabwe Tumani Malinga-Musamba, MSW Botswana, Gaborone, Botswana

Lecturer, Department of Social Work, University of

Tapologo Maundeni, PhD Associate Professor, Department of Social Work, University of Botswana, Gaborone, Botswana Judith L. M. McCoyd, PhD, LCSW, QCSW Associate Professor, School of Social Work, Rutgers, The State University of New Jersey, Camden, New Jersey Laurence Miller, PhD Independent Practice in Clinical and Forensic Psychology, Boca Raton, Florida, Adjunct Professor, Florida Atlantic University & Palm Beach State College, Boca Raton & Lake Worth, Florida Emma Mosley, PhD, NCC Assistant Professor, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania Elias Mpofu, PhD Professor, Head of Discipline, Rehabilitation Counselling, Faculty of Health Sciences, The University of Sydney, Sydney, Australia Helena K. Y. Ng, MS, NCC Doctoral Candidate, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania

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Contributors Evadne Ngazimbi, PhD, LPC, NCC Assistant Professor, Department of Psychology and Counseling, Northern State University, Aberdeen, South Dakota Frank M. Ochberg, MD Lansing, Michigan

Clinical Professor, Psychiatry, Michigan State University, East

Eric W. Owens, PhD, NCC, ACS Assistant Professor, Department of Counselor Education, West Chester University of Pennsylvania, West Chester, Pennsylvania Barbara Peck, EdD, LPC Therapist, Chestnut Ridge Counseling Services, Uniontown, Pennsylvania, Adjunct Faculty, Graduate School of Counseling, Waynesburg University, Waynesburg, Pennsylvania Kirrily Pells, PhD Policy Officer, Young Lives, Oxford Department of International Development, University of Oxford, Oxford, United Kingdom Staci Perlman, MSW, PhD Assistant Professor, Department of Social Work, Kutztown University, Kutztown, Pennsylvania Cynthia Diane Rudick, PhD, LPCC-S Private Practitioner and Professional Mediator and Arbitrator, Fordyce & Associates, Canton, Ohio, and Professor of Continuing Education, John Carroll University, Cleveland, Ohio Susan Rachael Seem, PhD, LMHC, NCC, ACS Professor, Department of Counselor Education, The College at Brockport: State University of New York, Brockport, New York June Ann Smith, PhD, LMHC, LCSW, LMFT, NCC, ACS Associate Professor, Department of Counseling and Development, Long Island University, C.W. Post Campus, Brookville, New York Vilia M. Tarvydas, PhD, LMHC, CRC Professor, Rehabilitation and Counselor Education, The University of Iowa, Iowa City, Iowa John R. Tomko, PharmD, BCPP Assistant Professor of Pharmacy Practice, Mylan School of Pharmacy, Duquesne University, Pittsburgh, Pennsylvania Scott Tracy, EdD, LPC, NCC, CSC, EMT-P Director and Assistant Professor of Graduate Counseling, Waynesburg University, Waynesburg, Pennsylvania Karen Treisman, BA, DClinPsy Clinical Psychologist, Department of Applied Psychology, Canterbury Christchurch University, Tunbridge Wells, United Kingdom Elizabeth M. Ventura, PhD, LPC, NCC Assistant Professor, Graduate and Professional Studies Counseling Program, Waynesburg University, Canonsburg, Pennsylvania Gwen Vogel, PsyD Denver, Colorado

Licensed Clinical Psychologist, Director of Field Operations, SalusWorld,

Carolyn Ambler Walter, PhD, LCSW Professor Emerita, Center for Social Work Education, Widener University, Chester, Pennsylvania

Foreword

Over the last two decades, we have made great progress confronting the realities of trauma. The academic community has begun to pay appropriate attention to trauma—to documenting the prevalence of trauma in the lives of so many members of our society, to understanding the aftermath of traumatic events, and to preparing future clinicians and counselors to recognize the centrality of traumatic experiences in the lives of their clients. The practice community is finally acknowledging that trauma is widespread— that good practice must include universal screening for trauma, a sharp focus on the role of trauma as an underlying cause of so many social problems, and a collaborative approach to building resilience. The general public, however, remains unaware of the role that trauma plays in everyday life. Too often, individuals who are survivors of trauma face the shame of coming forward, or simply suffer with the consequences of the traumatic incident in their lives. Too often, they are given subtle messages that recovery is a solitary process and that nobody can help them. We now know that it takes courage for people who have experienced trauma to trust others enough to share their stories. Who would understand? Who would believe them? Who would listen without judging? The horrors of human existence often feel unspeakable. Service providers often seem dismissive. It is not surprising, then, that research conducted in the United States and abroad indicates that very few victims of violence seek professional assistance. It is also difficult for “healers” to bear witness to this trauma, which often involves deliberate acts of human cruelty. Their faith in people is tested; their vision of humanity contorted. It may be easier for them to look away, to minimize the stories, to deny the horror. I come at these issues as someone who has worked for many years with victims of crime. My perspective has been informed by the emerging understanding of the impact of trauma, particularly the impact of intentional human cruelty. Like many readers of this book, I have witnessed firsthand the debilitating effects of violence. I understand the feeling of inadequacy that comes with the realization that some wounds cannot be healed. Perhaps unlike many readers of this book, however, I situate my work with crime victims in a justice framework. I try to imagine what our communal response to victims should be in the aftermath of crime. I find it critically important to define government’s obligations to victims and to ask what communities and individuals should do to provide a just response.

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While I have worked in a number of capacities to improve the criminal justice response to crime victims, on a more fundamental level, I have conceptualized—and advocated for—a justice response that does not depend on the criminal justice system. I believe we need an additional set of responses both within and outside the criminal justice process called Parallel Justice. Unlike the traditional criminal justice process, which focuses on the apprehension, prosecution, and conviction of offenders, Parallel Justice envisions a societal approach dedicated to helping victims of crime rebuild their lives. I believe all victims of crime deserve assistance to regain a sense of safety, to recover from the trauma they have suffered, and to regain a sense of control over their lives. There is a creative synergy between the concept of Parallel Justice and the recent focus on trauma. Crime is often a traumatic experience. Accordingly, justice requires a thorough understanding of, and effective response to, the trauma experienced by victims. Stated differently, the urgency to create Parallel Justice is fueled by our appreciation of the nature and extent of trauma. We have made a lot of progress in our response to victims over the past generation. In terms of crime victim services, we have developed a much greater understanding of the need for trauma victims to reestablish a sense of safety. For example, in the early 1970s, we had only a handful of shelters for battered women in this country, and now we have over 2,000. More and more health care professionals are trained to recognize the context of many intentional injuries, so they are more likely to recognize gang members, battered women, and abused children, not just gunshot wounds, black eyes, and broken arms. But we still live in a world where too many people admitted to our emergency rooms are crime victims who have suffered traumatic incidents. Too many people who access our homeless shelters are homeless because they have experienced trauma in their lives and are having difficulty coping. Too many people need drug and alcohol treatment because they are trying to numb their trauma-related pain. Too many people in prison have been on both sides of violent acts and have never addressed either the trauma they inflicted on others, or the trauma and violence that they experienced themselves. And, unfortunately, too many of our criminal justice, health care, and social service institutions are still not equipped to identify or address this trauma. So I am quite pleased to celebrate the publication of this book. From my work with victims, I have come to believe that even otherwise well-intentioned and well-trained practitioners often feel unprepared to respond to trauma. Our societal justice goal should be to help victims of crime reintegrate back into healthy and productive communal life. We will never succeed in helping victims rebuild their lives if the people they turn to for help are not trained to respond effectively. This book validates the emergence of a new field of trauma studies and a growing body of trauma-related best practices. The lessons in this volume reflect the powerful awareness that trauma is experienced in a context—within a life, a family, a community, and a culture—and that each individual experiences it differently. We now live in a difficult netherworld. We know much more about the widespread nature of trauma and its far-reaching ripple effects. We know how to improve practice and what new research questions to ask. But our understanding of the problem far outstrips our ability to respond effectively. We still have so much more to do. I hope this book accelerates our progress. Susan Herman, JD Associate Professor, Pace University Former Executive Director of the National Center for Victims of Crime Author of Parallel Justice for Victims of Crime

Preface

The inspiration for this book came perhaps as early as late 1975. It was toward the end of my master’s degree, when I was an idealistic 23-year-old counselor intern, also volunteering my services at a crisis intervention agency where I was getting my “real-world” education. I remember learning in a graduate class not to worry about incest abuse; according to the authoritative wisdom at the time, we would never see a case of incest, and if we were to see one, it would only occur one time in a million cases. I recall finding this odd at the time, considering the strength of the universal cultural taboo regarding incest. I thought it strange that the incest taboo would be so profound and so enduring in the face of one in a million odds. But what did I know? So I accepted the knowledge of experts who told me to believe something that seemed so counterintuitive. Shortly after finishing my master’s degree in December 1975, I turned 24 and left on a backpacking journey to various countries in Europe. I also served as one of the few American delegates at the International Tribunal on Crimes against Women (orchestrated by Dr. Diana E. H. Russell, professor emerita), held in March 1976, in Brussels. At the tribunal, I learned about multiple cases of incest, along with other types of gender-based and political violence. Regarding the incest, I reasoned that it was possible because of the international presence—thousands of women from hundreds of countries, representing millions of people around the world—narratives of multiple incidences could have been attributable to global scale alone, but I remained unsettled about the statistical accuracy of what the experts had said and what we were taught. Regarding the other types of violence, I recall being very stunned and feeling so woefully unprepared to process many of the horrible firsthand accounts of atrocities that were reported at the tribunal as well as what I learned from some of the other women in casual conversation. For example, I met Aboriginal women from Australia who had experienced severe cultural oppression; I bunked with women from South Africa who provided personal details about the evils of apartheid. I learned more at the tribunal than my young mind even could absorb on a conscious level. In retrospect, I have come to regard this experience as profoundly relevant training for my next 15 years of community mental health work and my ensuing career as an academic. After an initial 6-month stint as the first professional counselor on a female maximum security ward at a large state psychiatric facility (at the very beginning of that state’s implementation of its newly enacted patient rights and deinstitutionalization legislation) followed by my transition to the community mental health sector (where I spent the next 15 years of my career), it did not take long to see how wrong the experts

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actually were regarding incest abuse as well as other types of sexual assault. I read the files of the women in the state facility, and I listened to the narratives of my clients at the community mental health center; certainly not all clinical reports are accurate, but neither should reports of personal events automatically be disregarded or dismissed. Not only were my clients teaching me about incest abuse, I also was witness to the psychosocial aftermath of all sorts of traumatic events; some of them were more unspeakable than others, and many of them were beyond the ability of a young clinician to process, especially at a time (beginning in the mid-to-late 1970s) when so little in the professional literature addressed trauma. Eventually, I began to see clients with increasingly more complex trauma histories. I already had become one of the few go-to therapists when the local, newly established rape crisis and domestic violence centers had a client who needed immediate counseling services—again, it was the mid-to-late 1970s, centers dealing with sexual assault and partner abuse were just developing, and most did not have in-house counselors. I had gained the trust of the agencies, having a reputation for being willing to rearrange my schedule to see someone, usually a female victim of interpersonal violence, who was in immediate crisis. The clinical challenges were great, and there was a point at which I had to search throughout the city to acquire the trauma-specific clinical supervision that was not available at the community mental health center where I was employed. This led to connecting with a group of therapists who had formed a trauma study group, which provided a format for our supporting one another in our clinical work with trauma survivors. This also hints at some of the systemic challenges during this same time frame. An example of such a challenge occurred in the late 1970s, when the director of one of the rape crisis agencies (I was a board member at the time) and I compared notes about trends we had been observing with clients at our respective agencies. Both being master’s level mental health practitioners, we decided to initiate the first incest survivor support group in a large metropolitan area in northeastern Ohio. When word got out regarding recruitment for the group, both of our agencies began to receive hostile and threatening calls from members of the mental health establishment attributing all sorts of catastrophic outcomes to such a support group, including the patronizing accusation that we would be “feeding the delusions of these poor women.” The satisfactory ending to this story was that the administrator of my agency was a feminist who insisted that we proceed with our plans, and the rape crisis center had a supportive board of directors, enabling its director to move forward as well. We conducted the support group, to the benefit of the clients involved, and, indeed, there were no associated catastrophes. After providing 15 years of community mental health services and engaging in trauma-focused private practice, I made a transition to the professoriate, teaching graduate courses in counselor education. Part of the motivation for my move was that of course the university environment would be more intellectually progressive, and of course I would be able to put into instructional practice all that I had learned on the front lines of community mental health and working with traumatized clients. What a surprise it was to engage a whole new set of systemic and administrative challenges, along with a recapitulation of the unease with which issues of trauma are regarded, even by academicians who are knowledgeable about clinical mental health matters. I learned quickly that I would need to acquire new sets of skills to navigate the academic system of getting new trauma-related courses approved. It seemed that, at the time, the academy was not ready for graduate courses that focused on issues of interpersonal violence and other trauma events. Although I preferred to take this on as an advocacy project rather than a fight, there was only one academic institution (of the four where

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I have taught) at which I did not need to advocate strongly to be able to teach an elective course associated with issues of trauma (I have greatly appreciated my mentors at the University of New Orleans, Louis Paradise and Peggy Kirby, for believing in my ability to design and teach the well-received Children and Violence course). At many junctures in the current textbook, the authors of the chapters highlight a variety of the controversies, throughout the decades, which have surrounded the clinical issues of trauma. I feel like I have survived some of the battle zones of these controversies in both my clinical and academic work, in terms of advocating for the clinical needs of traumatized clients as well as the instructional needs of counseling students. All of this brings us to the present landscape in which the human services field finally has recognized the overwhelming presence of everyday trauma in the lives of many people along with the frequent highly publicized global disasters to which we are more immediately exposed than ever before. Preservice academic programs, especially those training entry-level master’s practitioners who arguably provide the bulk of direct psychosocial services, need to catch up with what our graduates are certain to see once they enter the field—indeed, what our students already are seeing, and for which many are unprepared, in their pregraduation practicum, internship, and other field-based experiences. I have had the privilege of teaching several elective courses on counseling survivors of trauma for over 2 decades now. Although more and more good books that are devoted to issues of trauma are published regularly, I have not yet found a textbook that serves as an adequate source for grounding students and clinicians with an introduction to the theories and practices associated with trauma while also preparing them for the emotional intensity of trauma work. I finally decided, humbly, that perhaps I should take on the responsibility of preparing such a textbook.

The Relevance of This Textbook Those of us who have done clinical work for any length of time know that trauma is as ubiquitous as the many other psychosocial issues that we consider to be pervasive, for example, issues like alcoholism and substance abuse. We all have dealt with so many cases in which clients present with a plethora of other issues, but once we scratch the surface of the situation, we often learn that the real problem is not the alcoholism or the substance abuse—or the depression, or the anger, or any number of other clinical issues that permeate the problems bringing people to mental health clinics or to the offices of private practitioners to seek help—rather, it is the underlying experience of trauma. Still, it has taken the helping professions some time to grapple with the ubiquity of trauma and to understand the effects of traumatic events on the people who experience them. The major purpose of this book is to provide a much-needed text for a traumaspecific course in the preservice training of master’s level professional counselors, social workers, psychologists, and other human service providers. Because trauma is such a pervasive and overwhelming phenomenon, and because there are so many mental health clinicians practicing today without the advantage of having had trauma- or crisis-related course work or supervision as a part of their respective curricula, such a text is relevant to and much needed by a variety of practicing human service providers. This textbook offers a relatively comprehensive review of the various types of traumatic experiences; the human vulnerability for traumatic experiences across the life span; and the intersections among trauma, crisis, and disaster events. It discusses pertinent diagnostic and case conceptualization issues as well as presents individual and systems interventions and collaborations. The perspective from which this

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textbook was conceptualized and organized is one that is anchored in an ecological and systemic view of people’s psychosocial needs and interactions. A unique feature of this textbook is that, at the end of each chapter, the authors have provided a list of helpful resources for use by students, instructors, and clinicians. These resources are specific to the trauma-related topic of the chapter and include websites, manuals, films, instructional videos/DVDs, and a variety of other useful tools. In addition, most of the chapters have appendices that either offer a case study or explicate an important detail to assist readers in understanding the relevance of the chapter topic. An Instructors Manual is available from Springer; it includes sample syllabi for a semester-long course and a week-long seminar, along with discussion questions and activities for each chapter. Qualified instructors can request the manual by e-mailing [email protected]

The Content of This Textbook Trauma Counseling: Theories and Interventions is a much-needed textbook that focuses on relevant issues of traumatic, crisis-related, and disaster events from a systemic paradigm. In the chapters in Section I, “Trauma and Context,” the aim is to offer a foundation for understanding the various trauma-associated issues in this textbook. Chapter 1, by Lisa Lopez Levers, introduces a bioecological and systemic perspective of trauma that establishes the tone for the rest of the book. In Chapter 2, Debra Hyatt-Burkhart and Lisa Lopez Levers provide the historical context for how we have come to regard trauma-related issues, explicating a number of the controversies surrounding the development of a clinical understanding of trauma. Martin F. Lynch discusses a variety of theoretical contexts related to trauma counseling in Chapter 3. The neurobiological effects of trauma and psychopharmacology are detailed in Chapter 4 by John R. Tomko. Together, these four chapters provide a foundation for considering contextual, theoretical, and neurobiological aspects of trauma. In Section II, “Trauma of Loss, Vulnerability, and Interpersonal Violence,” relevant constructs are explicated, such as loss and grief. This section also offers information about the traumatic events that may be experienced by specific age groups, people who are vulnerable, and other particular populations. Judith L. M. McCoyd, Carolyn Ambler Walter, and Lisa Lopez Levers discuss important psychosocial constructs associated with loss and grief in Chapter 5. In Chapter 6, Eboneé T. Johnson, Jessica M. Brooks, Elias Mpofu, Jasim Anwer, Kaye Brock, Evadne Ngazimbi, and Fambaineni Innocent Magweva discuss issues of disability and trauma survivorship. Laura Hensley Choate, in Chapter 7, emphasizes an ecological approach to conceptualizing and treating sexual trauma. In Chapter 8, Staci Perlman and Andrea Doyle explicate the nature of traumatic experiences of early childhood; in Chapter 9, Doyle and Perlman describe the developmental aspects of trauma that may be experienced in adolescence. Barbara Peck discusses the clinical treatment issues of adult trauma survivors in Chapter 10. Intimate partner violence is the focus of Nancy N. Fair and Frank M. Ochberg’s Chapter 11. In Chapter 12, Erika Falk identifies the traumatizing effects of elder abuse. Patricia A. Burke and Bruce Carruth describe the interactions of addictions and psychological trauma in Chapter 13, identifying effective counseling strategies. In Chapter 14, Laurence Miller describes the traumatic experiences associated with criminal victimization. Tumani Malinga-Musamba and Tapologo Maundeni detail the specific traumatic aftermath of homicide and suicide in Chapter 15. These 11 chapters identify and examine many of the psychosocial constructs and relevant issues associated with personal trauma and interpersonal violence.

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The focus of Section III is on “Intolerance and the Trauma of Hate.” Alison L. DuBois, Lisa Lopez Levers, and Charles P. Esposito begin the section with their discussion, in Chapter 16, of existential perspectives on the psychology of evil. In Chapter 17, Emma Mosley highlights how racial and ethnic intolerance serve as a framework for violence and trauma. In Chapter 18, Kathleen M. Fallon and Susan Rachael Seem explicate sexual and gender prejudice and victimization and suggest best clinical responses. These three chapters emphasize the personal and social dynamics of othering in an attempt to unravel some of the dark side tendencies of humanity. In Section IV, the emphasis on “Community Violence, Crisis Intervention, and LargeScale Disaster” presents a broader systemic context for understanding the effects of trauma on groups of people. Lisa Lopez Levers and Roger P. Buck detail the contextual issues of community-based violence, violence-specific crisis and disaster, and institutional response in Chapter 19. In Chapter 20, Jeffrey A. Daniels and Jenni Haist focus on the traumatic effects of school violence. Eric W. Owens discusses workplace and campus violence in Chapter 21. Scott Tracy explains some of the natural phenomena associated with natural disasters in Chapter 22, outlining important mental health issues related to first responders. In Chapter 23, Kirrily Pells and Karen Treisman consider the community and personal effects of genocide, ethnic conflict, and political violence. Elaine Hanson and Gwen Vogel discuss the impact of war on civilians in Chapter 24, and in Chapter 25, Roger P. Buck examines the impact of war on military veterans. Concluding this section, in Chapter 26, June Ann Smith and Jo Ann Jankoski address the issue of disaster behavioral health, examining the ways in which counselors can respond to terrorism. These eight chapters illuminate the profound impact that large-scale violence and natural and human-made disasters can have on individuals, families, communities, and nations. The focus of Section V is on “Clinical Assessment and Treatment Issues.” In Chapter 27, F. Barton Evans analyzes assessment methods and interventions associated with psychological trauma. Lisa Lopez Levers, Elizabeth M. Ventura, and Demond E. Bledsoe identify and discuss larger scope integrative approaches to trauma intervention in Chapter 28, thus emphasizing the importance of more systemic models. In Chapter 29, Elizabeth M. Ventura details selected strategies and techniques for counseling survivors of trauma. These three chapters offer a framework for beginning to consider the nature of clinical work with clients who have experienced traumatic events. Section VI highlights “Collaborative Work in the Area of Trauma Counseling.” Vilia Tarvydas and Helena K. Y. Ng begin the section by presenting ethical perspectives on trauma work in Chapter 30. Jo Ann Jankoski explicates vicarious traumatization in Chapter 31, highlighting the need for counselor self-awareness. In Chapter 32, Cynthia Diane Rudick focuses on the importance of therapist self-care, encouraging clinicians to be healing counselors rather than wounded healers. In Chapter 33, Demond E. Bledsoe emphasizes the absolute necessity of clinical supervision when working with survivors of trauma. Lisa Lopez Levers concludes this section and the book, with Chapter 34, by asserting the need for continued development of ecological applications and offering a conceptual framework for an integrative systemic approach to trauma (ISAT) model. The focus of these five chapters is on the critical juncture between the personhood of the clinicians and their professional conduct; collaborative work refers to the interconnection of ethical behavior, acute self-awareness and self-reflection, responsible supervision, and advocacy for a systemic approach that brings all of these collaborative endeavors back to the best interests of clients who have experienced traumatic events. The six sections of this book are interrelated in many ways. First, the various sections underscore the pervasiveness of traumatic experiences across societies, in general,

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and specifically within mental health populations. Second, the authors of each of the chapters attest to the ultimate importance of therapists being able to recognize the effects of trauma in their clients and knowing how to assess and treat victims of trauma, crisis, and disaster events. Third, the connections between individual experiences of trauma and larger contextual issues are highlighted. Finally, bearing clinical witness to the lived experiences of trauma survivors is emphasized across the sections of this textbook as part of a larger systemic process. We need to view clients who have been affected by traumatic events as whole people, we need to acknowledge our own roles and responses in the therapeutic relationship, and we need to engage the contextual and systemic aspects of trauma work if we are going to assist our clients in healing and growing. Trauma Counseling: Theories and Interventions is a textbook that aims to provide a basis for doing this important work.

Acknowledgments

To my mother, Gloria Isabella Lopez Levers: “Salud!”

I wish to acknowledge the unwavering support of my dear friends: Mogakolodi Nelson Boikanyo, Sarah Castelli, Jo Ann Jankoski, Carole Justice, Helen Manich, Ngwakwana Malema, Emma Mosley, and Cynthia Diane Rudick. Thank you.

I also want to thank Donovan Jackson and his little brother Darron for the daily smiles, laughter, and hugs that kept me going.

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Section 1: Trauma and Context CHAPTER 1

An Introduction to Counseling Survivors of Trauma: Beginning to Understand the Context of Trauma LISA LOPEZ LEVERS

INTRODUCTION The world can be a violent and dangerous place, thus making people vulnerable to all sorts of traumatic experiences. Emotional trauma typically is viewed as inflicting severe harm to a person’s psyche. Traumatic events can have profound effects on the individuals who experience them, and the impact of such stressful events or circumstances usually results in people feeling overwhelmed, vulnerable, betrayed, helpless, frightened, and alone. The influences of trauma may manifest in many ways; some may be unique to the individual, whereas others appear to be more culture based, and yet others may be relatively universal. Some traumatic experiences are so unspeakable that victims go without verbalizing the cruelty or assault inflicted upon them. The symptoms of trauma, as clinically defined by the psychiatric profession at the current time, represent only one dimension of the lived experience of trauma. There are many ways that people experience and live through traumatic events. This textbook aims to explore these variations in a way that can help social science and human services students and clinicians to understand trauma from a systemic and contextual perspective and to learn about the best practices associated with trauma counseling. Traumatic events can cause not only physical and psychological wounds, but deep spiritual or existential wounds as well. For many victims, the notion of reliving the trauma is agonizingly unthinkable; yet, with great courage, many come forward, seeking trauma counseling. The request for trauma counseling also serves as a request to engage in what needs to be a healing journey for the client. By definition, then, for therapists working with traumatized clients, trauma counseling inherently involves a focus on the client’s healing process and a holistic view of the person. In order to understand the whole person who has experienced trauma, clinicians need to grapple with the ubiquity and the ugliness of traumatic events as well as to engage with the complexity of traumaassociated responses. The aftermath of a traumatic event is profoundly personal; at the same time, the lives of individuals intricately intersect with the lives of other people and also with pets, places, time, social institutions, and cultural systems. So, many treatment questions emerge concerning trauma, and the answer frequently is, “it depends.” It depends on the developmental stage at the time of the trauma event; it depends on whether the trauma event was of a personal nature or a large-scale disaster; if personal, it depends on whether the perpetrator was a trusted family member/friend or a stranger; it depends on the extent of the person’s support system; it depends on gender

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Trauma and Context

and cultural perspectives; it depends on numerous variables that are not always evident immediately. For these reasons, and precisely because so much about working with a trauma victim depends on the person’s circumstances, this book offers a comprehensive view of trauma and disaster events, one that is situated within a systemic understanding of the whole person. Of necessity, once a survivor of trauma seeks counseling, this person’s support system extends to the therapeutic milieu, thereby including the therapist, clinical supervisors, the treating agency, and any larger arenas of the treatment system. Survivors of trauma need the clinical world to be more aligned and harmonized in this matter. Once we make the decision to work with traumatized clients, we owe them this level of respect. This kind of integrative approach requires a holistic and systemic perspective of trauma; it requires looking at trauma through a particular contextual lens. I intend for this first chapter to offer such a lens, one that enables the reader to begin to understand the impact of traumatic experience from multiple personal and systemic perspectives. The purpose of this chapter is to ground the construct of psychosocial trauma within its various phenomenological, clinical, and sociocultural contexts. My aim is to have crafted this in a way that enables readers to see readily and to understand clearly the connections between the personal and the systemic impacts of trauma. I hope that this is accomplished through the discussion of relevant contextual issues in the following sections: (a) Context for Thinking About Trauma, (b) Defining Trauma, and (c) Counseling Implications. These sections are followed by a brief summary of the chapter and relevant resources for instructors, students, and clinicians.

CONTEXT FOR THINKING ABOUT TRAUMA Since the earliest days of psychoanalysis in the late 19th century, professional discussions about the construct of trauma have been fraught with controversy. Even Sigmund Freud recanted some of the trauma-related parts of his theory in response to the furor that it caused in affluent Viennese society. Whereas the historical details and nuances are important, as they relate to how the international psychotherapeutic establishment has come to comprehend and deal with issues of trauma, before turning to a historical understanding of trauma in Chapter 2 of this text, it is essential, in this chapter, to address the variety of meanings, controversies, and contexts associated with the discourse on trauma. Clinicians from the various helping disciplines—professional counselors, psychiatric nurses, psychiatrists, psychologists, social workers, and other behavioral scientists, along with religious helpers and other spiritual guides—have recognized the profound impact that traumatic experiences can have on individuals’ psyches, and this has been ongoing, long before the more or less recent wave of related research and theory building of the last couple of decades. Psychotherapists working with trauma survivors have realized that the resulting effects of trauma range from acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and other serious psychopathological responses, to existential crises, to posttraumatic growth. Those working in the field have learned from clients that the causes of trauma differ widely and include interpersonal violence, sexual assault, physical maltreatment, political- or community-scale violence, war, various crisis situations, large-scale disasters, and witnessing or vicariously experiencing any of these. Yet controversies continue to abound concerning the etiology, diagnosis, and treatment of trauma-related sequelae and disorders. Some of these controversies relate directly to systemic failures that impede rather than assist traumatized people in acquiring access to needed help. In many ways, the

An Introduction to Counseling Survivors of Trauma

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controversies may reflect an elementary psychodynamic about helping professionals and about the very nature of trauma. It may be much easier to intellectualize about abstract diagnostic constructs than to grasp and to engage with the perverse reality of a parent raping or sodomizing his or her child or of a child soldier who has been trained to kill his immediate family and his neighbors. Offering counseling to survivors of trauma can be emotionally intense work and thus requires a strong self-reflective orientation. Some clinicians may feel that they are bearing witness to evil, whereas others elect to refer traumatized clients elsewhere. Understanding the effects of traumatic events is a complex endeavor. Trauma affects people on multiple levels, including in the most intimately personal, as well as in relational, social, and cultural ways. Examining some of the various theories of human development can offer a base upon which to build understandings concerning the effects of trauma. For this reason, I believe that it is helpful to revisit briefly some of the relevant models of human growth and development before moving on to trauma theory. In this section, I focus on relevant issues of life span development and the importance of a bioecological perspective, thus providing the background for the next section of this chapter on defining trauma.

Life Span Development Numerous theories and models exist to help us in understanding how people grow and develop across the life span. Several relevant psychological models have influenced our knowledge of human development and motivation, including Maslow’s hierarchy of needs and the developmental theories of Freud, Erikson, and Piaget. However, although these theories are necessary to our understanding, they are not sufficient in addressing the concerns of individuals who have been traumatized. They do not lay out an adequate foundation for grappling with some of the fundamental questions of development, especially child development, as these concern traumatic experiences, for example: How does a traumatic event or ongoing trauma interrupt or delay developmental tasks? What developmental trajectories might we expect when abnormal events occur in the lives of ordinary people? How do these alternative developmental trajectories reflect individuals’ environmental conditions, especially concerning relative levels of risk, security, and attachment? In spite of their inadequacy to answer questions of trauma fully, these models offer important background information and are discussed briefly in the following text.

Maslow Although more of a motivational theory, Maslow’s (1998) widely recognized model has some utility in considering certain aspects of trauma. The model has posited that the categorical needs of human beings are hierarchical; these needs are represented in the figure of a pyramid (see Figure 1.1). The base of the pyramid represents physiological needs, those involving such basic necessities as food, water, and shelter. The rungs of the pyramid, in ascending order above physiological needs include the following: safety needs, composed of such features as security, law, order, and stability; love and belonging, composed of such elements as affiliation and friendships; esteem, composed of such attributes as confidence, respect, and status; and, at the very top of the pyramid, self-actualization, or the ability to realize one’s full potential. It is important to note that each of these need levels can be interrupted and affected by violent or traumatic events. One practice limitation of this model is that it often is engaged by professionals at the esteem level, without much consideration of the important foundational needs

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Figure 1.1 Maslow’s Hierarchy of Needs

Self Actualization personal growth and fulfillment, realization of potential

Esteem achievement, respect, responsibility, status

Love and Belonging family, affection, friendship, affiliation

Safety Needs physical and emotional security, stability, order

Physiological Needs health, shelter, food, water

The data for the diagram are based on Hierarchy of Needs from “A Theory of Human Motivation,” in Motivation and Personality, (2nd ed.) by A. H. Maslow. Copyright 1970 by Abraham H. Maslow. Copyright 1991 by Wm. C. Brown Publishers. Adapted with permission.

at the base of the model. An example of this would be a school counselor or a school psychologist who focuses on a child’s self-esteem without understanding that the child might have walked to school from a local domestic violence shelter where his or her mother sought safety the night before, or that the child might not have had dinner the night before or breakfast that morning. The child potentially would have difficulty focusing on self-esteem issues when more basic and immediate needs have not been addressed. This model is one that offers necessary constructs about basic needs, but it is not sufficient in explaining the needs of at-risk individuals or those who have experienced a traumatic event.

Freud, Erikson, and Piaget Important pioneers in theories of human development, Freud, Erikson, and Piaget have presented their developmental theories as stage models. A comparison of these stages can be seen in Table 1.1.

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An Introduction to Counseling Survivors of Trauma

Table 1.1 Comparison of Freud, Erikson, and Piaget’s Stage Theories Stages (Approximate Age Ranges)

Freud

Erikson

Piaget

Infancy (birth to around 18 months)

Oral

Trust vs. mistrust

Sensorimotor period

18 months to 3 years

Anal

Autonomy vs. shame and doubt

Preoperational thought

3–5 years

Phallic

Initiative vs. guilt

6–12 years

Latency

Industry vs. inferiority

Concrete operations

12–18 years

Genital

Identity vs. role confusion

Formal operations

Young adulthood (around 19–40 years)

Intimacy vs. isolation

Middle adulthood (40–65 years)

Generativity vs. stagnation

Maturity (65 years to death)

Integrity vs. despair

The information in this table is drawn from the work of Freud, Erikson, and Piaget.

Freud’s theory of psychosexual development includes five sequential stages: oral, anal, phallic, latency, and genital. However, these stages, like much of Freudian theory, long have been criticized for many reasons. For our purposes in this chapter, it suffices to say that beyond noting their historical importance, these stages tend to be less relevant to the contemporary discourse on developmental issues, at least outside of a psychoanalytic context. Influenced by Freud, Erikson’s sequential eight-stage developmental theory has involved the completion of stage-specific tasks and resulting alternative consequences or crises when these tasks are not completed in stage-salient ways. Although Erikson’s model was designed with the healthy individual in mind, it is helpful to see, especially in the initial stages, how early childhood maltreatment potentially can establish pathways of development that may deviate from a healthy norm and even initiate a developmental trajectory eventually marked by developmental psychopathology. For example, let us consider the case of a child who is so severely abused or neglected during the first year of life that this child is not able to engage in a trusting relationship with a primary caregiver. Instead, the child learns to mistrust the world around him or her. This has serious implications for the child’s developmental pathway, from both psychological and biological perspectives, as well as for attachment issues, at the time and in the future (child and adolescent attachment issues are discussed more fully in Chapters 8 and 9 of this book). Piaget’s sequential sensorimotor and operational periods have relevance to physical and neurocognitive development; in fact, as we have continued to learn more about brain function (National Research Council and Institute of Medicine, 2000), it becomes clearer how early childhood deprivation and maltreatment can affect the developing child (neurological issues related to trauma are discussed in Chapters 4 and 10 of this book). Some may argue that such age- or stage-dependent theories are somewhat deterministic and reductionist. Far too often, purely psychological approaches may ignore other factors in the environment and may place the onus of developmental deviations on the individual. For these reasons, I argue that these

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historically important theories allow us to understand necessary information about individuals, but that they are not sufficient in helping us to understand the full needs of trauma survivors. Additional models. Purely mechanistic models do little to assist our understanding of peoples’ lived experiences and worldviews. So in contrast to the aforementioned more linear and more or less purely psychological models, other theoretical models, which also have influenced our understanding, perhaps better account for individuals’ worldviews and their interface with social influences. These theories include Bowlby’s (1969/1982, 1973, 1980, 1988) attachment theory, Bandura’s (1977) social learning theory, and Vygotsky’s (1978, 1986, 1997) social development theory. It is not my purpose in this chapter to analyze the corpus of these works; rather, I raise these pertinent and pervasive theories of human development and social learning to remind us of concepts that are necessary in understanding human development but perhaps not sufficient for understanding the impact of traumatic events on the developing and growing individual. Just as Lerner (2002) has emphasized the centrality of the nature versus nurture (genetic vs. environmental/contextual influences) discourse along with the interplay of continuity and discontinuity dynamics throughout the life span, I turn the conversation to a more ecological perspective.

Toward a Bioecological Perspective Uri Bronfenbrenner (1979, 1981, 1994) has offered an elegant model for understanding the comprehensive influence of multiple systems on children’s development. Simply put, ontogenic (individual) development is nested within larger systems that affect the person’s development (see Figure 1.2). From proximal (closer) to distal (at a greater distance), these systemic influences include the microsystem (immediate family environment), the mesosystem (situations in which two or more microsystems come together to have some effect on the individual’s life), the exosystem (community and neighborhood), the macrosystem (broad cultural values and beliefs), and the chronosystem (denoting sociohistorical time as well as the real-time personal events and developmental transitions in an individual’s life since birth). Environmental factors, along with genetic predispositions, influence the child, and continual reciprocal transactions within the environment, or ecology, determine risk and protective factors. After the initial development of his ecological model, Bronfenbrenner later renamed the model, changing it from the former ecological model to the more newly termed bioecological model, thus reemphasizing the interactions between heredity and environment. Most contemporary theories of development have acknowledged the roles of both heredity and environment, and many have suggested the importance of a systemic perspective. Lerner’s (2002, 2006) notion of developmental contextualism, for example, has offered a framework for integrating important developmental theories and beginning to arrive at a developmental systems theory. The literature on developmental psychopathology (e.g., Belsky, 1993; Cicchetti & Lynch, 1993, 1995; Cicchetti & Toth, 1995) has provided a developmental–ecological framework for understanding the profound interplay between normal development and abnormal events, especially in the form of child maltreatment. Developmental psychopathology has emphasized the role of attachment in children’s lives (Belsky, Spritz, & Crnic, 1996), seeking to assess connections between the quality of attachment and the impact of maltreatment. This perspective has offered a baseline for comprehending the effects of chronic violence on children—and by extension, some of the trauma-related sequelae of adults who experienced severe maltreatment in early childhood. Developmental psychopathology has

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An Introduction to Counseling Survivors of Trauma

FIGURE 1.2 Bronfenbrenner’s Bioecological Model of Human Development Macrosystem

rs bo

Ex ten d

m, Social Institutio al Syste n s, S olitic ocia P , s c l Va i s y t s e m m Exo lu e no o s c E y s s o t s e e m y l M i m Ne Fa ig h ed Microsystem Family

School The Individual

So

lS

Neighborhood er

v ic

di

c

ia

Peers

a

Religion

M

es

s as

M

e

Chronosystem Passage of Time

served as a rich mechanism for examining the risk factors, as well as the compensatory or protective factors, which exist across the multiple and interactive environments in which we all live (e.g., Garmezy, 1993). From this theoretical paradigm, Cicchetti and Lynch (1993) have detailed a related ecological–transactional model that offers an avenue for understanding, in a comprehensive way, the influence of multiple factors—at multiple levels—on children’s development. Such an articulation of the transactional nature of development is paramount to understanding the complex, sometimes paradoxical, effects of maltreatment on children at multiple systemic levels. An understanding of the bioecological model, its transactional and systemic nature, and the role of attachment across the life span is an essential aspect of understanding the impact of trauma. An ecological–transactional perspective allows us to situate the lived experiences of traumatized persons within the time and space of a relevant ecology in order to understand the trauma event as well as personal meaning making. Lynch and Levers (2007) have suggested the compatibility of ecological, transactional, and motivational perspectives in applying developmental theories to trauma counseling (relevant theoretical constructs are discussed in Chapter 3 of this book).

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DEFINING TRAUMA Beginning to define trauma and its psychological effects is a daunting task. The effects of traumatic events are complex, reflecting the intricacy of the human beings who are exposed to trauma. Traumatic events involve objective or factual situations, and DSMrelated criteria attempt to quantify symptoms in an objective fashion. However, the way in which people experience traumatic events is highly subjective, and trauma theories must allow for the reality that people construct personal meanings from their traumatic experiences. Current theories about trauma offer a framework for understanding the various types of trauma, such as simple versus complex, and the different ways in which people respond, such as being completely overwhelmed and stuck there versus making meaning of the trauma in a way that eventually may produce growth and transformation. Although many discussions of PTSD appear in the chapters that follow in this textbook, the diagnostic category of PTSD is only one facet of defining trauma. Laurence J. Kirmayer (2007), MD, James McGill professor and director of the Division of Social and Transcultural Psychiatry at McGill University, offers the following comment regarding PTSD: Diagnostic constructs also work as metaphors, both in terms of their explicit use as conceptual models and their implicit connotations as labels that affect social relations between people. The construct of PTSD, which has dominated discussions of the treatment of trauma in recent years, emphasizes the enduring effects of fear conditioning on subsequent adjustment and response to later stressors. But PTSD is a limited construct that captures only part of the impact of violence, ignoring issues of loss, injustice, meaning and identity that may be of greater concern to traumatized individuals and the their families and children or later generations. (p. vi) The various discussions in this textbook acknowledge PTSD as an important but limited construct. Indeed, as explicated in Chapter 2, the history of the Diagnostic and Statistical Manual of Mental Disorders illustrates the extent to which the notion of PTSD is socially constructed and ever changing, even within the psychiatric model. One powerful tool in understanding the effects of trauma is through interdisciplinary means. For example, during my initial exposure to clinical trauma narratives early in my career as a young counselor, I recall thinking about the cubist paintings that I had seen in European museums, perceiving the trauma experience through the disciplinary lens of my undergraduate work in literature and art history. Focusing on the deconstructed images in the Cubist paintings, like those of Picasso, for example, assisted me to comprehend, even in a limited fashion, the fragmentation that traumatized clients had experienced and tried to share with me. Psychiatry and psychology are not the only professional fields of endeavor that enhance understandings of trauma; rather, not only do other social and behavioral sciences focus on issues of trauma, for example, counseling, sociology, social work, anthropology, nursing, and other allied health professions, but those pursuits involving the arts and humanities and fields such as technology and journalism also contribute to illuminating the effects of trauma (see Appendix 1.1). In this section, I emphasize some of the multiple facets of how people experience trauma through the following discussions: trauma as a clinical issue; the phenomenology of trauma; trauma as a systemic issue; and the intersection of constructs related to stress, crisis, disaster, and trauma.

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Trauma as a Clinical Issue The word “trauma” has been popularized and often is used to indicate almost any stressor experienced by an individual. However, in its clinical sense, trauma refers to events that are extremely difficult and overwhelming for individuals (Briere & Scott, 2006). One might think that turning to the official nosology of the profession would provide a clear definition of the clinical sense of trauma; however, this would not be an entirely accurate assumption. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) specifies two trauma-specific diagnostic categories: PTSD and ASD; these are classified within the Anxiety Disorder category. Although it is not unusual for someone with PTSD also to experience dissociation or depersonalization, such symptoms are classified separately, within the Dissociative Disorders category. A constellation of other symptoms (e.g., self-destructive and impulse-control behaviors, somatic complaints, and hostility, to name a few), which may be associated with trauma, also are categorized separately with other disorders. Comorbidity of PTSD with other DSM diagnoses is discussed in further detail in Chapter 2 of this book, but in the DSM-IV-TR, the American Psychiatric Association (APA, 2000) emphasizes this very point in the following passage: Posttraumatic Stress Disorder is associated with increased rates of Major Depressive Disorder, Substance-Related Disorders, Panic Disorder, Agoraphobia, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Social Phobia, Specific Phobia, and Bipolar Disorder. These disorders can either precede, follow, or emerge concurrently with the onset of Posttraumatic Stress Disorder. (p. 465; Extracts reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [Copyright ©2000]. American Psychiatric Association.) Thus, differentiating the diagnostic classifications associated with trauma, especially PTSD, can be difficult, especially for the new or inexperienced clinician. The importance of accurate assessment, discussed in Chapter 27 of this book, cannot be underscored enough. In the DSM-IV-TR, the APA (2000) characterizes the core features or criteria of PTSD in the following way: The essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1). The person’s response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and persistent symptoms of increased arousal (Criterion D). The full symptom picture must be present for more than 1 month (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). (p. 463)

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The major differentiation between ASD and PTSD is that “the essential feature of Acute Stress Disorder is the development of characteristic anxiety, dissociative, and other symptoms that occurs within 1 month after exposure to an extreme traumatic stressor” (APA, 2000, p. 469). The history of the psychiatric and psychological diagnosis and treatment of trauma, as well as its codification in the DSMs, has been fraught with controversy and a lack of professional agreement. For example, in a correspondence to the The British Journal of Psychiatry, the Royal College of Psychiatrists’ flagship journal, Miller, Resnick, and Keane (2009) argue that PTSD has a distinct phenomenology and point to data that “raise concern about conceptualising PTSD simply as the manifestation of a vulnerability to anxiety-related psychopathology” (p. 90). According to some (e.g., Friedman, Keane, & Resnick, 2007), in the last couple of decades, even though progress has been gained in the area of PTSD, there also have been numerous challenges. Criticisms of current DSM codifications have led to increasingly greater discourse surrounding the rationale for including a trauma spectrum disorders category in the DSM (e.g., Moreau & Zisook, 2002; Scaer, 2005) as well as the need for a complex trauma classification (e.g., Briere & Scott, 2006; Courtois, 2004; Herman, 1992/1997). Given US involvement in recent war situations over the past decade, the issue of trauma spectrum disorders has continued to gain even more attention in America (e.g., O’Donnell, Begg, Lipson, & Elvander, 2011). Many have advocated for differentiating between PTSD and complex PTSD (a discussion of complex trauma is found in Chapter 2 of this book). According to a DSM-V-related American Psychiatric Association (APA; 2010) website, the architects of the DSM-V (anticipated for publication in May 2013) intend to implement a separate Trauma- and Stressor-Related Disorders category. However, although of interest, perhaps of equal concern to most clinicians as the diagnostic categories associated with trauma is the phenomenology of trauma and its clinical manifestation among clients who seek assistance in dealing with the aftermath of traumatic events.

Phenomenology of Trauma People’s lived experiences of traumatic events are highly personal and subjective; and at the same time, some of the phenomena associated with trauma are fairly consistent, across cultures and from person to person. Some of the issues related to the core experience of trauma and to trauma as an existential issue of suffering are explored briefly in the following text.

Core Experience of Trauma In her landmark book, Trauma and Recovery, Judith Lewis Herman, MD (1992/1997) has identified the core experiences of trauma as terror and disconnection. Stating that “psychological trauma is an affliction of the powerless. . . . [in which] the victim is rendered helpless by overwhelming force” (p. 33), Herman has qualified the experience of terror as one of disempowerment, helplessness, and abandonment; she has cast disconnection in similar terms as Courtois (1988, 2004), that is, as shattered trust. When an individual has experienced a traumatic event, the person’s worldview and the very foundation of his or her being can be shaken or crushed, what Stolorow, Atwood, and Orange (2002) have framed as “the shattering of an experiential world” (p. 123). Herman has noted that “traumatic events call into question basic human relationships” (p. 51); victims of trauma may experience disconnection from loved ones or other significant people in their lives, as well as a sense of separation from self.

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Hyperarousal is an initial major symptom of trauma, what Herman (1992/1997) has described as a “permanent alert, as if the danger might return at any moment” (p. 35). This startle response is relatively easy for most clinicians to recognize. Herman further has described the additional two sets of PTSD symptoms: those that are intrusive and those that are constrictive. Symptoms of intrusion include those readily associated with PTSD, such as “reliving” the trauma through flashbacks and nightmares; symptoms of constriction include some that are less likely to be attributed as quickly to PTSD, such as depression, numbing, and a detached state. One of the most important aspects of Herman’s work has been her recognition of what she has termed “the dialectic of trauma” (p. 47). In the absence of appropriate intervention, when a victim of trauma develops PTSD and the condition goes untreated, the person eventually may begin to vacillate between symptom sets; the dialectic of trauma is represented by this cycling, back and forth, from intrusive symptoms to constrictive symptoms. It is easy to see, especially if a history of trauma has not been documented adequately, how observing a client who is presenting with either set of symptoms could receive an inaccurate diagnosis. At surface, someone exhibiting intrusive symptoms might appear agitated and anxious, and someone exhibiting constrictive symptoms might appear depressed. Therefore, it is extremely important for clinicians who are working with trauma survivors to ask about trauma history and to recognize this dialectic in order to avoid misdiagnosis. Stolorow (2007) has stated that one theme of trauma is that it “is built into the basic constitution of human existence” (p. xii). Such a phenomenological perspective of trauma is essential in understanding others’ lived experiences of trauma as well as in enabling counselors in helping survivors to recover and heal. Herman (1992/1997) has articulated a stage-wise recovery process aimed at addressing the core experiences of trauma. She has detailed the clinical work that needs to take place in each of the following phases: (a) establishing safety, (b) reconstructing the trauma story, and (c) reconnecting with ordinary life. This recovery process corresponds to phenomenological aspects of trauma and assumes the potential for an existential transformation from victim to survivor. In addition, Herman’s model illuminates the need for therapists to be highly intentional in their clinical work with survivors of trauma.

Suffering as an Existential Component of Trauma When people are subjected to the most adverse of human situations, they naturally experience psychic pain and suffering. Miller (2004) has posited that most people seek psychotherapy to relieve suffering and are therefore not focused on the clinical aspects of symptomatology, asserting that the science of psychology has long ignored this aspect of the therapeutic encounter. Daneault et al. (2004) have asserted that a major mandate of medicine—and by extension, psychiatry and other psychological practices—is the relief of suffering. Yet very little analysis of the construct of suffering has existed in the professional literature (Makselon, 1998). A core consequence of all types of trauma, crisis, and disaster events is human suffering. Mental, emotional, existential, and physical suffering can affect people in a variety of negative ways, including personality changes, health status, and the ability to function on multiple levels. The connection between suffering and illness—illness defined as an ethnomedical concept, relative to cultural construction—is profound and calls for existential and multicultural approaches (Levers, 2006a, 2006b). Suffering also can affect people positively, in the long run; the connection between suffering and transformation has been the subject matter of theological and philosophical discourses for centuries. Although a lacuna exists in the contemporary scientific literature regarding

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a psychology of suffering, the theoretical and existential basis for this discourse exists, for example, among such notable scholars as Bruner (1990), Frankl (1959), Fromm (1947), and May (1992). Understanding the nature and the phenomenology of human suffering can assist clinicians in defining the subjective meaning making of trauma survivors, thereby guiding the quality of client-informed interventions. This process is central to the transformation from being a victim to being a survivor and is a profound step toward recovery.

Trauma as a Systemic Issue Although the clinical features and phenomenological aspects of trauma involve victims at the individual level, there are at least three areas of potential systemic impact. First, groups of people may simultaneously experience the same natural disaster, accident, or human-made catastrophe; many of them may develop trauma-related symptoms. Second, when groups of people are affected by a traumatic event or a disaster, there is usually a coordinated reaction by an official system of responders. Third, even when a traumatic event only involves an individual, as explained previously in the bioecological model, the person is nested within and potentially affected by any or all other systems at the microsystemic, mesosystemic, exosystemic, macrosystemic, and chronosystemic levels. The implications for how a victim or survivor of trauma may be able to navigate these various systems and for how systemic responses to crisis, disaster, and trauma events adequately help or fail to help victims are too numerous for a full discussion in this chapter. However, some of the systemic features of trauma are next explored briefly in terms of their cultural, public health, social justice, and pedagogical dimensions.

Cultural Dimensions of Trauma Just as cultural assumptions have been made across mental health theories and practices, culture profoundly shapes peoples’ experiences of trauma, along with molding the rites and rituals of grief and suffering that enable the expression of trauma (Drožd¯ek, 2007b). Locating trauma—and by extension, PTSD—in a global context raises transnational issues. As Breslau (2004) has suggested, “. . . problems [are] generated when the process of defining the disorder is viewed simplistically as a matter of scientific technology rather than as a cultural practice in itself” (p. 121). Expressions of suffering and healing vary across cultures and arise from differing world views; for people outside of Western cultures, as well as for non-Western people who have immigrated to a Western country, an ethnomedical perspective may be useful (ethnomedicine is a subspecialty area of medical anthropology, focusing on indigenous paradigms of healing and cultural variations of constructs like illness and disease). Culture has informed the ways in which people make meaning of trauma, the rituals for expressing the impact of trauma, and the manner in which people are able to heal. For example, Castillo (1997) has asserted that “cultural schemas affect the subjective experience and expression of dissociation” (p. 219). Dissociation is but one symptomatic manifestation of trauma that offers a good example of cultural nuance. Dissociation has been pathologized within Western biomedicine. Yet when examining non-Western paradigms of indigenous medicine or traditional healing, dissociation actually may play a proactive role in the transactions between client and healer (e.g., Comaroff, 1978, 1980, 1982; Kleinman, 1986; Levers & Maki, 1995; Moodley, 2005; Torrey, 1986; Turner, 1968) and also can offer adaptive mechanisms (Castillo, 1997) such as with the use of yoga, hypnosis, tai chi, mindfulness, and other focus-oriented techniques as part of the recovery process.

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Public Health Dimensions of Trauma Professionals working in the arena of traumatology increasingly have cited the effects of trauma on individuals as a public health issue (e.g., Drožd¯ek, 2007a; Musisi, 2004). A growing corpus of literature has highlighted the impact of early childhood adversity on later health across the life span (e.g., Felitti, 2002; Felitti et al., 1998; Lanius, Vertmetten, & Pain, 2010). Breslau (2004) has suggested that “epidemiological surveys have been an important vehicle for bringing PTSD into the global health arena” (p. 117). The rise of all types of technology has increased the capacity for more violence on broader scales; communication technology has increased the potential for members of the public to witness acts of violence, immediately, even when they are not present. The reality of amplified violence increasingly has become a part of the global discourse on trauma (e.g., Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002; Levers, 2012; Levers, Magweva, & Mpofu 2007). Some analysts even have concluded that the issue of trauma has been exploited for political and economic reasons; in her exploration of associated challenges, James (2004) has introduced the notion of a trauma portfolio, a kind of hierarchical cataloging of events that have institutional currency.

Social Justice Dimensions of Trauma Geopolitical atrocities continue to occur internationally, even though the phrase “never again” has been repeated over and over in reference to events such as the enslavement of Africans, the near extinction of indigenous peoples in North America, the Jewish Holocaust, apartheid in South Africa, the Bosnian genocide, the Rwandan genocide— and now, again, in reference to the Democratic Republic of Congo and to Sudan. Circumstances like these have exposed people to such a degree of extreme cruelty and unspeakable horror that the ensuing trauma not only affects the individuals directly involved but can live on as transgenerational trauma. Trauma that continues across generations, also called historical trauma, (e.g., Alexander, 2004; Estrada, 2009; Sotero, 2006), has been discussed at greater length in Chapter 2 of this book. Both human-made and natural catastrophes can leave the poorest, the youngest, the oldest, and the weakest in highly vulnerable positions. The world has witnessed the devastation of the most vulnerable in recent instances such as Hurricane Katrina, earthquakes in Haiti and Japan, and so forth. Children (Lanius, Vertmetten, & Pain, 2010) and older adults (Bonnie & Wallace, 2003) have been exploited in many ways that can evoke trauma responses (issues associated with child and adolescent trauma are discussed in Chapters 8 and 9, and with elders in Chapter 12 of this book). Levers and Hyatt-Burkhart (2011) have questioned human rights violations associated with migration, for example, among Mexicans trying to enter the United States via Arizona, or Africans trying to enter Europe via Greece, and asserted that these can have a traumatic effect on the immigrants. Trauma-based issues that represent human rights violations need to be examined from a social justice perspective. The effects of a traumatic event can be intensified and worsened when the traumatized person also has cause to feel that he or she has been betrayed by the very social community that should be extending assistance. This was the palpable pain that was witnessed in living rooms across the country and around the world when victims of Hurricane Katrina were televised on the nightly news, corralled in the most unsanitary conditions and begging for water. Although trauma survivors whose rights have been violated need to be treated individually and to engage in a recovery process, the group aspect of a social justice perspective may require some type of restorative or reparative justice to take place. Restorative justice, which focuses on the needs of the victim rather than legal principles or the punishment of the offender, has

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been used, as one example, in the Gacaca courts in Rwanda, offering a format for reconciliation between victims and perpetrators in a situation where parties need to live together again in the same society (this aspect of the Rwandan genocide is discussed in greater detail in Chapter 23 of this book).

Pedagogical Dimensions of Trauma Opportunities for in-service and professional association trainings concerning all issues related to trauma have swelled during the last several decades. However, preservice clinical instruction, specifically related to the psychosocial impacts of trauma, has been less forthcoming, as has much focus on the clinical supervision of trauma-related cases, although there have been some recent attempts to redress this tremendous training gap. For example, the Council for the Accreditation of Counseling and Related Education Programs (CACREP, 2009) recently instituted the curricular requirement, for both the master’s level and doctoral training of professional counselors, that content related to the area of crises, disasters, and other trauma-causing events be included in the curriculum of accredited programs. Counseling, psychology, and social work programs gradually have been adding courses that deal with trauma and crisis issues, but little is known about pedagogical best practices and trauma. Simon and Eppert (1997); Simon, Rosenberg, and Eppert (2000); and Walcott (2000) have noted the existence of pedagogical problems and difficulties in teaching the matters that are associated with trauma. Obviously, care needs to be taken not to overwhelm or traumatize students in the process of helping them to understand the clinical dimensions of trauma. At the same time, educators concerned with trauma issues need to create opportunities for advancing relevant skill sets. Although adding courses that are specific to trauma, especially at the graduate level, is a necessity, embedding trauma-sensitive skills across the curriculum would go a long way in addressing the instructional gap. For example, working with survivors of trauma requires empathic engagement; this is a skill that typically is included in a basic techniques course and so presents an opportunity for illustrating the skill as one related to trauma as well as other mental health issues. So in addition to offering an adequate clinical knowledge base within a specialty trauma course, preservice programs could enhance the way they teach basic counseling skills across the curriculum to include issues of trauma.

Intersection of Constructs Related to Stress, Crisis, Disaster, and Trauma Issues associated with trauma constitute a major focus of this book. Crisis intervention and crisis theory are detailed in Chapter 19, and various types of disaster situations are examined in Chapters 20–26 of this book. Of relevance at this juncture are the nexus of constructs regarding stress, trauma, crisis, and disaster experiences and the importance of differentiating their varying characteristics (Yeager & Roberts, 2003). In the now classic The Stress of Life, Hans Selye, MD (1956/1978) was the first to talk about the impact of stress, both biologically and emotionally, on humans. Stress is a hormonally driven, therefore automatic, physiological state that occurs in response to situations that demand change. This state is not necessarily always negative—Selye also coined the term eustress, which implies the kind of “good” stress that can motivate an individual—but when people talk about being “stressed out,” the connotation usually relates to a negative state of tension or agitation. Even this kind of pressure is not necessarily a “bad” thing, as under precipitating circumstances, stress activates a primitive part of the brain to initiate the fight-or-flight response; stress is like the body’s instant messaging system for protecting us from danger. It is when danger has

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passed, and we are unable to “turn off” the stress response that the effects of prolonged stress can begin to take a toll on our bodies, including on important regulating systems like the endocrine and immune systems. Alternatively, sometimes when we are under extreme stress, instead of defaulting to the fight-or-flight response, our bodies instead go into a kind of freeze response, like a deer in the headlights; although not necessarily stressful, in and of itself, this type of inertia may replace the fight-or-flight response or even heighten the original danger. Although stress is a common feature of everyday life and has the same psychophysiological effects, whether real or imagined, unrelenting stress can be biologically and emotionally harmful. In this instance, a person may need to engage in stress management techniques and prevention activities to alleviate the pressure and tension. A crisis or disaster is usually a time of increased stress or danger. A crisis is an event or situation in which a person perceives a threat to be greater or more intolerable than his or her ability to cope with or assimilate the circumstances. A disaster is usually a sudden accident or a natural or human-made catastrophe that may or may not be perceived as a crisis or a trauma, depending on the individual. A traumatic event is typically so overwhelming that the victim experiences a sense of terror or helplessness. Not every stressor constitutes a crisis or a disaster, and not every crisis or disaster is traumatizing. However, a traumatic event typically involves extreme stress and some element of crisis. It is useful for every mental health professional to be equipped with basic stress management and crisis intervention skills. Several recent texts detail the skills necessary for crisis and disaster counseling (e.g., Cavaiola & Colford, 2011; Dass-Brailsford, 2010; Echterling, Presbury, & McKee, 2005; Greenstone & Leviton, 2011; Jackson-Cherry & Erford, 2010; Kanel, 2012; Roberts, 2005). These skill sets do not rely on long-term counseling as much as assisting clients to regulate their responses to extremely stressful or crisis-oriented situations or disasters; they require the counselor to attend to what needs to be done, in the most immediate sense. However, survivor responses to traumatic events, especially if the response is enduring enough to qualify as PTSD, usually require longer term counseling, and this suggests that the mental health professional have clinical preparation in delivering trauma counseling. Determining when a person’s sense of intense fear or horror, in response to an overwhelming event, moves from the stress of a crisis to a fully traumatic experience may rely on the clinician’s ability to combine two different sets of counseling skills: (a) active listening to the client’s narrative, and (b) keen assessment and diagnostic skills (Roberts, 2002). Developing both of these skill sets requires professional experience, but acquiring as much training as possible is also an essential factor.

COUNSELING IMPLICATIONS Several implications arise from the aforementioned overview of a contextual and systemic perspective of trauma. Perhaps a pertinent first implication is that the most effective approach to understanding trauma is one that engages multiple disciplines. Drožd¯ek (2007a) points to the importance of interdisciplinarity, from local to transnational trauma events and responses to these events. As discipline-based professionals, we can learn from our confederate colleagues of all disciplinary persuasions. A second implication relates to trauma therapists being adequately grounded in their understandings of the clinical and contextual factors associated with trauma. This is a double-edged issue of professional responsibility: (a) preservice training programs need to offer adequate instruction concerning the ubiquitous mental health issue of trauma, and (b) clinicians working in the arena of traumatology need to ensure that

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they have an adequate education, whether preservice or in-service training, to support their work with trauma survivors. Mental health professionals who work with survivors of trauma can provide more effective and culturally sensitive treatment when they conceptualize client concerns through the bioecological and transactional models described in this chapter. So a third implication is that these models offer an interdisciplinary format for understanding client risks, for engaging and enhancing existing protective factors, and for creating mechanisms that facilitate client recovery. A related fourth implication regards a systemic understanding of the impact of trauma. Because of the very personal nature of the usual traumatic event, along with the overwhelming intensity that is typical of any trauma situation, people who experience a traumatic event are affected profoundly in every area of their lives. To ignore the dynamics between individuals and the relevant systems that play essential roles in everyday living is really to ignore central features of the trauma situation. When clinicians first recognize trauma and begin to treat the client, this constitutes an ecological transition for the therapist, thus providing a strong reason for seeking clinical supervision, a fifth implication. Working with survivors of trauma entails intellectually demanding and emotionally charged scenarios, ones that require clinicians to maintain professionally appropriate boundaries. In addition to the central importance of boundaries, therapists working with traumatized clients need to be keenly aware of the potential for countertransference. The need for self-reflexive skills, for the ability to formulate intentional treatment strategies, and for unwavering attention to boundary and countertransference issues speaks to the essential importance of clinical supervision when working with trauma (see Chapter 33 of this book for a fuller discussion). Even highly experienced trauma counselors find clinical supervision helpful, and for more seasoned therapists, this can be conducted as peer supervision or even in trauma-informed learning groups that are developed by clinicians to support one another in this intense line of work. Therapeutic intentionality is an important sixth implication for counseling. For a long time, clinicians working in community settings that are not trauma or survivor specific (in the sense that rape crisis centers and domestic violence shelters attend particularly to traumatic events) have had tendencies to provide crisis intervention immediately to distressed or traumatized clients, perhaps without even recognizing the trauma per se; they then may refer these clients so that the trauma is likely to be caught so much later that there are additional and more complex sets of problems for the clients. This seems to constitute therapeutic defaults rather than intentional therapy. The mental health field has been defaulting on trauma, in this sense, for decades. In order to avoid systemic failures and to aspire toward best practices, the delivery of mental health services to trauma survivors needs to be trauma informed (trauma-informed care is discussed in Chapter 28 of this book), to be offered from a pluralistic professional perspective, and to advance strategies of care that are intentional rather than of a default nature.

CONCLUSION The construct of trauma has sparked controversies for well over a century, and we have arrived at multiple ways of perceiving trauma. This chapter has emphasized that the effects of a traumatic event are perhaps best understood from a multidisciplinary perspective, and that an awareness of the bioecological and transactional nature of life span development can assist therapists in dealing with the aftermath of clients’ traumatic experiences. The connection between the personal and the systemic has been highlighted.

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A clinician’s ability to understand the profound effects of a traumatic event on the psyche of a client goes well beyond codified clinical definitions and includes a phenomenological understanding of clients’ lived experiences of trauma. This chapter has identified some of the common criticisms of DSM categorizations of trauma-based diagnoses, particularly PTSD, as these have established the basis for contemporary arguments that favor the consideration of a complex trauma classification or a trauma spectrum disorders category. The intrusive and constrictive symptom sets of PTSD have been identified, and Herman’s (1992/1997) notion of a dialectic of trauma has been presented. In addition to defining trauma from a clinical perspective, insight has been derived from a contextual viewpoint, thereby enabling an examination of the cultural, public health, social justice, and pedagogical dimensions of trauma. This chapter also has reviewed constructs associated with stress, crisis, and disaster, exploring their nexus with relevant trauma issues. The counseling implications of this chapter’s contextual orientation toward trauma have been identified, emphasizing the need for adequate training and clinical supervision. Trauma has been viewed here as a complex human issue that requires informed and intentional personal and systemic responses.

APPENDIX 1.1 Trauma Journalism Deirdre Stoelzle Graves Trauma journalism is dangerous, emotionally challenging work. Covering earthquakes in Japan and Haiti, the shootings in Tucson, and all manner of tragedies and violence at home and abroad carries personal and professional risks. Founded in 2003 by a group of alumni fellows of the Dart Center for Journalism and Trauma, the nonprofit Dart Society provides direct outreach and information to journalists who cover the most difficult stories of our time. We undertake direct outreach missions and sponsor symposia to enable trauma journalists to share experiences and further the type of reporting that connects humanity. Through The Mimi Award, the Dart Society annually recognizes editors who are committed to helping journalists stay safe and sane, and who guide the reporting process to excellence. Our founder, psychiatrist Frank Ochberg, MD, calls our work a “ministry of presence”—being there for fellow members and colleagues who need us. We’ve worked alongside journalists rebuilding their neighborhoods and their lives after Katrina and 9/11, helped reporters and photographers struggling to make sense of community tragedy, most recently after the shootings in Tucson earlier this year. We also maintain contact with members and colleagues covering conflict and tragedy abroad—in the Caucasus, Africa and the Middle East, Afghanistan, Latin America, and Australasia. The Dart Society strives to be a paragon of nonprofit organizations, and we have the relationships with fellow journalism organizations, academic programs, trauma experts, and nonprofit professionals to ensure that this happens. Ochberg fellow Melissa Manware Treadaway, a former crime reporter at The Charlotte Observer, wrote the following about what the Dart community means to her: I care about the Dart Society because it is made up of people who think like I think, who see what I saw, who write what I wrote, who internalize their (continued)

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APPENDIX 1.1 (continued) stories—and who need likeminded people to support them. . . . This organization—the Dart Center and the Society—gave me a lot. And I think it’s my responsibility to give back. Journalists are different from the cops and the lawyers. We are different from the soldiers and the brass, the EMTs and the surgeons who save lives. We are not considered first responders like 9/11 rescuers, although we’re right there at the scene. Nor do we have the training of a psychiatrist or a soldier to know what to do when things get ugly. But we learned the hard way, ducking bullets, blood, and insanity to report the kinds of stories no one wants to read and no one wants to tell. What we do know is how other journalists feel when they witness the genocides in Rwanda and Bosnia, when they interview the parents of murdered schoolchildren or survivors of 9/11. We try to make sure, above all, that our fellow journalists know we have their backs when they’re on assignment, and that when they come back, we’ll be there for them— journalists helping journalists. We in the Dart Society have had the benefit of coaching from Frank Ochberg and his peers at the International Society of Traumatic Stress Studies; we know they have our backs as mentors. As the Dart Society begins to come into its own, we cement our mission: to provide outreach and support to journalists who cover violence, trauma, and social injustice. A former board member, Tina Croley, proposed the goal of a “Dart” in every newsroom. Being selected for the Ochberg Fellowship means you are a newsroom leader, a natural peer supporter, and as Frank says, an “indigenous rabbi.”

RESOURCES Websites Killbourne, J. (2006). Killing Us Softly 3 [Video file]. (http://video.google.com/videoplay?docid=-19933 68502337678412#) Killbourne, J. (2010). Killing us softly 4: Advertising’s image of women [Video file]. (http://www.youtube. com/watch?v=PTlmho_RovY) Substance Abuse and Mental Health Services Administration. (2011). Leading change: A plan for SAMHSA’s roles and actions 2011-2014. (http://store.samhsa.gov/product/SMA11-4629) Substance Abuse and Mental Health Services Administration. (2011). Trauma and justice. (http://www. samhsa.gov/traumaJustice/) Trauma Information Pages. (n. d.) Trauma support. (http://www.trauma-pages.com/support.php) Films and Videos Films for the Humanities & Sciences. (Producer). (2008). Zimbardo speaks: The Lucifer effect and the psychology of evil. [DVD]. Insight Media. (Producer). (1976). Everybody rides the carousel. [DVD]. Insight Media. (Producer). (2007). Maslow’s hierarchy of needs. [DVD]. Insight Media. (Producer). (2001). Aggression, bullying, and intimidation. [DVD]. Walt Disney Productions. (Producer). (1968). Understanding stresses and strains. [Video]. Zimbardo, P. G. (Producer). (2004). Quiet rage: The Stanford prison study. [Video].

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Courtois, C. A. (1988). Healing the incest wound: Adult survivors in therapy. New York, NY: W. W. Norton. Courtois, C. A. (2004). Complex trauma, complex reactions: Assessment and treatment. Psychotherapy: Theory, Research, Practice, Training, 41(4), 412–425. doi:10.1037/0033-3204.41.4.412 Daneault, S., Lussier, V., Mongeau, S., Paillé, P., Hudon, E., Dion, D., & Yelle, L. (2004). The nature of suffering and its relief in the terminally ill: A qualitative study. Journal of Palliative Care, 20 (1), 7–11. Dass-Brailsford, P. (Ed.). (2010). Crisis and disaster counseling: Lessons learned from hurricane Katrina and other disasters. Thousand Oaks, CA: Sage. Drožd¯ek, B. (2007a). Preface: Voices of trauma across cultures: Treatment of posttraumatic states in global perspective. In B. Drožd¯ek & J. P. Wilson (Eds.), Voices of trauma: Treating survivors across cultures (pp. 1–26). New York, NY: Springer Publishing. Drožd¯ek, B. (2007b). The rebirth of contextual thinking in psychotraumatology. In B. Drožd¯ek & J. P. Wilson (Eds.), Voices of trauma: Treating survivors across cultures (pp. 1–26). New York, NY: Springer Publishing. Echterling, L. G., Presbury, J. H., & McKee, J. E. (2005). Crisis intervention: Promoting resilience and resolution in troubled times. Upper Saddle River, NJ: Pearson/Merrill Prentice Hall. Estrada, A. L. (2009). Mexican Americans and historical trauma theory: A theoretical perspective. Journal of Ethnicity in Substance Abuse, 8 (3), 330–340. doi:10.1080/15332640903110500 Felitti, V. J. (2002). The relationship of adverse childhood experiences to adult health: Turning gold into lead. Retrieved from http://www.acestudy.org/files/Gold_into_Lead-_Germany1-02_c_Graphs.pdf Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14 (4), 245–258. Frankl, V. E. (1959). Man’s search for meaning: An introduction to logotherapy. Boston, MA: Beacon Press. Friedman, M. J., Keane, T. M., & Resnick, P. A. (2007). PTSD: Twenty-five years of progress and challenges. In M. J. Friedman, T. M. Keane, & P. A. Resnick (Eds.), Handbook of PTSD: Science and practice. New York, NY: Guildford Press. Fromm, E. (1947). Man for himself: An inquiry into the psychology of ethics. New York, NY: Henry Holt. Garmezy, N. (1993). Children in poverty: Resilience despite risk. Psychiatry, 56(1), 127–136. Greenstone, J. L., & Leviton, S. C. (2011). Elements of crisis intervention: Crises and how to respond to them (3rd ed.). Belmont, CA: Books/Cole. Herman, J. L. (1992/1997). Trauma and recovery. New York, NY: Basic Books. Jackson-Cherry, L. R., & Erford, B. T. (2010). Crisis intervention and prevention. Upper Saddle River, NJ: Pearson Education. James, E. C. (2004). The political economy of ‘trauma’ in Haiti in the democratic era of insecurity. Culture, Medicine and Psychiatry, 28 (2), 127–149; discussion 211–220. Kanel, K. (2012). A guide to crisis intervention (4th ed.). Belmont, CA: Books/Cole. Kirmayer, L. J., (2007). Forward. In B. Drožd¯ek & J. P. Wilson (Eds.), Voices of trauma: Treating psychological trauma across cultures (pp. v–vii). New York, NY: Springer Publishing. Kleinman, A. (1986). Social origins of distress and disease: Depression, neurasthenia, and pain in modern China. New Haven, CT: Yale University Press. Krug, É. G., Dahlberg, L. L., Mercy, J. A., Zwi, A. B., & Lozano, R. (Eds.). (2002). World report on violence and health. Geneva, Switzerland: World Health Organization. Retrieved from http://whqlibdoc. who.int/publications/2002/9241545615_eng.pdf Lanius, R. A., Vertmetten, E., & Pain, C. (2010). The impact of early life trauma on health and disease: The hidden epidemic. Cambridge, England: Cambridge University Press. Lerner, R. M. (2002). Concepts and theories of human development (3rd ed.). Mahwah, NJ: Erlbaum. Lerner, R. M. (2006). Developmental science, developmental systems, and contemporary theories of human development. In W. Damon & R. M. Lerner (Eds.), Handbook of child psychology (pp. 1–17). Wiley Online Library. Retrieved from http://media.johnwiley.com.au/product_data/ excerpt/84/04712728/0471272884.pdf Levers, L. L. (2012). Disability issues and the role of rehabilitation Counselors in a global context. In D. R. Maki & V. Tarvydas (Eds.), The professional practice of rehabilitation counseling: Formative perspective and features (pp. 163–188). New York, NY: Springer Publishing.

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Levers, L. L. (2006a). Samples of indigenous healing: The path of good medicine. International Journal of Disability, Development and Education, 53 (4), 479–488. Levers, L. L. (2006b). Traditional healing as indigenous knowledge: Its relevance to HIV/AIDS in southern Africa and the implications for counselors. Journal of Psychology in Africa, 16 (1), 87–100. Levers, L. L., & Hyatt-Burkhart, D. (2011). Immigration reform and the potential for psychosocial trauma: The missing link of lived human experience. Analyses of Social Issues and Public Policy. doi:10.1111/j.1530-2415.2011.01254.x Levers, L. L., Magweva, F. I., & Mpofu, E. (2007). A literature review of district health systems in east and southern Africa: Facilitators and barriers to participation in health. Retrieved from http://www. equinetafrica.org/bibl/docs/DIS40ehsLOPEZ.pdf Levers, L. L., & Maki, D. R. (1995). African indigenous healing, cosmology, and existential implications: Toward a philosophy of ethnorehabilitation. Rehabilitation Education, 9, 127–145. Lynch, M. F., & Levers, L. L. (2007). Ecological-transactional and motivational perspectives in counseling. In J. Gregoire & C. Jungers (Eds.), The counselor’s companion: What every beginning counselor needs to know (pp. 586–605). New York, NY: Lawrence Earlbaum Associates. Makselon, J. (1998). The psychology of suffering. Folia Medica Cracoviensia, 39 (3–4), 59–66. Maslow, A. H. (1998). Toward a psychology of being (3rd ed.). New York, NY: John Wiley & Sons. May, R. (1992). The cry for myth. New York, NY: Delta. Miller, R. B. (2004). Facing human suffering: Psychology and psychotherapy as moral engagement. Washington, DC: American Psychological Association. Miller, M. W., Resnick, P. A., and Keane, T. M. (2009). DSM-V: Should PTSD be in a class of its own? The British Journal of Psychiatry, 194 (1), 90. doi:10.1192/bjp.194.1.90 Moodley, R. (2005). Shamanic performances: Healing through magic and the supernatural. In R. Moodley & W. West (Eds.), Integrating traditional healing practices into counseling and psychotherapy (pp. 2–14). London, United Kingdom: Sage. Moreau, C., & Zisook, S. (2002). Rationale for a posttraumatic stress spectrum disorder. The Psychiatric Clinics of North America, 25(4), 775–790. Musisi, S. (2004). Mass trauma and mental health in Africa. African Health Sciences, 4 (2), 80–82. National Research Council and Institute of Medicine. (2000). From neurons to neighborhoods: The science of early childhood development. Committee on Integrating the Science of Early Childhood Development. In J. P. Shonkoff and D. A Phillips (Eds.), Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press. O’Donnell, L., Begg, L., Lipson, L., & Elvander, E. (2011). Trauma spectrum disorders: Emerging perspectives on the impact on military and veteran families. Journal of Loss and Trauma: International Perspectives on Stress & Coping, 16(3), 284–290. doi:10.1080/15325024.2010.519269 Roberts, A. R. (2002). Assessment, crisis intervention, and trauma treatment: The integrative ACT intervention model. Brief Treatment and Crisis Intervention, 2(1), 1–21. Roberts, A. R. (Ed.). (2005). Crisis intervention handbook: Assessment, treatment, and research (3rd ed.). Oxford, United Kingdom: Oxford University Press. Scaer, R. C. (2005). The trauma spectrum: Hidden wounds and human resiliency. New York, NY: W. W. Norton. Selye, H. (1956/1978). The stress of life. New York, NY: McGraw-Hill. Simon, R. I., & Eppert, C. (1997). Remembering obligation: Pedagogy and the witnessing of testimony of historical trauma. Canadian Journal of Education, 22(2), 175–191. Simon, R. I., Rosenberg, S., & Eppert, C. (2000). Between hope and despair: Pedagogy and the remembrance of historical trauma. Lanham, MD: Rowman & Littlefield. Sotero, M. M. (2006). A conceptual model of historical trauma: Implications for public health practice and research. Journal of Health Disparities Research and Practice, 1(1), 93–108. Retrieved from http:// ssrn.com/abstract=1350062 Stolorow, R. D. (2007). Trauma and human existence: Autobiographical, psychoanalytic, and philosophical reflections. New York, NY: Taylor & Francis Group. Stolorow, R. D., Atwood, G. E., & Orange, D. M. (2002). Worlds of experience: Interweaving philosophical and clinical dimensions in psychoanalysis. New York, NY: Basic Books.

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Torrey, E. F. (1986). Witchdoctors and psychiatrists: The common roots of psychotherapy and its future. New York, NY: Harper & Row. Turner, V. (1968). The drums of affliction: A study of religious processes among the Ndembu of Zambia. Oxford, United Kingdom: Clarendon Press. Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press. Vygotsky, L. S. (1986). Thought and language. In A. Kozulin (Ed. & Trans.). Cambridge, MA: MIT Press. Vygotsky, L. S. (1997). Educational psychology. Boca Raton, FL: St. Lucie Press. Walcott, R. (2000). Pedagogy and trauma: The middle passage, slavery, and the problems of Creolization. In R. I. Simon, S. Rosenberg, & C. Eppert (Eds.), Between hope and despair: Pedagogy and the remembrance of historical trauma (pp. 135–152). Lanham, MD: Rowman & Littlefield. Yeager, K. R., & Roberts, A. R. (2003). Differentiating among stress, acute stress disorder, crisis episodes, trauma, and PTSD: Paradigm and treatment goals. Brief Treatment and Crisis Intervention, 3 (1), 3–25.

CHAPTER 2

Historical Contexts of Trauma DEBRA HYATT-BURKHART AND LISA LOPEZ LEVERS

INTRODUCTION The types of lived experiences of trauma that result from human violence, medical crises, natural disasters, and other disruptive circumstances have had repeated histories that span millennia. Religious, literary, and artistic traditions have captured and represented this history, and contemporary media continue to replay the effects of trauma on a daily basis. Perhaps the first narrative of interpersonal violence is found in the account of the offspring of Adam and Eve. Cain killed his brother Abel, thus committing the first homicide, as recorded in the Old Testament as well as in the Holy Quran. Adam and Eve not only had to deal with the existential consequences of “the fall,” but two of their children set the stage for the primordial discourse on the traumatic effects of homicide. Modern archaeological discoveries have revealed early evidence of killing and warfare (Thorpe, 2003), and representations of trauma continue to be depicted in contemporary art (e.g., Pollock, 2009; Rapaport, 2002), film (e.g., Blake, 2008; Hirsch, 2004; Levers, 2001; Lowenstein, 2005), and literary discourses (e.g., Caruth, 1996; Stringer, 2009). The reality is that there always has been and, unfortunately, there most likely always will be perpetrators who prey on the vulnerable and natural disasters and accidents that decimate populations and dramatically alter the lives of individuals and families. In other words, the experience of trauma is a long-lived human dilemma, and in spite of everything that we have learned over the millennia, we continue to deal with the overwhelming consequences of trauma. The purpose of this chapter is to ground the construct of psychosocial trauma within its historical contexts. This is accomplished in the discussions in the sections that follow: Historical Contexts, Modernity and the Conceptualization of Trauma, Posttraumatic Stress Disorder (PTSD) and the Diagnostic and Statistical Manuals (DSMs), and Posttraumatic Growth. Following the discussions in these sections, counseling implications are identified, and the content of the chapter is summarized. The chapter concludes by offering helpful resources for instructors, students, and clinicians.

HISTORICAL CONTEXTS People have long recognized the profound psychological impact that trauma can have upon the psychological well-being of those who encounter it (Herman 1992; Sexton, 1999), but it has been only since 1980 that the formal diagnosis of the trauma-related disorder

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PTSD has been included in the DSM (American Psychiatric Association [APA], 1980). Acute stress disorder (ASD) was added to a later edition of the DSM (APA, 1994) in 1994. The presentation of a full history of the evolving perceptions and understandings of psychological trauma is not possible here, yet an understanding of the historical context is important. Contemporary understandings of trauma are perhaps more relevant than recapitulations of long-ago historical events, and we focus on this in the remaining sections of the chapter; however, we believe that a brief discussion of high-impact past events can be instructional. This discussion also forecasts important information detailed in other chapters in this volume, particularly those chapters that deal with gender- and age-related issues (Chapters 7, 11, and 12), scapegoating and “othering” (Chapter 16), racial and ethnic intolerance (Chapter 17), gender orientation (Chapter 18), and massive ethnic and political violence and genocide (Chapter 23). Discussion of historical events and the role of the scapegoat naturally leads to the discussion of a relatively new concept in traumatology, that of historical trauma. Therefore, the remaining parts of this section deal with these important issues.

The Role of Social Scapegoat as Victim Our perceptions about trauma are culturally and historically determined. Ancient societies, like modern ones, have been marked by the effects of interpersonal violence, social violence, warfare, and natural disaster. Although we could learn much from an examination of the Greek and Roman empires, along with non-Western civilizations, such a full historical examination is beyond the scope of this chapter. Although normative definitions of civilization tend to oppose violent practices and tend to endorse assisting others in times of disaster, we believe that historical events, over at least the last several centuries (spanning the dark/middle ages and the age of reason/enlightenment), have influenced how our contemporary psychiatric paradigm has come to conceptualize the impact of traumatic events on the human psyche. Psychosocial stressors and their aftermath often have led to the institutionalization and marginalization of those who have experienced trauma. Indeed, the history of institutionalizing people for medical and psychiatric reasons in Western society offers rich illustrations of scapegoating. In his book, Madness and Civilization: A History of Insanity in the Age of Reason, Michel Foucault (1973) traced the origins of the mental asylum in Western civilization to the leprosy epidemic in the middle ages. He illuminated how the number of leprosaria, the asylums in which lepers were institutionalized, grew in proportion to the number of cases of leprosy that were diagnosed. Foucault posited that as the need for the leprosaria declined, the centers originally built for the seclusion of lepers began to be filled with paupers, “incurables,” the “mentally ill,” and others perceived as socially deviant. Foucault (1973) suggested that although leprosy disappeared, the residential structures remained, and “. . . the formulas of exclusion would be repeated, strangely similar two or three centuries later. Poor vagabonds, criminals, and ‘deranged minds’ would take the part played by the leper” (p. 7). The “part” referenced by Foucault was the social role played by groups of people who have been marginalized; these disenfranchised persons have represented the social “other,” thereby enabling societal institutions to justify, in some cases, brutal treatment. Foucault outlined the history of the leprosaria, or lazar houses, as they came to be known, through their transformation to asylums for the “insane” throughout Western Europe; he cited this as the birth of the classical experience of “madness.” In the introduction to Foucault’s book, Jose Barchilon, MD, pointed out that “as leprosy vanished, in part because of segregation, a void was created and the moral values attached to the leper had to find another scapegoat” (Foucault, 1973, p. vi). Cast in a parallel fashion by Berger and Luckmann (1967) is an assertion of the institutional world as human

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construction, one that does not have “ontological status apart from the human activity that produced it” (pp. 60–61). Foucault also noted that, although it was common knowledge that in the 17th century large hospitals/houses of confinement were created, it was not commonly known that “more than one out of every hundred inhabitants of Paris found themselves confined there within several months” (p. 38). This legacy continued and gave birth to the “mental asylum”; even into the 20th century, “insane” people were placed into abhorrent conditions and exposed to horrendous treatments. Whereas Foucault (1973) offered an astute inquiry of the architectural confi nement of the scapegoat, Thomas Szasz (1970/1997) illustrated how the myth of “mental illness” has been manufactured by a society in need of a scapegoat, thus providing social sanction and cultural legitimacy to the persecution of certain people. In his book, The Manufacture of Madness, Szasz examined the powerful metaphoric constructions of “mental illness,” suggesting parallels between the Inquisition and some of the consequences of modern psychiatry. Szasz clearly delineated the persecution of witches, the persecution of Jewish people, and ultimately the persecution of people with psychiatric disorders as artifacts of the Inquisition. In doing so, he illuminated the ways in which multiple strands of human behavior, belief, or status can become encoded as violations of the ideology of those in power, and thus, those who maintain control. According to Szasz, the transformation of the role of social scapegoat to witches, heretics, Jews, and “the insane” paralleled the moralistic transformation of dogmas from religion to science: “The metamorphosis of the medieval into the modern mind entailed a vast ideological conversion from the perspective of theology to that of science. . . [and] the development of the concept of mental illness is best understood as part of this change” (p. 137). As the role of one social scapegoat declined, new scapegoats emerged (Thurston, 2007). The Inquisition, initiated by the politically powerful Roman Catholic Church in the 12th century, was aimed at the persecution of heretics. People were tortured and killed in gruesome ways during the centuries that spanned the Inquisition. Some groups of people were affected more than others, and this included the persecution of anyone thought to be a witch and anyone thought to be of Jewish ancestry. For the first time in history, in 1215, by decree of Pope Innocent III, Jews were ordered to wear yellow badges in order to identify themselves (Szasz, 1970/1997). The roots of anti-Semitism were embedded in European culture long before the expulsion of Jews from Spain in 1492 and long before the 20th century Holocaust. All sorts of misfortunes were blamed on witches and Jews, who were massacred for such events as epidemics and poor crops. During the Inquisition, witches—or at least those accused of witchcraft—also took on the role of societal scapegoat. Thousands, and by some estimates, hundreds of thousands of women, were executed throughout Europe from the 14th to the 17th centuries (Ehrenreich & English, 1973; Thurston, 2007). Pope Innocent VIII’s papal bull intended to systematize the persecution of witches. Implemented in 1486 with the infamous manual for witch-hunters, the Malleus Maleficarum (The Hammer of Witches), the manual detailed how to identify the so-called witches and prescribed ensuing treatments of heinous and unspeakable natures. Not surprisingly, the publication was followed by an “epidemic” of witchcraft (Szasz, 1970/1997). Szasz explained that the incidence of witches increased, as the authorities charged with their suppression covertly demanded that it should; and a corresponding increase of interest in methods aimed at combating witchcraft developed. For centuries the Church struggled to maintain its dominant role in society. For centuries the witch played her appointed role as society’s scapegoat. (p. 7)

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Szasz (1970/1997) affirmed that in the 17th century, as the power of the Church and its religious worldview began to decline, “the inquisitor-witch complex disappeared and in its place there arose the ‘alienist-madman complex’” (p. 13). In this new secular and scientific order, parallel conformity was still demanded; Szasz cited this shift in the social order as a move from a worldview, conceptualized in terms of “divine grace,” to one cast more in terms of health. In reference to institutional psychiatry (“forced” psychiatry, in contrast with what he regarded as a less imposing contractual psychiatry), Szasz (1970/1997) asserted that “the principal problem has always been, and still is, violence: the threatened and feared violence of the ‘madman,’ and the actual counter-violence of society and the psychiatrist against him” (p. xvii). Whether or not one agrees with Szasz’s position regarding institutional psychiatry and its historical implications, this type of projective dynamic has been at play in myriad ways across societies and social structures; it unfortunately has been linked with peoples around the world, representing various types of societal needs for scapegoats and also representing the ways in which individuals are willing to act, uncritically, in accordance with institutional demands that equate with evil. For example, the “good Nazi soldier,” along with the results of social psychology experiments in the 1960s and 1970s (e.g., the Milgram experiment and the Stanford Prison experiment) have constituted testimonials to this. Such power-related links between Inquisition-era violence and social scapegoats perhaps have been clearer in the more recent near-extermination of indigenous peoples in the Americas, the brutal enslavement of Africans, the Jewish Holocaust, and genocides in Rwanda and Sudan; these represent manifestations of a psychology of exclusion or of othering and a lack of morality that have had egregious consequences. The perpetration of violence has presumed the ability to instill fear and ultimately to control or to take power over others; indeed, it has presumed the role of a more or less passive victim. In many ways, early conceptualizations of trauma were linked to sin, a fall from grace, or moral weakness on the part of the victim who somehow “deserved” punishment or persecution. These historical examples have indicated as much about the perpetrators of violence—and the abusive power of the institutions that they have represented—as about the cultural assumptions regarding how experiences of trauma have been conceptualized. The effects on individuals of such brutal behaviors as those justified during the Inquisition or those justified more recently for medical, ethnic, religious, or other reasons do not go away—they continue to resonate for many generations with the offspring and in the family systems of people who have been brutalized and victimized—and we do not fully understand, as yet, the social and cultural effects on the people who allow such conduct to occur in their midst.

Historical Trauma Sotero (2006) has described historical trauma theory as a relatively new concept in public health that aims to assess the higher prevalence of disease among populations exposed to long-term traumatic experiences (e.g., racism, slavery, genocide, etc.) across generations. Alexander (2004) examined the construct of cultural trauma as a constructivist concept. He asserted that events are not inherently traumatic; rather, it is the beliefs of individuals and societal groups that make them such (Alexander, 2004). In short, it is not the events, but their meanings, which disturb and shock the social consciousness. The process of cultural trauma, according to Eyerman (2002), has evolved from the reconstruction and reconceptualization of collective memory and identity. Estrada (2009) has pointed out that it is precisely the intergenerational stress, in response to atrocious and traumatic social and historical events, that is at the core of historical trauma theory.

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This applies to many groups of indigenous and oppressed peoples around the world, for instance, colonized Africans across the continent of Africa, African Americans and other previously enslaved peoples of the African diaspora, Native American and First Nations people of North America, colonized indigenous peoples throughout South America, and Aboriginal people of Australia, among others. The concept of historical trauma, or collective trauma, implies that the experience involves generational transmission across a group of people who have established a cohesive identity or a sense of group affinity (Evans-Campbell, 2008; Mendelssohn, 2008). As research into generational trauma is still a relatively recent phenomenon, there remains work to be done in refining definitions, explaining modes of transmission, and delineating the impacts of intergenerational trauma. Such detailed exploration is not the focus of this chapter; however, an overview of the salient research to date is in order. At its core, intergenerational or cultural trauma is suggested to be a result of a population’s identification with the emotional distress and suffering of previous generations (Brave Heart, 2003, 2007; Brave Heart, DeBruyn, Crazy Thunder, Rodriguez, & Grube, 2005). There appear to be common characteristics to the type of events that lead to cultural trauma. Most notably, the incidents are generally perpetrated by an “outside” group whose intent is to subjugate or harm. Although natural disasters have been found to contribute to collective trauma, it is generally the course of human events that seems to breed the greatest devastation. Additionally, events that are experienced by a large number of members of a specific group, where the event created significant distress and bereavement, tend to create trauma that is transmitted to future generations (Brave Heart, 2003, 2007; Brave Heart et al., 2005; Evans-Campbell, 2008; Whitbeck, Adams, Hoyt, & Chen, 2004). All too often, these events involve genocide, enslavement, or decimation of marginalized factions of people. Brave Heart (2003, 2007) has identified the following symptoms as one example of historical trauma among indigenous peoples of North America: depression, anxiety, isolation, loss of sleep, anger, discomfort around White people, shame, fear and distrust, loss of concentration, substance abuse, and violence and suicide. In other studies, evidence of generation trauma has been found in the children of Holocaust survivors (Gangi, Talamo, & Ferracuti, 2009). Wiseman, Metzl, and Barber, in their 2006 exploration of second-generation Holocaust survivors, found that these offspring exhibit anger and guilt related to parental overprotectiveness, enmeshment, and expectations. The monumental losses suffered by Holocaust survivors dramatically influence their familial relationships, which often are characterized by an intense need to protect and maintain family cohesion as a survival strategy. Behaviors that are rooted in the trauma of a past are an ongoing influence in the actions of the present, and these even may be propagated to third-generation survivors (Scharf, 2007) and beyond. It is clear that the responses of individuals are related to the responses of their families, which are, in turn, influenced by the responses of the community as a whole. Although there is considerably more research to be done, we can view cultural trauma as a multisystemic influence that has long-term social manifestations across generations.

MODERNITY AND THE CONCEPTUALIZATION OF TRAUMA Modern study of the effects of trauma on the individual human condition is an endeavor that is rooted in the studies of the mind that constituted the beginnings of modern psychiatry. In the mid-1800s, Jean-Martin Charcot studied young Parisian women who were hospitalized at the Salpêtrière. In his consideration of “neurosis,” Charcot examined the repercussions of lives filled with sexual assault, poverty, and violence.

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Charcot recognized that these women were acting out of their subjective realities and that their conditions were psychological (Herman, 1992). Charcot’s students, Sigmund Freud, Joseph Breuer, and Pierre Janet, expanded upon his exploration of hysteria and neurosis and further hypothesized that these conditions were caused by exposure to psychological trauma (Brooks, 1998). Freud, Janet, and Breuer’s conceptualization of what constituted psychological trauma was initially quite narrow and was constrained to the idea that hysteria and neuroses were caused by psychosexual events. However, by 1917, extensive exploration of the subject of traumatic conditions had created an expanded definition of psychological trauma. In his Introductory Lectures on Psychoanalysis, Freud proposed a broadened concept of psychological trauma that included “war, railway collisions, and other alarming accidents involving fatal risks” (Freud & Strachey, 1966/1977, p. 274). This more inclusive definition would later prove to be foundational in the delineation and classification of trauma-related disorders within the APA’s DSMs. In the remaining parts of this section, we outline relevant developments in discussions regarding an emergent understanding of trauma in World War I and World War II and the growing awareness of the impact of trauma (the impact of trauma on war veterans is detailed in Chapter 19).

World War I and World War II Initial investigations into the psychological consequences of traumatic exposure were not limited to hysterical women. The advent of World War I, with its proliferation of emotionally disturbed soldiers, brought the psychological devastation, which could manifest from combat, to the attention of the field of psychology. Charles Myers, a pioneering psychologist in the study of combat-related disturbance, recognized that the soldiers’ symptoms appeared to be similar to behaviors that Freud observed in women who suffered from hysteria. Myers originally hypothesized that the behaviors had a physical cause and attributed the behaviors to the intensity of the concussions resulting from exploding ordnance (Herman, 1992). As a result of his hypothesis, Myers labeled the syndrome “shell shock.” Much to the dismay of the military, further study showed that many soldiers exhibited the characteristic symptoms of the syndrome without being exposed to the physical trauma of concussive force (Herman, 1992). Eventually, the soldiers’ neurosis was acknowledged to be the result of the psychological trauma and stress of combat, with its constant state of violence, threats to life, and horrific images (Herman, 1992; Van der Kolk, 1996). By the end of World War I, psychiatric professionals had adopted the position that combat fatigue, or “war hysteria” as it became known, was a disease created by a lack of “will to be well” on the part of the suffering soldier (Van der Kolk, 1996). This view, especially prevalent among professionals serving in the military or in positions with connection to the armed services, followed a similar course of development as the earlier studies of hysteria in women. Soldiers were expected to be brave, heroic, and stoic in their adaptation to the rigors of their war experiences. Those who succumbed to psychological distress were categorized as being of poor moral character or of weak temperament (Herman, 1992; Van der Kolk, 1996). This view mirrored initial interpretations of women who exhibited neurotic symptoms as internally weak and flawed. There were those, most notably W. H. R. Rivers, who viewed the affliction of combat neurosis, or war hysteria, as a pathological, traumatic syndrome that was a result of the severity of the stressors of combat and not a weakness of character (Herman, 1992; Van der Kolk 1996). Rivers, who based his treatment interventions upon psychoanalytic principles, strongly believed that any soldier could be afflicted by combat-related hysteria, regardless of his moral character or the height of his bravery (Van der Kolk, 1996). When the war was over, veterans’ hospitals continued to serve the psychiatric needs of

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soldiers who were experiencing persistent disability as a result of their combat experience. These men garnered little attention from the medical community. It was as if the horrors of war and the lasting consequences could be forgotten if they were ignored (Herman, 1992). Between World War I and World War II, the field of traumatic study was quiet during the new-found time of peace. The study of traumatic exposure remained of interest to a few professionals within the field of psychology. After a career in psychoanalysis and anthropology, American psychiatrist Abram Kardiner began to study combat-related disorders and psychological trauma. Kardiner explored past assessments, theoretical frameworks, and studies on combat-related hysteria, and he synthesized his findings in his 1941 work, The Traumatic Neuroses of War. Kardiner decried the use of the label hysterical in reference to suffering soldiers, as he felt that it propagated the impression that the experienced disturbance was a result of weakness or internal flaws (Herman, 1992).

Growing Awareness of the Impact of Trauma Social awareness of PTSD evolved concomitantly within the psychiatric community and the public (Friedman, Keane, & Resnick, 2007; Jones & Wesseley, 2006). As an example of emerging public awareness, the symptoms of PTSD were portrayed in Hollywood film noir in the 1940s, more than 30 years before the diagnosis first was included in the DSM III (Miller, cited in Levers, 2001). Earlier war-related investigations of trauma eventually piqued the interest of the civilian sector, and conditions born from non-combat-related trauma began to be examined. As televised atrocities routinely were broadcast into living rooms across the globe, the social movements of the 1960s and 1970s spawned an expansion of the exploration of traumatic experiences and their impact. Several of these are discussed in the following text.

Vietnam As the men and women who served in combat in Vietnam returned to the United States, there was again interest in the effects of combat upon the human psyche. The tensions related to the social discourse around the war brought the issue to the forefront of the national media. Television broadcast images of long-haired, wild-eyed soldiers into the homes of unsuspecting Americans, who were forced to consider the negative psychological results of war upon the nation’s sons. The images of the conquering hero, which had been the theme of the returning World War II soldier, were replaced with a more disturbing reality. American men and women were returning home with traumarelated mental health conditions that seriously affected their ability to function in all of the domains of their lives. This new breed of veteran was often guilt-ridden, angry, and emotionally volatile, which had serious implications for their spouses and children (Solomon, Mikulincer, Fried, & Wosner, 1987). The general population was drawn into awareness of combat-related trauma conditions.

Violence Against Women and the Rape Crisis Movement Professional and popular conceptualizations of trauma continued to expand through the end of the 20th century. With the advent of the women’s liberation movement, issues related to the “tyranny of private life” of women began to be examined (Herman, 1992). Early exercises of consciousness-raising groups soon led to open, and heretofore unprecedented, discussions of the psychological impact of rape, sexual assault, incest, and the sexual subjugation of women for political purposes (Herman, 1992; Lating & Everly, 1995).

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The field of psychiatry soon acknowledged that sexual assault led to psychological distress that substantially mimicked combat neurosis in its symptom presentation. Psychiatric nurses Lynda Holmstrom and Ann Burgess observed a pattern of numbing, increased startle response, nightmares, dissociative symptoms, nausea, and insomnia in rape victims who presented themselves for treatment at Boston Hospital (Burgess & Holmstrom, 1974). Labeling this pattern of symptom presentation as “Rape Trauma Syndrome,” Burgess and Holmstrom (1974) spurred the field to consider an even broader definition of traumatic victimization that later would be incorporated into the formal diagnostic criteria for PTSD.

Violence Against Children and the Child Protective Movement As traumatic exposure in non-combat-related situations became more widely recognized as a source of emotional distress and disturbance, issues related to children emerged as a particular area of focus. It long had been acknowledged that children are equally susceptible to the stressors of traumatic events as are their adult counterparts, but it was thought that the reactions of children were of a less severe nature and shorter lived than adults (Yule, 1998). Prior to 1987, there was little research that defined or delineated the differences between stress responses in adults and children. Since the 1990s, differential diagnosis of PTSD in children has included refi nements of symptom presentation that may manifest in children. Some significant differences have included displays of disorganized or agitated behavior—instead of fear, helplessness, or horror— along with generalized nightmares and traumatic play (APA, 2000). Statistically speaking, children experience rape, robbery, assault, and physical violence at a greater rate than adults (Clark & Miller, 1998). According to a 1990 study by the U.S. Department of Justice, adolescents are 2.5 times more likely to be the victim of a violent crime than adults. Unfortunately, these experiences often occur within the child’s family system. A recent development in the study of PTSD in children has been the increase in research that is related to exposure to family and domestic violence as a catalyst for the development of stress-related disorders. Confounding studies of family violence and PTSD is the disturbing fact that children who experience trauma at home are also more likely to experience violence in their community, with their peers, and in their personal relationships (Margolin & Vickerman, 2007). Often these exposures are of a chronic nature and present challenges to accepted definitions of trauma and trauma experience. These challenges are addressed later in this chapter when complex trauma is examined. What is currently accepted is that PTSD appears to be one of the most common psychiatric disorders in children and young adults (Breslau, Davis, Andreski, & Peterson, 1991). Unfortunately, the measurement of stress disorders in children generally has been conducted using assessment tools designed for use with adults. There continues to be a need to develop reliable means for assessing children. The complex nature of childhood exposure, the variety with which symptoms are manifest, and the obstacles that often are present in gathering trustworthy qualitative data make empirical conclusions difficult regarding the trauma experiences of the young (Davis & Siegel, 2000). Current research continues to focus on early detection and prevention of childhood traumatic exposure, methods for accurate assessment, and effective treatment intervention.

POSTTRAUMATIC STRESS DISORDER (PTSD) AND THE DSMs The construct of psychological trauma has changed over time. Especially pertinent to this discussion is how the construct has changed in relationship to mental health diagnostics. In this section, we briefly explore the evolution of the Diagnostic and Statistical

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Manuals, the recent discussion of complex trauma, and the interface of trauma with multiple diagnostic categories.

Development of the Diagnostic and Statistical Manuals In 1952, the American Psychiatric Association released the first Diagnostic and Statistical Manual of Mental Disorders as a means to mitigate some of the limitations found in using nomenclature from the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD-6). In the ICD-6, stress-related reactions where labeled as “acute situational maladjustment” (WHO, 1949). The DSM-I labeled stress-related conditions under the heading of “Transient Situational Personality Disturbance” (APA, 1952). Included under this heading was the diagnosis of gross stress reaction, which defined psychic disturbance related to combat or civilian catastrophe. Under the same heading, other stress-related conditions were given the labels of adult situational reaction and also of adjustment reaction of infancy, of childhood, of adolescence, or of late life (APA, 1952). In 1968, a revised edition of the DSM was released; the DSM-II reclassified traumatic experience into a category called “Adjustment Reaction of Adult Life.” There was no longer a description of the diagnosis, and criteria were explained through the provision of three examples of qualifying experiences. These experiences were unwanted pregnancy, military combat, and being sentenced to death (APA, 1968). There was an asterisk next to the category, which directed the reader to the appendices, where additional examples of similarly qualifying stressful events could be found. These events included railway, car, boat, and plane accidents (Wilson, 1995). There was cause to wonder about the lack of explication of the various types of trauma and the resultant psychological manifestations, but clearly, the intent of the authors was to provide an inclusive category within which to place reactions related to all traumatic experiences that resulted in anxiety, fear, and feelings of overwhelming loss of control (Van der Kolk, 2007; Wilson, 1995). In 1980, the third edition of the DSM realized another recategorization of trauma-related syndromes, within the anxiety disorder section of the manual. The manual contained a new diagnosis—PTSD, which encompassed combat neurosis, rape trauma syndrome, and battered women syndrome. Based substantially upon Kardiner’s 1941 work, the diagnosis was a compendium of symptoms culled from clinical records, research, and literary explorations of those working within the fields of the various trauma-related syndromes (Van der Kolk, 1996). The symptoms of PTSD were clustered into three distinct categories from which an individual needed to exhibit four symptoms in order to meet criteria for diagnosis. These clusters encompassed symptoms of reexperiencing the trauma, the display of the effects of numbing and detachment, and changes in personality. In order for diagnostic criteria to be met, the manual further specified the need for the “existence of a recognizable stressor that would evoke distress in almost everyone” (APA, 1980). This statement of the necessity of a recognizable stressor replaced the previously provided list of examples of qualifying traumatic events that were present in earlier editions of the manual. Although there appeared to be tacit understanding that certain types of events would be particularly distressing, there was no discussion of etiology or dissection of how human perception of events as traumatic can vary from person to person (Everly & Lating, 1995). The notion of the variability of human perception of events as traumatic became a salient feature for the diagnosis of PTSD in future iterations of the DSM and is discussed at a later point in this chapter. In 1987, the DSM III-R was published with further revisions to the diagnosis of PTSD. In an attempt to provide clarification of what constituted a traumatic event or recognizable stressor, the phrase “outside of the range of normal human experience” was added

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to the criteria (APA, 1987). Further, a list of examples of qualifying events was again provided. These examples included serious harm or threats of serious harm to self, children, spouse, or other loved ones; seeing another person killed or seriously injured as a result of violence or accident; and experiencing the sudden destruction of one’s home (APA, 1987). Of note, traumatic events that were within the realm of normal human experience, such as being the victim of a violent crime or experiencing or witnessing a serious automobile accident, and that we now view as highly traumatic and as potential triggers for PTSD, were not included in the description (Spitzer, First, & Wakefield, 2007). Additionally, the list of symptoms was expanded to 17, although the number of symptoms necessary for diagnosis was increased to six. The final significant change in the DSM III-R diagnostic criteria for PTSD was the extension of special qualifiers that related to the manifestation of the disorder in children. Heretofore, the field promulgated the assumption that children experienced, processed, and exhibited symptoms of traumatic exposure in much the same way as adults, if at all. The DSM III-R clarified that children may display disorganized or agitated behavior instead of the fear, helplessness, or horror listed as adult symptoms under criteria A (APA, 1987). According to criteria B, children may demonstrate repetitive play with themes related to the trauma instead of having intrusive recollections, and further, children’s dreams may be frightening but without recognizable content of the trauma, as would be present in adult experiences (APA, 1987). Although the revisions were intended to provide clarity and to refocus on PTSD as a disorder, debate continued well into the preparation of the DSM-IV. The 1994 revision of the Diagnostic and Statistical Manual again brought substantial changes to the PTSD diagnosis. The statements regarding the need for the stressor to “cause distress in most everyone” and to be “outside of the normal range of human experience” were removed from the criteria in an effort to define trauma more explicitly and to address the problem of common, yet clearly traumatic, events being excluded from the criteria. There were those who suggested that the stressor be defined in more subjective terms. Most notable were Solomon and Canino (1990), who advocated that qualifying circumstances or traumas should be defined in a sweeping and general manner, such as an “extremely shocking event,” that would speak to the subjective perception of the individual and provide for broad inclusion of experiences. Others advocated for a more objective classification that would further delineate the symptom and response presentation necessary for differential diagnosis (Lasiuk & Hegadoren, 2006; Van der Kolk, McFarlane, & Weisaeth, 2007). Eventually, a combination of subjective and objective measures was included within criterion A. Criterion A1 addressed the subjective nature of traumatic exposure by defining a qualifying event as one in which the individual “experienced, witnessed, or was confronted by an event or events that involved actual or threatened death, serious injury, or a threat to the physical integrity of self or others” (APA, 1994, p. 427). The addition of criterion A1 mitigated the previous omission of consideration of the subjective or perceptual reality of the individual who experienced the event. The external nature of the event sustained the notion that the etiology of the disorder is external to the individual. Criterion A2 addressed the need for an objective component of the definition, by describing the individual’s response as one that demonstrated “intense fear, helplessness, or horror” (APA, 1994, p. 428). These changes propagated the controversy surrounding the diagnosis by, perhaps, going too far with the notion of perception by using the words “confronted with” in criterion A1 (APA, 1994, p. 427). As a broad concept, open for significant interpretation, the addition of this wording substantially expanded the number of individuals who meet the criteria for the disorder and allowed for conceptual bracket creep, or a stretching of the boundaries of the diagnosis, beyond the categorical limitations of earlier definitions (McNally, 2003). The last substantive change to the diagnostic criteria of PTSD in the

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DSM-IV was the addition of specifications regarding the duration of symptoms. The following delimitations primarily affected timeframes: (a) acute, which was defined as duration of symptoms of less than 3 months; (b) chronic, with duration of symptom presentation of 3 months or more; and, (c) delayed onset, with a symptom presentation that did not appear until 6 months or more after exposure to the stressor (APA, 1994). In an attempt to separate what could be viewed as an early, simple reaction to traumatic exposure from the more chronic, debilitating sequelae of PTSD, a new traumarelated disorder was included in the DSM-IV. Placed within the anxiety disorder category, ASD had many of the same diagnostic criteria as PTSD but had an onset of occurrence of symptom presentation within 1 month of the traumatic exposure and was described as lasting for at least 2 days and for a maximum of 4 weeks (APA, 1994). Additionally, ASD criteria included the presence of three or more dissociative symptoms from a list of five that was provided (APA, 1994). Some have argued that the high rates of individuals who progress from ASD to PTSD and the shared symptom profile of the two disorders strongly points to ASD as an early form of PTSD, not a separate condition (Classen, Koopman, Angell, & Spiegel, 1996; Marshall, Spitzer, & Liebowitz, 1999). By extension, PTSD can be viewed as an interrupted or impaired recovery from an early, intense stress response or ASD. The controversy regarding the validity of ASD and PTSD as separate conditions has prompted some in the field to advocate for a spectrum-based view of PTSD and trauma-related disorders (Lasiuk & Hegadoren, 2006). In 2000, the APA released the DSM-IV-TR. There were no substantive changes to the trauma-related diagnostic criteria in this edition. Rather, as the last edition was published some 16 years prior, and the next full revision was not expected until 2012 at the earliest, changes in the descriptive text were made to reflect the current state of research and empirical literature. Debate has continued to rage regarding trauma-related disorders, and many changes have been proposed for the DSM-V. Currently, events such as the terrorist attacks of September 11, 2001, the Oklahoma City bombing, the shootings at Columbine High School and the University of Tennessee, the shootings and bombing in Norway, the 2010 earthquakes in Haiti and Chile, and the 2011 earthquake/tsunami/ nuclear disaster in Japan again have brought the exploration of the human response to extraordinary circumstances to the forefront of social science. According to the APA, the proposed revisions to the diagnostic criteria for PTSD in DSM-V are numerous. Potential revisions include the addition of new items such as experiencing exaggerated negative expectations, having a distorted sense of selfblame, and experiencing persistent negative emotions. Additionally, the proposed revisions contain clarification of what constitutes “experiencing a traumatic event” and a redefinition of the symptom presentation of dissociative reactions and the concept of avoidance. Some suggest that perhaps the best and most efficacious approach is to reconceptualize the diagnosis as a spectrum disorder rather than a single entity (Lasiuk & Hegadoren, 2006). Regardless, with the examination of the criteria remaining under scrutiny for the coming revision of the DSM, the controversy is likely to continue with that edition and beyond.

Posttraumatic Stress Disorder and the Effects of Complex Trauma The diagnostic criteria for PTSD have undergone revisions as research regarding the phenomena of traumatic experience has continued to elucidate its effect on the human condition. By the early 1990s, clinicians and researchers, who were exploring PTSD in those who experienced domestic violence, child abuse, and other long-term exposures, began to identify that the symptom pattern produced by these types of exposures was not adequately defined by the prevailing diagnostic criteria (Briere, 1987; Courtois, 2008;

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Herman, 1992). At issue seemed to be what were classified as “comorbid” conditions that, arguably, appeared to be a result of traumatic exposures of a more complex nature (Courtois, 2008). Children who have been exposed to family violence, child abuse, or other ongoing maltreatment experience trauma over extended periods, during different phases of their emotional development, and at the hands of their family members or other significant caregivers, which makes their experiences substantially different than that of combat veterans or individuals who experience acute types of trauma such as accidents or natural disasters. Although the effects of such exposure were found to be similar in nature to the prevailing understanding of PTSD, there were significant differences (Herman, 1992), especially as these relate to the developmental trajectories of children experiencing brutality early in childhood, at the hands of the very caregivers who the children ought to be able to trust. In evidence were psychological disturbances not within the DSM-III diagnostic criteria for PTSD, such as medical and somatic complaints, depression, anxiety, dissociative disorders, substance abuse issues, and interpersonal relationship problems (Courtois, 2008). As a result of research regarding the experience of complex exposure to trauma, experts in the field proposed that the PTSD committee, which had been empanelled to explore stress disorders for the DSM-IV, also conduct field trials regarding complex exposure to trauma. The committee set out to investigate the possibility of including a diagnosis of Complex PTSD, as well as a constellation of trauma-related symptoms not currently under the umbrella of trauma-related conditions, which could be classified as “disorders of extreme stress not otherwise specified (DENOS)” (Roth, Newman, Pelcovitz, Van der Kolk, & Mandel, 1997). Focusing primarily on the effects of early interpersonal trauma, DESNOS would consist of seven additional criteria that may result from chronic victimization: (a) Changes in emotional regulation, including difficulty with modulation of anger and self-destructive behavior; (b) alterations in consciousness, including amnesias and dissociative episodes; (c) alterations in self-perception such as shame, guilt, and stigmatization; (d) changes in relationship to others, including a lack of trust or loss of intimacy; (e) somatic complaints; (f) change in one’s sense of meaning such as loss of faith or despair; and (g) changes in perceptions about the perpetrator (Herman 1992; Pelcovitz et al., 1997; Van der Kolk, 2001). The DSM-IV field trial, conducted between 1991 and 1992, found 92% comorbidity between DESNOS and PTSD and, as such, a separate diagnosis was not included in the revision of the manual; however, the symptom pattern was incorporated as an associated feature of PTSD (APA, 1994). Since those first field trials, interest in the impact of early and repetitive exposure to relational trauma has continued to increase, and based on continuing research, support for a separate diagnosis has continued to grow. Ford found that DESNOS could, in fact, occur in the absence of PTSD, despite the substantial overlap. Further, he found that PTSD and DESNOS were substantially different in terms of symptoms and functional impairment features (Ford, 1999). Research continues to examine whether these conditions are, indeed, separate conditions that frequently may be comorbid but are patently unique. A primary issue is the budding awareness that treatment interventions between individuals with PTSD and with DESNOS may need to be significantly different in order to safely and effectively intervene with those with complex trauma histories (Ford, 1999; Van der Kolk, 2001).

The Interface of Trauma with Multiple Diagnostic Categories As previously discussed, the notion that traumatic exposure and stress can create psychiatric illness in “normal” individuals has a long and well-researched history. By definition, the diagnosis of PTSD remains unique in that its etiology stems from

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an outside stressor. Although exposure rates to traumatic events among the general population range from 36% to 81%, only 7% to 10% of exposed individuals develop PTSD (Breslau et al., 1998). What has continued to confound those in the field is the prevalence of comorbid conditions, which suggest that, perhaps, there is a combination of factors at work (Yehuda & McFarlane, 1995). Although no real consensus has been reached regarding the true nature of PTSD, there is an extant body of research that describes the spectrum of disorders often present in those who have survived traumatic exposure. There is abundant evidence that traumatic exposure can lead to a wide array of psychological disturbances that meet the diagnostic criteria within the DSM. The disorders vary in severity from adjustment disorders to more lasting and grave manifestations. Traumatic exposure has shown a strong correlation with anxiety disorders (Allen, Coyne, & Huntoon, 1998), substance abuse disorders, dissociative disorders (McDowell, Levin, & Nunes, 1999), major depression (Brady, Killeen, Brewerton, & Lucerini, 2000), and eating disorders (Brady et al., 2000). Additionally, borderline personality disorder (BPD) displays commonality with the symptom cluster of complex PTSD and shares, at its core, a high frequency of interpersonal trauma (Yen et al., 2002). When a broad definition of trauma is applied to the life experiences of people seeking treatment for psychological disorders, most are found to have experienced at least one traumatic exposure during their lifetime. Given the statistical probability that an individual will experience traumatic exposure during his or her lifetime, it is the expectation rather than the exception that mental health clients will present with trauma histories. Indeed, a significant percentage of patients who are diagnosed with serious mental disorders such as psychotic disorders, schizophrenia, and bipolar I and II disorders detail extensive trauma backgrounds (Goodman, Rosenberg, Mueser, & Drake, 1997). Further, individuals with extensive trauma histories often present with complex symptom patterns that involve multiple disorders, making differential diagnosis difficult. Najavits et al. (2009) describe this as a “central paradox,” stating that “comorbidity with PTSD is the norm, yet treatment outcome studies routinely exclude patients with significant comorbid conditions and fail to assess for them” (p. 508).

POSTTRAUMATIC GROWTH Exposure rates to traumatic events have been high among the general population, as discussed in the previous section; yet only about 7% to 10% of people exposed to trauma actually develop symptoms of PTSD (Breslau et al., 1998). Recent psychological literature has begun to examine the positive changes that can result from traumatic exposure. For example, Hyatt-Burkhart (2011) has discussed the exploration of positive responses to trauma in mental health professionals working with children. Positive changes have been labeled variously as stress-related growth (Park, Cohen, & Murch, 1996), adversarial growth (Linley & Joseph, 2005), thriving (Carver, 1998), and flourishing (Ryff & Singer, 1998). Most currently, the concept of positive personal change that results from a crisis or traumatic event has been called posttraumatic growth (PTG; Tedeschi & Calhoun, 1996). The concept of PTG does not discount the negative psychological experience of traumatic exposure, but rather, emphasizes that in addition to negatives, the experience can lead to an enhanced sense of meaning and purpose in life that promotes personal change and growth (Smith & Cook, 2004). In the remaining parts of this section, we discuss the domains of PTG, the theoretical foundation of PTG, and controversy involving PTG.

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Domains of Posttraumatic Growth A significant body of literature has examined the phenomenon of PTG in relationship to specific types of trauma such as heart attacks (Affleck, Tennen, Croog, & Levine, 1987), death of a loved one (Lehman et al., 1993), natural disasters (Coffman, 1998; McMillen, Smith, & Fisher, 1997), and rape (Burt & Katz, 1987; Frazier & Burnett, 1994). In these studies, between 10% and 90% of individuals reported that they experienced benefit from coping with a traumatic event (Tedeschi, Calhoun, & Engdahl, 2001). Empirical evidence has suggested that those who endorse PTG have experienced this growth within the following five broad domains: strength, new possibilities, relationships, appreciation of life, and spirituality (Tedeschi & Calhoun, 1995). These are discussed briefly in the following text.

Strength The first domain encompasses changes in the perception of self, with respect to strength. The most common change in the perception of self is that although there may be an increased sense of vulnerability, there also may be an increased sense that the individual is stronger, more capable, and better able to survive than he or she previously had believed (Collins, Taylor, & Skokan, 1990; Janoff-Bulman, 1992; Tedeschi & Calhoun, 1995). This shift readily can be observed in the studies of widows who report that, upon the death of their spouses, they had to assume new roles and responsibilities such as dealing with financial concerns and cars and handling home repairs. These women have reported an increased sense of self-efficacy as a result of their new accomplishments (Calhoun & Tedeschi, 1990; Lund, Caserta, & Dimond, 1993; Znoj, 2006). This increased sense of self-efficacy did not supplant their grief, but rather, it existed simultaneously. Examinations of the experience of individuals who have suffered a serious health crisis has produced evidence that such experiences can create a sense that the individuals are “tougher” or more tenacious than they previously perceived themselves to be (Stanton, Bower, & Low, 2006). Individuals who have reported these changes have expressed seeing them as positive results of their struggle.

New Possibilities The second domain is related to an increased sense that there are new possibilities for the future. It is common for individuals who have suffered a significant trauma to realign their everyday lives as a result of their experience (Cadell, Regehr, & Hemsworth, 2003; Tedeschi & Calhoun, 1998, 2004). Many people adopt a new, enthusiastic, “carpe diem” attitude toward life that previously was absent. Others may change career paths or even choose to dedicate their lives to helping others who have experienced similar trauma—what Herman (1992) terms as “survivor mission.” People such as John Walsh, who spearheaded efforts around law enforcement and child abduction as a result of the kidnapping and subsequent murder of his son Adam; Cristy Lightner, founder of Mothers Against Drunk Drivers, which she began after her child was killed by a drunk driver; and Jim and Sara Brady, who dedicated much of their lives to lobbying for gun control legislation after Jim was shot, all found a new calling or passion as a result of their traumatic experiences (McMillen, 1999).

Relationships The third domain regards changes in how the individual perceives and experiences relationships with others. The most consistently reported positive change that results from a traumatic exposure is improvement in human relationships (Affleck et al., 1987; Affleck,

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Tennen, Urrows, & Higgins, 1991; Collins et al., 1990; McMillen & Fisher, 1998; McMillen et al., 1997; Tedeschi & Calhoun, 1996). Those studied have reported having a deeper appreciation for family and friends, resulting in closer relationships of a more meaningful nature (Janoff, 2006; Park, Aldwin, Fenster, & Snyder, 2008; Tedeschi & Calhoun, 1989, 2006). Informants in some studies have reported an increased sense of how quickly relationships or people could be lost and how this, in turn, can create an enhanced sense of their value (Affleck, Allen, Tennen, McGrade, & Ratzan, 1985; Znoj, 2006). Many people have experienced this exact phenomenon when faced with the sudden death of a loved one. Being confronted with the reality that life is finite, and that the amount of time we have with a loved one is unknown, seem to make other significant relationships all the more precious. The “wake-up call” that life is short can alter an individual’s cognitive processes about the value of connectedness and change how he or she goes about creating and maintaining relationships with others (Tedeschi & Calhoun, 1999, 2004).

Appreciation of Life The fourth domain involves changes in the appreciation a person has for life. This can involve a change in perception about the general value of life (Affleck, Tennen, & Gershman, 1985; Putterman, 2005) or a feeling that one has been given a second chance that should not be wasted. There may be a significant shift in the priorities of life. Changes in behaviors such as spending less time at work and more time with family, focusing less on what one doesn’t have and more on what one does have, and adopting more “don’t sweat the small stuff” and “take time to smell the roses” attitudes all have been reported commonly as areas of PTG (Calhoun & Tedeschi, 1995, 2004; Park, 1998).

Spirituality Finally, the fifth identified domain is spiritual change. Although there is no dispute that traumatic exposure can have negative ramifications upon spiritual beliefs, people have reported that they have a renewed or strengthened sense of religious belief as a result of their struggles with trauma (Calhoun & Tedeschi, 1989, 1991, 1999). Although it may seem somewhat paradoxical to have one’s belief in God strengthened through adversity, studies find that meaning-making often is tied to religious constructs (Cadell, Regehr, & Hemsworth, 2003; Tedeschi & Calhoun, 2004b). Individuals may express a sense that a higher power helped them through the struggle, that the struggle was a gift designed to promote growth, or even that the journey was part of a plan to be revealed later.

Theoretical Foundation of Posttraumatic Growth The theoretical foundation of PTG represents a growing area of scholarly focus. There appear to be two basic conceptualizations of the phenomenon. Affleck and Tennen (1996) conceptualize PTG as a coping strategy that is employed to deal with extreme stress. Encompassed by an adaptive response view, coping theorists suggest approaches based on meaning-making (Davis, Nolen-Hoeksema, & Larson, 1998), information processing (Filipp, 1999), and positive appraisal of self or positive illusion (Taylor, 1983). These views of PTG as a coping mechanism suggest that it is an adaptive function for psychological adjustment after traumatic exposure. Schaefer and Moos (1992) and Tedeschi and Calhoun (1995, 2004) originally conceptualized PTG as an outcome born from the struggle with traumatic events (Zoellner & Maercke, 2006). By revising their theory and relating it to constructivist self-development

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theory, Tedeschi and Calhoun (2004b) posit a theoretical conceptualization that validates PTG as both process and outcome. Tedeschi and Calhoun (2004a) endorse people actively constructing their internal realities through external experiences. When exposed to traumatic events that are challenging to the person’s world view and established schemas, a cognitive processing occurs that can change the basic assumptions that a person holds to be true (Tedeschi & Calhoun, 2004b). Called rumination by Tedeschi and Calhoun (2004a), this cognitive process can lead either to the construction of adaptive schemas and positive meaning (PTG) or to dysfunctional negative schemas, such as PTSD symptoms.

Controversy Involving Posttraumatic Growth There are those who dispute that PTG is authentic (Cohen, Hettler, & Pane, 1998; Maercker & Zoellner, 2004; Nolen-Hoeksema & Davis, 2002). Problems with obtaining prestressor data from those who go on to suffer a traumatic exposure result in suspicious poststressor data. Additionally, barring a few exceptions (Milam, 2004; Sears, Stanton, & Danoff-Burg, 2003; Tennen & Affleck, 2002), the literature relies upon studies based on cross-sectional data gathered through retrospective self-reports. There are several postulates as to why people may report or exaggerate successful coping after traumatic exposure. Carver, Smith, and Antoni (2005) suggests that people want to be perceived as coping well or that they hold the belief that their supportive networks want to hear that they are doing fine (Frazier & Kaler, 2006; Linley & Joseph, 2005; Wortman, 2004). Further, there may be cultural expectations for growth in the face of adversity as a societal norm (Calhoun & Tedeschi, 2004a; Frazier & Kaler, 2006; Maercker & Zoellner, 2004). Other critics point out that self-reported PTG actually may be a result of positive illusions that are employed adaptively during stressful periods (Taylor, Kemeny, Reed, Bower, & Gruenewald, 2000). In research born from temporal self-appraisal theory (Ross & Wilson, 2002), evidence suggests that people tend to see growth in themselves, even when evidence of growth is not present. Further, a biased, negative assessment of one’s past self, when compared to a biased, positive assessment of one’s current self, leads to an inflated notion of positive change or growth (McFarland & Alvaro, 2000). That is to say, people downplay their past selves in order to enhance their esteem related to the current self and alleviate the stress of the current trauma. When examined longitudinally, the stability or sustainability of PTG also has been found to have mixed results. Over time, some of those individuals, who previously had endorsed growth, report decreases in their growth levels, calling into question whether or not their experiences represented actual growth (Frazier, Conlon, & Glaser, 2001). Finally, Davis and McKearney (2003) suggest that the exaggerative quality of growth-related fi ndings after traumatic exposure may be a self-protection strategy that is, indeed, an integral part of the growth process. Davis and McKearney also postulate that perhaps some of the controversy and difficulty in assessing PTG come from the fact that researchers are trying to conceptualize a process as a state, a notion with which we resonate.

COUNSELING IMPLICATIONS As suggested by the rates of exposure to traumatic events among the general population, trauma is a factor that clinicians need to consider when they embark upon treatment with any client. Although most mental health agencies and practitioners routinely obtain information regarding medical and psychosocial histories, it is not nearly as

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routine to ask about a history of trauma. This should, in fact, be a standard line of inquiry that is a part of any routine intake process; and the information should be requested in as normalized a fashion as possible—in other words, a simple question that is a part of the larger intake protocol. Diagnoses are not dogma; by reviewing the history of how the effects of traumatic events have been viewed through the ages, we can see that the psychological notion of trauma is one that has been constructed by humans, over time, and that is connected to the cultural ethos in which people pay attention to those affected by traumatic events. Clinicians need to listen to the narratives of clients describing the effects of traumatic events and to pay attention to family dynamics. Statistically speaking, the potential is high that most therapists are likely to be presented with clients who have trauma histories. It also is likely that any practicing clinician may see the effects of historical or transgenerational trauma. One of the most robust implications across the various clinical fields is the need for more preservice training around issues pertaining to the effects of traumatic events. We need to assist students in understanding the evaluation and treatment of persons who have been exposed to trauma. Along these lines, more research is needed regarding assessment, treatment, and instructional issues associated with the effects of psychosocial trauma.

CONCLUSION In this chapter, we have explored the historical context of the way in which we have come to view the effects of traumatic events and how we have arrived at several traumarelated diagnostic categories. Although trauma has been a part of the human experience, probably since the beginning of time, an awareness of the impact of trauma on the lives of affected people has developed slowly and only within recent history. We have described how, in certain historical eras, specific groups of people have been marginalized and targeted for violence. In these instances, the abuse of institutional power seems to be linked with the willingness of some members of society to perpetrate violence against the targeted groups. We also have described how an interest in the experience of psychological trauma emerged with the advent of psychoanalysis and continued through the lens of war and particular social movements. We have offered a brief discussion regarding recent emphasis on PTG as an alternative response to trauma rather than psychopathology. Finally, we have identified some of the implications for counselors of understanding the historical context of trauma. We believe that an awareness of the historical context of certain traumatic events and an understanding of societal responses can help those mental health professionals working with trauma to be more effective in their practice.

RESOURCES Websites Killbourne, J. (2006). Killing Us Softly 3: Advertising’s image of women. [Video file] (http://video.google. com/videoplay?docid=-1993368502337678412#) Killbourne, J. (2010). Killing us softly 4: Advertising’s image of women. [Video file] (http://www.youtube. com/watch?v=PTlmho_RovY) Zimbardo, P. (2009). Stanford prison experiment. (http://www.prisonexp.org/)

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Films and Videos Films for the Humanities & Sciences. (Producer). (2008). Zimbardo speaks: The Lucifer effect and the psychology of evil. [DVD]. Fink, M., Douglas, M., & Zaentz, S. (Producers), & Forman, M. (Director). (1975). One flew over the cuckoo’s nest [Motion picture]. United States of America: Warner. Gift From Within. (Producer). (2011). Making peace with chronic PTSD—Marla’s story. [DVD]. Litvak, A., & Bassler, R. (Producers), & Litvak, A. (Director). (1948). Snake pit [Motion picture]. United States of America: 20th Century Fox. Zimbardo, P. G. (Producer). (2004). Quiet rage: The Stanford Prison Experiment. [DVD].

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Yule, W. (1998). Post traumatic stress disorder in children and its treatment. In T. W. Miller (Ed.), Children of trauma: Stressful life experiences and their effects on children and adolescents (pp. 219–243). Madison, WI: International Universities Press. Znoj, H. (2006). Bereavement and posttraumatic growth. In L. G. Calhoun & R. G. Tedeschi (Ed.), Handbook of posttraumatic growth: Research and practice (pp.176–196). Mahwah, NJ: Lawrence Erlbaum Associates. Zoellner, T., & Maercker, A. (2006). Posttraumatic growth in clinical psychology—a critical review and introduction of a two component model. Clinical Psychology Review, 26(5), 626–653.

CHAPTER 3

Theoretical Contexts of Trauma Counseling MARTIN F. LYNCH

INTRODUCTION The study of trauma, both its effects and treatment, includes a rich tradition of theoretical reflection. Early on, much of this tradition was based primarily on clinical observations, but theory is increasingly incorporating the contributions of empirical research as well. This chapter provides an overview of several theories of trauma, some older and more traditional, and others more recent and innovative, with varying degrees of support either from clinical practice, from an empirical research base, or from both. Although the focus of this chapter is not on the therapeutic applications of these theories, implications for clinicians working with those who have experienced trauma are highlighted along the way, with a brief summary of therapeutic implications at the end of this chapter.

THEORY-BASED PERSPECTIVES Many theoretical perspectives, including those drawn from the study of human development, developmental psychopathology, personality theory, or psychotherapy, can offer insight into the phenomenon and treatment of trauma. Of course, any discussion of trauma theory necessarily begins with Freud’s classical psychoanalytic approach, with its emphasis on the process of repression. Indeed, Freud’s contributions to the study of traumatic experience serve substantially as the springboard for various contemporary approaches, including what broadly might be called contemporary trauma theory (Herman, 1992; Putnam, 1989; Siegel, 1995; van der Kolk, 1991), which emphasizes the process of dissociation in contrast to that of repression (see Piers, 1996, 1998). Also influenced by the Freudian tradition is self-determination theory (Ryan, 1995; Ryan & Deci, 2000a, 2000b, 2008; Ryan, Deci, Grolnick, & La Guardia, 2006), which considers the integrative processes in human development from the perspective of basic psychological needs. These views share a common emphasis on the potential of traumatic experiences to produce serious psychological and developmental sequelae and, more broadly, on the importance of understanding childhood experiences and nonconscious processes in the etiology and treatment of adult psychopathology. Despite the commonalities, there are important theoretical differences in these approaches that have implications for the process of counseling and psychotherapy. This chapter focuses on the theoretical understanding of traumatic experience, and necessarily deals with treatment implications only briefly.

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Classical Freudian Perspective: Repression Freud’s theory, relative to the role of trauma in pathology, went through several refinements. In his early collaboration with Josef Breuer, their work with hysterics led them to postulate that these patients suffer from “reminiscences,” which were conceptualized as a return to conscious awareness of an anxiety-provoking memory in the symbolic form of a symptom (Breuer & Freud, 1892/1959). In this earliest formulation, the trauma giving rise to the anxiety was considered to be intrapsychic rather than external (Piers, 1996). In other words, anything—any memory, thought, or feeling—that might be considered unacceptable or overwhelming to the person’s ego, given his or her personality and idiosyncratic sensitivities, could by definition be considered “traumatic” and therefore be pushed into forgetfulness by the ego. This process of pushing traumatic material into forgetfulness—or what came to be known as the process of repression— ordinarily relieved the person of the anxiety associated with the traumatic memory, thought, or feeling. For hysterics, however, the process of forgetting, or repression, was only partially successful: Although the content of the traumatic memory or idea might be forgotten, the associated affect remained and was expressed as a symptom, indirectly and often somatically. Importantly, this early formulation provided a basis for understanding traumatic experience broadly, functionally, and idiosyncratically: “Trauma” was anything (whether a memory of an actual event, or a thought or a feeling) that was capable of creating within the individual sufficient intrapsychic conflict such that it would, if left in conscious awareness, produce an intolerable level of anxiety. What could be considered traumatic was, in effect, subjectively determined by the person himself or herself. Repression involved an unconscious, defensive pushing out of awareness of the conflictual material. Treatment of the hysteric’s neurotic symptom involved reconnecting the displaced affect with its original content through catharsis, and, indeed, S. Freud (1894/1959) took the successful symptom relief provided by this treatment as support for the underlying causal mechanism postulated in his theory of repression of traumatic material. Within just a few years, Freud had further refined his theory. He found in his work with hysterical patients that the content that was uncovered did not always seem to have sufficient “traumatic power” or to be sufficiently connected to the hysterical symptom. He postulated that there must, in fact, be some experience or memory at work that did possess sufficient traumatic power to account for his patients’ symptoms, a memory that had been pushed even further into the unconscious. Thus, in S. Freud’s “Aetiology of Hysteria” (1896/1959), he proposed that every case of hysteria could be linked to a “premature sexual experience” (p. 198), that is, to an earlier sexual trauma experienced in childhood. This refinement in Freud’s earlier thinking is typically referred to as his “seduction theory,” suggesting that the adult patient presenting with the symptoms of hysterical conversion had in fact been traumatized as a child by an adult, and that the memory of the event itself—the content of the memory, but not the associated affect—had been pushed from conscious awareness through repression. The symptoms currently being experienced by the adult patient were traceable back to that earlier, traumatic sexual experience. The third refinement in Freud’s theory came with the development of what is called the “fantasy theory” (S. Freud, 1894/1959). By this time, Freud wanted to find a more universal explanation for the causes of neurotic symptoms, and he recognized that it was not necessary to postulate that an actual sexual trauma was at the base of every patient’s symptoms. However, he wished to retain his emphasis on the sexual nature of these symptoms and found what he thought would provide a more universal basis for the

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emergence of neurotic symptoms in what he understood to be the nature of childhood sexuality. In this reformulated account, a sufficient and more universal explanation for the neurotic’s symptoms could be found by positing that all children experienced sexual fantasies toward a parent, fantasies which generated intrapsychic conflict, which therefore must be repressed. This intrapsychic conflict was called the Oedipal complex for boys and the Electra complex for girls. However, because psychic energy is “conserved,” the repression of the child’s conflictual desires was rarely entirely successful and typically would emerge during adulthood in the form of neurotic symptoms. These symptoms, again, only indirectly and symbolically pointed to their underlying cause. It is important to point out that this third refinement, involving the transition from Freud’s seduction theory to his fantasy theory, has served as the source of considerable controversy in the field of trauma studies. The argument has been made that Freud retracted his earlier seduction theory, which situated the etiology of neurotic symptoms in actual, traumatic experiences of a sexual nature, and that he did so possibly under social pressure (e.g., Herman, 1992). This argument indeed seems reasonable when one considers the magnitude of the implications of the seduction theory for Victorian society of the time as well as for Freud’s own place within that society. On the other hand, others have pointed out that even Freud’s seduction theory involved some interpolation on his part regarding the presence of sexual trauma in childhood (i.e., it is not accurate to state that his patients, themselves, always or necessarily volunteered or even endorsed such information during their therapy with him), and, more to the point, that a review of Freud’s writings throughout his career demonstrates that he never abandoned his acknowledgement of the traumatic potential of actual sexual violence against children (see, e.g., Piers, 1996). He did, however, de-emphasize the centrality of actual sexual events in his theory of trauma, in the search for a more universal explanation for his patients’ symptoms. Still, it seems true that this theoretical shift in emphasis, away from actual seduction, had consequences for the practice of psychotherapy and for those who would experience actual sexual abuse as children (Herman, 1992). Ultimately, perhaps Freud’s most enduring contribution to trauma theory rests with neither his seduction theory nor his fantasy theory but, rather, with his initial formulation of the functional and idiosyncratic understanding of traumatic experience. In his initial formulation, trauma is understood as that which is subjectively intolerable to the individual (regardless of its source), and which, therefore, is pushed from conscious awareness in an effort to reduce the associated anxiety. Such traumatic experience nevertheless continues to have the power to impact the person negatively and powerfully through the presence of various (often somatic) symptoms.

Newer Psychodynamic Approaches: Character Freudian psychoanalysis has itself undergone numerous revisions in the century or so since it was first proposed. Many clinicians now accept, with few reservations, Freud’s notions that childhood experiences continue to exert an influence on the person throughout adulthood, and that some forms of psychopathology reflect the operation of unconscious processes and conflicts. These clinicians do not necessarily accept other psychoanalytic propositions such as drive theory or the presumed etiology of neurosis in the Oedipal/Electra complex. Relevant to trauma theory is one perspective that incorporates the more widely accepted aspects of psychoanalysis while building on the more recent work of Reich (1972) and Shapiro (1965). In this vein, Piers (1998) has proposed that character provides a critical lens for understanding the ongoing significance of past traumatic experiences. Drawing upon Reich’s notions of character structure and character armor,

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character—which may be distinguished from the broader construct—personality represents “the individual’s formal way of organizing subjective experience” (p. 15). In other words, the mere fact of a traumatic experience is not sufficient to understand its impact on the individual; one must take into account the person’s characteristic ways of organizing and interpreting his or her experiences. In this regard, character pathology refers to “a dynamic and restrictive way of organizing conscious experience through which entire aspects of ongoing subjectivity (including thoughts, reactions, sensations, and feelings) are effectively excluded, leaving the patient estranged from himself or herself” (p. 16). This process of self-alienation can refer both to one’s past traumatic experience as well as to ongoing experiences in the present. Similar to Freud’s earlier view, this view proposes that the experience and interpretation of events as traumatic is subjective and idiosyncratic. Importantly, working with clients entails understanding their character, because any retelling of past or present experiences takes place through the interpretive lens of character. This approach focuses on helping clients “become more able to explore feelings, thoughts, and reactions to past trauma, as well as to any other area of conflict,” so as to increase their “capacities to tell their therapists, and, more important, themselves, what they have experienced and are currently experiencing, rather than their therapists telling them” (p. 31). This latter point comes in part as a response to the criticism that therapists who work with trauma may be guilty of implanting “false memories” in their clients’ minds, a criticism which most often has been cited as a problem associated with the dissociative approach, to be discussed next.

Contemporary Trauma Theory: Dissociation Many contemporary trauma theorists have adopted a traumagenic approach to psychopathology that is based on the process of dissociation rather than that of repression entailed in the Freudian model (e.g., Herman, 1992; Putnam, 1989; Siegel, 1995; van der Kolk, 1991). With dissociation, a traumatic experience is thought to be recorded in memory whole and intact, unaltered by any interpretive process on the part of the one experiencing the trauma. Whereas repression involves a motivated or defensive forgetting, dissociation reflects a passive encoding and “encasing” of the traumatic experience. In this view, the traumatic memory is segregated, or “disassociated,” from the rest of the person’s memories and remains nonconscious. The dissociated traumatic memory, however, can continue to influence the person in various ways. Of particular relevance are “trigger” experiences, which typically come in the form of cues in the environment (auditory, visual, tactile, olfactory, relational) that resemble features of the encoded traumatic memory. Because the memories themselves are encoded in a way that bypasses higher cortical processing (Siegel, 1995; van der Kolk, 1991), when they are triggered, they can lead to behavioral enactment and re-experiencing of the traumatic event in ways that also bypass higher cortical processing. In a certain sense, the person who has been traumatized is essentially passive, transmitting into the future and reliving in the present (when environmental cues are present) the traumatic experience that happened in the past. Recovery involves “truth-telling” (Herman, 1992), in which the person revisits aspects of the traumatic experience so that they can be reintegrated. Abreaction or catharsis is an important component of this process, as is the relationship between client and therapist. This relationship, ideally, is “corrective” to the extent that it assists the client in developing psychological capacities—such as trust, competence, initiative, intimacy, and identity— that were destroyed or severely damaged by the traumatic experience. According to Piers (1998), the dissociation perspective on trauma opens itself to the criticism of false memories, precisely because it proposes that memories of traumatic events are recorded whole

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and intact, bypassing higher cortical processing, and that the forgetting is not motivated but rather represents disassociation from the rest of one’s memories. Conceptually, recovery of the memory by the individual himself or herself is thus made problematic, to the extent that the memory is encapsulated and cut off from the higher cortical processes.

Self-Determination Theory: Basic Psychological Needs, Integration, and the Self Another contemporary theory with the potential to shed light on the nature and experience of trauma is self-determination theory (SDT; Ryan, 1995; Ryan & Deci, 2000a, 2000b, 2008; Ryan et al., 2006). SDT is an empirically grounded theory of motivation, personality, and development that has roots in the existential-phenomenological and humanistic traditions. However, it also shares an appreciation for the understanding of unconscious and defensive processes first explored by Freud and, in particular, for Freud’s articulation of the synthetic function of the ego (S. Freud, 1936). In Freudian thought, the synthetic function suggests that the ego serves to organize and integrate aspects of experience into a coherent and meaningful whole. In addition, SDT acknowledges the contributions of newer psychodynamic approaches such as the attachment and object relations perspectives (e.g., La Guardia, Ryan, Couchman, & Deci, 2000); these perspectives underscore the importance of interpersonal experiences that serve to support or undermine the psychological needs of the child, and later of the adult, throughout development (Ryan & La Guardia, 2000). From an SDT standpoint, integration of experiences into the self happens organismically as a result of natural propensities for growth in interaction with environmental affordances.

Organismic Growth Processes, Basic Psychological Needs, and Environmental Affordances With regard to environmental affordances and their role in human development, SDT argues that both growth and psychopathology can be understood as at least partly the result of either provisions for or deprivations of basic psychological needs within and by the environment. When the environment provides opportunities for the individual to satisfy these basic needs, growth and integration occur; when the environment fails to provide such opportunities, or, perhaps worse, actively thwarts their satisfaction, there are expectable negative consequences for the “normal” processes of growth and development and the ability of the self to integrate experience. On the basis of theory and empirical research, SDT argues that there are three basic psychological needs that humans require for optimal growth and development, from childhood and throughout the life span. These are the needs for relatedness, or the feeling of being connected in meaningful and mutually satisfying ways to important others; for competence, or the feeling that one is able to use and to extend one’s current abilities through experiences of optimal challenge; and for autonomy, or the feeling that one is able to make personally meaningful choices, and that one endorses or “stands behind” the choices one makes. Although the needs for relatedness and competence are relatively uncontroversial in contemporary psychological theorizing, the need for autonomy has required some justification, as it has frequently been confused with independence or individualism. This distinction is important because the need for autonomy may have particular relevance to the experience of traumatic events.

The Concept of Autonomy and its Role in Human Development SDT draws its concept of autonomy from the phenomenological tradition (e.g., Husserl, 1980) and means, literally, rule by the self. In the context of SDT, this implies that one’s

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behaviors and beliefs are experienced as emanating from the self, that they are volitional, and that one has given assent to them. The inverse of feeling autonomous in one’s actions and beliefs is feeling controlled or pressured, whether by outside forces (e.g., the expectations of a parent, a teacher, or a therapist) or by internal forces (variously termed introjects, “shoulds,” or conditions of worth that translate into contingent self-esteem; see for example Assor, Roth, & Deci, 2004). As noted, SDT strongly distinguishes autonomy from either independence or individualism (Chirkov, Ryan, Kim, & Kaplan, 2003; Lynch, Vansteenkiste, Deci, & Ryan, 2011), both of which suggest detachment from others or a feeling of self-sufficiency. In the SDT view, however, one can be autonomously dependent on others, and this ability to rely willingly on others in fact can have important benefits for development and wellness (e.g., Lynch, et al., 2011; Ryan, La Guardia, Solky-Butzel, Chirkov, & Kim, 2005; Ryan & Lynch, 1989). Importantly for this discussion, SDT argues that autonomy represents an important line of development (A. Freud, 1965; Ryan, 2005) that has continuity across the various phases of psychosocial development. In this regard, many theories of development (e.g., Hartmann, 1958; Piaget, Brown, Kaegi, & Rosenzweig, 1981) consider movement toward greater autonomy, as an aspect of self-regulation, to be an expectable, healthy developmental outcome. Moreover, as individuals develop across the life span, their capacities for self-regulation also continue to develop, particularly in response to the changing demands of their expanding and evolving environment (Ryan & La Guardia, 2000). However, failures on the part of early caregivers in the provision of supports for the developmental line of autonomy can have deleterious consequences for the developing child’s ability to self-regulate, and a traumatic insult (as in the case of abuse) can have a particularly powerful impact in this regard. As just one example of this phenomenon, Ryan (2005) traced the potential impact of “nontraumatic” and traumatic failures in autonomy support in the etiology of borderline personality disorder (BPD). In particular, chronic and egregious failures on the part of caregivers in providing supports for the need for autonomy, as well as the need for relatedness, can result in “the disrupted capacities for self-regulation and relating to others” that characterize BPD (p. 988), disruptions which are further reflected in the lack of a coherent and stable sense of self with which BPD is associated. Most saliently, a traumatic insult, such as that represented by the experience of physical or sexual abuse, represents a violent expression of control that may do more than merely fail to support the autonomy of the one who experiences the abuse. Particularly to the extent that the abuser is in a position of power with respect to the one abused, such traumatic insult threatens to undermine that person’s autonomy: asserting one’s autonomy in the face of threatened or perceived future harm from a powerful “other” may entail overwhelming risks to the self (the construct of “otherness” is discussed more fully in Chapter 16). Children, in particular, are vulnerable to sacrificing autonomy for the sake of preserving relatedness, or some semblance of relatedness, with an abusive parent. Failures to support the developmental line of autonomy may even have implications at the neurocognitive level. Ryan (2005), for example, pointed to the importance of affective and memory-related processes in supporting autonomous functioning, with regard to the executive functions: indeed, interference, “inhibition or damage in the development or functioning of prefrontal areas and connections with limbic structures produces vulnerabilities to autonomy disturbance, especially when the processing of affectively salient events is entailed” (p. 990). This line of reasoning has important implications for understanding traumatic events. As we have seen, the experience of a traumatic event has been linked in various theoretical perspectives with disturbances in the storage within memory of the content of the traumatic event as well as the affect associated with it. The SDT perspective argues that one consequence of this disturbance

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in the way that memories for traumatic events are encoded is that it can create problems in executive functioning and consequently in autonomous self-regulation. These problems can manifest themselves as symptoms, such as the difficulties in self-regulation experienced by those suffering from BPD. A traumatic insult in the form of abuse at the hands of caregivers represents a disruption in both autonomy and relatedness, and, among other consequences, can result in the child’s (and later the adolescent’s or adult’s) inability to recognize his or her own inner needs, a capacity which is essential for selfregulation. Importantly, it should be noted in this regard that BPD, from which the current example of SDT’s perspective on trauma is being extrapolated, has itself often been linked to early traumatic experience in the form of abuse (see, e.g., Herman, Perry, & van der Kolk, 1989; Zanarini, 1997).

Therapeutic Implications In therapeutic work with clients who have experienced trauma, an SDT approach would include the validation and acceptance of experience that are key concepts in Linehan’s (1993) dialectical behavior therapy (DBT) for persons with BPD. Validation and acceptance are critical for the development of self-awareness and for the organization of the self. As well, when provided by the therapist in the context of the client–counselor relationship, they reflect supports for the basic needs for autonomy and relatedness (Ryan, 2005). Another component of DBT that has relevance for this discussion is the cultivation of mindfulness, or mindful awareness, which plays a critically important role in reflective self-awareness, impulse control, and tolerance of distress (Brown & Ryan, 2003, Ryan, 2005). These elements—validation and acceptance of experience, and mindfulness—may be helpful not only in the treatment of BPD, per se, but may also prove essential for clinical work with any who have experienced a traumatic event, insofar as exposure to trauma can undermine both one’s sense of security and safety, including within relationships, and one’s ability to autonomously self-regulate. In terms of the client–therapist relationship, an increasing body of literature points to the importance of an autonomy-supportive stance on the part of the therapist, both in terms of establishing a therapeutic alliance, and for promoting the internalization and maintenance of change across contexts (e.g., Lynch & Levers, 2007; Lynch, et al., 2011; Ryan, Lynch, Vansteenkiste, & Deci, 2011). Indeed, promoting a therapeutic alliance may be especially challenging and especially important for the client who has experienced trauma because the ability to trust within interpersonal relationships can so easily be damaged, particularly when the traumatic insult was itself interpersonal in nature.

COUNSELING IMPLICATIONS In this chapter, I have described three broad conceptual or theoretical frameworks for understanding the nature and consequences of traumatic experience: the repression, the dissociation, and the SDT approaches. Of course, the importance of theory for counselors and other therapists lies not only in helping them to understand the nature and etiology of the client’s presenting problems or symptomatology, but also in providing possible interventions, strategies, and ways of being with the client that therapeutically address those problems and symptoms. As previously noted, all three perspectives recognize that early childhood experiences and nonconscious processes can play an important role in how clients perceive and interpret subsequent experiences, and in how they integrate or fail to integrate those experiences, with consequences for development and well-being.

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In terms of implications for therapy, viewing traumatic experience within the framework of repression suggests the importance of recovering the repressed material, both in terms of content and the associated affect. Toward this end, classical Freudian techniques—working with the client’s dreams, free association, and so on—may be employed to facilitate a cathartic reconnecting of content and affect. More contemporary approaches within this broad tradition emphasize that it is essential for the therapist to bear in mind the importance of helping the client to reconnect not only with past traumatic experience, including its affective tone, but also with his or her present experiences and emotions, which may have become obscured by distortions and defenses employed to protect the self in the past, but which no longer serve an adaptive purpose in the present. Viewing trauma through the lens of dissociation, recovery similarly involves revisiting the traumatic experience accompanied by a cathartic release of emotions. The relationship between therapist and client provides a corrective experience that assists the client in developing psychological capacities and functions that were destroyed or severely damaged by the traumatic experience. These capacities and functions include trust, competence, initiative, intimacy, and identity. The SDT perspective acknowledges the important contributions made by the repression and dissociation traditions, particularly the more recent emphasis on the importance of the therapeutic relationship in helping the client reconnect with the past in order to more fully experience and engage life in the present. In addition, SDT emphasizes the client’s inherent, organismic capacity to integrate experience into a coherent sense of self. Although traumatic experience may have injured the client’s natural integrative abilities, SDT suggests that the relationship between therapist and client, characterized by an autonomy-supportive stance on the part of the therapist, has the potential to serve as a space wherein clients can feel safe to explore their past traumatic experience and to gradually integrate it into a coherent sense of self. In the context of a supportive relationship with the therapist and through growth in mindful awareness, clients can rediscover their basic psychological needs for autonomy, relatedness, and competence, learning how to satisfy those needs in healthy ways in their current relationships, thus gradually overcoming the harmful interpersonal legacy of past traumatic experience.

CONCLUSION This chapter reviewed several theoretical perspectives on the nature and experience of trauma. This review is necessarily incomplete, and should be supplemented by other perspectives; for example, the perspective offered by developmental psychopathology, which is covered elsewhere in this volume. However, the commonalities and unique contributions across the three theories reviewed herein—the Freudian theory of repression, contemporary trauma theory also known as dissociation theory, and SDT—offer important insights that can serve as a starting point for clinicians and others interested in understanding the phenomena of trauma. Regarding the unique contributions of the three approaches, whether traumatic memories are repressed in a motivated process of forgetting, or whether they are encased and dissociated from the rest of one’s experience, will almost surely be the subject of future theoretical debate and empirical research. This discussion is likely to be enriched as our understanding of the multiple neurocognitive processes involved in the encoding of memories continues to expand. Further, our understanding of the role played by relationships in the etiology and experience of trauma, in particular, by relationships that either support or thwart autonomy

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as a basic psychological need with an important line in human development, is likely to be refined. Although all three approaches share an emphasis on the potentially serious psychological and emotional sequelae of traumatic events, and on the importance of understanding childhood experiences and nonconscious processes in the etiology and treatment of adult psychopathology, each points to some aspect or dimension of trauma that may resonate more or less accurately with the experience of clinicians in the field. Even more important is that the theories resonate with the experience of those who carry within themselves the memory of trauma. Ultimately, the purpose of trauma theories, and the models of therapeutic intervention to which they lead, is to help alleviate the burden of an intolerable past so that life can be lived in the present.

APPENDIX 3.1 Self-Concept Discrepancies, Well-Being, and Autonomy Support As presented in this chapter, self-determination theory (SDT) suggests that satisfaction of the basic psychological need for autonomy plays a critical role in human beings’ natural tendency to organize and integrate their experiences into a coherent sense of self, echoing Freud’s notion of the synthetic function of the ego. In this regard, autonomy serves an important developmental role. One aspect of the self with important clinical implications is the self-concept. Years ago, Carl Rogers argued that the self-concept, or how people think about themselves, reflects the nature of their relationships with others, in particular, whether the important other people in one’s life, beginning with one’s parents, are unconditionally accepting, or whether they attach “conditions of worth” to their acceptance (see, e.g., Rogers, 1961). In addition, however, people also have an ideal view of self—that is, how they would, ideally, like to see themselves. When the difference between the ideal and actual self-concept is substantial, people generally experience a decrement to their self-esteem; often, the distress associated with this fragmentation in self-concept is enough to bring the person to counseling. Rogers and colleagues conducted a series of ingenious studies in which they demonstrated that, in the context of person-centered therapy, characterized by genuineness, empathy, and unconditional positive regard, clients moved closer to their ideal view of self (Rogers & Dymond, 1954). Rogers, in fact, argued that such movement could be used as an indicator of successful counseling, and considered it to represent positive change in the personality structure. A recent study (Lynch, La Guardia, & Ryan, 2009) explored Rogers’ predictions about the self-concept from an SDT perspective. College student participants from three different countries—China, Russia, and the United States—rated their current, actual self-concept in terms of the Big Five personality traits: openness to experience, conscientiousness, agreeableness, extraversion, and neuroticism. Specifically, participants were asked to think about how they saw themselves when they were with each of six specific relationship targets (mother, father, best friend, romantic partner, roommate, and teacher). They also rated how they would ideally like to see themselves in terms of each of these five personality traits, and how much autonomy support they experienced from each of their six relationship partners. Relationship-specific well-being was captured through measures of relationship satisfaction, vitality, and positive and negative affect. Within-persons analyses were conducted using multilevel modeling. As predicted by Rogers, the further people felt themselves to be from their ideal self-concept when in particular relationships, the lower their well-being in that (continued)

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APPENDIX 3.1 (continued) relationship. On the other hand, as predicted by SDT, when people felt themselves to be in relationships they experienced as autonomy supportive, the closer their relationship-specific self-concept was to their own personal ideal. Importantly, these patterns held across all three countries, providing important cross-cultural support both for Rogers’ prediction about the self-concept, and for SDT’s prediction about the role of autonomy support in the integration of the self-concept. In terms of trauma studies, this research provides another possible way to conceptualize both the nature of the injury to the self, caused by traumatic experiences, and the role of the therapist in working with the traumatized client. It is possible, for example, that the controlling nature of traumatic abuse, which undermines the individual’s sense of autonomy, also creates a fragmentation between actual self-concept and ideal self-concept. As a result of abuse, there is often a tendency to see oneself in especially unfavorable terms, potentially creating a large discrepancy from one’s ideal view of self, with attendant consequences for personal and interpersonal well-being. In the course of working with the client, the counselor who is aware of this possibility will be all the more attentive to the importance of fostering the client’s autonomy, through appropriately autonomy-supportive interactions, in order to facilitate the client’s ability both to validate his or her personal ideal view of self, and to move toward that ideal through need-satisfying relationships and experiences. Future research in this area might explore the following questions: ■ Is traumatic experience, in fact, associated with greater discrepancies between

actual and ideal self-concept? ■ Does traumatic experience affect not only the actual view of self, but perhaps

also the ideal view of self? ■ How can counselors best promote a client’s natural integrative abilities, for

example, by helping the client to understand, to validate, and to satisfy his or her basic psychological needs for relatedness, for competence, and, in particular, for autonomy?

RESOURCES For more information on the self-determination theory approach to human motivation and development, readers are referred to the SDT website. This website contains helpful information for clinicians, researchers, and all who are interested in the theory and its many applications beyond counseling and psychotherapy. SDT Website: http://www.psych.rochester.edu/SDT/

REFERENCES Assor, A., Roth, G., & Deci, E. L. (2004). The emotional costs of perceived parental conditional regard: A self-determination theory analysis. Journal of Personality, 72(1), 47–87. Breuer, J., & Freud, S. (1892/1959). On the psychical mechanism of hysterical phenomena: Preliminary communication. In J. Riveier (Trans.), Sigmund Freud: Collected papers (Vol. 1, pp. 24–42). New York, NY: Basic Books.

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Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84 (4), 822–848. Chirkov, V., Ryan, R. M., Kim, Y., & Kaplan, U. (2003). Differentiating autonomy from individualism and independence: A self-determination theory perspective on internalization of cultural orientations and well-being. Journal of Personality and Social Psychology, 84 (1), 97–110. Freud, A. (1965). The writings of Anna Freud: Vol. 6. Normality and pathology in childhood: Assessments of development. New York, NY: International Universities Press. Freud, S. (1894/1959). The defense neuro-psychoses. In J. Riviere (Trans.), Sigmund Freud:Vol. 1. Collected papers (pp. 59–75). New York, NY: Basic Books. Freud, S. (1896/1959). The aetiology of hysteria. In J. Riviere (Trans.), Sigmund Freud: Collected papers (Vol. 1, pp. 183–219). New York: Basic Books. Freud, S. (1936). Inhibitions, symptoms, and anxieties. Psychoanalytic Quarterly, 5, 415–443. Hartmann, H. (1958). Ego psychology and the problem of adaptation. New York, NY: International Universities Press. Herman, J. L. (1992). Trauma and recovery. New York, NY: Basic Books. Herman, J. L., Perry, J. C., & van der Kolk, B. A. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146(4), 490–495. Husserl, E. (1980). Ideas pertaining to a pure phenomenology and to a phenomenological philosophy—Third book: Phenomenology and the foundations of the sciences (T. E. Klein & W. E. Pohl, Trans.). Dordrecht, Netherlands: Kluwer. La Guardia, J. G., Ryan, R. M., Couchman, C. E., & Deci, E. L. (2000). Within-person variation in security of attachment: A self-determination theory perspective on attachment, need fulfillment, and well-being. Journal of Personality and Social Psychology, 79 (3), 367–384. Linehan, M. M. (1993). Cognitive–behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Lynch, M. F., La Guardia, J. G., & Ryan, R. M. (2009). On being yourself in different cultures: Ideal and actual self-concept, autonomy support, and well-being in China, Russia, and the United States. The Journal of Positive Psychology, 4 (4), 290–304. Lynch, M. F., & Levers, L. L. (2007). Ecological-transactional and motivational perspectives in counseling. In J. Gregoire & C. M. Jungers (Eds.), The counselor’s companion: What every beginning counselor needs to know (pp. 586–605). Mahwah, NJ: Lawrence Erlbaum Associates. Lynch, M. F., Vansteenkiste, M., Deci, E. L., & Ryan, R. M. (2011). Autonomy as process and outcome: Revisiting cultural and practical issues in motivation for counseling. The Counseling Psychologist, 39 (2), 286–302. Piaget, J., Brown, T. A., Kaegi, C. E., Rosenzweig, M. R. (1981). Intelligence and affectivity: Their relationship during child development. Palo Alto, CA: Annual Reviews Inc. Piers, C. (1996). A return to the source: Rereading Freud in the midst of contemporary trauma theory. Psychotherapy, 33 (4), 539–548. Piers, C. (1998). Contemporary trauma theory and its relation to character. Psychoanalytic Psychology, 15(1), 14–33. Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. New York, NY: Guilford Press. Reich, W. (1972). Character analysis (3rd ed.). New York, NY: Simon & Schuster. Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston, MA: Houghton Mifflin. Rogers, C. R., & Dymond, R. F. (Eds.). (1954). Psychotherapy and personality change: Co-ordinated research studies in the client-centered approach. Chicago, IL: University of Chicago Press. Ryan, R. M. (1995). Psychological needs and the facilitation of integrative processes. Journal of Personality, 63 (3), 397–427. Ryan, R. M. (2005). The developmental line of autonomy in the etiology, dynamics, and treatment of borderline personality disorders. Development and Psychopathology, 17(4), 987–1006. Ryan, R. M., & Deci, E. L. (2000a). The darker and brighter sides of human existence: Basic psychological needs as a unifying concept. Psychological Inquiry, 11(4), 319–338. Ryan, R. M., & Deci, E. L. (2000b). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. Ryan, R. M., & Deci, E. L. (2008). Self-determination theory and the role of basic psychological needs in personality and the organization of behavior. In O. P. John, R. W. Robbins, & L. A. Pervin (Eds.), Handbook of personality: Theory and research (pp. 654–678). New York, NY: Guilford Press.

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Ryan, R. M., Deci, E. L., Grolnick, W. S., & La Guardia, J. G. (2006). The significance of autonomy and autonomy support in psychological development and psychopathology. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Theory and method (2nd ed., pp. 795–849). Hoboken, NJ: Wiley. Ryan, R. M., & La Guardia, J. G. (2000). What is being optimized over development?: A self-determination theory perspective on basic psychological needs across the life span. In S. H. Qualls & N. Abeles (Eds.), Psychology and the aging revolution (pp. 145–172). Washington, DC: American Psychological Association. Ryan, R. M., La Guardia, J. G., Solky-Butzel, J., Chirkov, V. I., & Kim, Y. (2005). On the interpersonal regulation of emotions: Emotional reliance across gender, relationships, and culture. Personal Relationships, 12, 145–163. Ryan, R. M., & Lynch, J. H. (1989). Emotional autonomy versus detachment: Revisiting the vicissitudes of adolescence and young adulthood. Child Development, 60 (2), 340–356. Ryan, R. M., Lynch, M. F., Vansteenkiste, M., & Deci, E. L. (2011). Motivation and autonomy in counseling, psychotherapy, and behavior change: A look at theory and practice. The Counseling Psychologist, 39, 193–260. Shapiro, D. (1965). Neurotic styles. New York, NY: Basic Books. Siegel, D. J. (1995). Memory, trauma, and psychotherapy: A cognitive science view. Journal of Psychotherapy Practice and Research, 4 (2), 93–122. van der Kolk, B. A. (1991). The intrusive past: The flexibility of memory and the engraving of trauma. American Imago, 48 (2), 425–454. Zanarini, M. C. (Ed.). (1997). Role of sexual abuse in the etiology of borderline personality disorder. Washington, DC: American Psychiatric Association.

CHAPTER 4

Neurobiological Effects of Trauma and Psychopharmacology JOHN R. TOMKO

INTRODUCTION The purpose of this chapter is to explore the underlying neurochemistry and subsequent pathology of posttraumatic stress disorder (PTSD). Subsequently, medications that are commonly prescribed in the treatment of PTSD are discussed. Emphasis is placed upon the expected drug mechanism of action in the treatment of this disorder. Through the integration of knowledge of the underlying disorder, coupled with the understanding of drug mechanisms, the reader should achieve a greater appreciation of the pharmacotherapy of PTSD. Armed with this knowledge, mental health professionals can better treat and monitor their patients affected by trauma. The goals of this chapter are achieved in the discussions found in the following sections: Physical Response to Trauma, The Brain and Physiologic Impact of Trauma, When Talk Therapies Are Not Enough, Commonly Prescribed Medications, and Implications for Counseling Professionals. These discussions are followed by a closing summary and a list of helpful resources for instructors, students, and clinicians.

PHYSICAL RESPONSE TO TRAUMA It is generally known that physiologic trauma influences a person’s health, well-being, and quality of life. Recovery from trauma of this sort may be a long-term, possibly lifelong, and often incomplete process. Psychological trauma, however, may be missed or discounted upon patient evaluation, leading to underdiagnosis (Blank, 1994; Grinage, 2003; McPherson, 2003). As in physiologic trauma, psychological trauma recovery processes may involve long-term, possibly lifelong, care and management. Trauma of this type affects patients in quality of life, activities of daily living, and can severely influence overall functioning (Grinage, 2003). Exposure to a traumatic event can lead to traumatic stress. The traumatic stress caused by exposure to an actual or perceived risk of death of serious injury, or the threat to physical integrity of oneself or others can lead to a potentially chronic and debilitating illness referred to as posttraumatic stress disorder (PTSD). PTSD is characterized by a cluster of symptoms that includes persistent intrusive thoughts, avoidance, and hyperarousal. These signs can express in affected patients with such behaviors as impulsivity, aggression, or even depression (American Psychiatric Association [APA], 2000; Davis, English, Ambrose, & Petty, 2001). Common classifications of such types of psychological or physical trauma which can induce PTSD include abuse

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(mental, physical, sexual, or verbal), catastrophe (accidents, natural disasters, or terrorism), violent attack (assault, rape, or battery), and combat/warfare exposure. Estimates of the lifetime prevalence of PTSD in the general adult US population are 1%–12% (Lange, J., Lange, C., & Cabaltica, 2000; Yehuda, 2004), with an estimated 30% of men and women who have been in war zones having been diagnosed with the disorder (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kulka et al., 1990). Early life trauma is recognized as a risk factor for development of psychiatric illnesses later in life, such as major depressive disorder (MDD; Ballenger et al., 2004). It also is known that females develop the condition at between two and four times the rate as males (Grinage, 2003; Yehuda, 2002). Patients who go on to develop PTSD after exposure to a stressful and traumatic event exhibit the hallmark signs of the disorder, which include reexperiencing of the event, avoidance of reminders of the event, and hyperarousal. Further, these symptoms express in conjunction with feelings of fear and helplessness. The onset of the disorder is also characterized by three different subtypes of PTSD: acute, chronic, and delayed onset. The acute PTSD subtype has a very rapid onset following the event, with symptoms lasting less than 3 months. Chronic PTSD symptoms may last 3 months or longer. Finally, the delayed onset patient may begin experiencing symptoms of PTSD 6 months or longer following exposure to a traumatic event (APA, 2000). Psychological trauma can lead to significant changes in neurochemical and neurobiological functioning. Early life trauma has been shown to be a significant risk factor for the development of psychiatric illness later in life, including PTSD, other anxiety disorders, and depression. The neurobiological and neurochemical changes that occur as a result of early life stressors may persist or express later in life (Heim & Nemeroff, 1999, 2001). These changes have been well documented and have a significant influence upon the development of PTSD (Bremner et al., 1997; Carlson & Earls, 1997; DeBellis, Baum, et al., 1999; DeBellis, Keshaven, et al., 1999). Although many persons have been exposed to trauma in their lives, only a portion goes on to develop the signs and symptoms of PTSD. The factors for the risk of the development of PTSD are not fully understood. The experiencing of abusive relationships, victimization of physical or mental abuse, surviving violent attacks or overtures, witnessing a violent act or traumatic event, or being interjected into a violent or disturbing situation do not necessarily cause a person to develop PTSD. Patients’ risk for development of the disorder and their resilience following exposure to an event are areas that require further study. Studies suggest that previous exposure to trauma and intensity of the response to acute trauma may affect the development of PTSD. Neurochemical changes, particularly lower cortisol levels, may influence information processing of traumatic memories and may be associated with the underlying pathology of PTSD (Yehuda, 2004).

THE BRAIN AND PHYSIOLOGIC IMPACT OF TRAUMA Following a traumatic event or witnessing a traumatic event, the central nervous system (CNS) begins to develop neurochemical pathways and physiological adaptations in order to respond to the situation. Areas of the brain which involve memory, such as the amygdala and hippocampus, have increased reactivity to stimuli following acute situations (Yehuda, 2002). Persons also develop changes in hippocampus function and memory processing, suggesting a possible reason for the symptoms of reexperiencing of a traumatic event. PTSD also has shown increased levels of CNS norepinephrine— the neurotransmitter released from the locus coeruleus and responsible for the “fight-or-flight” response, as well as increased reactivity of the alpha-2 adrenergic

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receptors, stimulation of which is responsible for increased heart rate, blood pressure, and anxiety response. Increased levels of norepinephrine, coupled with increased sensitivity of the adrenergic binding sites, promote worsening of the anxiety symptoms common in PTSD and anxiety disorders (Southwick et. al, 1999). Anxiety disorders such as generalized anxiety disorder, panic disorder, and PTSD are characterized by a CNS imbalance between two distinct neurotransmitters: serotonin and norepinephrine. Serotonin, which is responsible for mood regulation in the brain, is found to be normal to slightly diminished in anxiety disorders. The serotonin center of the brain is located within the upper brain stem in the form of two organelles: the dorsal and rostral raphe nuclei. The raphe nuclei release serotonin for mood regulation as well as other bodily functions such as gastrointestinal regulation, skeletal muscle tone, platelet function, and temperature regulation. Located just near the rostral raphe nuclei is the norepinephrine center of the brain, the locus coeruleus. Norepinephrine release from the locus is greatly increased in anxiety disorders. Increases in norepinephrine in the brain and periphery are characterized by anxiety, tremors, increased focus, increases in blood pressure, and tachycardia. When an increase in norepinephrine is overlaid with normal to decreased serotonin function, patients present with symptoms attributable to psychic anxiety (Charney, Woods, Goodman, & Heninger, 1987). Centrally (within the brain and spinal cord), patients present with nervousness, agitation, sleep disturbances, hypervigilance, and heightened memory and thought processing. Peripherally, patients may present with physiologic or somatic symptoms of anxiety, such as tachycardia; high blood pressure; rapid, shallow breathing; and tremors (see Figure 4.1). Another type of physiological change that is unique to PTSD, in contrast to the other anxiety disorders, involves CNS and peripheral adaptation of the body’s response to corticotropin-releasing hormone (CRH) from the pituitary gland, located in the basal

Figure 4.1 Brain Structures That Are Affected in Anxiety Disorders Take particular notice of the location of the locus coeruleus, dorsal raphe nucleus, amygdala, hypothalamus, and hippocampus. parietal lobe

frontal lobe

occipital lobe

thalamus hypothalamus

cerebellum

amygdala locus coeruleus

hippocampus dorsal raphe nucleus

Source: Adapted from Lundbeck Institute (2000).

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Trauma and Context

anterior portion of the brain. The pituitary gland works on a feedback mechanism in conjunction with the hypothalamus (located in the midbrain) and the adrenal glands, located on the dorsal area of the kidneys. These organs comprise the hypothalamuspituitary-adrenal axis (HPA axis). In normal body function, CRH is released by the pituitary gland, located in the basal anterior portion of the brain. The normal progression of function of the HPA axis is as follows: CRH is released from the hypothalamus, which in turn signals the pituitary gland to release adrenocorticotropic hormone (ACTH), otherwise called corticotropin. Corticotropin release causes the adrenal glands to release cortisol, a glucocorticoid which has many responsibilities in the body, one of which is mitigation of the stress response. In PTSD, altered response to CRH occurs. Increased levels of CRH are detected in PTSD patients. Therefore, based upon the normal progression of the HPA axis, greatly decreased levels of cortisol are released from the adrenal glands. The net effect is decreased levels of cortisol, which produces a diminished stress response from the body (Yehuda, 2002). With the presence of a pronounced norepinephrine effect, coupled with a diminished cortisol response, patients who develop PTSD may have an increased and protracted exposure to high levels of norepinephrine. This norepinephrine increase, coupled with an imbalance with serotonin, may cause patients to express signs and symptoms of an anxiety disorder. In addition to the stress and anxiety response caused as a part of norepinephrine increase, the PTSD patient also presents with diminished cortisol production. Because cortisol is attributed to mitigation of the stress response through neuroprotection, the amygdala and hippocampus memory areas of the brain are subject to a sustained exposure to high norepinephrine levels. Additionally, patients diagnosed with PTSD have been shown to have higher levels of norepinephrine in the cerebrospinal fluid compared to an unaffected population (Geracioti et al., 2001). This sustained exposure to high norepinephrine leads to increased levels of norepinephrine within the cerebrospinal fluid, leading to increased and prolonged excitability and signaling within the CNS. In the absence of the neuroprotective effects of cortisol, sustained norepinephrine exposure within the amygdala and hippocampus may lead to an ingrained response to the offending stimuli. Research has shown that, in addition to amygdala and hippocampal damage, high levels of unchecked norepinephrine may be a possible trigger to emotion expression in the prefrontal cortex area of the brain, the area attributed to executive functioning (Arnsten, 2007). It further has been shown that there are definitive changes in the locus in some diagnosed PTSD patients on autopsy, which possibly may be a reason for prolonged norepinephrine response (Bracha, Garcia-Rill, Mrak, & Skinner, 2005).

WHEN TALK THERAPIES ARE NOT ENOUGH In the treatment of anxiety disorders such as PTSD, psychotherapies (talk therapies) have been considered the mainstay of treatment. Some of the more familiar therapies include several strategies such as cognitive behavioral therapy (CBT) in the form of exposure therapy, stress inoculation, cognitive therapy, and eye movement desensitization and reprocessing (Seedat, Stein, & Carey, 2005), and therapy may include combinations of these CBT methods (Bryant, Sackville, Dang, Moulds, Guthrie, 1999). Supportive counseling also has been employed (Bryant, Harvey, Dang, Sackville, & Basten, 1998). Patients engage in these therapies to de-escalate, discover root causes of behaviors and reactions, and develop new coping mechanisms to manage the stressors brought about by the anxiety disorders. As we already know, PTSD is characterized by the three sets of core symptoms exhibited by the disorder, that is, reexperiencing, avoidance, and hyperarousal, which

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persist for greater than 1 month. During psychological treatments, or in the performance of activities of daily living, core symptoms may cause inordinate anxiety, which can pose significant barriers to successful emoting of feelings, beliefs, and reactions. Inability to manage these barriers subsequently may lead to suboptimal outcomes throughout the course of treatment, causing patients to feel overwhelmed and hindering therapeutic alliance formation during these therapeutic encounters. In cases such as these, the addition of medication therapies is warranted. Individuals diagnosed with mild acute PTSD may not need medications to engage in psychotherapy. Patients with the diagnoses of mild chronic PTSD, severe acute PTSD, and severe chronic PTSD would benefit from the dual treatment modalities that combination pharmacotherapy and psychotherapy can provide. Therefore, the choice of whether or not to use medications is based upon severity and duration of symptoms. The medications used for the treatment of PTSD work on one or all of these symptoms, allowing the patient to engage fully in psychological therapies to gain maximal benefit from treatment. These medications provide the patient with resolution of the symptoms during activities of daily living and in psychotherapy sessions, giving patients a better opportunity to experience improved day-to-day functioning while simultaneously allowing them to apply the coping mechanisms garnered during these therapy sessions.

THE NEED FOR MEDICATIONS IN THE TREATMENT OF POSTTRAUMATIC STRESS DISORDER Medications have become a valuable management tool in the treatment of PTSD. Although talk therapies such as CBT, group therapies, eye movement desensitization and reprocessing, and others are effective in the treatment of this disorder, medications are a welcome addition to the treatment armamentarium of clinicians. Medications have been shown to be helpful in the management of core symptoms of the disorder, which can aid patients in their engagement in various psychotherapies and assist persons afflicted with the disorder in improving their function in activities of daily living. Many different agents have been employed in the medical treatment of PTSD, despite the fact that many of these agents do not carry an approval from the United States Food and Drug Administration (FDA) for PTSD treatment. When medications are used that do not have FDA approval for treatment of a specific condition, despite the fact that there is evidence demonstrating effectiveness of the agent, the use of the agent in such circumstances is termed “off-label use” in practice. Most medications that are used to treat PTSD are employed “off-label.” Currently, only two medications have FDA approval for the treatment of PTSD. The following sections discuss the various classes of drugs employed in treatment, both FDA-approved medications and off-label medications. The list of commonly prescribed medications, both approved and off-label, are provided in Tables 4.1 through 4.3.

COMMONLY PRESCRIBED MEDICATIONS IN TREATMENT OF PTSD Antidepressants: Selective Serotonin Reuptake Inhibitors Selective Serotonin Reuptake Inhibitor (SSRI) agents are a class of medication that have been studied and used extensively in the treatment of various medical conditions. Each individual agent (with the exception of fluvoxamine) has been approved by the FDA for the treatment of MDD. They also carry FDA approvals for the treatment of various

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Table 4.1 Antidepressants Used in Posttraumatic Stress Disorder Generic Name

Brand Name

Usual Dosage Range (mg/day)

SSRIs Sertraline # Paroxetine

Zoloft #

Paxil Paxil CR

25–200 20–60 12.5–62.5

Citalopram

Celexa

20–60

Escitalopram

Lexapro

10–20

Fluoxetine

Prozac

20–80

Fluvoxamine

Luvox*

25–300

Effexor

37.5–225

SNRIs Venlafaxine

Effexor XR Duloxetine

Cymbalta

20–120

Remeron

15–45

Wellbutrin

75–450

Mixed mechanism agents Mirtazapine Bupropion

Wellbutrin SR Wellbutrin XL Nefazodone

Serzone*

100–600

Trazodone

Desyrel*

50–600

Amitriptyline

Elavil*

25–300

Imipramine

Tofranil*

25–300

Tricyclic Agents

Toframil PM Desipramine

Pamelor

25–300

Nardil

45–90

MAOI Phenelzine #

FDA approved for PTSD. *Brand name discontinued; generic available.

anxiety disorders; however, each individual agent may carry approvals for specific subsets of anxiety disorders. The mechanism of action of these agents, as described by their drug class, is the prevention of serotonin reuptake into the neural presynaptic vesicles. Simply put, these agents prohibit serotonin from being reabsorbed into the presynaptic nerve terminal, thereby increasing the amount of serotonin available in the nerve synapse. By increasing the available serotonin in the synapse between the neurons, there is an increased amount of serotonin available to stimulate the postsynaptic neuron. Increasing serotonin stimulation at the postsynaptic neuron allows more serotonin-mediated signaling to be carried forth. As previously discussed, serotonin is responsible for mood regulation. Therefore,

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Table 4.2 Antipsychotic Agents Used in Posttraumatic Stress Disorder Generic Name

Brand Name

Usual Dosage Range (mg/day)

Atypical Agents Risperidone Quetiapine

Risperdal

2–6

Seroquel

200–900

Seroquel XR Olanzapine

Zyprexa

5–40

Ziprasidone

Geodon

40–200

Typical agents Haloperidol

Haldol*

Fluphenazine

Prolixin*

2.5–40

2–100

Perphenazine

Trilafon*

8–64

*Brand name drug discontinued; generic available.

by increasing serotonin stimulation, patients can see improvement in mood symptoms (Stahl, 2000). This mechanism has been shown to be quite useful in treating MDD, where there is a decrease in serotonin as well as a decrease in norepinephrine. By increasing serotonin from the raphe nuclei in MDD, the locus coeruleus may respond as well by increasing norepinephrine output. Therefore, serotonin and norepinephrine achieve a balance, which improves mood, energy, and concentration. Anxiety disorders, however, have a different type of neurochemical imbalance. Anxiety disorders such as generalized anxiety disorder, panic disorder, and PTSD exhibit an increased amount of norepinephrine in the CNS, contrasted with a relative decrease in serotonin, leading to neurochemical balance. Because CNS serotonin is decreased in anxiety disorders, the attributes of norepinephrine are exhibited that are characteristic of anxiety disorders: psychic anxiety, tremulousness, somatic anxiety, hyperreactivity, increased blood pressure, and increased heart rate. Because the effects of increased norepinephrine express in anxiety disorders due to the inability of serotonin to offset the increase, SSRI agents are helpful in managing all three core symptoms of PTSD through an increase in available serotonin, creating a balance between serotonin and norepinephrine. Upon examination, core symptoms of PTSD (reexperiencing, avoidance, and hyperarousal) can be attributed to increases in CNS norepinephrine as well as decreases in serotonin. Reestablishing this balance can help to improve core symptoms and improve

Table 4.3 Adjunctive Agents Used in Posttraumatic Stress Disorder* Generic Name

Brand Name

Usual Dosage Range (mg/day)

Clonidine

Catapres

0.1–0.6

Guanfacine

Tenex

1–3

Prazosin

Minipress

1–20

*No agents approved for PTSD.

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patient daily functioning. Patients also are able to participate in their psychological treatments in a more enriching manner and to function at a higher degree in their daily lives. SSRI agents are considered first-line agents in the pharmacotherapy of PTSD and have been used extensively in patient treatment. Of the SSRIs, the only ones that have been approved by the FDA for the treatment of PTSD are sertraline (Zoloft, 2010) and paroxetine (Paxil, 2010). Additionally, they are the only two of any medication class that are FDA approved for the treatment of PTSD. This is not to say that other SSRIs have not been used in the treatment of PTSD or have been shown to be ineffective in treatment of the disorder. As discussed earlier in this chapter, many of these medications have been used off-label in PTSD treatment. This practice is common in medicine, and the use of unapproved agents to treat various conditions sometimes may be considered the standard of practice. An everyday example of this is the use of a daily aspirin tablet for the prevention of heart attack or stroke. Aspirin was never approved by the FDA for this; nonetheless, the agent has been studied and shown to decrease the risk of developing a coronary event. Likewise, many SSRI agents also have been employed in the treatment of PTSD. If we stop and take a brief moment to examine the root causes of the psychic and somatic symptoms of PTSD, it can be seen that, based upon the serotonin and norepinephrine imbalance, SSRI agents should be quite effective in restoring balance. Of primary concern, however, is an effect that was discussed; if serotonin is stimulated from the raphe nuclei, a reflexive increase in norepinephrine may occur from the locus coeruleus that may occur more rapidly than the serotonin increase. In order to prevent this, dosing of SSRI agents in PTSD treatment, as well as in other anxiety disorders, usually begins at the low end of the dosing range. Once the patient shows a positive improvement from the selected agent, the dose is titrated upward slowly, observing the patient for worsening anxiety symptoms. If no worsening occurs, the patient continues to be titrated slowly upward to higher drug doses. It should be kept in mind that SSRI agents do not exhibit an immediate onset of effect. These agents increase synaptic serotonin concentrations slowly, gradually allowing the serotonin concentration to increase in the neural synapses. This concentration increase should occur over 8 to 12 weeks in PTSD, which is slightly longer than in other anxiety disorders or depression; therefore, the resolution of symptoms occurs over time. Patients who are treated with SSRI agents should be educated to have patience for the onset of optimal drug effects. It is also important for them to understand that adherence to psychotherapies and medications will provide them with the best opportunity for positive treatment outcomes. As SSRI medications begin their action, stimulation caused by increased serotonin may improve mood and offset anxieties with a concurrent increase in headache, nausea, and diarrhea. Some of these side effects may be self-limiting, and as the CNS and gastrointestinal (GI) tract accommodate, the side effects should subside. If they do not subside within a few weeks, patients may need to switch the medication to a different SSRI or other medication treatment. Other side effects that are attributed to the use of SSRI agents include changes in sexual drive or sexual dysfunction as well as weight gain, both of which may be particularly distressing in younger patients. Although SSRI agents are considered first-line pharmacotherapy, these agents have been shown to be more effective in the treatment of civilian trauma such as domestic violence, rape, and mental abuse as opposed to combat-related trauma. SSRIs may have some value in combat-related trauma, and modest improvement seen in combat-related stress may be caused by lack of chronicity of illness in younger patients, confounded by their use in predominantly male populations (Hertzberg, Feldman, Beckham, Kudler, & Davidson, 2000; Zohar et al., 2002). It also has been shown that both paroxetine and sertraline have improved short-term outcomes in PTSD (Beebe, Pitts, Ruggiero, Ramming, & Zaninelli, 2000; Brady et al., 2000; Davidson, Rothbaum, van der Kolk, Sikes, & Farfel, 2001);

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however, sertraline also exhibits the added benefit of long-term symptom improvement (Davidson et al., 2001). Other types of antidepressants or medications have shown greater improvement on Clinician Administered PTSD Scale (CAPS) scores than SSRI agents in Veterans Administration-treated patients (Davis, Nugent, Murray, Kramer, & Petty, 2002).

OTHER ANTIDEPRESSANTS: ADJUNCT MEDICATIONS Although no other antidepressants other than the SSRIs sertraline and paroxetine carry FDA approval for the treatment of PTSD, we know that others are used off-label for treatment. Such is the case for the following classes of antidepressants.

Serotonin–Norepinephrine Reuptake Inhibitors Perhaps the best studied of these agents in the treatment of PTSD is venlafaxine. Venlafaxine is FDA approved and has been used in the treatment of MDD, generalized anxiety disorder, panic disorder, and social anxiety disorder in order to increase serotonin concentrations at the neural synapse, much in the same way SSRI agents do. The agent is not FDA approved for the treatment of PTSD; however, it has been used for treatment (Hamner & Frueh, 1998; Smajkic et al., 2001). What is interesting about venlafaxine is that it inhibits serotonin at approximately 10 times the rate of inhibiting norepinephrine. Therefore, this medication is usually dosed at the lower dose ranges in anxiety disorders. If doses exceed 225 mg per day, the norepinephrine effects begin to exhibit, leading to anxiety and increases in blood pressure. Therefore, venlafaxine is prescribed and FDA approved for anxiety disorders in doses less than 225 mg per day (Preskorn, 1994). Venlafaxine, although effective, exhibits some side effects that are more severe than those found with SSRIs, namely nausea and headache (Agency for Healthcare Quality and Research [AHRQ], 2007). Another agent considered an SNRI is duloxetine. Duloxetine is an antidepressant that exhibits both serotonin and norepinephrine reuptake inhibition and is approved for the treatment of MDD, generalized anxiety disorder, diabetic nerve pain, and fibromyalgia (Cymbalta, 2010). Results of trials of duloxetine in PTSD have shown mixed results, and this agent is generally not used in PTSD. One such study indicated that duloxetine may have some benefit in the treatment of PTSD by causing improvements in sleep (Walderhaug et al., 2010). In contrast, another study has shown exacerbations of PTSD core symptoms with the use of the agent (Deneys & Ahearn, 2006). It also should be kept in mind that duloxetine carries a contraindication to use in alcoholism and liver dysfunction. Because substance dependence can co-occur at a high rate in the PTSD patient, consideration should be given to the possibility of comorbid alcohol abuse in the PTSD patient.

Mirtazapine Mirtazapine is an agent that has been used adjunctively, or in addition to primary medication treatment, in the treatment of PTSD. Very few clinical studies supporting the use of mirtazapine have been performed; however, its ability to help with sleep induction is the reason it is used as an add-on agent to the primary antidepressant. The drug has a unique mechanism of action: a centrally acting synaptic ␣2 antagonist. In the neural synapses, ␣ receptors are present that interact with sympathetic neurotransmitters such as norepinephrine. Interacting with ␣2 receptors on the presynaptic surface of the nerve within the brain (e.g., centrally acting agent) causes negative feedback. This negative feedback leads to a release of serotonin and norepinephrine from the presynaptic vesicles contained in the terminal of the neuron. In summary, the effect makes more serotonin and norepinephrine available to stimulate the postsynaptic neuron

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receptors, allowing for increased action and transmission from these neurotransmitters (RemeronSolTabs, 2010). Mirtazapine also possesses antihistamine activity, which can cause drowsiness, especially at lower doses (de Boer, 1996). As stated earlier, the drug has been employed in anxiety disorders and depression for sleep in conjunction with the primary antidepressant. Therefore, this agent is used as a part of combination therapy and not as a primary treatment.

Tricyclic Antidepressants The tricyclic antidepressants (TCA) are some of the oldest marketed antidepressants available. These drugs work by inhibiting reuptake of serotonin and norepinephrine into the neural presynaptic vesicles, thereby increasing the availability of neurotransmitters. This mechanism may sound familiar; the action is similar to the SNRI agents. Unfortunately, these agents also possess action at many other receptor systems in the body, leading to adverse effects. TCA agents interact with the cholinergic system, blocking acetylcholine effects and leading to such side effects as dry mouth, constipation, and urinary retention. They also have an antihistamine effect, leading to drowsiness. TCA agents also can cause cardiac-related adverse effects through blockade of ␣1 receptors and calcium channel blockade. These interactions can lead to orthostatic hypotension and some cardiac arrhythmias, especially in higher doses. Based on the increased risk of adverse effects with the TCA agents, they are not employed as first-line pharmacotherapy in PTSD today, nor are they approved for use by the FDA. TCAs that have historically been used in PTSD include desipramine, amitriptyline, and imipramine. These agents were used in the treatment of the disorder prior to the advent of SSRI agents. In the past, amitriptyline was used as a treatment of PTSD much in the same way as SSRI and SNRI agents are employed today. Despite its use, most patients still continued with persistent symptoms of the disorder despite attempts to optimize dose. In one study (Davidson et al., 1990), patients receiving amitriptyline showed greater improvement if they presented with another comorbid disorder versus placebo; however, recovery rates were low in the presence of comorbid disorders such as depression, panic disorder, and alcoholism. Imipramine also has been used historically for management of PTSD symptoms with similar results to amitriptyline (Frank, Kosten, Giller, & Dan, 1988). Bearing this in mind, newer agents such as the SSRI drugs provide much more effective treatment of core symptoms than their older counterparts.

Nefazodone and Trazodone This agent has been used in the treatment of depression and other anxiety disorders; however, nefazodone is not FDA approved for the treatment of PTSD. Nefazodone is considered a mixed mechanism antidepressant. These agents exhibit a mixed effect upon serotonin; they can work upon serotonin reuptake inhibition like a SSRI, but also block the action of serotonin at certain serotonin receptor subtypes in the postsynapse area (Nefazodone, 2010). This is theorized to improve serotonin transmission through the serotonin receptor subtypes that help to improve mood and anxieties. Nefazodone has been used to improve some PTSD symptoms, subjectively improve sleep quality, and decrease nightmares (Nefazodone, 2010). It also has been shown to cause PTSD symptom improvement in combat-related stress as well as in domestically induced stress (Asnis, Kohn, Henderson, & Brown, 2004). The use of nefazodone has fallen out of favor in recent years, since the inclusion of a “black box” warning from the FDA. It was determined that nefazodone can cause increased risk of irreversible hepatic failure, resulting in death or need for liver

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transplantation. Patients should be advised to be alert for early signs and symptoms of liver dysfunction (jaundice, anorexia, gastrointestinal complaints, malaise, etc.) and to report them to their doctor immediately if they occur (Frank et al., 1988). Patients who are taking nefazodone should be adherent to physician appointments in order to have their hepatic function monitored by their physician. Trazodone is another agent with a similar mechanism as nefazodone. Because this agent has a serotonergic effect, it was thought that it would be effective in PTSD. Earlier clinical trials have alluded to this. A preliminary study in PTSD patients showed that trazodone was effective on all three core symptoms of PTSD (Hertzberg, Feldman, Beckham, & Davidson, 1996). Despite this encouraging data, trazodone is known to cause excessive sedation. Therefore, further trials of the agent were studied as an adjunctive agent, in addition to a primary antidepressant, for improvement of sleep and prevention of nightmares. Insomnia, nightmares, and next-day anger all have been improved. Consequently, trazodone is used in addition to antidepressant agents for improvement in sleep dysregulation due to coexisting depression (Mellman, Clark, & Peacock, 2003).

Monoamine Oxidase Inhibitors Antidepressants such as SSRI, SNRI, and TCA agents are known to produce their mechanism of action by prevention of neurotransmitter reuptake into the presynaptic vesicles, leading to increased concentrations of serotonin and norepinephrine available in the neural synapse. In the synapse between neurons, the enzyme monoamine oxidase (MAO) also is present. Its purpose is to degrade excess neurotransmitters such as serotonin and norepinephrine (MAO type A inhibitor [MAOI-A]) and dopamine (MAOI-B). MAOI agents inhibit the enzyme MAO, thus allowing greater concentrations of neurotransmitters to be present in the synapse by preventing their degradation. The agent phenelzine has been used for this purpose in PTSD. This drug has been used in PTSD and, further, has been shown to be effective in the treatment of combat-related stress (Kosten, Frank, Dan, McDougle, & Giller, 1991). Despite their effectiveness, many severe adverse events limit their use in treatment. Patients who are prescribed MAOI agents must be aware of the drug–food interaction with foods containing tyramine. Tyramine restriction is necessary, as tyramine is a precursor of the production of norepinephrine. Ingestion of tyramine-containing foods can lead to increased norepinephrine production. This increase, coupled with the inhibition of the breakdown of norepinephrine caused by MAOI action, may cause a dangerous medical condition known as hypertensive crisis. Hypertensive crisis is the increase in blood pressure to sustained, dangerously high levels. Therefore, patients should be told to avoid such foods as aged cheeses, red wine, and organ meats. Increased intake of tyrosine should be avoided as well, because tyrosine is the precursor to serotonin synthesis. MAOI drugs are also notorious for numerous drug–drug interactions. Because these drugs inhibit neurotransmitter degradation, the clinician should be careful to avoid MAOI use in patients who are taking other medications, which increase neurotransmitter concentrations. Agents used for asthma, attention deficit disorder, Parkinson’s disease, certain pain medications (tramadol and meperidine), weight loss medications, dextromethorphan, and even other antidepressants can cause serious, life-threatening interactions. Because of the comorbidity of substance abuse with PTSD, agents such as amphetamines, cocaine, 3,4-methylenedioxymethamphetamine (MDMA [Ecstasy]), and lysergic acid diethylamide (LSD) can interact with MAOI agents, leading to the same deadly interactions. Because of the potential for these types of drug and food interactions, MAOI agents like phenelzine have been relegated to last-line pharmacotherapy in the treatment of PTSD. Additionally, MAOI agents are not FDA approved for PTSD.

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Bupropion Bupropion has been tried as a possible alternative to SSRI agents as a treatment for PTSD symptoms but has not been approved by the FDA for the treatment of PTSD. The drug works not through serotonin reuptake but upon preventing the reuptake of dopamine and norepinephrine into presynaptic vesicles. Bupropion has been used as a first-line agent in the treatment of depression in patients where sexual dysfunction caused by SSRI agents may be problematic. The use in PTSD, however, has been limited. In one small study (Cañive, Clark, Calais, Qualls, & Tuason, 1998), the improvement seen in hyperarousal symptoms was significant but was less significant than the change in depressive symptoms in subjects with both PTSD and depression. There was no significant change in reexperiencing, avoidance, or total CAPS scores. Therefore, PTSD symptoms remained essentially unchanged (Cañive et al.). There has been little research in the form of placebo-controlled studies using bupropion in the treatment of PTSD. Bupropion has been studied in smoking cessation in patients who have been diagnosed with PTSD and was found to be effective for this use; however, no effect was seen upon PTSD symptoms. In this study (Hertzberg, Moore, Feldman, & Beckham, 2001), patients were allowed to continue with their previous PTSD treatment, leading to the belief that this agent is an effective smoking deterrent in patients with PTSD. In yet another study (Becker et al., 2007) of thirty patients taking bupropion, and compared to a placebo-controlled group, no between-group differences were found between placebo and bupropion. Despite this, a post hoc analysis of responders showed that patients not previously prescribed an antidepressant were more likely to respond to bupropion (Hertzberg et al., 2001). Further study of this agent is needed before recommendation of its use can be made in PTSD. The role of bupropion would most likely be as a second-line agent in patients who have experienced severe sexual dysfunction with serotonergic antidepressants.

Antipsychotic Agents: Atypical Antipsychotics The term “atypical” can be considered almost a misnomer today. This term is used to identify the newer antipsychotic agents, which inhibit serotonin and dopamine activity. The older agents, also known as the “typical” agents, neuroleptics, or phenothiazines, work predominantly on dopamine blockade. Therefore, the newer agents work somewhat differently than the historical agents; hence “atypically.” The most studied of these newer agents in the treatment of PTSD are risperidone, olanzapine, and quetiapine. Older “typical” agents such as haloperidol have been used as well. Both typical and atypical antipsychotics have been used in the treatment of PTSD. Currently, the atypical agents are much more commonly used in pharmacotherapy. Antipsychotic agents have been used as add-on therapy in PTSD patients, especially on reexperiencing symptoms in which there has been inadequate symptom resolution with an antidepressant (Bartzokis, Lu, Turner, Mintz, & Saunders, 2005; Pivac, KozaricKovacic, & Muck-Seler, 2004). Because of dopamine blockade, either of these classes can induce involuntary movement disorders similar to Parkinson’s disease. The atypical agents, when used in the recommended dosages, have a much lower propensity to induce these movements. Atypical agents, however, can cause such things as weight gain, increase in serum cholesterol, and increased blood glucose, all of which may lead to worsening hypertension. Patients who are prescribed these medications should be monitored for all of the aforementioned adverse events during therapy. Recently, information regarding the use of atypical agents in the treatment of combat-related PTSD have questioned their effectiveness. One such study found that the use of risperidone in this sub-set of traumatized patients, who were also resistant

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to SSRIs, was no more effective than placebo on the reduction of symptoms as measured by the CAPS scale (Krystal et al., 2011).

Antihypertensive Agents Certain medications that have been used for the treatment of hypertension (high blood pressure) have been used in the treatment of PTSD for reduction of nightmares. In order to understand how these medications may cause this effect, we need to understand a bit about how these medications are believed to cause this effect. Prazosin, a postsynaptic ␣1 antagonist, works by decreasing the stimulation of norepinephrine on the postsynaptic receptors by blocking these receptors. Therefore, norepinephrine action (also called sympathetic outflow) is decreased, leading to increased drowsiness and decreased anxiety. Prazosin has been used in combat-related PTSD in the veteran population (Raskind et al., 2000). Other agents that have been used for this purpose include clonidine and guanfacine. These agents are centrally acting presynaptic ␣2 agonists. This means that the drugs attach to the ␣2 receptors on the nerve terminal. They stimulate these receptors just as norepinephrine would. By stimulating the neuron in this way, the drug provides a negative feedback to the neuron. This essentially tricks the neuron into believing that there is an adequate supply of norepinephrine available in the synapse, causing a decrease in the amount of available norepinephrine in the synapse. The decreased norepinephrine, in turn, decreases the sympathetic outflow, similar to the effect of the aforementioned prazosin (Harmon & Riggs, 1996).

Benzodiazepines It is interesting to note that benzodiazepine agents have been shown to be of no benefit in PTSD. Benzodiazepines exert their effect by increasing the effect of gamma-aminobutyric acid (GABA). GABA is the predominant inhibitory neurotransmitter within the CNS. Increases in GABA decrease the effect of norepinephrine, leading to anxiety relief (Stahl, 2000). Many of these agents are used as short-term therapy in other anxiety disorders, such as generalized anxiety disorder, in order to cause rapid decrease of the intrusive anxiety symptoms until the predominant drug therapy begins to exert its effect (SSRI agents). Examples of medications in this class include lorazepam, diazepam, alprazolam, and clonazepam. Paradoxically, and perhaps surprisingly, these agents have been shown to produce no positive benefits in PTSD, with no effect on reexperiencing, hypervigilance, or avoidance (Braun, Greenberg, Dasberg, & Lerer, 1990). Likewise, early administration following trauma exposure did nothing to prevent development of PTSD (Gelpin, Bonne, Peri, Brandes, & Shalev, 1996). Therefore, because benzodiazepine agents have been shown to be of no benefit in PTSD, their use is discouraged in this population.

Drug Therapy Duration Where pharmacologic treatment is indicated, patients who are receiving medications for the treatment of PTSD should be continued on medication for varying lengths of time, based on the severity of symptoms and onset of the illness following psychological insult. A patient diagnosed with acute onset of the disorder (symptoms present in more than 1 month but less than 3 months) should be continued on drug therapy for 6 to 12 months, at which time a slow downward titration off of the medication should be attempted. In patients who experience chronic trauma symptoms (greater than 3 months), medications should be continued for at least 1 year. If the patient experiences adequate response or resolution of symptoms, medications should be continued for 1 to 2 years. At that time,

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the medication(s) may be slowly decreased in dose until the medication(s) can be safely discontinued. In cases wherein patients are experiencing residual symptoms following optimization of drug therapies, medications may continue for 24 months or longer. In some patients, medications may be warranted indefinitely based on factors determined by the severity of the condition or social stressors. Such factors as lack of social support, “suicidal ideation,” comorbid Axis I diagnosis, propensity for aggression or violence, and poor patient function may indicate the need for long-term treatment with pharmacotherapy. Some patients may require medications throughout their lifetime.

Post Medication Recovery Pharmacotherapy that is used for acute or chronic trauma symptoms is an important treatment for the survivor of trauma by restoring physiologic, neurochemical balance. In cases wherein medications may be decreased slowly or discontinued, it is important for patients to continue with currently prescribed psychotherapeutic modalities. Adherence with these types of treatments can aid patients in coping with symptoms and developing new approaches to management of stress. Insight into the symptoms of their condition is important for patients to develop in order to recognize reemergence of intrusive symptoms, which can cause relapse into the disorder. In such cases of worsening symptoms, patients should be restarted on pharmacotherapy, beginning with the medication or combination of medications that were useful in the prior episode.

COUNSELING IMPLICATIONS It is important for each and every professional involved in the care of the PTSD patient to be cognizant of any changes, both mentally and physically, that occur. Treatment of patients involves many disciplines, and optimal care for those afflicted with the disorder requires an integrated approach to care. Because of regular interactions, counselors are well positioned to observe the patient for improvement in core symptoms of the disorder as well as the emergence of side effects. Patients who present with untoward, intolerable side effects such as worsening anxiety, nausea, headache, uncontrolled movements, dizziness, or drowsiness can be referred to their physician for evaluation of the patient. Therefore, the accessibility of the counselor, coupled with the therapeutic alliances built with them, provide a perfect “clearing house” for improvements in psychological symptoms, while avoiding side effects or adverse drug reactions that may cause patients to become nonadherent with treatment. This is not to say that counselors are responsible for all clinical aspects of care. Healthcare-aware professionals need to be cognizant of the emergence of psychological symptoms of the disorder and to refer the patient to the appropriate member of the care team. Optimal care of the patient who presents with physical and mental symptoms cannot be performed in “silos” with little interaction among all professionals involved in treatment. Integrated care between health care and mental health professionals provides an all-encompassing, gestalt approach to care so that all aspects of the patient’s care are well managed.

CONCLUSION Therapists who care for clients suffering from trauma-related disorders should be keenly aware that this subset of anxiety disorders has both psychological and physiological components, each of which requires optimal treatment. A thorough understanding of

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the pathology, both physical and mental, provides the groundwork for care and outcomes in the afflicted. Recognition of the client’s needs and core symptoms is paramount to provision of favorable therapies, but it is not enough. Understanding how and when to intervene on these needs and symptoms provides clients with meaningful ways of living with and coping with PTSD. Integrating psychotherapy and pharmacotherapy allows the person to alleviate the intrusive core symptoms of the disorder, while simultaneously developing coping strategies for improved quality of life. Using both methods, recovery from PTSD can be a distinct reality.

APPENDIX 4.1 Patient Case A 32-year-old female patient presents to the clinic today exhibiting fearfulness and anxiety. She is well known to the clinic staff. About 2 months ago, the patient was physically and sexually assaulted in the side parking lot near her local grocery store. The patient was treated by the clinic’s physician following the assault, and she was referred to a local therapist. She has been attending therapy sessions on a regular basis. Recently, the patient complains of difficulty sleeping, with frequent awakenings during the night caused by nightmares. She states that she also drives an extra seven miles to purchase her groceries, stating that she “does not even want to see the place.” All laboratory testing and imaging are within normal limits, and her presentation is not consistent with intoxication, infection, or metabolic abnormalities. After assessment, her physician diagnoses her with posttraumatic stress disorder. What would be an appropriate choice for first-line pharmacotherapy? Answer: An SSRI agent would be initial pharmacotherapy. Because the trauma is associated with an attack in a civilian environment, these agents are considered first-line pharmacotherapy. Of the available agents, both FDA approved and off-label, sertraline has been shown to provide both short-term and long-term benefit. Side note: Because this is a woman of childbearing age, we would want to avoid paroxetine. It is considered a pregnancy category “D” agent, which means that there is higher risk than benefit in using the agent during pregnancy. Paroxetine has been implicated in the development of cardiac abnormalities in fetuses of pregnant women at a higher rate than other antidepressants. If this young woman would happen to become pregnant, we would have to change her therapy. In order to avoid this, sertraline would be chosen, as it is a category “C” agent (physician should weigh risk versus benefit—all other SSRIs are category “C” as well) and may be a safer choice for PTSD management. Therefore, clinical choices must include prevention of any future issues that may occur in an individual patient. If further treatment is necessary, the patient may be prescribed an atypical antipsychotic such as risperidone, quetiapine, or olanzapine. Of these, risperidone may cause the least amount of weight gain and be helpful for the re-experiencing symptoms of the disorder. Lastly, an agent such as an antihypertensive agent (prazosin, guanfacine, clonidine) may be helpful at bedtime to decrease sympathetic outflow and help in normalizing frequent nighttime awakenings and nightmares.

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Hertzberg, M. A., Moore, S. D., Feldman, M. E., & Beckham, J. C. (2001). A preliminary study of bupropion sustained-release for smoking cessation in patients with chronic posttraumatic stress disorder. Journal of Clinical Psychopharmacology, 21(1), 94–98. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. R. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048–1060. Kosten, T. R., Frank, J. B., Dan, E., McDougle, C. J., & Giller, E. L., Jr. (1991). Pharmacotherapy for posttraumatic stress disorder using phenelzine or imipramine. Journal of Nervous and Mental Disease, 179 (6), 366–370. Krystal, J. H., Rosenheck, R. A, Cramer, J. A, Vessicchio, J. C, Jones, K. M, Vertrees, J. E., . . . Stock, C. (2011). Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military servicerelated PTSD: a randomized trial. The Journal of the American Medical Association, 306(5), 493–502. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). The National Vietnam Veterans Readjustment Study: Tables of findings and technical appendices. New York, NY: Brunner/Mazel. Lange, J. T., Lange, C. L., & Cabaltica, R. B. (2000). Primary care treatment of post-traumatic stress disorder. American Family Physician, 62(5), 1035–1040. Lundbeck Institute. (2000). The areas of the brain affected in phobia. CNS Forum. Retrieved from http://www.cnsforum.com/imagebank/item/Neuro_biol_PHB/default.aspx McPherson, D. (2003). Anxiety disorder. In R. B. Taylor (Ed.), Family medicine: Principles and practice (6th ed., pp. 285–288). New York, NY: Springer Publishing. Mellman, T. A., Clark, R. E., & Peacock, W. J. (2003). Prescribing patterns for patients with posttraumatic stress disorder. Psychiatric Services, 54 (12), 1618–1621. Nefazodone. (2010) [package insert]. New York, NY: Micromedex 2.0. Micromedex Inc., Thomson Reuters Healthcare. Paxil® (paroxetine). (2010) [package insert]. Triangle Park, NC: GlaxoSmithKline USA. Pivac, N., Kozaric-Kovacic, D., & Muck-Seler, D. (2004). Olanzapine versus fluphenazine in an open trial in patients with psychotic combat-related post-traumatic stress disorder. Psychopharmacology, 175(4), 451–456. Preskorn, S. H. (1994). Antidepressant drug selection: Criteria and options. The Journal of Clinical Psychiatry, 55(Suppl. A:6–A:22); discussion 23–24, 98–100. Raskind, M. A., Dobie, D. J., Kanter, E. D., Petrie, E. C., Thompson, C. E., & Peskind, E. R. (2000). The alpha1-adrenergic antagonist prazosin ameliorates combat trauma nightmares in veterans with posttraumatic stress disorder: A report of 4 cases. The Journal of Clinical Psychiatry, 61(2), 129–133. RemeronSolTabs® (mirtazepine oral disintegrating tablet). (2010) [package insert]. Kenilworth, NJ: Schering Corporation. Seedat, S., Stein, D. J., & Carey, P. D. (2005). Post-traumatic stress disorder in women: Epidemiological and treatment issues. CNS Drugs, 19 (5), 411–427. Smajkic, A., Weine, S., Djuric-Bijedic, Z., Boskailo, E., Lewis, J., & Pavkovic, I. (2001). Sertraline, paroxetine, and venlafaxine in refugee posttraumatic disorder with depression symptoms. Journal of Traumatic Stress, 14 (3), 445–452. Southwick, S. M., Bremner, J. D., Rasmusson, A., Morgan, C. A., III, Arnsten, A., & Charney, D. S. (1999). Role of norepinephrine in the pathophysiology and treatment of posttraumatic stress disorder. Biological Psychiatry, 46(9), 1192–1204. Stahl, S. M. (2000). Essential psychopharmacology: Neuroscientific basis and practical applications (2nd ed.). Cambridge, England: Cambridge University Press. Walderhaug, E., Kasserman, S., Aikins, D., Vojvoda, D., Nishimura, C., & Neumeister, A. (2010). Effects of duloxetine in treatment-refractory men with posttraumatic stress disorder. Pharmacopsychiatry, 43 (2), 45–49. Yehuda, R. (2002). Post-traumatic stress disorder. New England Journal of Medicine, 346(2), 108–114. Yehuda, R. (2004). Risk and resilience in posttraumatic stress disorder. The Journal of Clinical Psychiatry, 65(1), 29–36. Zohar, J., Amital, D., Miodownik, C., Kotler, M., Bleich, A., Lane, R. M., & Austin, C. (2002). Double blind placebo-controlled pilot study of sertraline in military veterans with posttraumatic stress disorder. Journal of Clinical Psychopharmacology, 22(2), 190–195. Zoloft® (sertraline). (2010) [package insert]. New York, NY: Pfizer Inc.

Section II: Trauma of Loss, Vulnerability, and Interpersonal Violence CHAPTER 5

Issues of Loss and Grief JUDITH L. M. MCCOYD, CAROLYN AMBLER WALTER, AND LISA LOPEZ LEVERS

Although the world is full of suffering, it is full also of the overcoming of it. —Helen Keller (1880–1968)

INTRODUCTION According to Walter and McCoyd (2009), “Loss is at the heart of life and growth” (p. 1). A similar sentiment might be expressed concerning the experience of trauma: Loss, grief, and destabilization are at the center of experiencing trauma. Not all experiences of loss and grief necessarily involve trauma; however, loss, grief, and destabilization are implicit aspects of trauma across the varying circumstances that may manifest as traumatic experience. The purpose of this chapter is to explicate these constructs contextually and to illuminate their centrality to the experience of trauma. We hope that this chapter enables practitioners to understand the ways that individuals experience grief as it is influenced by psychological responses to loss in the face of previous attachments, by social norms and support networks, by cultural attitudes, and by biological responses to stress. We expect that the intertwined nature of trauma and loss is clear: losses of people, ideals, and things often are traumatic in the intensity of the loss; trauma always entails a loss of the assumptive world (Parkes, 1988) in ways that destabilize just as loss does. We hope that this understanding allows practitioners to conceptualize their work with individuals in ways that allow the mourner to make meaning of his or her losses. We envision practitioners who are client centered rather than advocates of a particular grief model and who therefore help mourners process their losses and traumas in a manner tailored to their needs. Practitioners can actively help mourners in exploring new identities in the face of the loss, and in learning more about themselves and their “fit” in the world as a result of working together. The aims of this chapter are introducing concepts of loss and grief, describing the phenomenology of loss and grief, and explicating counseling implications. These main sections are followed by a summary of the chapter and helpful resources for students, clinicians, and instructors. The material in this chapter originally appeared in Walter and McCoyd, Grief and Loss Across the Lifespan: A Biopsychosocial Perspective (Springer Publishing Company, 2009). It has been adapted for use in this volume.

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LOSS, GRIEF, AND TRAUMA When one experiences a traumatic event, such as sexual or physical assault, among the myriad of feelings, thoughts, and dynamics are a sense of loss and a sense of grief— often accompanied by suffering or pain, in the broadest sense. This is even more obvious when one loses a loved one. But such loss is at the heart of life and growth. This seems a bit paradoxical; however, the reality is that new life, change, and forward movement only come as a result of losing (changing) a prior lifestyle, behavior pattern, or other functioning of the status quo. Trauma and loss both entail a destabilizing set of forces that can leave people in a vulnerable state, questioning their assumptions about the way the world works and their place in it. Yet this also opens them to growth as they process their response to the loss or trauma. Practitioners who strive to assist clients in their growth must be aware that change and maturation, even toward a more positive state of functioning, also can involve losses that often go unrecognized. Losses may involve death, but might also include normal lifespan issues, like the physical changes of puberty that can be so dramatic that some individuals experience them as traumatic, or the loss of a beloved job. Walter and McCoyd (2009) have offered a unique focus on loss as a normative, though destabilizing, experience and process. The normative, destabilizing force of loss also promotes self-reflection and growth, particularly when the mourner’s experience is validated and supported. We view normative losses as those that are relatively common in each age group, although not necessarily experienced by every particular individual of that age. These often are met with little support, precisely for the reason that they are either considered “fairly normal” or are stigmatized. Of course, “normative” becomes an especially interesting concept in the face of trauma. For example, as one widely held statistic posits, if we can expect one in every four girls to experience sexual assault before the age of 18 years, does this then imply that rape is a “normal” experience of female youth and adolescence? Worden (2009) suggests that grieving certain types of losses warrants special attention from counselors; these nonnormative experiences include suicide, sudden death, miscarriages, stillbirths, abortions, the consequences of AIDS, and other assaults against a sense of well-being. Jaffe (2011, May 27) also reminds us of the number of US military personnel returning home from current war theatres with bereavement issues. Therefore, we discuss the constructs of loss and grief in light of a more normative, growth orientation, while also attending to the implications of complicated bereavement as this may relate to traumatic experiences.

PHENOMENOLOGY OF LOSS AND GRIEF Loss and grief, though uncomfortable, are a part of human existence and not pathological states. We believe that these loss states can produce growth and insight, with or without professional help, though we also believe that most people process losses more easily when they talk with someone. Although complicated grief reactions exist (Shear, Boelen, & Neimeyer, 2011), we also are aware that people have experienced losses since the beginning of humankind, but that grief therapy has existed for only a little over a century. We write from the perspective of clinicians who fully believe in the power of most human beings to manage their grief responses, while also believing in our ability to be present with people as they make this journey in ways that are beneficial and promote the most growth and insight. In this section, we examine the phenomenology of loss and grief through discussions of grief theory and transition to postmodern grief theory.

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Classical Grief Theory Classical grief theory arises from the work of Sigmund Freud, evolving into a taskbased set of theories that includes subsequent work by other theorists and researchers (e.g., Lindemann, 1944; Worden, 2009). Also arising from classical origins is the parallel set of stage-oriented grief theories (e.g., Bowlby, 1980/1998; Kübler-Ross, 1969). In the remaining parts of this section, we review the implications of these task-based and stage-oriented theories of grief.

Classical Grief Theory and the Implications of Task-based Grief Theory According to Freud (Freud, 1917/1957), “Mourning is regularly the reaction to the loss of a loved person, or to the loss of some abstraction which has taken the place of one, such as one’s country, liberty, an ideal, and so on” (p. 243). Although assumed to be experienced since the beginnings of human attachment and separations, Freud was one of the first to address grief, melancholia, and mourning in a scholarly manner. He contributed the understanding that mourning can occur for things, values, and statuses and does not only occur in response to a death. He also assures that grief and mourning are “not pathological” but goes on to say: This demand (to decathect libidinal drive) arouses understandable opposition— it is a matter of general observation that people never willingly abandon a libidinal position, not even, indeed, when a substitution is already beckoning to them. This opposition can be so intense that a turning away from reality takes place. (Freud, 1917/1957, p. 244) Freud allowed for the possibility of psychotic (turning away from reality) thoughts, feelings, and behaviors as an understandable (and normal) reaction to loss. In many ways, his was a “task-based theory,” predicated on the idea that the mourner must decathect from the lost entity. Freud’s theory of behavior states that the psyche “cathects” people and loved entities with libidinal energy that must be withdrawn for a mourner to heal after loss. He believed that people experiencing melancholia had not successfully withdrawn the libidinal energy (cathexis) and needed help to do this. In Freud’s understanding, the next task was to transfer cathexis to a new love object. He asserted (Freud, 1917/1957) that mourning is only completed when the ego becomes free by virtue of decathecting libido from the lost love object. He suggested a year as the customary amount of time necessary for this process to occur. As a person of Jewish heritage, despite his skepticism of religious belief and practice, he may have internalized the traditional year of mourning accepted and ritualized in the Jewish faith. Freud’s was the primary theoretical paradigm for early grief work efforts. Usually couched in the language of “letting go,” counselors have long held to the idea that a mourner must separate from his or her attachment to the lost entity, even if he or she did not necessarily view this through Freud’s paradigm of decathexis. Though simplistic, this task-based model for grief work has periodically reemerged as a template for grief work in other forms. Indeed, the task of decathexis or separation continues to be a theme running through clinicians’ “practice wisdom,” despite the development of new theoretical understandings of loss and grief. Freud himself set the context for some of the modern reinterpretations of grief work. Freud wrote to a friend, who had experienced the death of a child (as Freud himself had): . . . Although we know that after such a loss the acute state of mourning will subside, we also know we shall remain inconsolable and will never find a

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He implies that decathexis may occur, but that recathexis is not likely to fill the gap, that it “remains something else” as a way of not relinquishing the loved one. This is something to which we will return as we address the theories of meaning-making (Neimeyer, 2001) and continuing bonds (Klass, Silverman, & Nickman, 1996). Some of the first empirical work to explore the grieving process was done by Erich Lindemann (1944). He studied the responses of people following the Cocoanut Grove nightclub fire in Boston in November 1942, thereby precluding anticipatory grief as a factor that might change mourners’ responses. Trauma theory had not yet developed and was not incorporated into his theory about grieving and loss. He theorized that grief normally includes somatic distress, preoccupation with the deceased, guilt, and sometimes hostile reactions. He asserted that 8 to 10 sessions with a psychiatrist over the course of a month and a half were sufficient to manage grief work (Lindemann, 1944). As an assertion based on research rather than theoretical speculation, this met with widespread acceptance. He believed that tasks of grief must be accomplished, but moved beyond Freud’s two tasks of decathexis and recathexis. He postulated the following tasks: 1. Emancipation from bondage to the deceased 2. Readjustment to the environment in which the deceased is missing 3. Formulation of new relationships In some ways, step 1 mirrored decathexis and step 3 mirrored recathexis, but Lindemann (1944) contributed the idea that this was not a totally interior, psychological process. He acknowledged through step 2 that bereft individuals live in a social world and that they must adjust to a world that no longer has their loved one living in it. Yet he allowed 4 to 6 weeks as the time frame to accomplish these tasks as a norm. The unfortunate consequence of his time frame was that mourners who wanted to be perceived as healthy would avoid grief expression after 4 to 6 weeks and grief work practitioners began to view grief that lasted much longer as pathological in some way. Lindemann (1944) contributed to our understanding by asserting that symptoms experienced by bereaved people are quite customary, and he expected that the social world has an impact on grief. He did little, however, to normalize and validate the grief experience of the majority of people who experience grief and mourning long after 2 to 3 months post loss. Bertha Simos (1979), a social worker who recognized the limitations of task- and stage-centered grief theories, said, “Anyone who took longer than the prescribed number of weeks to get over a loss was considered maladjusted and treated as emotionally disturbed. Thus the helping professionals themselves became deterrents to the proper working through of grief” (p. 41). Most recently, William Worden (2009) developed his task-based grief theory and intervention framework as a response to some of the stage- and phase-based models of the late 1960s through the early 1990s. Worden’s model includes the following steps: 1. 2. 3. 4.

Accept the reality of the loss Experience the pain of the grief Adjust to a world without the deceased Find an enduring connection with the deceased while embarking on a new life.

Worden (2009) adds the experience of emotional ventilation, something that recently has become known as the grief work hypothesis. Many have embraced Worden’s and

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others’ suggestion that emotional ventilation (crying, mourning, anger, etc.) needed to be expressed before one could begin to heal from a significant loss. The implication is that if this type of ventilation did not occur, and if the person were seemingly healthy, the attachment to the lost one must not have been that strong. This has been found to be inaccurate in multiple studies (e.g., Carr, Nesse, & Wortman, 2006; M. Stroebe & Stroebe, 1991; Wortman & Silver, 2001), which reveal that a significant group of bereaved people actually become worse if emotional ventilation is pushed on them; this subgroup can do quite well without any professional intervention. Yet Worden’s tasks allow for recognition that a relationship with the deceased does continue in a modified manner—this is a major step forward in grief work and grief theory. Freud depathologized grief, and the other task-based theorists helped to explicate what tasks the bereaved needed to accomplish to heal. Yet the tasks were invariant, oversimplified, and implied that work on each of these tasks would lead to a completion of the grief and mourning in a “cookie-cutter” type of intervention. The same critique of an invariant and oversimplified model also is applied often to stage-based theories.

Classical Grief Theory and the Implications of Stage-oriented Grief Theory Elisabeth Kübler-Ross (1969) was, like Lindemann (1944), more interested in empirical data than theorizing. She is known as a leader in the field of death and dying, yet her classic stages have been applied to a population that is different from the population she researched. She was interested in people who were dying. She lived through the societal transition from when people died at home surrounded by family to when people died in hospitals, often with little information about the true status of their prognosis. As part of a seminar on death and dying at Chicago Theological Seminary, she and her students began interviewing dying people about their beliefs and experiences. Her book, On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families (1969), was the source of the now widely accepted and reified stages of denial and isolation, anger, bargaining, depression, and acceptance. It is notable that following these stage-based chapters in her book is a chapter entitled “Hope,” a characteristic that she identified as crucial: No matter what we call it, we found that all our patients maintained a little bit of it and were nourished by it in especially difficult times. They showed the greatest confidence in the doctors who allowed for such hope—realistic or not—and appreciated it when hope was offered in spite of bad news. This does not mean that the doctors have to tell them a lie; it merely means that we share with them the hope that something unforeseen may happen that they may have a remission, that they will live longer than is expected. If a patient stops expressing hope, it is usually a sign of imminent death. (Kübler-Ross, 1969, pp. 139–140) Her stages of adjustment to a terminal diagnosis are now widely applied to all types of losses, despite their development from an anticipated loss of self after critical illness. The stage of denial is particularly misunderstood. Kübler-Ross (1969) originally conceptualized it as a stage during which the diagnosed would “shop around” to ensure an accurate diagnosis or express hopes that the testing results and terminal diagnosis were incorrect. She viewed this as a “healthy way of dealing with the uncomfortable and painful situation with which these patients have to live for a long time” (p. 39). It is unfortunate that this stage has been misinterpreted widely and misapplied in grief counseling. It often has been viewed as a stage to be “broken through” or confronted, with counselors often applying Draconian methods to ensure that denial is not

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maintained in connection with a death loss. Indeed, Vamik Volkan (1985) developed regrief therapy as an intervention for those viewed as pathologically bereaved. His useful concept of a linking object, an object that reminds the mourner of the lost one, is used within a therapy designed to cut through any denial that may remain: Throughout treatment, patients experience a variety of emotions as they gain insight into their inability to let the dead person die . . . The use of the linking object brings about special emotional storms that are not curative without interpretation that engages the close scrutiny of the patient’s observing ego. (Volkan, 1985, pp. 289–290) This assertive confrontation of denial has become one of the suspect interventions associated with early grief work counseling. Yet, in trauma work, denial often is encountered as a tendency to deny the impact of the trauma; individuals are ready to dismiss the impact of trauma without spending much time actually processing the events. One of the more recent developments in trauma work with veterans is to use similar flooding techniques to have the veteran grapple with the impact of the trauma (Foa & Meadows, 1997). Time will tell how this will be viewed, but it is currently empirically supported as a method of treating trauma. We may find that it, like Volkan’s method, is efficacious for a certain type of individual and not for others. The fact that denial is viewed as a stage to get through, rather than as the protective adjustment time that Kübler-Ross described, reveals one of the difficulties of stage theories more generally. Individuals, both the bereaved and less reflective practitioners as well, can view these models as a recipe, an intervention plan to be applied with a broad sweep. This assumes a one-size-fits-all quality to mourning. It also implies that knowledge of the stages or phases can allow one to move more quickly through them— a fallacy with major implications. Kübler-Ross’s (1969) model of moving from this protective denial to a state of anger and irritation (in her study, often directed at caregivers) is usually viewed as a one-way journey. Her notion of stage-wise progression implies movement through the stages rather than the back-and-forth or recursive movement seen most commonly among the bereaved. It is notable that acceptance for Kübler-Ross’s population has a very different quality than that of the acceptance of a loss by a bereaved person. Kübler-Ross asserts the following: Acceptance should not be mistaken for a happy stage. It is almost void of feelings. It is as if the pain had gone, the struggle is over, and there comes a time for “the final rest before the long journey” as one patient phrased it. This is also the time during which the family needs usually more help, understanding, and support than the patient himself. While the dying patient has found some peace and acceptance, his circle of interest diminishes. He wishes to be left alone or at least not stirred up by news and problems of the outside world. (1969, p. 113) This is quite different from acceptance in the bereaved, from whom we expect more breadth of emotional expression (including happiness occasionally), more involvement with prior interests, and more engagement with the greater world. These differences are seldom acknowledged in the simplified formats often provided as the stage theories for loss. Kübler-Ross herself was quite clear that these stages were developed from empirical data about individuals who were dying, which may not apply to other populations. She also cautioned against the belief that stages occur in an exact sequence. Her cautions rarely are incorporated when people learn about the stages she postulated.

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A second classic stage theory grows from the empirical data of John Bowlby (1980/1998), who followed the children of World War II as they were separated from their parents in war-torn countries and cared for in safer areas. He later studied widows (and a few widowers) and believed that this population confirmed his findings in the children’s study. He postulated the following stages: ■ Numbness—Defined as being shocked and stunned, not as denial; Bowlby iden-

tified the protective nature of this stage. ■ Separation Anxiety (yearning/searching)—Defined as an alternating state of

despair and denial, with anger folded in, much like that found in children separated from parents. He claims that pathological grief is characterized by being stuck in one of these modes—either yearning, or angry and detached. Bowlby (1980/1998) noted the following: Thus anger is seen as an intelligible constituent of the urgent though fruitless effort a bereaved person is making to restore the bond that has been severed. So long as anger continues, it seems, loss is not being accepted as permanent and hope is still lingering on. (p. 91) ■ Despair and Disorganization—As the loss sinks in, there is an attempt to recog-

nize the loss and develop a “new normal.” It is a time of lost objects (e.g., keys or other personal items) as well as lost thoughts and lost time. ■ Acquisition of New Roles/Reorganization—When the bereaved relinquishes attempts at preparing for the deceased’s return (gets rid of clothes, etc.) and moves into new aspects of life and relationships with others, the bereaved is viewed as moving through reorganization. Bowlby’s (1980/1998) stages are reminiscent of what he recognized in children— they yearn and pine for their parent(s) when separated. He theorized that the attachment style that the child exhibited (secure, anxious, avoidant) would influence the impact of the loss, and that children who were less secure in their attachments would be more likely to exhibit anxious or detached feelings when experiencing a loss. He and others have speculated that these influences carry on into adulthood, with adults playing out their reactions to loss via one of the attachment styles. This is an important conceptualization, with current research actively exploring its basis (Fraley & Shaver, 1999; Zech & Arnold, 2011). Yet, it does not incorporate the reality that bereaved individuals experience a sense of uncertainty about what the future holds, a legitimate uncertainty that is intensified by trauma, as many of the plans for the future change abruptly as a result of loss and separation. This uncertainty itself may provoke anxious behavior and attempts to defend against attachments that may leave the individual open for more emotional distress if circumstances change once again. Maciejewski, Zhang, Block, and Prigerson (2007) recently explored the stage theories of Kübler-Ross (1969) and Bowlby (1980/1998) and found support for the stages they theorized. They studied 233 bereaved individuals over the course of 2 years and concluded that stages of disbelief, yearning, anger, and depression all had discrete peaks over time, and that acceptance ran as a concurrent trend in a linear positive fashion. Almost immediately, their findings were questioned. Roy-Byrne and Shear (2007) asserted that the authors had “overstated their findings” and that they “drew oversimplified conclusions that reinforce formulaic, unhelpful ways of thinking about bereavement.” Concerns remain about stage theories and their susceptibility for being approached as a recipe for grief work, with the implication that they are applicable to all.

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A recent classic comes from the work of Therese Rando (1993). Although framed as processes the bereaved go through rather than stages, Rando continues the paradigm that individuals move through similar phases (whether stages or processes) that are fairly universal. She identifies these as the six “R” processes—a blend of stage- (phase in her language) and task-centered models that she asserts are the outcome of a healthy grieving process. Her model (1993, p. 45), is listed in the following text and consists of phases and tasks for the mourner to accomplish in each of the processes. It is prescriptive in that it describes a process the bereaved must participate in if he or she is to proceed toward healing. Using Rando’s (1993) terminology for the phases, we offer brief descriptions of each phase in the following: ■ Avoidance Phase

1. Recognize the loss. The bereaved must acknowledge and understand the reality of the death. ■ Confrontation Phase 2. React to the separation. The bereaved must experience the pain of the loss, give it expression, and mourn secondary losses. 3. Recollect and reexperience the deceased and the relationship. The bereaved is to review and remember the relationship realistically and also review and reexperience the feelings he or she has as a result of that relationship. 4. Relinquish the old attachments to the deceased and the old assumptive world. The bereaved is to let go of previous bonds and beliefs and develop a “new normal” with new relationships and attachments. ■ Accommodation Phase 5. Readjust to move adaptively into the new world without forgetting the old. The bereaved is to revise his or her assumptive world, develop a new relationship with the deceased, adopt new ways of being in the world, and form a new identity. 6. Reinvest. This is a time to invest in new relationships and roles and indicates a resolution to active grieving. Although Rando (1993) provides a model with more room for individualized tailoring of the treatment process, it remains an accepted assumption that complicated grief is common and requires treatment when grief is deemed to be too extended, too brief (or absent), or when it does not follow the typical trajectory as outlined in these various stage and process models. Despite Rando’s obvious compassion and concern for bereaved people, she is subject to some of the same criticisms as the other early grief work theorists: These models are viewed as normative in a way that means that any deviation from the models is viewed as pathological.

Transition to Postmodern Grief Theory Some theorists in the Foucauldian tradition critique Rando (1993) and others for their “disciplining of grief” (Foote & Frank, 1999). This is viewed as a means of pathologizing grief in ways that allow therapeutic intervention as a form of diffuse power, which produces conformity to societal norms. This is not overt coercion, but a form of self-care and self-improvement (something Foucault [1988] calls “technologies of the self”) that functions to contain grief within a therapeutic context. Foote and Frank also note that Kübler-Ross’s (1969) focus on psychological processes means less—or no—focus on the actuality of the physical and social changes that occur concurrently, allowing people

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to avoid the discomfort of confronting these very real aspects of dying and death. They comment: Grief, like death itself, is undisciplined, risky, wild. That society seeks to discipline grief, as part of its policing of the border between life and death, is predictable, and it is equally predictable that modern society would medicalize grief as the means of policing. (Foote & Frank, 1999, p. 170) T. Walter (2000) too has recognized how policing grief can be destructive. He traces the evolution of policing grief from an enforcement of contained, formalized, and time-limited grieving during the Victorian era to a current expectation of more expressive grief with a tendency toward medicalization of the grief process. He asserts that mutual help/self-help support groups have evolved as a form of resistance to policing and medicalization, although they, themselves, are evolving norms that contain an expectation of grieving similarly to other group members (Walter, 2000). He notes: In postmodern times, both old and new maps are challenged by those who claim no maps can be made of a land that is entirely subjective and individual (M. Stroebe, Gergen, Gergen, & Stroebe, 1992). . . . Yet the evidence presented in this article also suggests that the desire (of both mourners and their comforters) for security, for a map, for fellow travelers, for rules that must be policed, is sufficiently strong that most mourners will never be allowed to be entirely free spirits. (Walter, 2000, pp. 111–112) Postmodern theories of grief grow from a social constructionist understanding of the world (Berger & Luckmann, 1967), which asserts that humans construct their understanding of the world in ways that they then see as self-evident and believe to be true. This “trueness” is part of the construction because others construct their own truths in different ways. This leads to the postmodern understanding that there are many truths, each created within the context of that particular individual’s social and historical milieu, his or her individual and family experiences, and his or her capacity for reflection and insight. The narrative tradition of therapy (White & Epston, 1990) grew from these social constructionist and postmodern understandings and is predicated on each individual developing his or her own story with the help of the therapist as someone to help construct, edit, and frame the story. Making meaning of the deceased’s life, death, and relationships becomes critical to the bereaved processing his or her grief (Neimeyer, 2001; Neimeyer & Sands, 2011). Along with the evolution of this meaning-making approach to grief work, grief theorists and practitioners began to question classic models and templates for grief. The implications of social constructionism and postmodernism include the idea that no individual’s grief must follow a certain preset path; further, decathexis, resolution, and acceptance no longer are envisioned as unitary end states for all. This allowed Klass, Silverman, and Nickman (1996) to theorize about what many mourners had been saying all along, that the end of active grieving does not have to entail a separation from the deceased. Indeed, most often, it actually entails continuing bonds that change in quality. Foote and Frank (1999) assert that postmodern meaning-making narrative approaches provide more promise for resistance to disciplining of grief, at least until they too are institutionalized and become a form of policing grief.

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Meaning-Making and Grief Although Viktor Frankl (1946/1984) is most associated with Man’s Search for Meaning and White and Epston (1990) are most associated with the application of meaning-making and storytelling via narrative therapies, Robert Neimeyer is perhaps the best known for applying these concepts to grief theory and intervention. He traces this back to . . . Kant (1787/1965) who emphasized that the mind actively structures experience according to its own principles and procedures. One contemporary extension of the argument is that narrative—the distinctly human penchant for storytelling—represents one such ordering scheme (Bruner, 1986). . . . Significant loss—whether of cherished persons, places, projects, or possessions—presents a challenge to one’s sense of narrative coherence as well as to the sense of identity for which they were an important source of validation. . . . Bereaved people often seek safe contexts in which they can tell (and retell) their stories of loss, hoping that therapists can bear to hear what others cannot, validating their pain as real without resorting to simple reassurance. Ultimately, they search for ways of assimilating the multiple meanings of loss into the overarching story of their lives, an effort that professionals can support through careful listening, guided reflection, and a variety of narrative means for fostering fresh perspectives on their losses for themselves and others (Neimeyer, 1998). (Neimeyer, 2001, pp. 263–264) This is quoted at length because Neimeyer’s (2001) explanation fits with our own perspectives—that understanding grief and working with people in grief therapy is a mutual project, not one of diagnosis and therapeutic intervention. Grief therapy is a respectful project and process of hearing and witnessing the stories people tell of their lives and their losses, questioning them in ways that allow them to open other perspectives while also leaving room for them to reject those interpretations. At its best, grief work encourages mourners as they construct and reconstruct stories of meaning that enable them to move into their new lives and their new assumptive worlds in the physical absence of the entity who or which was lost. It is important that clinicians working with people who are grieving recognize that the stories may take multiple forms, and the task of the therapist is not to force an adherence to a “true” or “real” one. Instead, we are there to help the client create his or her own coherent story while assisting in shining new light on the possibilities of blind spots that may enable a story that fits the client’s evolving and dynamic worldview in evermore useful and function-promoting ways. This is a relational project involving a willingness on the part of the therapist to truly engage with the client in an authentic and caring manner, exhibiting genuine curiosity about the way the client is unfolding her or his story. Successful grief therapists convey realistic hope that this process can enable the client to return to full engagement with her or his life and loved ones. Clinical work with survivors of trauma is likely to benefit from a similar stance.

Dual Process Theory Dual process theory is another evolution of grief theory built on the ideas of Bowlby (1980/1998) and the stages of disorganization and reorganization. Although Bowlby conceptualized these as discrete stages that one passes through as one heals from a loss, Stroebe and Schut (1999) envisioned an ongoing cyclical process of loss orientation and restoration orientation. This differs from the linear organization stages in that the bereaved person cycles between times of experiencing grief actively and focusing on

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the loss, and then moving into times of restoration orientation. During the restoration orientation, the bereaved focuses on rebuilding one’s new life and engaging in new relationships, activities, and other distractions that move one away from active grieving. It is imperative to understand that these are not viewed in any hierarchy of value for the bereaved; indeed, it is clear that both have value, and that the cycling back and forth between these two orientations provides distraction and restoration time that allows the mourner to move into new roles and activities. Alternately, moving into a loss orientation allows a processing time for the loss. Both are necessary. Notably, children and adults seem to cycle between these stages somewhat differently, with children spending more time in restoration orientation (particularly using distraction), whereas adults may linger in loss orientation more frequently. Current research suggests that people with dismissive attachment styles may need more help engaging with the loss orientation, whereas those with an insecure/anxious style may need strong encouragement to engage in the restoration orientation (Stroebe, Schut, & Stroebe, 2005a; Zech & Arnold, 2011), recommendations that have implications for trauma work as well. Another concept that is implicit within the dual process theory is the revision of the assumptive world. Parkes (1988) was one of the first to write about the assumptive world as a set of assumptions (e.g., my husband will always be there to kiss me good night; buildings will never fall to the ground) that coalesces into a schema, defining how one views one’s world. Parkes defines grief as a psychosocial transition necessitating a readjustment of the assumptive world: For a long time it is necessary to take care in everything we think, say, or do; nothing can be taken for granted any more. The familiar world suddenly seems to have become unfamiliar, habits of thought and behavior let us down, and we lose confidence in our own internal world. (Parkes, 1988, p. 57) Parkes (1988) implies that this is primarily an issue of “our own internal world,” yet the assumptive world entails levels of assumptions from personal to societal, and we argue that these must be understood in much the way social workers and counselors use an ecological perspective. For instance, on the micro levels, assumptions exist along the lines of “I’ll predecease my child”; on the mezzo level, one may hold assumptions like “once a mother, always a mother”; but macro level assumptions can be violated too as when Hurricane Katrina devastated Mississippi and Louisiana, and assumptions that “communities and the country will always take care of people when tragedy hits” were shown to be false. Whenever assumptions require revision, an individual’s world feels uncertain; yet, when these assumptions are dashed at multiple levels, it may be assumed that the challenges to adapting and revising the assumptive world will be greater.

Continuing Bonds and Grief A pivotal understanding in contemporary grief theory came when Klass and colleagues (1996) each examined the data from their disparate research populations and realized that “rather than letting go, they [the bereaved] seemed to be continuing the relationship” (p. xviii). They challenged the notion that disengaging from the deceased or lost one is the goal and illuminated the concept that “the bereaved remain involved and connected to the deceased, and that the bereaved actively construct an inner representation of the deceased that is part of the normal grieving process” (p. 16). They later noted the following: When we discuss the nature of the resolution of grief, we are at the core of the most basic questions about what it is to be human, for the meaning of the

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Trauma of Loss, Vulnerability, and Interpersonal Violence resolution of grief is tied to the meaning of our bonds with significant people in our lives, the meaning of our membership in family and community, and the meaning we ascribe to our individual lives in the face of absolute proof of our own mortality. Th[is] . . . challenges the idea that the purpose of grief is to sever the bonds with the deceased in order for the survivor to be free to make new attachments and to construct a new identity . . . the constant message of these contributions is that the resolution of grief involves continuing bonds that survivors maintain with the deceased and that these continuing bonds can be a healthy part of the survivor’s on-going life. (Klass et al., 1996, p. 22)

Again, this is quoted at length because it clearly defines a major paradigm shift in how grief theorists and therapists approach the nature and goals of grief. Aside from the implication that, like meaning-making, each individual may have a fairly unique outcome to her or his grief, this also carries a caution. Just as bereaved people were “policed” into nonexpression of their grief (or more recently into full expression, even when this did not fit their needs), we must remain cognizant that some subgroup of grievers may not feel the need to have continuing bonds, whereas many others can find this comforting. Cultural understandings are important here as well. Mexican “Day of the Dead” celebrations and Buddhist worship at shrines of deceased loved ones reflect the practices of only two of many cultures that have allowed maintenance of continued bonds, despite the fact that most U.S. culture has not recognized these ties/bonds. The individualized assessment of the client, the discussion of cultural inputs into the grief process and customs, the intuitive and respectful stance of the therapist, and the awareness of the wide range of ways in which people move through and process their grief are imperative for sensitive, competent grief work with bereaved people. Another imperative is to recognize that although grief is partially a psychological state, it also is defined socially, in both cultural context and normative inputs, and has physical effects as well. When social expectations are violated, grief and grieving are affected. The notions of disenfranchised grief and ambiguous grief are fundamentally social as well and also have been part of the evolving theorizing of grief.

Disenfranchised Grief Doka (1989, 2000, 2002) coined the term disenfranchised grief to conceptualize grief that is not recognized, validated, or supported by the social world of the mourner. Essentially, the concept of disenfranchised grief involves grief that does not meet the norms of grief in the griever’s culture. Hochschild (1979, 1983) has referred to norms such as these, which guide the individual in what is an “appropriate” feeling in a given situation, as feeling rules. Disenfranchised grief comes as a result of breaking the feeling rules, or of living in a time when feeling rules are not established or are discrepant (McCoyd, 2009). This then leaves the griever uncertain as to whether she or he is “allowed” to feel sad about a loss experience that is not recognized by social peers. Further, it may leave the griever wondering if she or he is even “allowed” to call the experience a loss (or a trauma). Doka (2002) breaks the types of disenfranchised grief into five categories: (a) grief in which the relationship is not recognized, such as gay and lesbian relationships, extramarital relationships, and other relationships that lack social sanction; (b) grief in which the loss is not acknowledged by societal norms as a “legitimate” loss, as when abortion, adoption, pet loss, amputation, and other losses are not viewed as worthy of sympathy; (c) grief in which the griever is excluded, as is often the case for individuals who are children, aged, or developmentally disabled and are (inaccurately)

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not believed to really experience grief; (d) grief in which the circumstances of death cause stigma or embarrassment, such as when a person dies of AIDS, alcoholism, crime, or in other ways that are viewed as moral failures on the part of the deceased; and (e) grief that is expressed in nonsocially sanctioned ways, as when a griever is deemed to be either too expressive, or not expressive enough (Doka, 2002). The nature of disenfranchised grief means that grieving individuals do not receive the social support and sympathy from others that has been shown to be crucial to being able to process grief and move on from it in healthy ways. The very core of this experience (for most) is to actively engage the pain of grieving. Yet, for many, this pain is exacerbated by social isolation or rejection. Many types of losses fall into some of these categories, particularly losses that are not recognized as worthy of support by others. In these cases, the mere validation that it is accurate to perceive the event as a loss, along with normalizing the grief response, can allow the griever to move through the loss response without the complications that may occur when the griever is bereft not only of the lost entity, but of validation, recognition, and normalization of his or her grief. Certainly trauma such as childhood abuse of all forms often entails disenfranchised losses.

Ambiguous Loss Ambiguous loss (Boss, 1999) appears to be a form of disenfranchised loss. What Boss describes as “frozen grief” is difficult to process, because the definition of who is lost is so uncertain. In ambiguous loss, the lost entity is ■ physically present but psychologically absent—for instance, a loved one with

Alzheimer’s disease or head trauma/brain injury; or ■ physically absent but psychologically present—such as when someone is kid-

napped or missing in action during a war. These types of losses are confusing because it is unclear how one is to adjust to them. Without an overt death in the first case, it seems premature and even cruel to grieve in socially sanctioned ways; in the second, to begin to grieve would remove the hope of the return of the lost one to the social milieu. Boss points to the following factors as creating difficulty for those experiencing ambiguous loss: ■ Uncertainty means adjustment cannot occur because it is unclear what one is

supposed to adjust to. ■ Rituals are not available and there are few social supports. ■ The irrationality of life is on display. It is hard to feel that there is a rational

world when nothing seems clear or rational. ■ The grief is unending. The uncertainty drags out and there is little ability for

resolution. These types of losses also confuse formal and informal support people who are just as perplexed about whether to express sympathy or maintain a stolid sense of normalcy and hope. Disenfranchised and ambiguous losses are heightened in intensity by the lack of social support. This may be why peer support and mutual help groups seem so efficacious with grievers such as these. Theoretically, it is appropriate to create groups for those for whom social nonrecognition of the loss occurs, because the group members are all in similar situations and are aware of a sense of loss. Although having similar types of losses does not ensure having similar responses to that loss, the social milieu can be discussed, and strategies for coping with it can be addressed.

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BIOPSYCHOSOCIAL EFFECTS OF GRIEF The biopsychosocial approach requires an understanding of the ways that mind and body interact within a social context. The biological impact of psychosocial factors seldom is addressed, explicitly, in much of the therapeutic literature. This said, the link between higher mortality and bereavement has been strong, long lasting, and significant (Bowling, 1988; Parkes, Benjamin, & Fitzgerald, 1969; Stroebe, Stroebe, Gergen, & Gergen, 1981; Young, Benjamin, & Wallis, 1963), despite findings that the rates are higher for widowers than widows (Helsing, Comstock, & Szklo, 1982; Jones, 1987; Stroebe & Stroebe, 1993) and that a few studies actually find no significant statistically raised risk (Clayton, 1974; Niemi, 1979). Understanding the possible mechanisms for the increased mortality and morbidity risk is important. A full understanding of the interaction of emotions and physical health is beyond the scope of this chapter, but having a basic understanding of how immune systems, neurological systems, and cardiovascular systems may be affected by stress, grief, depression, anxiety, and traumatic events can help practitioners to think about ways of promoting health despite bereavement and of recognizing the impact of psychosocial factors on physical health. The immune system is one of the most potent mediators of the interaction between mental and physical health (Cohen & Rodriguez, 1995; Herbert & Cohen, 1993; Pennebaker, Kiecolt-Glaser, & Glaser, 1988; Salovey, Rothman, Detweiler, & Steward, 2000). A significant body of work (well summarized in Salovey et al., 2000) shows that negative emotions decrease secretory immunoglobulin A (S-IgA), which then causes individuals to be much more susceptible to infection from viruses such as the common cold. The natural killer cells associated with good immune system functioning are also lower in the presence of negative mood and unpleasant affective states (Knapp et al., 1992). More recent studies in nonhuman primates have worked to differentiate psychoneuroimmune functions in monkeys who are separated from their mothers (some of whom receive surrogate maternal care and some of whom do not) and found that they each experienced reduced levels of immunoglobulin M (IgM) and immunoglobulin G (IgG) along with other lymphocytic activity necessary for ideal immune system functioning (Laudenslager, Boccia, & Reite, 1993). Further studies have found that monkeys with longer term separations from their mothers experienced long-term decreased lymphocytic activation and lower natural killer cell activity into adulthood, even after reunification (Rager, Laudenslager, Held, & Boccia, 1989), which implies the potential for longer term effects than just the discrete bereavement period. Neurotransmitters and other neurochemical interactions also play a major role in the interaction of mental and physical health. The major mediator of brain chemistry under stress is the hypothalamic–pituitary–adrenal axis (HPA), which, when activated, causes a release of cortisol, the stress hormone. Norepinephrine and adrenocorticotropic hormone (ACTH) are also released when the HPA is activated, with rises in ACTH typically providing a feedback loop with cortisol, which then rises, ideally leading to lowered ACTH production. This feedback loop seems to break down in depressed individuals, with cortisol staying elevated. These hormones promote hypervigilance; decreased food intake; reduced libido; poor sleep; and increased blood pressure, heart rate, and cardiac output (Kim & Jacobs, 1993). This disturbance of the ACTH– cortisol feedback loop has not been found in bereaved people, despite many of the same behavioral symptoms, though higher levels of norepinephrine were found in bereaved individuals (Kim & Jacobs). An important caveat for many of these studies exists: The subgroups of the bereaved (gender, age, social network availability, relationship to the deceased, coping styles) have been found by various researchers to affect

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neuroimmune function as well, and the individual differences well may be masked when statistical averages hide individual differences (Kent & Hayward, 2007). Recent work (Gundel, O’Connor, Littrell, Fort, & Lane, 2003; O’Connor, Gundel, McRae, & Lane, 2007) provides an intriguing link between the biological effects of grief and the reasons narrative meaning-making is a useful intervention. The researchers used functional magnetic resonance imaging (fMRI) to scan acutely bereaved individuals’ brains after interviewing them about their loss. They then said words from the interview to the bereaved and watched the response on the fMRI. They discovered that the posterior cingulate cortex, the cerebellum, and the inferior temporal gyrus are all affected and each has a role in autobiographical memory and creation of the “storyline” of individual’s lives. Van der Kolk, McFarlane, and Weisaeth’s (1996) understandings about trauma suggest that grief is affected differently when the loss is experienced as traumatic. At this point, the emotional memory of the loss is “stamped in” by the flood of neurotransmitters that occurs at the time of a trauma; further, the amygdala is activated, though often in a less than conscious manner so that similar events and thoughts may provoke the amygdala to continue to send signals of arousal even when the loss has already occurred (van der Kolk, 1998). The physiological effect on the cardiovascular system of hormones like cortisol and neurotransmitters like norepinephrine and epinephrine, as a result of psychological factors, is fairly well established (Booth-Kewley & Friedman, 1987). Cardiac arrhythmias also appear to occur more commonly during separations (Laudenslager et al., 1993). The positive connection between cardiac well-being and generalized health (or its opposite, sudden death) appears to be well established; therefore, factors that create stress on the cardiac system are believed to be another mechanism for interaction between mental and physical health, and particularly between bereavement and morbidity and mortality (Stroebe & Stroebe, 1993). In light of the physiological aspects of bereavement just described, it becomes important for the grief counselor to be aware of how to promote physical health and wellness. Regular exercise, a balanced diet with an increase of B vitamins and antioxidants, increased omega-3 intake, and exposure to light (Zisook & Shuchter, 2001) all need to be encouraged. During the bereavement period, a checkup by a physician is indicated; counselors should encourage conscious provision of self-care and monitoring of risks to one’s health.

INTERVENTIONS As noted in the many task- and stage-related grief theories initially detailed, there is a tendency among grief theorists to identify phases (and associated tasks) through which the mourner must move to heal. Newer theories avoid the prescriptive nature of many of the earlier theories; yet, the onus remains on the bereaved to move through the process. Interestingly, when working with students and others who want to be of use in assisting those who are grieving, their question tends to be “What can I do?” not “What should the bereaved do?” This is actually a much more important question, and newer theories of meaning-making, although critically important, provide little guidance on what the practitioner is to do to intervene effectively. Lloyd (2002) suggests that the practitioner do the following: (a) explore attitudes toward death and dying from psychological, sociological, and philosophical/religious perspectives; (b) explore and analyze the bereaved’s constructions of life; and (c) explore the processes of adjustment to the world without the lost entity. Within each area for exploration, attention is paid to how the bereaved is redefining roles, rebuilding identities, negotiating transitions, surviving trauma, and maintaining the spirit.

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Another framework for intervention was developed by McCoyd (1987, October) for use with perinatal loss but has been applied to multiple types of loss over the last decades. Called the “five Vs,” this model provides domains for exploration as well as interventions; these guide the practitioner without resorting to structured, predetermined tasks. The Five Vs are validating, valuing, verifying, ventilation, and being visionary. Validating is often one of the first steps of work with the bereaved, particularly if the loss is a disenfranchised one. Helping the bereaved to identify any areas where they may not feel that they have social sanction for grieving, and helping to recognize and validate the individual’s right to be a mourner, are major aspects of the validation domain. Valuing and verifying are often subsumed within the validating domain; recognizing that the lost entity had value to the mourner and supporting the bereaved in discussing all aspects of the way the lost entity/person had value to him or her are major parts of validating the importance of the bond that has been disrupted. Verifying is any intervention done to assist the bereaved in gathering concrete mementos or developing rituals that “make real” the loss. These concrete reminders may be used to help enlist the support of social networks. Ventilation is the domain with which most grief therapists are very familiar; it has become almost stereotyped in that people are urged to “vent,” to “let it all out,” or in other ways to be emotionally expressive. Ventilation can be done in various ways and does not always need to incorporate tears. Indeed, if the therapist falls prey to the grief work hypothesis (Stroebe & Stroebe, 1991), and insists on tears as a form of ventilation, he or she actually risks harming the mourner. The ventilation domain entails an expectation that the bereaved is able to talk about the loss with authenticity and consistent affect and content, not necessarily overt tears. Ventilation is often the domain within which meaning-making begins to occur, and the bereaved is helped to explore the many ways in which the loss has affected the bereaved person’s life. Further, this is the domain in which the grief therapist is most compelled to remain quiet and provide support but not utter platitudes or trite phrases that could interrupt the mourner’s ability to ventilate her or his thoughts, feelings, and reflections freely. The final domain, being visionary, is often a part of the ending process but is found in small amounts throughout the work (whether formal grief work in a therapeutic setting or in informal supportive friendships). This generally entails assisting the bereaved person to think through events that are likely to occur in the future and to recognize their potential for intensifying grief feelings. Rando (1993) calls these STUG reactions—sudden temporary upsurges of grief. Often, they come without warning, but in being visionary, the grief therapist can share lessons learned from others about when grief is likely to be heightened. For instance, with perinatal loss, the arrival of the due date for a pregnancy that has been lost is often a time of intensified feelings of grief; the bereaved may need to allow time for reflection and mourning. The Five Vs can provide a model for grief therapists who desire some structure for the work, yet who recognize the importance of allowing the bereaved to follow their own needs and inclinations for grief work. In her research with people who were adapting after the loss of a life partner, Walter (2003) also emphasized the issue of validation, particularly for gay and lesbian couples who may have little recognition and validation of the nature of the love relationship. Mourning an often disenfranchised loss, and often denied access to the rituals of support after death that others have, these individuals benefit from having someone with whom to reflect on the ways their identity is changing and has changed. Further, C. Walter recognizes the “two incompatible urges” (p. 245) of wanting to cling to the pain of the loss but also to move on and begin to reinvest in the new life ahead. Seldom do people have social contacts ready and able to provide the nondirective approach necessary to accompany bereaved individuals as they review these

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opposing urges and consider the experiences that have led them to the present. This means that grief counselors often may be called upon to witness the pain and growth that comes from these types of loss. Particularly in cases where loss was traumatic, processing the destabilization with someone who can provide a safe, stable holding environment (Winnicott, 1953) is crucial.

COUNSELING IMPLICATIONS A strong focus in the literature (e.g., Walter & McCoyd, 2009; Worden, 2009) suggests that attention be paid to the counselor’s own history of grief and loss as well as to the counselor’s self-reflexive capacity. Clinicians often experience the parallel process of feeling overwhelmed by client losses and moving into a passive role of hopelessness. Clinical supervision may become a necessary instrument for dealing with the compassion fatigue that may be associated with counseling complex bereavement. Unidentified countertransference can lead clinicians to do grief work at rather than with their clients. Several serious questions arise regarding the efficacy of grief work and the potential for iatrogenic effects (e.g., Bonanno & Lilienfeld, 2008; Neimeyer, 2000; Stroebe, Schut, & Stroebe, 2005b). At the same time, Larson and Hoyt (2007) argue that the empirical evidence counters extreme skepticism and supports grief therapy as being as effective as other forms of psychotherapy. The prudent therapist certainly wants to be aware of theoretical nuances, which may contribute to best practices for particular clients. In 1991, Stroebe and Stroebe asked the question, “Does ‘grief work’ work?” Their answer was a tepid “maybe.” Findings that widowers who avoided emotional expression seemed to have worse outcomes than those who were not actively avoiding their grief showed tepid support for grief work; however, widows did not exhibit this same association. This led the authors to suggest that “the view ‘everyone needs to do grief work’ is an oversimplification” (Stroebe & Stroebe, 1991, p. 481). Indeed, Bonanno, Wortman, and Nesse (2004), in a prospective study with 276 older couples, found that 46% of the older widows and widowers they interviewed were classified as “resilient,” with little depression or active search for meaning-making after their spouse’s death, but neither were they considered avoidant. Another 10% were called “depressed improved” and actually improved in mood and coping after the death of the spouse (often those who were caretakers or who had been abused). The people they classified with “common grief” typically experienced depressive symptoms intensifying to about 6 months post loss and then resolving over the course of the following year. This implies that more than half of typically bereaved mourners are capable of adapting to loss, given time and a modicum of supportive social outlets. This reinforces the notion that grief is a normal part of life and something that can promote growth, even in the absence of professional assistance. Yet another 25% or so struggle to manage adaptation after loss, and these individuals may benefit from someone with whom to reflect on their loss and its meaning in their lives. The reflective practitioner must weigh the factors of skepticism about one-sizefits-all grief work for all mourners against the paralysis that can result from giving so much weight to these concerns that we neglect to provide support for those who are asking for our assistance. Remaining open and reflective about new understandings in grief theory and trauma theory, while also using the empirical data derived from one’s actual interaction with individual clients, and how they perceive the work to be useful (or not), are requirements of ethical and sensitive practice in the world of grief support.

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CONCLUSION In this chapter, we have introduced the phenomenology of loss and grief, especially as these constructs apply to losing a loved one and the implications for traumatic loss. We have provided an overview of classical grief theory and examined the transition from the classical to more contemporary theories that are anchored in social constructionism. We have emphasized the importance of understanding the biopsychosocial effects of grief, along with the relevance of adequate and appropriate counseling interventions, especially in situations where bereavement is connected with trauma. We have addressed the implications for counselors working with clients who have experienced the grief and suffering that may result from loss.

RESOURCES Websites American Academy of Grief Counseling (http://www.aihcp.org/aagc.htm) American Death Education and Counseling (http://www.adec.org//AM/Template.cfm?Section=Home &WebsiteKey=c3643141-23ca-4efb-bcdc-4448aaebe4f7#) Counseling for Loss and Life Changes (http://www.counselingforloss.com/) Grief Counseling Resource Guide (http://www.omh.state.ny.us/omhweb/grief/GriefCounseling ResourceGuide.pdf ) Films and Videos Insight Media (Producer). (2005). Not too young to grieve [DVD]. Insight Media (Producer). (2009). Helping children grieve [DVD]. Media Kits Sesame Street. (2010). When families grieve [includes manuals and DVD]. Materials are free and downloadable from http://www.sesameworkshop.org/grief Substance Abuse and Mental Health Services Administration. (2007, October). The courage to remember: Childhood traumatic grief curriculum guide with CD-ROM [DVD]. Available from http://www .nctsn.samhsa.gov/

REFERENCES Berger, P. L., & Luckmann, T. (1967). The social construction of reality. Garden City, NY: Anchor. Bonanno, G. A., & Lilienfeld, S. O. (2008). Let’s be realistic: When grief counseling is effective and when it’s not. Professional Psychology: Research and Practice, 39 (3), 377–378. Bonanno, G. A., Wortman, C. B., & Nesse, R. M. (2004). Prospective patterns of resilience and maladjustment during widowhood. Psychology & Aging, 19 (2), 260–271. Booth-Kewley, S. & Friedman, H. S. (1987). Psychological predictors of heart disease: A quantitative review. Psychological Bulletin, 101(3), 343–362. Boss, P. (1999). Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University Press. Bowlby, J. (1980/1998). Attachment and loss: Vol. 3 Sadness and depression. Attachment and loss. London, United Kingdom: Pimlico. Bowling, A. (1988). Who dies after widow(er)hood? A discriminant analysis. OMEGA-Journal of Death and Dying, 19 (2), 135–153. Bruner, J. (1986). Actual minds, possible worlds. Cambridge, MA: Harvard University Press. Carr, D. S., Nesse, R. M., and Wortman, C. B. (2006). Spousal bereavement in late life. New York, NY: Springer Publishing Co.

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CHAPTER 6

Trauma Survivorship and Disability EBONEÉ T. JOHNSON, JESSICA M. BROOKS, ELIAS MPOFU, JASIM ANWER, KAYE BROCK, EVADNE NGAZIMBI, AND FAMBAINENI INNOCENT MAGWEVA

INTRODUCTION An analysis of global disability concerns suggests that the impact of trauma, crisis, and disaster on persons with disabilities has emerged as one trend in the international disability-related literature (Levers, 2011). Yet the theory- and research-based literature regarding disability and trauma remain limited, despite the fact that disability trauma is profoundly distressing. A lack of access to health and rehabilitation services, education, and employment, as well as the high cost of medical care, hinders the ability of people with disabilities (PWD) to participate fully in society. Injury prevention can reduce the causes of disabilities, and improved care and services can enhance the lives of people living with injury-related disabilities (World Health Organization [WHO], 2007). However, although injuries can be treated and managed, the larger challenge continues to be discrimination, avoidance, exclusion, and abuse of PWD. These challenges can cause distressing and bewildering psychological trauma. In this section, we aim to define relevant trauma issues and disability-related terms and concepts, and offer a discussion of discrimination as a context for understanding some of the intersections of trauma and disability.

Defining Relevant Trauma Issues Since the beginning of history, the experience of trauma has both appalled and fascinated humans. Surprisingly, there is still a lack of consensus on how to define or conceptualize trauma, with only a quarter of studies included in a recent meta-analysis (Green, Rasmussen, & Rosenfield, 2010) that explicitly define trauma. Definitions of trauma have evolved over time to reflect the influence of sociopolitical movements on the construction of health in populations (Norris, 1992). Noteworthy mental health practitioners have documented human rights atrocities, deepening the understanding of trauma survivorship (Steel, Bateman Steel, & Silove, 2009). Of importance, people experience events that they may perceive as trauma inducing; a large number of people survive these traumatic events, and are fitting of the title survivors. The potential of specific events that cause traumatic stress is “an empirical question” (Norris, 1992, p. 490). In the recovery process, contextual factors and personal resiliency influence survivorship with trauma (Harvey, 1996). A traumatic event may be the catalyst to shortterm or long-term disability, depending on survivorship competencies and resources.

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Defining Relevant Disability Terms and Concepts Disability, including both temporary and permanent impairments, depends mainly on the nature and type of disaster (Iezzoni & Ronan, 2010). In human populations, trauma is predicted to cause disability mostly at the extremes of the events. Limited research has explored the short-term and long-term disabilities following natural or man-made disasters (Diaz, Murthy, & Lakshminarayana, 2006). However, sociocultural mediation appears to influence what events would cause trauma and the likely circumstances for an event to be experienced as traumatic. Also, the effectiveness of therapies for survivorship with trauma is influenced socioculturally. Indeed, the construct of disability, as collateral to or from the experience of an event (or series of events) that would comprise trauma, is substantially influenced by aspects of culture (Mpofu, Chronister, Johnson, & Denham, in press). Several disability-related terms and concepts need to be operationalized to illuminate underlying sociocultural constructs and to understand fully the double impact of trauma survivorship and disability. We provide brief descriptions of selected terms.

Access Access, in the fullest sense, refers to how PWD make use of facilities, information, and services without assistance or undue difficulties.

Attitudes This construct represents the core ways in which individuals think about and feel toward disability and PWD. Such cognitions and affect lead to practices that either include or exclude PWD.

Disability Models Several disability models conceptualize the PWD in profoundly different paradigms. The medical model views disability as a health issue with PWD as patients who need medical treatment. The social model regards disability as a social issue; a person with impairment becomes disabled as the result of societal, systemic, and environmental barriers. The multidimensional model conceptualizes disability in light of four dimensions: impairments, activity limitations, participation restrictions and environmental barriers, and facilitators. It is sometimes referred to as a biopsychosocial model. The political perspective understands disability as a human rights issue.

Discrimination on the Basis of Disability Disability-related discrimination relates to any distinction, exclusion, or restriction of a person, based on disability, which has the purpose or effect of impairing or nullifying the recognition, enjoyment, or exercise of all human rights and fundamental freedoms in the political, economic, social, cultural, civil, or any other field. This concept includes direct and indirect discrimination and implies that PWD be ascribed human rights on an equal basis with all others.

Disabled Persons Organization (DPO) A disabled persons organization (DPO) includes any organization that represents PWD in a particular country or region and that has a majority of members consisting of PWD,

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who ordinarily pay a membership fee. A DPO typically has a governing body with a majority of PWD, as elected by the members at regular intervals.

Empowerment This process entails an increase in the capacity of individuals or groups to make choices and to transform these choices into desired actions and outcomes.

Discrimination as Context PWD face particular discrimination and neglect, related to very basic rights such as the right to food, shelter, or even to life. The scale of exclusion due to disabilities is often dramatic; for example, globally, poor children with disabilities are less likely to receive early education, and many adults with disabilities have limited opportunities for employment in the formal sector (WHO, 2011). In addition to the violation of human rights experienced by PWD because of practical impediments, foremost among them being negative attitudes, PWD may be denied their rights by law; for example, the right to form a family or marry or the right to participate in elections and to be elected to office (Honduras; Christoffel-Blindenmission [CBM] 2006). Most of the bias faced by PWD is premised on the three pillars of attitudinal, environmental, and institutional disability discrimination (Handicap International [HI] and CBM, 2006). These practices may torment PWD worse and longer than the physical trauma of loss of a limb, sight, hearing, or any other physical trauma. We view discrimination and exclusion of PWD as both a potential cause and effect of trauma among PWD. We briefly explore the different types of discrimination faced by PWD.

Attitudinal Discrimination Stereotypes and stigma regarding disability exist across all cultures and permeate all social classes, even in the contemporary landscape that emphasizes disability as a human rights issue. Attitudinal discrimination toward people with disabilities often creates the most difficult obstacles; even in countries that adhere to equity legislation, individual members of the society may harbor the remnants of old and stale stereotypes. Such stigma often arises from scapegoating or “othering” those who appear to be different in some way (these and related constructs are discussed more fully in Chapter 16 of this book). Objectification of the person with a disability may translate into violence against this person. While numerous environmental circumstances may render any PWD more vulnerable to violence, it may be that gender is more often associated with vulnerability to interpersonal violence. Historically, passive stereotypes of women with disabilities have led to abuse of women with disabilities, and the abuse has caused worse trauma than the physical disability itself. Although the actual number of incidents is unknown, examples of this abuse included women being raped in their homes, communities, and institutions. For example, an investigation carried out in California in 1984 in community care facilities for the physically and mentally disabled and the elderly found that the residents were being sexually abused and beaten on a daily basis. In long-term rehabilitation facilities, it was found that women were being sterilized, without permission, in order to hide the molestation that was occurring (Asch & Fine, 1988). The DisAbled Women’s Network (DAWN) of Canada sponsored a survey (Cusitar, 1994) of women with disabilities and found that 40% had been abused, and 12% had been raped. Perpetrators of abuse included their spouses and ex-spouses, strangers, parents, service providers, and dates (Young, Nosek, Howland, Chanpong, & Rintala, 1997).

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In the past, negative attitudes and lack of knowledge made it difficult for law enforcement entities to effectively deal with perpetrators. Unfortunately, in some areas, this difficulty may remain. As an example, Kaminker (1997) cited instances in which local authorities dismissed claims of abuse from women with disabilities related to speech and/or motor coordination. In these instances, there was a greater likelihood that the predator was deemed more credible than the woman with a disability. Additionally, in 1995, the Canadian Abilities Foundation cited females with disabilities as being two times more likely to be sexually or physically assaulted compared to their non-disabled counterparts. The risk of assault was greater in foster homes due to negative attitudes toward women and also PWD. With the advent of disability rights campaigns and education, hopefully these incidents have decreased over time. However, there may still be incidents where women with disabilities are viewed as easy targets for rape and physical assault, especially in the areas of harassment, sexual abuse, and exploitation. Particularly in patriarchal societies, women with disabilities may be less likely to benefit from the few services that are available, as these services may be geared towards men. A disability and HIV and AIDS situational analysis, commissioned by NASCOH in 2003, revealed that PWD are particularly vulnerable to AIDS because of their low literacy levels, poor access to health care, high vulnerability to sexual abuse, lack of information on AIDS (especially for the visually impaired and hearing impaired), and consequent lack of inclusion in AIDS intervention programs. Stigma, fear, and ignorance result in the majority of PWD refraining from using available services such as voluntary testing and counseling (VTC), antiretroviral therapy, home-based care, and psychosocial counseling.

Environmental Discrimination Two forms of environmental discrimination exist: built or physical environment inaccessibility and social inaccessibility. The physical environment includes buildings, transport, and infrastructure. Some PWD might be left out of a family or organization excursion, for example, because the available transportation is not accessible for a person with certain disabilities. It is not unusual for important facilities, like those offering health and medical services, to lack accessibility for persons with mobility challenges. This level of exclusion can be extremely stressful. Social inaccessibility occurs when information is presented in formats that are not disability friendly; one example, which literally has life-and-death implications, is that little has been done to ensure that HIV and AIDS awareness and condom marketing campaigns are accessible to hearing or visually impaired persons—this inaccessibility is especially egregious in areas like subSaharan Africa, where the incidence rates are high.

Institutional Discrimination Institutional discrimination means legal discrimination. Examples include not being allowed to marry or to have children, exclusion from school or employment, and noncompliance with fair voting practices.

Trauma Linked to Disability Discrimination Many PWD experience stress pileup from an accumulation of traumatic stress over the lifetime. Yet a pileup of stress in adulthood—on top of the vulnerability resulting from childhood trauma—may become untenable. For example, adulthood stress can lead to depression, sometimes coupled with substance abuse; memories of earlier trauma may

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come to the forefront, eventually resulting in a diagnosis of posttraumatic stress disorder (PTSD; Allen, 2005). Children with disabilities may be particularly susceptible to attachment trauma, which includes physical abuse, sexual abuse, antipathy (rejection), psychological abuse (cruelty), emotional neglect (lack of responsiveness to emotional states), and physical neglect (lack of supervision and failure to provide for basic needs). Attachment trauma in childhood may be especially problematic because it can influence the course of psychological, social, and physiological development (Allen, 2005, 1. Trauma, para. 4).

VARYING PERSPECTIVES ON SURVIVORSHIP WITH TRAUMA The evolution in understanding trauma experience and survivorship is in part reflected in how the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: Third Edition (DSM-III) defined trauma in the last half century (American Psychiatric Association [APA], 1987). An earlier definition (APA, 1980) considered a traumatic event as an event “that is outside the range of usual human experience and that would be markedly distressing to almost anyone” (p. 250). However, in the fourth edition, this limited view was amended (APA, 1994). The DSM-IV and DSM-IV-TR manuals define trauma as posttraumatic stress symptoms that emerge within a month of a traumatic event and persist for more than 4 weeks. The assumption that the range of human experience is known enough to benchmark the definition of stress has been discarded. In the remaining parts of this section, we offer brief discussions of historical, contemporary, psychological, sociological, postmodern, and human rights perspectives on survivorship with trauma.

Historical Perspective Historically, trauma has been associated with the experience and survivorship of wars (Courtois & Gold, 2009; Mullins, 1999). Necessarily, physical trauma and collateral disability were the archetypical scenarios of trauma. Military and large municipal hospitals contributed to the development of comprehensive trauma systems (Blaisdell, 1992; Gertner, Baker, Rutherford, & Spitz, 1972). A trauma system was defined as public health policy beneficial to injured persons via the provision of timely and coordinated care (Mullins, 1999). Up to about the 1960s, trauma survivorship efforts of governmental agencies in the United States were focused mostly on reducing the country’s overarching burden of injury. The 1966 U.S. federal combined report of the Committee on Trauma, and Committee on Shock, Division of Medical Sciences, National Academy of Sciences/ National Research Council entitled Accidental Death and Disability: The Neglected Disease of Modern Society was the beginning of a nationwide effort to combat trauma and was a landmark publication highlighting the priority focus on surviving physical trauma. This report sought to stimulate innovative interventions for physical trauma, and to improve treatment, especially in emergency rooms. With the publication of this report, trauma became a political concern. There is no doubt that war is a stressful experience, an experience that has many implications and a far-reaching effect on many people. It presents the risk of being killed, mutilated, or captured, not only for those who serve in the war, but also for members of the communities in which the war is fought. The use of ceramic plates and Kevlar body armor has reduced the number of soldiers killed in action (Stinner, Burns, Kirk, & Ficke, 2010). However, the widespread use of improvised explosive devices in combat operations leaves the extremities susceptible to injury. During the current

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conflicts in Iraq and Afghanistan, it has been reported that 82% of casualties sustained injuries to their extremities (Owens, Kragh, Macaitis, Svoboda, & Wenke, 2007). These injuries have resulted in a high number of disability survivorship for combatants in war and a growing issue in counseling these survivors of trauma.

Contemporary Views Contemporary understanding of trauma survivorship is more holistic and considers physical, psychological, and social aspects. Trauma survivors may experience major depression, PTSD, generalized anxiety disorder, and major depressive disorder (Anwar, Mpofu, Matthews, Shadoul, & Brock, 2011; Carey, Stein, Zungu-Dirwayi, & Seedat, 2003; Gleaves, 2007; Kilpatrick et al., 2003; Noji, 1996; Rasmussen, Rosenfeld, Reeves and Keller, 2007). Traumatic stress, caused by conflict and war, can lead to serious mental health disorders. On returning home, ex-servicemen and women can be overwhelmed by numerous issues such as disturbing memories and images of death (Whyte, 2010). Other psychological disorders with trauma survivorship include dissociative disorders, substance abuse disorder, personality disorders, and psychosis (Gold, 2008). Thus, consideration of the psychological, social, and postmodern effects of trauma survivorship is important.

Psychological Perspectives Trauma as a psychological phenomenon is recognized in the works of Carlson (1997) and others who regarded an event as traumatic if (a) an individual’s perception of the event results in negative consequences (i.e., physical pain, injury, or death), (b) he or she perceives the sudden onset of the event as an immediate threat, and (c) the individual perceives the event as out of his or her control. One would be a survivor of a traumatic event if he or she experienced the event (whatever it might be) as subjectively shocking (Breslau & Davis, 1987; Solomon & Canino, 1990), and the event produced “symptoms of … stress,” including intrusion, numbing, and arousal (Norris, 1992, p. 490). In other words, survivorship of the traumatic event presents a challenge to the individual’s adaptive system, the mechanism for supporting psychosocial equilibrium within one’s environment (Silove, 1999). Historically, the phenomenon of trauma has been associated more with disability experience and much less with adaptive competencies.

Sociological Approaches Sociological perspectives, such as the work of Silove (1999), provide a systematic model to operationalize survivor adaptive systems. Silove considered five adaptive systems: safety, attachment, justice, existential meaning, and identity/role, which provide a homeostasis between an individual and his or her environment. In reference to the safety system, experiencing a threat to one’s health or life may initiate a psychobiological mechanism to ensure and preserve safety. For instance, the disruption of social ties from war, torture, refugee experiences, and so forth result in a disturbance to one’s interpersonal relationships. For instance, in war trauma, specific tactics may be used to impact negatively a person’s sense of community so that he or she feels alone and useless. Prior roles such as father, provider, and so forth are diminished or eliminated. This disruption may result in actual (i.e., the death of a family member) or symbolic (i.e., self-worth) losses to which an individual must adapt. In terms of existential meaning, survivorship is associated with contemplating the purpose of life or seeking an

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explanation or reason for enduring trauma. Also, it comes with reexamination of the individual’s value system (Wright, 1972).

Postmodern Approaches Postmodern approaches (e.g., Stolorow, 2009) consider trauma experience a part of the human condition. According to Stolorow, “human beings would be much more capable of living in their existential vulnerability, anxiety, and grief, rather than having to revert to the defensive, destructive evasions” (p. 208). Postmodern perspectives on trauma consider trauma survivorship, taking into account the environmental and societal context (Anwar et al., 2011; Harvey, 1996). When trauma survivorship is viewed in this manner, it may or may not lead to disability based on the framework that (a) persons are not equally susceptible to or affected by traumatic experiences, (b) persons may or may not receive clinical care, and (c) clinical intervention post trauma does not guarantee recovery in and of itself. Survivorship is compromised with continual distress and support deficits within the recovery environment. Thus, providing psychosocial support to trauma survivors is critical. Psychosocial support to trauma survivors has been found helpful in reducing disability. For instance, a study conducted in 1996, following the Bosnia war, provided evidence that psychosocial inventions when applied to women and children of war survivors have positive outcomes (Dybdahl, 2001).

Human Rights Perspective Trauma occurs because of human rights violations such as physical and/or psychological torture. International civil and human rights movements have cast trauma survivorship as a global issue, perhaps more than any other historical movement (Gruskin, 2004). For instance, protection from the experience of traumatic events and the rehabilitation of survivors aligns with the United Nations’ (1966) International Covenant on Civil and Political Rights (ICCPR). The ICCPR obligates governmental entities to respect the dignity and security of all persons via protection of physical integrity, procedural fairness in laws, freedom of speech and religion, and the right to political participation. This covenant is exemplified by related resolutions of the United Nations’ organization such as the resolution in 1973 on Libya to protect citizens from predatory regimes threatening to decimate citizens who hold contrary political ideology. As time passes, so-called second-generation human rights refer to survivors’ entitlements to have access to basic necessities, whereas third-generation human rights entail respect of cultural values such as maintaining heritage, a sense of community, and the right to self-determination. These rights are “universal, inalienable, and indivisible” (UNO, p. 359). Thus, human rights norms and standards have provided a broad-based view to understanding trauma survivorship. Combining health and human rights, in a public health framework, provides a benchmark for the assessment of progress and the success or failure of trauma protection and safety policy implementation (Gruskin & Loft, 2002; Gruskin, Mills, & Tarantola, 2007).

THE PHENOMENON OF COURTESY TRAUMA AND IMPACT ON SURVIVORSHIP Courtesy trauma occurs when significant others to a survivor are imputed by others to experience traumatic stress or actually show evidence of stress because of their relationship with the trauma survivor. Allied terms to courtesy trauma include vicarious trauma

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or compassion fatigue. With vicarious trauma, others associated with the occurrence of trauma and who may not share a personal or continuing relationship with the survivor are involved. However, courtesy trauma is characterized by the trauma experienced by those who have significant personal relationships with the actual survivor, thus they too inevitably are survivors. For instance, family members caring for another with trauma experience may be traumatized by both the loss of a significant other and the burden of care associated with helping a survivor to adapt. Thus, they would also be working, in a parallel fashion, to adapt to or survive the stress experienced by significant others. Trauma experience on others may depend on whether it follows congenital disability, as when a developmental disability is realized in a family or with an acquired disability with sudden onset. We offer brief discussions of congenital disability and acquired disability in the remaining parts of this section.

Congenital Disability With the occurrence of congenital disability in a child, parents and family members may be traumatized by the event and may develop an acute or chronic stress disorder for which they may need survivor skills to cope effectively and to adapt. Parents may dwell on the traumatic experience (guilt, blame, anxiety, depression, etc.) and blame themselves for the genetic anomaly. They may react by overprotecting or neglecting the child survivor with a disability. Intergenerational trauma may occur in PWD when the parents’ trauma experiences are projected onto the child with a disability so that he or she is perceived as carrying “bad genes.” Family members, not adequately trained for the caregiving role with a child survivor with a significant disability, may experience chronic stress from being survivors taking care of another survivor. An example of survivor role conflict occurs when a mother of a child with a significant disability working outside the home has to decide whether or not to continue working by relying on others to fulfill the caregiver role or stop working and be the primary caregiver. In developing or low-resource country settings, child siblings may be courtesy trauma survivors when they carry responsibilities to assist another who also may be a survivor. This early caregiving role is disadvantageous, because children must quickly adapt to an adult role with the responsibility of caring for someone before they adequately learn how to care for themselves (Foster, Makufa, Drew, Mashumba, & Kambeu, 1997; Robson, 2000). Consequently, these children may experience physical, emotional, and psychological trauma from caregiver roles at an early age (Sengendo & Nambi, 1997).

Acquired Disability With acquired disability arising from traumatic events such as accidental injuries as in motor vehicle accidents (MVA), falls, war injuries, torture, and so forth—not only do people have to deal with the immediate effects of trauma, but also with the long-term consequences of disability. Some nonimmediate survivors or those associated with primary survivors must deal with the consequences from historical trauma; for example, relatives and significant others of survivors of the Holocaust, slavery, political persecution, and discrimination must survive the long-term consequences of disability survived by forebearers. Primary survivors, in effect, experience retraumatization, or prolonged continuing traumatization that may lead to PTSD. On the other hand, with good social support and positive disposition, survivors across generations may cope, adapt, and be strengthened from the traumatic experience. In cases of extreme catastrophic experience, enduring personality change may occur

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regardless of personality disposition. Relationship and work issues may be the consequence of these survivors for a long time (Beltran, Silove, & Lilewellyn, 2009). The case of Sue, in Appendix 6.1, is illustrative.

RESEARCH ON TRAUMA AND DISABILITY Traumatic events are complex and challenging to study (Norris, 1992). Prior trauma studies have relied on small homogeneous samples, oftentimes focusing on only one particular event (i.e., TBI) at a time. Such a narrow method of evaluation has limited knowledge gains in the frequency and severity of traumatic events that occur in society. Even when considering the limitations of previous research, a theoretical/empirical understanding of the construct of trauma is important for several reasons. As noted previously, clinically, exposure to trauma is linked to dissociative disorders, depression, anxiety, substance abuse, personality disorders, and psychosis (Anwar et al., 2011; Gold, 2008). Exposure to trauma has been linked to various health-risk behaviors such as childhood physical and verbal abuse (Williamson, Thompson, Anda, Dietz, & Felitti, 2002); spousal, sexual, physical, and emotional abuse (Dube, Felitti, Dong, Giles, & Anda, 2003); and smoking, alcohol abuse, and high-risk sexual behavior. When examining the relationship between trauma exposure and physiological/psychological maladjustment, there is, at times, a direct causal relationship; but one must remember that the overall relationship is much more complex (Goodman, Rosenberg, Mueser, & Drake, 1997; Morrison, Frame, & Larkin, 2003). For instance, in the case of multiple traumatic experiences, exposure to trauma may make one more susceptible to future trauma (Gold, 2008).

Trauma Centrality, Identify, and Self-efficacy Research emphasizes trauma centrality, when the memory of a traumatic occurrence can become the main part of a survivor’s identity (Rubin, Bernsten, & Bohni, 2008). Survivor identity is positively correlated to PTSD symptoms in soldiers exposed to combat stress, even when controlling for depression and dissociation (Brown, Antonius, Kramer, Root, & Hirst, 2010). The implications of this study suggest that trauma centrality may contribute to the development and continuation of PTSD. A meta-analysis (Luszczynska, Benight, & Cieslak, 2009) provides evidence in support of an association between self-efficacy and PTSD symptoms (Benight & Bandura, 2004), on health-related outcomes such as distress, anxiety, and depression amongst survivors. Effect sizes were medium to large, in terms of cross-sectional studies of self-efficacy on general distress, severity, and frequency of PTSD (r ⫽ ⫺.36 to ⫺.77). Longitudinal studies on distress and PTSD symptoms produced analogous correlational fi ndings (r ⫽ ⫺.55 to ⫺.62). Moderators of the relationship included gender (greater benefit for men with strong self-efficacy beliefs) and perceived threat, as shown by one study, which also indicated that perceived lower threat and strong self-efficacy led to a decrease in severity of health symptoms (Sumer, Karanci, Berument, & Gunes, 2005). Surprisingly, active coping and social support in the Sumer et al. study did not mediate or moderate health-related outcomes, which may be due to the small sample size of 28 (met inclusion criteria) out of the original 8011 studies considered. Thus, this review highlights “the beneficial role of self-efficacy in the process of recovery from collective trauma” (p. 60), shows that “the effects of optimistic beliefs about the ability to deal with posttraumatic adversities on psychological health outcomes appear to be medium to large” (p. 60), and illustrates that

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“self-efficacy is related to better self-reported somatic functioning after collective trauma” (p. 60). Another empirical study showed that self-control, defined as the ability one has to control his or her cognition and behavior, predicted PTSD symptoms 3 months post trauma (R2 ⫽ .49, adjusted R2 ⫽ .47; F [2, 59] ⫽ 28.79, p ⬍ .01), thus, higher self-control was correlated less with symptoms of PTSD. These results may be the consequence of ego depletion (Walter, Gunstad, & Hobfoll, 2010), which occurs when individuals no longer have the resources to control behavior (Baumeister, Heatherton, & Tice, 1994). For persons with PTSD, self-control is necessary to combat potential negative emotions, flashbacks, and symptoms of anxiety (Walter, Gunstad, & Hobfoll, 2010). Thus, researchers theorize that “PTSD may serve as a model as to how the rapid, widespread loss of resources and a person’s ability to regulate their behavior can affect subsequent psychological symptoms” (p. 98). This finding has the potential to bridge the gap between clinical and social psychological research.

Premorbid Personality In another meta-analysis, Ozer, Best, Lipsey, and Weis (2003) show that peritraumatic psychological processes, as opposed to prior individual characteristics, are the strongest predictors of PTSD. Predictors included prior trauma, prior psychological adjustment, family history of psychopathology, perceived life threat during the trauma, post trauma social support, peritraumatic emotional responses, and peritraumatic dissociation. The largest effect size, which was moderate, was for peritraumatic dissociation (r ⫽ .35). Ozer and colleagues suggest that “the specific processes by which these factors may serve to influence the development of PTSD remain largely unexamined” and “further specification of the intervening as well as directly explanatory variable would point to areas of opportunity for intervention and possible attenuation or prevention of the development of PTSD” (p. 31). In terms of future research, it is necessary to generate more knowledge on the association between traumatic experiences and physical/psychological impairment (Gold, 2008). Specifically, researchers should investigate the factors that lead persons exposed to trauma to experience or not experience the adverse ramifications, that is, the variables of resiliency, social support, and so forth. Other research considerations include examining the impact of trauma survey research on the psychological well-being of participants. Further exploration is needed because researchers found that participants receiving treatment for PTSD who completed trauma-related questionnaires reported more feelings of sadness compared to participants completing nontrauma-related questionnaires (Ferrier-Auerbach, Erbes, & Polusny, 2009).

CURRENT PRACTICES IN TREATING TRAUMA IN SURVIVORS WITH DISABILITY Persons who seek treatment due to trauma-related difficulties experience high levels of stress and have not found ways to manage or cope (Calhoun & Tedeschi, 1998). Intervention strategies are dependent on the type of trauma experienced along with other personal and environmental characteristics. Clinicians who provide trauma-counseling interventions to individuals with disabilities face challenging dilemmas about how to provide evidence-based treatment to more than one condition. Most PTSD or trauma counseling theories and techniques are applicable to treating trauma in PWD. However, intervention strategies, resources, or facilities may need to be modified to meet the unique needs of people with specific disabilities.

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Trauma-focused Therapies Meta-analyses of treatments for PTSD provide empirical evidence that trauma-focused psychological treatments such as trauma-focused cognitive behavior therapy (TFCBT) are effective (e.g., Australian Centre for Posttraumatic Mental Health, 2007; Bisson & Andrew, 2009; Seidler & Wagner, 2006). These interventions focus on the meaning and memories of the traumatic events (Ehlers et al., 2010). Consistently, meta-analyses have found that there is no difference in efficacy between various types of trauma-focused treatments (Australian Centre for Posttraumatic Mental Health, 2007; Bisson & Andrew, 2009; Bradley, Greene, Russ, Dutra, & Westen, 2005; Seidler & Wagner, 2006). Currently, trauma-focused approaches are promoted as first-line treatment for PTSD (American Psychiatric Association, 2004; Australian Centre for Posttraumatic Mental Health, 2007; National Institute of Clinical Excellence, 2005; Veterans Health Administration & Department of Defense, 2004). A broad range of nontrauma-focused PTSD treatments have been studied; these include various stress-management programs (e.g., Carlson, Chemtob, Resnka, Hedlund, & Muraoka, 1998; Foa, Rothbaum, Riggs, & Murdock, 1991; Vaughan et al., 1994), supportive therapy (e.g., Blanchard et al., 2003), hypnotherapy (Brom, Kleber, & Defares, 1989), psychodynamic therapy (Brom et al., 1989), interpersonal therapy (Bleiberg & Markowitz, 2005; Krupnick et al., 2008), and eye-movement desensitization (Albright & Thyer, 2010). A recent meta-analysis by Benish, Imel, and Wampold (2008) analyzed a group of different psychological treatments for trauma from previous meta-analyses. The analysis showed that effect sizes for differences between treatments were distributed around zero; thus, Benish et al. (2008) concluded that trauma-focused and nontrauma-focused interventions are equally effective in treating PTSD. Future investigation should examine the treatment factors further needed for success in PTSD interventions (Ehlers et al., 2010; Wampold et al., 2010). In a randomized controlled study in Uganda with 277 Rwandan and Somalian refugees, trauma-focused treatment of PTSD was proven effective against the control group or non-treatment condition (Neuner et al., 2008).

Treatment Outcomes with Co-occurring Conditions Comprehensive trauma treatment delivery outcomes, with people with co-occurring trauma and disability, have been reported. For instance, a collaborative care (CC) pilot intervention, which reduced symptoms of PTSD and alcohol abuse among inpatients with physical injuries (Zatzick et al., 2004), was shown to be effective compared to the control (nontreatment condition) group. CC is a disease management strategy that integrates evidence-based mental health interventions into medical care. Collaborative interventions have the potential to improve rehabilitation from trauma and disability. Integrated treatment programs also have been specifically designed for women with disabilities who have experienced trauma from physical or sexual abuse (e.g., Finkelstein, 1993). For example, a meta-analysis of nine treatment sites found that trauma-informed integrated treatment programs were successful interventions for treating trauma and mental health symptoms in women (Morrissey et al., 2005). Other recent studies have supported the effectiveness of integrated treatment programs for women with co-occurring disabilities (Cocozza et al., 2005).

Alternative and Complementary Interventions A variety of current nontrauma-focused treatments hold promise, such as affective and interpersonal regulation (Cloitre, Koenen, Cohen, & Han, 2002), yoga breathing

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(Descilo et al., 2009), mindfulness training (Price, McBride, Hyerle, & Kivlahan, 2007), acupuncture (Hollifield, Sinclair-Lian, Warner, & Hammerschlag, 2007), and behavioral activation (Jakupcak et al., 2006). Further research is warranted to continue to investigate the efficacy of these new interventions for trauma.

Impact of Disability Service Delivery Services Physical, psychological, and vocational functioning often become personal barriers facing working-age adults with disabilities who seek employment opportunities. With respect to employment opportunities for PWD resulting from trauma, psychosocial factors play a significant role even though the exact impact of such factors on employment status is difficult to determine (Smeets, van Lierop, Vanhoutvin, Aldenkamp, & Nijhuis, 2007). Although PTSD or trauma survivorship counseling interventions are appropriate for treating trauma in PWD, there is limited understanding of the unique treatment needs for individuals with disabilities. Researchers should continue to investigate service delivery models for individuals with physical disabilities (e.g., spinal cord injury, traumatic brain injury) and trauma (Zatzick et al., 2001). Moreover, clinicians should aim to develop evidence-based interventions that could assist individuals who experience trauma from the diagnosis of a chronic illness or disability (e.g., HIV). To elaborate, these interventions are important for persons with co-occurring trauma and disability in order to improve rehabilitation outcomes, specifically in the area of socioeconomic participation. Survivors of trauma aspire to the same life chances as typical others. For instance, nearly half of all working-age PWD, including trauma-related disabilities, would like to be employed (Schmidt & Smith, 2007). A person’s disability status does not have an impact on how trauma symptomology affects certain career variables (Strauser, Lustig, & Uruk, 2006).

COUNSELING IMPLICATIONS Dealing with disability trauma needs a “twin pack” approach (CBM, 2008), one that deals with both the physical trauma of having acquired a disability and the psychological trauma of having experienced discrimination and exclusion. The use of this approach means both mainstreaming of disability into all strategic plans as well as supporting specific disability initiatives for the empowerment of PWD. The type of service provision model that is used typically influences the approach that is applicable in providing disability support services. The outdated charity model, which sees PWD as victims of their impairments and consequently in need of special services and care in special institutions, has seen the creation of special institutions that remove PWD from communities. This approach discriminates against PWD and does not address trauma that is caused by discrimination. The medical model tends to consider PWD as patients who need fi xing to make them ‘normal,’ and places PWD into the passive mode; all the while, rehabilitation ‘experts’ make all the decisions for them, thereby, again, not addressing the disability trauma caused by discrimination. The social model, the multidimensional model, and the political perspective model tend to address issues of disability mainstreaming, inclusion, participation of PWD, and involvement of disabled people’s organizations in empowerment programs. In this regard, the emphasis is not only on medical rehabilitation, but rather, it is on the support services that are required by

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PWD to participate fully in family and community activities and to access equitable services. The greatest implication for counseling relates to the aforementioned types of systemic service-provision features that may have profound effects upon PWD who have experienced trauma.

CONCLUSION Trauma is one of a broad range of human experiences that could cause disability in survivors. Understandings of trauma have evolved over time to emphasize social contextual factors that influence what comprises a traumatic event and related survivorship competencies. Human rights approaches provide a transcultural understanding of trauma experiences that are important for policy on protections from trauma and necessary resources for survivors. The research evidence suggests that disability from trauma experience and survivorship is influenced by premorbid functioning. Evidence is accumulating on the efficacy and effectiveness of therapies for trauma survivors with disability. Survivorship is an inclusive concept for understanding the lived experience of trauma and also the recovery process.

APPENDIX 6.1 The Case of Sue You are working as a vocational rehabilitation counselor at the U.S. Department of Veterans Affairs. You received a supported employment referral for Sue, a 56-year-old female Caucasian veteran. With supported employment, participants have work reentry support of job coaches both onsite and also from a facilitator (or case manager) of a vocational rehabilitation agency. Sue has a diagnosis of paranoid schizophrenia and military sexual trauma. During your initial consultation meeting, Sue described her interests and preferences for work. She also talked about her prior job as a secretary. Sue explained that she needed to quit her last job because she was having problems getting along with her male coworkers. Sue discussed how she has felt uncomfortable around men since she was sexually assaulted when she served in the military 15 years ago. Currently, she feels worried about her male neighbors because she believes that they are attracted to her and may try to pursue her. Consequently, Sue has not been sleeping well. You accept Sue into your supported employment program, but you plan to recommend that she seek counseling for her current stress and anxiety.

Reflection questions 1. How do you use the supported employment counseling to address her current stress and anxiety? 2. What other counseling intervention options would be appropriate for Sue and why? 3. What is the evidence for the interventions you recommend?

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APPENDIX 6.2 The Case of James James is a 35-year-old African American man who returned home from combat in Afghanistan 6 months ago. He is seeking counseling services from the local Veterans Administration because of PTSD. While in Afghanistan, James obtained an injury caused by an explosion and had to have a right below-the-knee amputation. He recovered at the local veteran’s hospital and now uses a prosthetic leg for mobility. During the clinical interview, James mentioned that upon returning home, he and his wife of 5 years are arguing a lot. He finds himself constantly losing his temper with her. James drinks about 4–6 alcoholic beverages per day to cope with stress. He states that drinking helps him to cope with the images of combat scenarios that haunt his dreams and the amputation he endured.

Reflection questions 1. What other background information may be needed before developing a treatment intervention to help James? 2. Considering courtesy trauma, what issues may James’s wife be experiencing? 3. Choose one counseling intervention that has been proven efficacious in helping persons with war-related PTSD. What are the benefits, risks, and considerations associated with using the intervention?

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CHAPTER 7

Sexual Trauma: An Ecological Approach to Conceptualization and Treatment LAURA HENSLEY CHOATE

INTRODUCTION Sexual violence is a significant social problem worldwide, and because of the intimate nature of sexual violence, it is considered one of the most distressing types of trauma an individual can experience (Frazier, Conlon, & Glaser, 2001). Sexual violence includes a broad spectrum of nonconsensual sexual activities that are perpetrated on a victim by partners, spouses, friends, acquaintances, family members, or strangers. It can include any of the following: rape (unwanted sexual acts that result in oral, vaginal, or anal penetration); unwanted sexual contact or touching; performance of sexual acts forced through threats of violence, intimidation, or coercion; sexual abuse, including childhood sexual abuse (CSA) and incest; sexual abuse of individuals who are physically or mentally disabled and unable to give consent; or forced prostitution and trafficking of individuals for the purpose of sexual exploitation (Jewkes, Sen, & Garcia-Moreno, 2002; Violence Against Women, 2009). It is disconcerting that sexual violence and its resulting trauma occurs at high prevalence rates, particularly for women. According to the National Violence Against Women Survey, more than half of all U.S. women report an experience of attempted or completed rape and/or physical assault (Tjaden & Thoennes, 2006). Approximately 18% of women report that they have experienced forcible rape (Tjaden & Thoennes, 2006). The World Health Organization’s World Report on Violence and Health suggested that nearly 25% of women experience sexual violence by an intimate partner, and that 33% of all adolescent girls report their first sexual experience as being forced (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Although women are disproportionately affected by all forms of sexual violence, men are also victims of these crimes. Approximately 1 in 33 men (compared to 1 in 6 women) have experienced an attempted or completed rape in their lifetime (Tjaden & Thoennes, 2006). Women and men of all cultural backgrounds experience sexual violence. When comparing most racial/ethnic groups, there are no statistically significant differences between groups, with the exception of Native American women, who experience significantly higher rates of sexual assault (34%) than do individuals from all other cultural backgrounds (Tjaden & Thoennes, 2006). Younger individuals are also at higher risk for all forms of sexual violence in general and for rape in particular. More than 60% of rape victims were raped before age 18, and 25% of female and 41% of male rape victims report that they were first raped before the age of 12 (National Center

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for Injury Prevention and Control, 2008). Because of these high prevalence rates that cut across all age groups and populations, counselors need to be knowledgeable about sexual violence and resulting trauma, how it operates in survivors’ lives, and how to provide effective treatment. The purpose of this chapter is to present an ecological model that enhances understanding of survivor responses to sexual trauma. This is accomplished by the discussions offered in the following sections: (a) a brief examination of the effects of sexual trauma; (b) an illumination of the ecological model for use in conceptualizing sexual trauma, including descriptions of the systems that affect survivors’ recovery; and (c) an explication of best practices for treating sexual trauma, including crisis intervention guidelines and explanations of specific treatment components. This chapter concludes with an identification of the counseling implications of sexual trauma; resources for assisting survivors of sexual trauma follow the Counseling Implications section.

SEXUAL TRAUMA It is not surprising that trauma resulting from sexual violence is associated with a host of negative mental health problems, including posttraumatic stress disorder (PTSD) and associated anxiety, depression, and substance abuse (Campbell, Dworkin, & Cabral, 2009; Resnick, Acierno, Holmes, Dammeyer, & Kilpatrick, 2000). Most individuals develop PTSD-like symptoms within 2 weeks of a sexual assault (Resnick, Acierno, Holmes, Kilpatrick, & Jager, 1999); in fact, these are considered normal and expected reactions to this type of trauma. Overall, lifetime prevalence rates indicate that PTSD develops in 17%–65% of sexual trauma survivors (Kilpatrick, Amstadter, Resnick, & Ruggiero, 2007). Because PTSD is likely to occur in individuals who experience sexual trauma, it is important for counselors to be knowledgeable of PTSD symptoms and how they might manifest in a particular client. The proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V; American Psychiatric Association [APA], 2010), groups PTSD symptoms into four clusters: (a) intrusion (e.g., reexperiencing of the trauma through nightmares, flashbacks), (b) avoidance (e.g., avoiding thoughts, feelings, physical sensations, people, activities, places, or physical reminders that arouse recollection of the event), (c) negative alterations in cognitions and mood (e.g., inability to remember certain aspects of the event, persistent self-blame, strong and persistent negative emotional reactions, feelings of detachment), and (d) alterations in arousal and activities associated with the event (e.g., irritability, reckless or self-destructive behavior, exaggerated startle response, problems with concentration and sleep). To meet DSM-V criteria for PTSD, this constellation of symptoms must occur for at least 1 month and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (APA, 2010). The frequency, severity, and duration of a client’s PTSD symptoms may be influenced by many factors, and the primary influences are addressed in the sections to follow.

ECOLOGICAL MODEL FOR CONCEPTUALIZING SEXUAL TRAUMA Recent research indicates the importance of understanding a survivor’s responses to trauma as a complex interaction between the individual and his or her environment. Several authors have recently examined sexual trauma through an ecological lens, describing ways in which an individual’s adjustment to trauma can be influenced by multiple systems—including the immediate environment, the broader community,

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and the larger cultural context in which sexual violence is understood (Campbell et al., 2009; Messman-Moore & Long, 2003; Neville, Heppner, Oh, Spanierman, & Clark, 2004; Ullman, 2007). For the purposes of this chapter, I draw on the ecological model of Campbell and colleagues (2009) for conceptualizing the impact of sexual trauma on a survivor’s posttrauma functioning. This systems model is based on Bronfenbrenner’s (1995) ecological theory of human development and consists of six levels, all of which are described in the paragraphs that follow.

Individual Level This level refers to the individual survivor’s particular sociodemographical characteristics. Although any individual can be a victim of sexual trauma, individual risk factors include being female, being younger, being a woman of Native American heritage living in poverty, and experiencing CSA (see Chronosystem Level section). Research highlighting other sociodemographic variables indicates that individuals who are lesbian/gay/bisexual/transgender (LGBT) experience sexual violence at rates roughly equivalent to the heterosexual population (Tjaden & Thoennes, 2006). Further, it should be noted that individuals with disabilities are raped and sexually assaulted at high rates, although these crimes are highly underreported, so accurate data regarding this population are difficult to obtain (Violence Against Women, 2009).

Assault Characteristics Level This level provides an understanding of the relationship of the survivor to the perpetrator and also refers to the use of alcohol or other drugs during the assault. Sexual trauma is generally classified as spousal/marital, partner, date, acquaintance, stranger, and incest. There is a pervasive stereotype that sexual assault is most likely to be perpetrated by a stranger, although data indicate that sexual assault is most likely to be perpetrated by someone whom the survivor knows, as more than half of survivors of rape report that they knew the perpetrator (U.S. Department of Justice, 2008). Survivors of acquaintance, date, partner, or spousal rapes tend to engage in more self-blame than do those who experience stranger rapes, although the negative psychological effects on survivors of both types of crimes are similar (Koss & Kilpatrick, 2001). Sexual violence committed by an intimate partner is particularly traumatic, in that although rape by a stranger may be experienced as a singular event, survivors of intimate partner rape typically endure multiple sexual assaults and must live with the continuous threat of repeated incidents of trauma, including other types of partner violence such as physical and psychological abuse (Temple, Weston, Rodriguez, & Marshall, 2007). In addition to the survivor’s relationship with the perpetrator, sexual trauma also may be classified as to whether or not alcohol or other drugs were used in the assault. Sexual assault is highly associated with alcohol use, both by the perpetrator and the victim, particularly for college students. Rapes in which alcohol and other drugs are involved occur five times more frequently than do forcible rapes in which alcohol was not used (Lawyer, Resnick, Bakanic, Burkett, & Kilpatrick, 2010). Frequently, a person is raped while he or she is unable to give consent for sexual activity because of intoxication; yet, he or she is hesitant to label the incident as rape, questions his or her role in the assault, and tends to engage in self-blame (Schwartz & Leggett, 1999). For these reasons, individuals are far less likely to report alcohol-related sexual assaults than they are to report forcible rapes. In one national study of college students, approximately 15% of rapes involved the use of substances administered without the survivor’s knowledge. Gamma hydroxybutyrate (GHB) is a drug commonly used in drug-facilitated sexual assaults and is

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poured easily into an individual’s drink without his or her knowledge. Because GHB produces permanent anterograde amnesia, a survivor typically awakens after approximately 5 hours and may realize that a rape occurred, but have no memory of the perpetrator or of events surrounding the rape. A survivor of this type of assault has no memory of the rape, may receive negative reactions from others because of his or her memory impairment, and is highly unlikely to report the assault to law enforcement (Lawyer et al., 2010).

Chronosystem Level This level refers to the cumulative effects of multiple developmental transitions in a survivor’s life. In the case of sexual trauma, it refers to a survivor’s particular history of victimization. There is a considerable line of research indicating that CSA is a significant risk factor for revictimization as an adult (Fortier et al., 2009; Koss & Kilpatrick, 2001; Tjaden & Thoennes, 2006; Walsh, Blaustein, Knight, Spinazzola, & van der Kolk, 2007). CSA survivors are two to three times more likely to be sexually assaulted in adolescence and adulthood than are individuals from the general population (Tjaden & Thoennes, 2006; Walsh et al., 2007), and there is some indication that there are even higher revictimization rates among LGBT individuals who experienced CSA (Heidt, Marx, & Gold, 2005). Counselors need to assess for and understand a survivor’s victimization history, as people who have been victimized previously are more likely to have differing treatment needs than other survivors. Revictimization is associated with increased levels of PTSD symptoms compared to a single incident of trauma, and those who experience revictimization report greater levels of depression, PTSD, dissociation, anxiety, and substance abuse than do other survivors of sexual trauma (Fortier et al., 2009). Grauerholz (2000) conceptualized the revictimization process as operating within a system composed of the following four levels: (a) a survivor’s initial abuse experience and family history (e.g., demographics, severity, duration, relationship to the perpetrator, and negative social reactions to initial disclosure; Ullman, 2007), (b) the exosystem (e.g., lack of resources or safe housing concerns that increase a survivor’s vulnerability to future sexual violence), (c) macrosystem factors (e.g., cultural norms and institutions that tend to blame the victim, particularly for causing the revictimization), and (d) microsystem factors (e.g., interpersonal and intrapersonal factors, and the interaction between the perpetrator’s behavior and the psychological vulnerability of the survivor). While recognizing revictimization as a multisystemic problem, most of the recent research in this area has centered on microsystem factors. Some studies have examined interpersonal factors such as engaging in high-risk activities that increase exposure to potential perpetrators (e.g., binge drinking or having two or more current sexual partners; Brener, McMahon, Warren, & Douglas, 1999; Grauerholz, 2000). Other studies have identified specific intrapersonal factors that may be related to revictimization, including psychological distress, relationship insecurity, low self-esteem, self-blame, low self-efficacy, use of avoidant coping styles, and deficits in risk appraisal and situational coping. All of these factors can reduce an individual’s ability to assess, assertively cope with, and escape from potentially dangerous situations; these factors also can increase the likelihood that a perpetrator may act with aggression (Walsh et. al, 2007). The most recent research in this area has examined the specific impact of coping strategies and chronic trauma symptoms on adult revictimization. Those individuals who have experienced CSA are most likely to employ avoidant coping strategies (e.g., denial, avoidance, numbing, or detachment). The use of avoidant coping strategies is related to increased PTSD symptoms over time when an individual attempts to avoid

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memories and feelings associated with the trauma rather than to actively process them. The resulting PTSD symptoms, in turn, have been shown to interfere with information processing, accurate risk perception and assessment, failures to react appropriately to threats, and the ability to engage in self-protective responses (Fortier et al., 2009). These responses are all related to increased risk to future victimization (Fortier et al., 2009).

Exosystem Level This level refers to a survivor’s contact with medical, legal, law enforcement, or mental health systems. It is common for survivors to report that their contacts with formal systems were quite negative and caused them to experience guilt, mistrust, and reluctance to seek further help (Campbell & Raja, 2005). These interactions can result in what often is termed a secondary victimization, which is the experience of insensitivity, victim blaming, minimization, and negative reactions from medical, legal, law enforcement, and mental health professionals, and which often exacerbates a survivor’s trauma symptoms (Campbell, 2006; Feldman, Ullman, & Dunkel-Schetter, 1998). Victim blame and negative social reactions are common for all survivors, but are particularly likely to occur in the cases of acquaintance, date, or partner rape (Resnick et al., 2000). It is also important to note that when survivors do attempt to seek assistance, there may be significant barriers for them in receiving needed services. Formal services tend to be less available and accessible for survivors who are disabled, non-English speaking, or who have low levels of education; such individuals often are unaware of available resources or have limited access to hospitals or rape crisis centers (Bryant-Davis, Chung, & Tillman, 2009). In addition, many social services are not designed to meet the needs of male survivors (Tewksbury, 2007) or of LGBT individuals (Gold, Dickstein, Marx, & Lexington, 2009). Further, even when services are readily available, individuals may be hesitant to seek help from formal service providers because of their cultural attitudes and experiences. This might include membership in a racial or ethnic group that has experienced a history of not being believed by law enforcement officials, or those who have developed a mistrust of agencies based on both personal experiences and historical experiences of violations perpetrated by such agencies. Some also may be hesitant to seek services because of their immigration status and fears of deportation (Bryant-Davis et al., 2009). Individuals might avoid seeking help in order to protect themselves from psychological harm (Patterson, Greeson, & Campbell, 2009; Ullman, 2007). After a sexual trauma, survivors may try to suppress their memories and emotions, deny the impact of the trauma on their current functioning, and fear that if they experience the memories and feelings, they may become overwhelmed. They may delay seeking help from professionals until they can no longer suppress their emotions or when their symptoms become intolerable. As a result, many survivors may delay seeking mental health treatment for years, and even when they do, they often present for counseling with a different presenting problem. In addition, survivors may delay seeking mental health treatment because of past negative experiences with the mental health system or with particular mental health professionals, or they might possess beliefs that treatment will cause them to feel worse, that they are unworthy of services, or that mental health treatment will not or cannot help them with their particular experiences (Patterson et al., 2009). Because of these findings, it is therefore important for counselors to be aware that (a) survivors may delay treatment and not seek help until their symptoms are chronic, (b) they may be highly mistrustful of the treatment process, and (c) they may initially present with a different problem until they feel comfortable in openly disclosing the sexual violence.

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Microsystem Level This level refers to an individual’s social support. As stated previously, many survivors experience negative reactions from others, and they often are blamed for bringing the traumatic event on themselves. Negative reactions from others, however, can be buffered by the availability of positive social support. Research indicates that social support can strongly affect a survivor’s reactions to trauma and the ability to recover from sexual violence (Ullman, 2007). The availability of social support increases the likelihood of early disclosure, which is related to more positive recovery. In fact, survivors with strong support systems, and those who disclose to family and friends, have more positive physical and mental health following sexual trauma (Kimerling & Calhoun, 1994; Ullman, 2007).

Macrosystem Level This level refers to broader societal factors such as cultural differences in responding to rape and the acceptance of rape myths that exist in a particular culture. It is important to understand a survivor’s reactions to sexual violence within a sociocultural context, examining the meaning of sexual assault not only to the individual, but also in terms of how it is perceived within the individual’s cultural community. For example, when examining rape within a gendered context, it is viewed not as a crime about sex but about power that serves to devalue women, limit their freedom, and maintain their inequality (Brownmiller, 1975; Low & Organista, 2000). According to Bryant-Davis and colleagues (2009), the sexual assault of ethnic minority women should be understood within the broader context of societal trauma, considering that an individual’s previous experiences with racism, sexism, classism, heterosexism, cultural violence, or historical violence are cumulative and contribute to the way in which a survivor experiences sexual violence when it occurs. For example, when Native American women are assaulted by non-Native men, they may be highly fearful of reporting or retaliation due to historical mistrust of social support agencies within the Native American community (BryantDavis et al., 2009).

Cultural Values Particular cultural values may play an important role for a survivor in making reporting decisions. As examples, only 1 in 5 women in the National Violence Against Women Survey reported the rape to the police, citing reasons such as embarrassment, not considering it a real crime, or fear of retribution by the rapist (Tjaden & Thoennes, 2006). Asian American families may place pressure on survivors to remain silent about their experiences so as not to bring the family shame or dishonor. African American women may subscribe to a perceived cultural mandate to protect African American male perpetrators so that males from their communities will not be incarcerated (Bryant-Davis et al., 2009). For male survivors, cultural beliefs about masculinity and sexuality may cause a man to question whether being raped by another man somehow makes him gay, whether there is something about him that makes others perceive him as gay, or whether or not he will be believed if he chooses to report (Tewksbury, 2007).

Cultural Myths Myths about rape may exist within a particular society that influence both survivors’ and others’ reactions to acts of sexual violence. Women in particular are harmed when the following types of commonly accepted rape myths are endorsed: “She must have

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deserved it because of the way she dressed and where she was when it happened”; “She must have wanted it because she didn’t say no or didn’t put up a struggle”; “If a woman sexually teases a man, she deserves to be raped”; “When she says ‘no’ she really means ‘yes’ and is just playing hard to get”; “Women who accuse a man of rape are doing it to get back at him for not going out with her”; or “It is not really rape if a woman has had many sexual partners” (Burt, 1991; Haworth-Hoeppner, 1998). For gay men and lesbians, the acceptance of negative myths or stereotypes about LGBT individuals (termed internalized homophobia [IH]) is related to an individual’s ability to recover from sexual assault. For example, an individual might have internalized either of these myths: “She deserves to be assaulted because lesbians are deviant, crazy, or weak” or “Men can’t be raped. It can’t be that bad because he must have wanted it” (Gold et al., 2009). Gold and colleagues (2009) reported that lesbians who had greater levels of IH had more severe PTSD symptoms than did those who had lower levels. It is clear that accepting rape-related myths perpetuated by society can lead to greater levels of negative reactions from others, to self-minimization by the survivor, and to the likelihood of increased victim blaming. All of these can have an impact on an individual’s ability to recover from sexual trauma (Campbell et al., 2009).

TREATMENT FOR SEXUAL TRAUMA Counselors generally provide assistance to survivors coping with sexual assault in two ways: either through referring to or providing crisis intervention in the immediate aftermath of the event, or through providing treatment at a later time when the survivor can no longer tolerate the symptoms that have emerged following the sexual trauma. As highlighted in the previous sections, it is important for counselors to be prepared with the knowledge and skill to provide contextually sensitive referrals and treatment. To this end, the sections that follow briefly outline crisis intervention services offered in most communities, and then describe treatment approaches that are most effective for counseling survivors of sexual trauma.

Crisis Intervention Programs Counselors should be familiar with the rape crisis intervention services in their communities so that they make appropriate referrals when necessary. Many communities have established rape crisis centers to serve as first responders to sexual violence in their communities. Most of these agencies provide crisis intervention through medical and legal advocacy. They provide volunteer advocates to accompany survivors to hospitals and police departments and to guide them through the process of medical forensic evidence collection and legal prosecution. The advocate not only facilitates the delivery of these services but also helps to protect the survivor from secondary victimization by promoting positive interactions with other professionals (Campbell, 2006). To assist in the medical aspects of rape crisis intervention, many communities have developed Sexual Assault Nurse Examiner (SANE) programs that hire nurses who are specifically trained to provide crisis/medical intervention, collect forensic evidence, provide appropriate postrape medical care, and coordinate services among multiple service providers (Campbell, Patterson, & Lichty, 2005). Rape crisis centers also provide survivors with information about available services and resources, promote social support, provide psychoeducation regarding common reactions to sexual assault, and offer options to facilitate a survivor’s ability to make informed decisions during this difficult time in his or her life (Ullman & Townsend,

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2008). Most rape crisis centers also offer supportive counseling and 24-hour hotlines for survivors and their support systems. One innovative approach for reaching survivors is offered through the Rape, Abuse and Incest National Network (RAINN), which recently launched the National Sexual Assault Online Hotline (NSAOH). Staffed by trained volunteers, the NSAOH involves a continuous, Internet-based one-to-one chat hotline for sexual assault victims or their significant others in dealing with immediate crises or in coping with issues related to longer term effects of the sexual assault (RAINN, 2010). The online approach to crisis intervention was based on the increasing comfort among younger people in accessing online social support and information and on the reluctance of many people in reporting victimization to formal service agencies. An initial evaluation of the program indicates that visitors find the online hotline helpful and easy to use, and volunteers report that they are satisfied with the program (Finn & Hughes, 2008).

Counseling Treatment Model When counselors work with sexual trauma survivors, they first should work to develop a trusting therapeutic alliance, as survivors may have great reluctance to discuss their memories of the trauma and may have had negative experiences with other service providers. Counselors should demonstrate empathy and positive regard for clients as they carefully assess client concerns through the multisystemic lens described in this chapter. This type of assessment is imperative in developing a treatment approach that is tailored to the client’s specific needs. To provide trauma-informed counseling services, counselors can integrate information regarding the client’s context while following research-supported treatment guidelines. The treatment approaches outlined in the following text are drawn from expert consensus guidelines for the treatment of PTSD (Foa, Davidson, & Frances, 1999; Foa, Keane, & Friedman, 2000) and are adapted specifically for rape-related trauma. The recommended treatment components address specific PTSD symptoms that occur following sexual trauma: (a) psychoeducation about commonly experienced PTSD symptoms, (b) exposure therapy (ET) to facilitate the client’s ability to process memories related to the event, (c) cognitive restructuring (CR) to challenge the client’s maladaptive beliefs about his or her role in the event, and (d) anxiety management techniques to enhance positive coping skills. For a complete discussion of these components, see Choate (2008), Foa et al. (1999), and Resick and Schnicke (1993).

Psychoeducation Survivors of sexual trauma benefit from receiving information regarding commonly experienced reactions to sexual assault (e.g., guilt, anger, shame, powerlessness, helplessness, fear) and the symptoms of PTSD as described previously (Marotta, 2000). Many survivors express that they feel relief when they realize they are not “crazy” but are rather experiencing an expected reaction to a highly traumatic event (Rauch, Hembree, & Foa, 2001). The counselor should be prepared to provide information and resources about medical and legal decisions and assist the survivor in accessing the services of the local rape crisis center, as appropriate.

Exposure Therapy The two treatment modalities for sexual trauma with the most research support are ET and cognitive behavioral therapy (CBT) with CR (Russell & Davis, 2007). CR is described in the next section. The goal of ET is to assist a survivor in working through painful

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memories, situations, thoughts, and emotions associated with the traumatic event and which currently evoke anxiety and fear. As noted previously, many survivors of sexual trauma engage in avoidant coping strategies in order to avoid this intense anxiety and fear (Fortier et al., 2009), and it is understandable that they will be resistant to this strategy when it is presented to them in counseling. To encourage clients to undertake this difficult work, counselors should express empathy and acknowledge a survivor’s fear, spend time educating the client about the rationale for this treatment strategy, and convey positive expectations for recovery (Draucker, 1999). As suggested by Foa, Rothbaum, and Steketee (1993) and as adapted by Choate (2008, p. 177), counselors can explain the use of ET to clients in the following way: 1. Memories, people, places, and activities now associated with the rape make you highly anxious, so you avoid them. 2. Each time you avoid them, you do not finish the process of digesting the painful experience, and so it returns in the form of nightmares, flashbacks, and intrusive thoughts. 3. You can begin to digest the experience by gradually exposing yourself to the rape in your imagination and by holding the memory without pushing it away. 4. You will also practice facing those activities, places, and situations that currently evoke fear. 5. Eventually, you will be able to think about the rape and resume your normal activities without experiencing intense fear. When the client is ready to begin the process, the counselor can use imaginal exposure to assist the client in repeatedly recounting memories associated with the sexual trauma until the memories no longer cause intense anxiety and fear (Foa et al., 1999). Clients are asked to close their eyes, to imagine the traumatic event in vivid detail, and to describe it as if it were happening in the present. Writing about the event in a journal also may be helpful for clients as they practice describing their memories outside of sessions (Harris, 1998). This is an extremely difficult phase of treatment for clients as they face the thoughts, feelings, and images associated with the event that they have been attempting to avoid out of fear. Counselors should acknowledge this difficulty and encourage clients in their willingness to process the event gradually in order to cope with their fears. ET also involves in vivo exposure, a process through which clients are asked to focus on activities and situations associated with the event that they currently avoid because it evokes intense fear and disrupts daily functioning. The client hierarchically lists all avoided situations and activities, ranking them from least to most distressing. It should be noted that the counselor should review this list to ensure that these situations or activities are actually safe and that it includes only those things that are interfering with the client’s ability to engage in his or her daily routines. Starting with the activity or situation that is least distressing, the client remains in this particular environment for a minimum of 30 minutes. This time is recommended because it is long enough for the client to experience fear, to evaluate the actual level of danger present in the situation, and to allow the fear and anxiety to decrease. Anxiety management techniques (as described in the following text) can be used during this time. Over the course of counseling, the client can progress through the hierarchy until he or she is able to resume daily routines and functioning.

Cognitive Restructuring CR is effective in reducing symptoms associated with sexual trauma (Foa et al., 1993; Resick & Schnicke, 1993; Russell & Davis, 2007). In this phase, clients learn

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to identify the automatic thoughts or beliefs that they experience during negative emotional states related to the sexual trauma. The counselor’s ability to understand the client’s broader context can assist the client in fully identifying and exploring thoughts and beliefs related to the traumatic event. As clients identify these thoughts and beliefs, they learn about typical cognitive distortions related to sexual trauma, learn to evaluate distortions, challenge them, and eventually replace them with more rational or beneficial thoughts (McDonagh et al., 2005; Meadows & Foa, 1998). One specific form of CBT with CR that is designed specifically for rape-related trauma is cognitive processing therapy (CPT; Resick & Schnicke, 1993). In CPT, survivors learn to identify and challenge “stuck points” in five specific areas: self-blame and guilt, power and control, self-esteem, trust, and intimacy. These are described briefly in the following text. Self-Blame and Guilt. As described throughout this chapter, self-blame is perpetuated by cultural beliefs and by negative reactions from others in the survivor’s life. Individuals who incorporate negative social reactions into their overall view of themselves tend to have the highest levels of PTSD symptoms (Regehr, Marziali, & Jansen, 1999; Ullman, Filipas, Townsend, & Starzynski, 2006). It is therefore important for counselors to help their clients distinguish between attributions of blame assigned to their character (e.g., “I am a bad person and deserved to be raped”) versus assigning blame to some aspect of their behavior (e.g., “I made a decision that day that I might not make now”). Guilt often is related to self-blame, in that the survivor may perceive that he or she is responsible for the violence or did not do enough to fight back or to prevent the crime. The counselor can assist the client in examining self-blaming and guilt-related beliefs and can help the client begin to replace these thoughts with more logical and growth-enhancing selfstatements (e.g., “I did not do everything right in this situation, but the rapist is fully responsible for this crime. I will now do everything I can to reclaim the power taken away from me by this crime”; Choate, 2008). Power and Control. During an act of sexual violence, an individual is stripped of his or her power, and often survivors continue to feel powerless and out of control long after the trauma has ended. Counselors can assist the client in focusing on restoring his or her sense of personal power, particularly regarding decisions made in the present. As part of regaining power and control, counselors should encourage clients to take an active role in the counseling process, providing them with as many choices as possible and allowing for flexibility in the timing and pacing of sessions. Self-Esteem. In their CPT treatment manual, Resick and Schnicke (1993) recommend helping clients to focus on the effect that the sexual trauma has had on their views of themselves. Clients’ answers to these questions can help to uncover automatic negative thoughts such as “I am unlovable” or “I am damaged goods.” Through CR, clients can learn to separate the events and their reactions from their views of themselves as individuals (e.g., “Being a survivor of sexual trauma is a part of who I am, but it does not define me. I have strengths and a sense of self that this trauma did not disrupt”). As a part of this process, the survivor can gradually learn to view the sexual violence as a traumatic but growth-enhancing event. It is helpful for clients to know that most individuals report some type of growth after a traumatic event, including greater selfawareness, strength, maturity, a more flexible worldview, increased empathy, greater sensitivity to the suffering of others, and changes in relationships, spirituality, life philosophy, or life priorities (Frazier & Burnett, 1994; Frazier et al., 2001; Koss & Kilpatrick, 2001; Williams & Sommer, 1994).

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Trust and Intimacy. Because sexual violence often is committed by someone the survivor knows and trusts, a client’s capacity for intimacy and ability to trust may be disrupted. If a survivor questions his or her judgment in selecting safe relationships, engages in self-blame, and receives victim-blaming reactions, he or she can develop particular problems in trusting both self and others. To change these stuck points, clients can explore beliefs they have developed related to relationships and about the world in general (e.g., “People are bad and can’t be trusted”; “The world is unsafe and unfair”; Frazier et al., 2001). They can then change those beliefs that are impediments to their recovery, evaluate current relationships and their interactions with others who can provide support, and fully explore the need for positive connections with others as part of the recovery process.

Anxiety Management Because one of the primary symptoms following a rape trauma is anxiety, anxiety management techniques are suggested both to prevent and to reduce these symptoms. Meadows and Foa (1998) suggest teaching clients coping skills to reduce anxiety-related symptoms such as hypervigilance, hyperarousal, sleep disturbances/nightmares, and difficulty in concentration. These coping strategies include progressive muscle relaxation training, controlled breathing exercises, role playing, covert modeling, positive thinking and self-talk, assertiveness training skills, guided self-imagery, and thought stopping. Clients can become empowered as they learn to employ these and other anxiety management strategies that promote recovery from sexual trauma.

COUNSELING IMPLICATIONS Counselors who work with survivors of sexual trauma can provide more sensitive and effective treatment when they conceptualize client concerns through the ecological model presented in this chapter. It should be clear that counseling treatment that is focused solely on an individual’s posttraumatic symptoms is inadequate, as the counselor ultimately fails to address the client’s unique responses as affected by the multiple systems that operate in his or her life. The more the counselor can understand the client’s background, cultural values, previous victimization history, the relationship to the perpetrator, current level of support, and experiences with victim blame from other service providers, the more effective the counselor will be in tailoring treatment to the client’s specific needs. While providing this multisystemic understanding of a client’s responses to sexual trauma, counselors also should be knowledgeable of best practice treatments for sexual trauma. Because these treatments require clients to address the memories and situations that produce intense fear and anxiety, counselors should balance treatment techniques with adequate support and validation so that the client remains in control of the direction of his or her treatment. As the counselor demonstrates empathy and an understanding of the client in context, the client can remain empowered as he or she undertakes the difficult but growth-enhancing process toward recovery. In sum, because of the pervasiveness of this problem, it is important for counselors to be able to provide effective treatment for sexual trauma in a contextually sensitive manner. Future research should prioritize a multisystemic approach to the conceptualization of sexual violence. Research also is needed to refine current best practice treatment components and how these may be best tailored for individual clients, based on their sociocultural context.

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APPENDIX 7.1 Case Example Roberta, a 45-year-old Hispanic American woman, has never been to counseling before. She seeks assistance from Mary, a counselor at the community college she is attending part-time. She has many reservations about being in Mary’s office and speaks hesitantly, wondering if Mary can actually be of help to her. While she initially talks about concerns with her children and time management issues, eventually she reveals that she needs to talk about an incident in which she was raped 1 year ago by a friend of her husband. At the time of the assault, she was home alone and allowed this friend to come in and wait until her husband returned from work. She never told her husband of this incident, nor did she discuss it with anyone else until today. She thought she could put the rape out of her mind, but she has recently had difficulty going to class because her professor reminds her of the man who attacked her. She is also experiencing flashbacks, nightmares, and persistent symptoms of anxiety. She keeps asking Mary if she is doing the right thing in discussing this private incident. Mary reassures Roberta that she is taking an important step toward recovery by talking about the rape with someone. When assessing Roberta’s attitudes toward helpseeking, she learns about her fears of counseling (i.e., that Mary will force her to report the incident to police, will make her leave college, or will force her to tell her husband). She is adamant that she does not want to go to the police because she has observed male police officers act in a nonresponsive manner with women in her neighborhood who have called them for help with domestic violence. She thinks the police will not believe her, and even if they did, she does not want her husband’s friend to go to jail. After Mary assures Roberta that she will respect her decision not to report, she tries to begin to understand Roberta’s cultural values and life history that might be contributing to her reactions to the rape. As a Latina woman, Roberta says that she learned that it is very important to defer to her husband and to be respectful of him at all times. She fears that if she tells her husband what happened to her, he will blame her, or even leave her, because she has disgraced the family. Because he values his male friendships, she is fearful that her husband will support his friend and will be angry that she is trying to cause trouble for his friends. When asked about social support, Roberta states that she is close to her sisters and a few women at her church, but she does not want to tell anyone about this because she fears they might blame her too and view her as an unfaithful wife. In treatment, Mary first reassures Roberta that her symptoms are normal reactions to a traumatic event such as rape. She educates her about symptoms of PTSD and describes the treatment approach she would like to take. With Roberta’s permission, they gradually implement ET techniques. Mary asks Roberta to describe the rape in detail and to reexperience her emotions around the event. Over time, Roberta learns to use anxiety management techniques, while sitting at her desk before class, and then once the professor enters the room. She uncovers self-blaming automatic thoughts: “I deserved this”; “I can trust no one”; “I am disgusting because this happened to me” and learns to let go of some of her blame, guilt, and mistrust of others. While she decides not to tell her husband about the rape at this time, she discusses the benefits and consequences of doing this in the future. With Mary’s encouragement, Roberta is able to disclose the rape to her sisters and one friend and is relieved when they fully support her. Gradually she experiences some symptom relief and is able to function better at home and school.

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RESOURCES Websites International Directory of Domestic Violence Agencies (http://www.hotpeachpages.net) International Directory of Domestic Violence Agencies’ goal is to provide information on abuse in as many languages as possible, along with lists of abuse help agencies for every country in the world. This site currently offers abuse information in 83 languages and provides direct links to local agencies that provide services to survivors. MaleSurvivor (http://www.malesurvivor.org/) This national organization against male sexual victimization is dedicated to prevention, treatment, and advocacy for all forms of sexual victimization in boys and men. It provides resources for both survivors and professionals. National Center for Injury Prevention and Control (http://www.cdc.gov/ViolencePrevention/sexualviolence/index.html) The National Center for Injury Prevention and Control (NCIPC; http//www.cdc.gov/injury) site provides facts and statistics regarding sexual violence, provides links to relevant research, describes effective prevention and training programs for professionals, and lists links to resources for survivors. The National Center for Victims of Crime, Violence Against Women (http://www.ncvc.org) The National Center for Victims of Crime, Violence Against Women site is dedicated to helping women, who have been victimized by crime, find appropriate resources. This site offers resources for practitioners and survivors regarding domestic violence, stalking, sexual assault, and legislation/policies regarding violence against women, including legal resources related to domestic violence, stalking, and sexual assault. National Sexual Violence Resource Center (http://www.nsvrc.org) The National Sexual Violence Resource Center provides a clearinghouse of information on sexual violence intervention and prevention strategies. 1in6 (http://www.1in6.org) The 1in6 organization provides information and resources for male survivors of unwanted or abusive childhood sexual experiences. This site also provides resources for families and friends of survivors. Rape, Abuse & Incest National Network (http://www.rainn.org/) Rape, Abuse & Incest National Network (RAINN) is currently the nation’s largest antisexual assault organization. RAINN created and operates the National Sexual Assault Hotline and National Sexual Assault Online Hotline (800-656-HOPE and rainn.org) in partnership with over 1,100 local rape crisis centers across the country. RAINN also carries out programs to prevent sexual assault, help victims, and ensure that rapists are brought to justice. Stop Violence Against Women (http://www.stopvaw.org/General_Resources_on_Sexual_Assault.html) Stop Violence Against Women provides general information to allow users to increase their understanding of domestic violence, sexual assault, sexual harassment, and trafficking in women through an exploration of definitions, the prevalence of the problem, and factors that contribute to the specific type of violence and its effects on victims. This site also outlines law enforcement and other strategies to protect and support victims and to hold perpetrators accountable. This site also provides prevention and training materials to eliminate violence against women and gives information about international and domestic laws/policies related to this area. U.S. Department of Justice, Office on Violence Against Women (http://www.ovw.usdoj.gov/) U.S. Department of Justice, Office on Violence Against Women administers financial and technical assistance to communities across the country that are developing programs, policies, and practices aimed at ending domestic violence, dating violence, sexual assault, and stalking.

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Violence Against Women Online Resources (http://www.vaw.umn.edu/) Violence Against Women Online Resources is a collaborative project between the Minnesota Center Against Violence and Abuse (MINCAVA), and the U.S. Department of Justice’s Office on Violence Against Women. This site provides resources regarding issues of violence against women, including sexual assault. Publications Warshaw, R. (1994). I never called it rape: The Ms. report on recognizing, fighting and surviving date and acquaintance rape. New York, NY: Harper Publishing. This classic book is frequently recommended for survivors of date and acquaintance rape.

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CHAPTER 8

Trauma Experienced in Early Childhood STACI PERLMAN AND ANDREA DOYLE

INTRODUCTION Advances in developmental science have marked an increased recognition of the formative nature of early childhood for growth and development across the life span. Early childhood encompasses the first 8 years of life—including infancy, toddlerhood, preschool, and the early elementary school years. During these years, children develop critical cognitive, social–emotional, and physical competencies that will enable them to successfully negotiate early developmental challenges and support their future well-being (National Research Council, 2000). These early years also are marked by increased vulnerability to traumatic events, such as child abuse and neglect or witnessing domestic violence. Of the nearly 900,000 children who were victims of a substantiated allegation of child abuse or neglect in the United States in 2008, more than 50% of them were between the ages of 0 and 7 years (U.S. Department of Health and Human Services, 2010). Similarly, nearly 60% of children who have witnessed domestic violence are younger than the age of 6 (Fantuzzo & Fusco, 2007). Given the critical nature of early childhood for children’s development, experiences of trauma in these early years can have a particularly adverse influence on development. The purpose of this chapter is to provide an overview of the influence of trauma on early childhood development. This is accomplished through discussions in the following sections: development in early childhood, the influence of trauma on early development, and practice implications for working with young children who have experienced trauma.

EARLY CHILDHOOD DEVELOPMENT A major national report indicates that early childhood is a critical time for brain development. Between birth and age 2, the brain more than triples in size—reaching 75% of its adult size by age 2 (Davies, 2004; National Research Council, 2000). Neural development begins soon after conception and continues at a rapid rate through early childhood (Nelson & Bosquet, 2000). The early stages of neural development consist largely of primitive cells migrating to and forming specific parts of the brain. Once this migration of cells has been completed, the processes of synaptogenesis and myelination begin (Nelson & Bosquet, 2000). Synaptogenesis is the process by which connections are made between brain cells, and myelination functions to increase the speed with which cells communicate with one another. The rate of development for synaptic connections is

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highest in the first few years of life. It is largely contingent on the quantity and quality of stimulation to which children are exposed—or neural plasticity. Positive early experiences have been associated with increased synaptic connections, whereas negative, adverse, or traumatic early experiences have been associated with decreased synaptic connections—or pruning (Perry, Pollard, Blakley, Baker, & Vigilante, 1995; Siegel, 1999). A primary source of information about the world, and thus a primary source of neural development, comes from infants’ and young children’s interactions with their caregivers (Siegel, 1999). For this reason, the development of the relationship between infants and their caregivers is a primary early developmental task.

Attachment as a Developmental Competency in Early Childhood A fundamental task of early childhood is the development of a secure attachment relationship(s) with a parent or guardian. John Bowlby (1982), who originated attachment theory, defined attachment as “any form of behavior that results in a person attaining or maintaining proximity to some other clearly identified individual who is conceived as better able to cope with the world” (p. 26). Attachment relationships are transactional, in that they result from the mutual interactions between the infant and his or her caregiver, and they serve to provide the infant with a “sense of security,” “affective” regulation, “expression of feelings and communication,” and a secure base from which to explore the world (Davies, 2004; Sroufe, Carlson, Levy, & Egeland, 1999). Starting at birth, infants begin a process of moving through phases of attachment. The first phase of attachment, “orientation and signals with only limited discrimination of figure,” occurs in the first 8 weeks of life (Ainsworth, 1964; Bowlby, 1982, p. 266). During this phase, the infant is relatively indiscriminant in terms of the target of his or her attachment behaviors. The second phase occurs between the 8th and 12th week of life and involves “orientation and signals towards one (or more) discriminated figure(s)” (Bowlby, 1982, p. 266). In other words, the infant is beginning to show preference for one or more specific caregivers. The third phase of attachment is characterized by “maintenance of proximity to a discriminated figure by means of locomotion as well as signals” (p. 267). This phase lasts from about the 12 weeks to 18 months. During the third phase, typically, developing infants gain mobility skills through crawling or walking. As such, they gain the capacity to retain close physical proximity to their caregiver. The fourth phase of attachment begins at about 18 months and lasts indefi nitely. This phase is characterized by “formation of goalcorrected partnership” (p. 267). As the infant progresses through each of these attachment phases, he or she engages in attachment behaviors. These behaviors are elicited with the purpose of drawing a caregiver into closer proximity, and as the child moves through the phases of attachment, the behaviors become increasingly discriminating in favor of the primary caregiver (Ainsworth, 1964). Even very young infants show evidence of these behaviors. For instance, as noted by Lieberman and Knorr (2007), a baby may cry, smile, track, cling, or follow a caregiver in an attempt to bring the caregiver closer. The nature of the caregiver’s response to the infant’s attachment behaviors has a direct relationship with the resulting pattern of attachment. Consistent and sensitive caregiver responses to infant attachment behaviors are positively associated with the creation of a secure attachment (Rothbaum, Weisz, Pott, Miyake, & Morelli, 2000; True, Pisani, & Oumar, 2001). In accordance with attachment theory, the development of a secure attachment relationship is critical to children’s early development. It is from the safety and security of the secure attachment relationship that an infant gains the confidence to explore the world around him or her.

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When parents/caregivers respond inconsistently, unpredictably, or adversely, infants are at risk for developing one of three forms of insecure attachment relationships: avoidant, ambivalent/resistant, and disorganized/disoriented (Schuder & Lyons-Ruth, 2007). Infants whose mothers either reject or discourage their children’s attachment behaviors typically exhibit “avoidant” attachment styles. Infants demonstrating an avoidant attachment style often seem indifferent to the presence or absence of their caregiver (Ringel, 2011). Although these children are capable of exploring the world around them, research demonstrates that these children are thought to camouflage their emotional need for their caregivers through a seeming indifference to whether or not the caregiver is present. In fact, research examining the cortisol (stress hormone) levels of children with avoidant attachment styles has found that children with this attachment style have higher cortisol levels than children with secure attachment styles. Children evidencing an anxious-avoidant attachment style are less likely to feel confident exploring the world around them, and they are more likely to evidence stronger attachment behaviors toward their caregivers. Unlike children with ambivalent attachments, these children are hypersensitive to maintaining proximity to their caregiver. Caregivers of children with anxious-avoidant attachment behaviors have been found to be inconsistent in their responses to their children. At times, they are highly attentive, and at other times, they are largely emotionally absent. The final attachment style is referred to as “disorganized” attachment. This attachment style is characterized by unstable, unpredictable patterns of attachment behaviors (Wenar & Kerig, 2000). This style of attachment is frequently observed in children who have experienced abuse or neglect and is the result of children seeking protection from a caregiver in times of stress, even if/when the caregiver is abusive.

Other Developmental Competencies in Early Childhood In addition to the formation of a secure attachment relationship, the infancy, toddlerhood, preschool, and early elementary school years are marked by the acquisition of several other stage-salient developmental competencies. These are outlined in the following text. Infancy: ■ Beginning gross motor regulation: Gross motor development follows cephalo-

caudal (head to toe) and proximodistal (inside to out) trends. This means that infants will learn to lift their heads before they learn to sit up or crawl. ■ Self-regulation: At birth, infants are completely dependent on their parents or caregivers to meet their needs. Parents/caregivers regulate the infant’s sleep and eating cycles. Through interactions with parents/caregivers, infants eventually begin to regulate these cycles for themselves. According to Piaget (1952), the infant learns that he or she can have control over and interact with his or her environment. ■ The formation of a secure attachment is tied into the infant’s development of trust versus mistrust, that is, the degree to which the infant experiences the world as a good and positive place (Erikson, 1968). Toddlerhood: ■ Language: During the toddler years, young children learn to speak and experi-

ence a rapid growth in vocabulary.

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■ Gross motor development: By the end of the first year/beginning of the second

year of life, children start to walk. Their increasing mobility offers children the opportunity to explore the world around them. Children with a secure attachment relationship can use their parent/guardian as a secure base. That is, the child can feel safe to explore the uncertainty of the world around him or her and secure in the knowledge that his or her parent/caregiver is there, if needed. Children without a secure attachment relationship may be more reticent or fearful of exploring their environments. ■ Autonomy: According to Erikson (1968), the “confl ict” of the toddler years is autonomy versus shame/doubt. The language and gross motor development of the toddler years lends itself to an increasing sense of independence. During this developmental stage, young children are eager, almost adamant, about trying to do tasks on their own. When supported by their parents/caregivers, toddlers begin to develop a positive sense of self. Children whose parents/ caregivers either overregulate or underregulate these opportunities may experience feelings of shame or doubt regarding their ability to accomplish new tasks. ■ Continued self-regulation: The newly acquired autonomy of the toddler years also offers increased possibilities of frustration (for instance, being unable to reach something or do something that he or she wants to do). Toddlers do not yet have the cognitive or language capacities to manage these frustrations, which can result in “temper tantrums,” particularly early in the toddler years. Toddlers evidence gains in self-regulation toward the end of the toddler years as they simultaneously gain increased language and cognitive capacities. ■ Egocentrism: According to Piaget (1952), toddlers and preschoolers have an egocentric view of the world. This means that the child believes that others around him or her experience the world the same way he or she does. Preschool Years: ■ Cause-effect thinking: Preschool children’s increasing cognitive capacities pro-

vide them with the ability to begin thinking about events in cause–effect terms (Piaget, 1952). Early in the development of this competency, children may confuse the sequencing of events or not account for the influence of other events (Davies, 2004). This confusion, coupled with a tendency toward egocentric thinking, may leave preschool age children prone to believing that they “caused” traumatic events. ■ Initiative: The developmental crisis of the preschool years is initiative versus guilt (Erikson, 1968). During this stage, children are eager to try to do new things.

TRAUMA AND EARLY CHILDHOOD Given the importance of the formation of a secure attachment relationship in early childhood, disturbances to the parent/caregiver–child relationship in these early years are particularly traumatic for young children. Young children depend on their parents/ caregivers for protection from external stressors and for helping them to understand how to respond to stressful/traumatic events (Lieberman & Van Horn, 2008; Sparrow, 2007). When parents cannot provide this protection, or the parents themselves are the source of the stress, young children’s development and well-being becomes increasingly vulnerable to poor outcomes.

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Child Maltreatment As noted previously, more than 50% of children who experience child maltreatment are younger than the age of 7. Child maltreatment includes experiences of physical abuse, neglect, sexual abuse, and emotional abuse. These experiences represent a proximal disruption to the caregiver–child relationship and thus have the potential to exert a strong influence on children’s development (Cicchetti, 2004). In cases of child maltreatment, the child’s caregiver often is both the threat/source of traumatic experiences as well as a source of comfort. As a result, the child is likely to experience an approachavoidance relationship with the parent or a disorganized attachment (Milot, Ethier, St-Laurent, & Provost, 2010; Schuder & Lyons-Ruth, 2007). Very young children who experience child maltreatment are at increased risk for evidencing poor developmental outcomes, including increased behavioral problems as well as poor educational wellbeing (De Bellis, 2001; Fantuzzo, Perlman, & Dobbins, 2011; Hildyard & Wolfe, 2002; Milot et al., 2010; Perlman & Fantuzzo, 2010).

Domestic Violence Young children are more likely than older children to be exposed to domestic violence (Crusto et al., 2010; Fantuzzo & Fusco, 2007). Research has demonstrated that young children who have witnessed domestic violence show evidence of elevated trauma symptoms (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006; Graham-Bermann et al., 2008; Levendosky, Huth-Bocks, Semel, & Shapiro, 2002; Scheeringa & Zeanah, 1995). Studies by Scheeringa and Zeanah (1995) and Bogat and colleagues (2006) examined trauma symptomology in infants and young children who had witnessed domestic violence. Scheeringa and Zeanah (1995) found that children show increased arousal and new fears after witnessing domestic violence. The researchers suggested that this may be due, in part, to concern that (following experiencing domestic violence) the child perceives that his or her caregiver is less capable of acting as a “protective shield” (Scheeringa & Zeanah, 1995). Additionally, Bogat and colleagues found that just less than half of all infants who witnessed domestic violence evidenced at least one trauma symptom (numbing, increased arousal, or fear/aggression), and that the number of symptoms that infants experienced was directly related to the number of symptoms evidenced by their mother. Levendosky and colleagues (2002) examined trauma symptoms among preschoolers who had witnessed domestic violence. Preschool children who witnessed domestic violence evidenced high levels of reexperiencing and hyperarousal. Notably, children who lived in households in which domestic violence was occurring, but who did not witness the domestic violence event, still evidenced increased levels of trauma symptoms.

Environmental Trauma Following the September 11, 2001 attacks and recent natural disasters (e.g., Hurricane Katrina), increased attention has been paid to how these events affect very young children. Chemtob and colleagues (2010) conducted a study examining the impact of September 11 on preschool children. This study examined maternal PTSD following September 11 and related it to child behaviors. Findings indicated that children of mothers with co-occurring depression and PTSD were more likely than their peers to evidence increased behavioral problems. Similarly, Celebi Oncu and Wise (2010) conducted a study examining trauma symptoms following the 1999 Turkish earthquake. Children who had experienced the natural disaster engaged in more negative storytelling than children who did not experience the natural disaster, even 2 years after the disaster event.

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EFFECTS OF TRAUMA IN EARLY CHILDHOOD The effects of traumatic experiences in early childhood vary and are based on several factors, including the individual child’s stage of development and the nature of the traumatic event. Given that very young infants cannot yet express their emotions verbally, the effects of trauma experienced in infancy usually are manifested through changes in the infant’s behaviors. Infants experiencing trauma may evidence higher levels of agitation, fussiness, and dysregulation of normal routines, including sleeping and eating (Lieberman & Knorr, 2007). Toddlers and preschoolers experiencing trauma may have the capacity to convey their experiences verbally, as well as to use their increased mobility to engage in flight-or-fight responses to traumatic events. However, because these years also are marked by egocentric thinking, children experiencing trauma in these developmental stages are more likely than older children to attribute the cause of the traumatic event to themselves. For instance, a preschooler who is physically abused by his or her parent is likely to believe that he or she did something to cause the physical abuse.

Posttraumatic Stress Disorder in Early Childhood Posttraumatic stress disorder (PTSD) in young children is diagnosed using the same three criteria that are used to diagnose PTSD in adults: reexperiencing, avoidance, and hyperarousal (Coates & Gaensbauer, 2009; Green, Crenshaw, & Kolos, 2010; Levendosky et al., 2002; Lieberman & Knorr, 2007; Markese, 2007). However, PTSD symptoms manifest differently in very young children than they do in older children or adults, and symptoms may persist for longer times (Coates & Gaensbauer, 2009; Scheeringa & Zeanah, 1995; Scheeringa, Zeanah, Myers, & Putnam, 2005). For very young children, trauma-reexperiencing symptoms are manifest as repetitive play (Coates & Gaensbauer, 2009). According to Coates and Gaensbauer (2009), young children who have experienced trauma may engage in play that is devoid of “fun or creative spontaneity” (p. 613). These play experiences may resemble the traumatic event in either content or expression of the emotions/affect from the traumatic experience (Coates & Gaensbauer, 2009; Markese, 2007). Avoidance symptoms manifest in terms of the child’s developmental capacity. If the child is mobile, he or she physically may avoid reminders of the traumatic event. On the other hand, if the child is not yet mobile, he or she actively may seek to avoid eye contact or, in the case of abuse or neglect, noticeably may be distraught by the presence of the abusive caregiver (Coates & Gaensbauer, 2009; Markese, 2007). Markese (2007) also points out that young children may avoid “symbolic play,” that is, substituting one object for another or pretending as a means of avoiding the traumatic experience. Finally, symptoms of hyperarousal can manifest in very young children as increased irritability, aggression, and in some cases, also may resemble symptoms of attention deficit/hyperactivity disorder (ADHD; Markese, 2007). Thus, care should be taken in the diagnosis of young children evidencing signs of ADHD. One other significant difference in the diagnosis of PTSD in very young children, compared to older children or adults, is that very young children need to evidence only one symptom in each of the diagnostic criteria to be diagnosed with PTSD (Lieberman & Van Horn, 2009). In recent years, increased attention has been focused on preverbal experiences of traumatic events. Initially, it was believed that because infants and toddlers could not verbally express their experiences of trauma, these experiences did not have a longterm impact on their development. Recent research has found that infants begin storing memories as young as 2 months of age (Markese, 2007). These memories are stored as “somatosensory experiences” in the brain (van der Kolk, 1994). In other words, traumatic

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experiences in infancy and toddlerhood are stored in the brain as sensory experiences, even if the child cannot yet verbalize these experiences (Green et al., 2010; Markese, 2007). The influence of these experiences on infant and toddler development is seen by the presence of the PTSD symptoms noted previously, as well as an increased likelihood of evidencing disorganized attachment relationships with caregivers (Markese, 2007).

COUNSELING IMPLICATIONS Given the primacy of the parent–child relationship in early childhood, therapeutic interventions for young children who have experienced trauma should focus on the parent–child relationship (Lieberman & Van Horn, 2009; Osofsky & Lieberman, 2011). Several implications for mental health professionals working with young children are identified and discussed in the following text.

Child–Parent Psychotherapy One evidence-based intervention approach is Child–Parent Psychotherapy (CPP; Lieberman & Van Horn, 2009). Lieberman and Van Horn suggest that “CPP has the goal of making the trauma knowable and sayable as a shared child-parent experience in which the parent becomes capable of acknowledging the reality of the events and the legitimacy of the child’s resulting terror, anger, and broken trust” (p. 714). According to this approach, CPP has four primary goals: (1) Create a common language to describe what happened; (2) regulate the over-whelming affects associated with the experience; (3) enhance the parents’ capacity to respond . . . to the child’s basic needs . . . and (4) restore [the child’s] trust in the parent’s ability to protect [him or her] from external and internal danger. (Lieberman & Van Horn, 2009, p. 710) Initial CPP therapy sessions are attended by the parent/caregiver and are focused on developing an understanding of the nature and magnitude of the traumatic experience. Following these initial sessions, both the child and the parent attend therapy sessions. In the case of preverbal infants or toddlers, much of the therapeutic effort is focused on helping the parent or caregiver to identify how his or her own childhood experiences are influencing his or her parenting. The use of CPP with older, verbal children focuses more on helping the child create a narrative about the traumatic experience through the use of play, on assisting the parent/caregiver in reclaiming his or her protective role with the child, and on rebuilding a trusting, positive relationship between the child and caregiver. To date, CPP has been found to be an effective intervention for young children who have experienced one or more traumatic events (Ghosh Ippen, Harris, Van Horn, & Lieberman, 2011; Lieberman, Ghosh Ippen, & Van Horn, 2006; Lieberman, Van Horn, & Ghosh Ippen, 2005).

Parent–Child Interaction Therapy Another evidence-based approach for working with young children who have experienced trauma is Parent–Child Interaction Therapy (PCIT; Eyberg, 1988). Similar to CPP, PCIT focuses on the parent–child interaction. PCIT was developed for use with young children (ages 4 to 7) who have been identified as having behavioral problems, and it consists of a two-phase intervention (Child-Directed Interaction [CDI] followed by

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Parent-Directed Interaction [PDI]) that is implemented across 14 to 20 weeks (Timmer, Ware, Urquiza, & Zebell, 2010). During the CDI phase, the therapist focuses on enhancing the parent–child relationship by encouraging and supporting parents in recognizing their children’s positive behaviors. During the PDI phase, the parent is taught specific parenting techniques for behavioral management to reduce the rates of child behavior problems. PCIT has been found to be effective for working with children who have been victims of or at risk of experiencing child maltreatment, as well as children who have witnessed domestic violence (Herschell & McNeil, 2005; Timmer et al., 2010).

Trauma-Focused Cognitive Behavioral Therapy Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is another evidence-based approach for working with parents and children who have experienced traumatic events (Cohen & Mannarino, 1993). This intervention was initially developed to treat young children who had experienced sexual abuse but has since been adapted for use with children who have experienced other forms of trauma (Cohen, Mannarino, Murray, & Igelman, 2006). TF-CBT combines cognitive behavioral therapy with traumainformed practice throughout a series of individual and combined sessions with the parent and child. TF-CBT uses a nine-component model (PRACTICE): (P)sychoeducation, (P) arenting skills, (R)elaxation skills, (A)ffective modulation skills, (C)ognitive coping skills, (T)rauma narrative and processing, (I)n vivo mastery of trauma reminders, (C)onjoint child–parent sessions, and (E)nhancing safety and future development (Cohen, Berliner, & Mannarino, 2010). The intervention lasts for approximately 12 weeks (Scheeringa et al., 2007). This intervention has been effective for use with preschool age children across an array of traumatic experiences, including child sexual abuse, motor vehicle accidents, and natural/environmental disasters (Cohen et al., 2010; Cohen et al., 2006; Scheeringa et al., 2007; Silverman et al., 2008).

Play Therapy Given that trauma that is experienced in infancy and toddlerhood is stored as sensory experiences in the brain, symbolic play can offer children a chance to process and heal following trauma (Green et al., 2010). Young children can, in effect, reenact the traumatic experience through symbolic play. During these play experiences, children have control over how directly they interact with the traumatic experience and can, with the guidance of a therapist, begin to create a narrative surrounding the experience. The therapist’s warm, empathic response to the child’s play can begin to rebuild the child’s sense of trust and attachment toward an adult caregiver.

Promising Practices In addition to interventions that have a strong empirical base, like CPP and play therapy, several new strategies have emerged for working with young children who have experienced trauma. These interventions, discussed briefly in the following text, include Together We Play, Ways of Seeing, mindfulness-based parenting programs, and bibliotherapy.

Together We Play One promising new strategy that works to improve the parent–child relationship is Together We Play (Nuzzo, 2006). This intervention is a parent–child coaching program that is grounded in attachment theory and recognizes the primacy of the parent–child

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relationship for positive early development. This program uses a combination of a parent–child journal, reflective engagement around parent–child play, and individualized goal setting. In Together We Play, the therapist reflects and coaches the parent in positive play interactions with the child. This intervention can be implemented in a wide variety of settings and varies in length, based on the needs of the parent and child.

Ways of Seeing Another promising new strategy that addresses the importance of the parent–child relationship is Ways of Seeing (Tortora, 2010). This intervention is a “multisensory psychotherapeutic treatment approach” that incorporates “dance/movement principles” (p. 37). This method capitalizes on very young children’s sensory processing of their experiences. In Ways of Seeing, the therapist observes interactions between the parent/ caregiver and child in the following areas: (a) quality of eye gaze, (b) facial expression, (c) use of space, (d) quality and frequency of touch and/or physical contact, (e) body shapes, (f) tempo of nonverbal movement style, (g) vocal patterns, and (h) nonverbal behavior and regulation (Tortora, 2010). In this intervention model, the therapist meets weekly with the parent and child. These weekly sessions are videotaped and then viewed by the therapist and parent to examine nonverbal interactions between the parent and child. The nonverbal interactions form the basis of the intervention, with a focus on helping parents/caregivers to understand how their own childhood experiences influence their parenting and on improving the nonverbal interactions between the child and parent/caregiver.

Mindfulness-Based Parenting Programs Mindfulness-based parenting programs are being used to address parent–child interactions (Cohen & Semple, 2010). These programs build on relationally oriented mindfulness programs to focus specifically on parent–child relationships by increasing self-awareness and intentionality. The evidence base for these programs is still relatively small, but promising.

Bibliotherapy A final intervention for young children who have experienced trauma, which warrants discussion, is bibliotherapy (Duncan, 2010). This approach involves the use of children’s literature as a way of helping young children process events. Children’s literature can provide a means for helping children learn adaptive messages about coping with traumatic experiences (Duncan, 2010). Although this method has been found to reduce child behavioral problems, it should be used in conjunction with other forms of therapy (Jack & Ronan, 2008).

CONCLUSION Early childhood experiences, both positive and negative, lay the groundwork for future growth and development. Of utmost importance during these years is the formation and maintenance of a positive attachment relationship with one or more caregivers. Traumatic events such as child maltreatment and domestic violence can undermine the protective nature of these early relationships. Given the primacy of a positive attachment relationship for young children’s growth and development, this

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relationship is the focal point of many interventions targeting young children who have experienced trauma. These interventions emphasize healing the parent–child relationship, as well as giving the child the opportunity to develop a narrative for the traumatic event (especially in the case of children who have experienced preverbal trauma).

RESOURCES Resource list for traumatized children and their parents, teachers, and other helping professionals. CHILDREN Publications Davis, D. (2010). Something is wrong at my house. Seattle, WA: Parenting Press. Federico, J. K. (2009). Some parts are not for sharing. Mustang, OK: Tate Publishing. Goldblatt, R. (2004). The boy who didn’t want to be sad. Washington, DC: Magination Press. Holmes, M. M., & Mudlaff, S. J. (2000). A terrible thing happened: A story for children who have witnessed violence or trauma. Washington, DC: Magination Press. Osbourne, J. (2008). Sam feels better now! An interactive story for children. Ann Arbor, MI: Loving Healing Press. Spelman, C. M. (2002). When I feel sad. Morton Grove, IL: Albert Whitman. Watts, G. (2009). Hear my roar: A story of family violence. Buffalo, NY: Annick Press. PARENTS Websites Child Trauma Academy (http://www.childtrauma.org/) Learning Center for Child and Adolescent Trauma (http://learn.nctsn.org/course/category.php?id=3) National Center for PTSD (http://www.ptsd.va.gov/) The National Child Traumatic Stress Network (http://www.nctsnet.org/nccts/nav.do?pid=ctr_top_ youth) Parents Trauma Resource Center (http://www.tlcinst.org/PTRCnottosay.html) Penn Center for Youth and Family Trauma Response and Recovery (http://www.med.upenn.edu/ traumaresponse/information.shtml) Publications Carter, W. L. (2009). Putting Humpty Dumpty back together again: Parenting a distressed child. Waco, TX: Restoration Publications. Doctor, R., & Shiromoto, F. (2009). The encyclopedia of trauma and traumatic stress disorders. New York, NY: Facts on File. Levine, P. (2004). It won’t hurt forever: Guiding your child through trauma. Boulder, CO: Sounds True. Monahon, C. (1997). Children and trauma: A guide for parents and professionals. San Francisco, CA: Jossey-Bass. Phone Numbers Mental Health InfoSource: 1-800-447-4474 National Alliance on Mental Illness (NAMI): 1-800-950-NAMI (6264) Parent Hotline: 1-800-840-6537 EARLY CHILDHOOD EDUCATORS/TEACHERS Websites Child Safety Commissioner. (2007). Calmer classrooms: A guide to working with traumatized children. (http:// www.ocsc.vic.gov.au/downloads/calmer_classrooms.pdf) The Impact of Trauma on Learning (http://www.sch-psych.net/archives/001169.php) The Language of Trauma and Loss (http://westernreservepublicmedia.org/trauma/) The National Child Traumatic Stress Network. (2008). Child trauma toolkit for educators. (http://www. nctsnet.org/nctsn_assets/pdfs/Child_Trauma_Toolkit_Final.pdf)

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The National Child Traumatic Stress Network. (n.d.). Responding to a school crisis. (http://www.nctsnet. org/nccts/nav.do?pid=ctr_aud_schl_crisis) Pynoos, R. S. (1999). Dealing with tragedy and trauma in the school community: An overview. (http://www. nctsnet.org/nctsn_assets/pdfs/Overview_of_Trauma_in_School_Communities.pdf) Substance Abuse and Mental Health Services Administration. (n.d.). Childhood trauma in early care and education settings. (http://www.samhsa.gov/children/dropin_trauma_earlycare.asp) Publications Nickerson, A., Reeves, M., Brock, S., & Jimerson, S. (2010). Identifying, assessing, and treating PTSD at school: Developmental psychopathology at school. New York, NY: Springer Publishing. MENTAL HEALTH AND CHILD WELFARE PROFESSIONALS Websites American Academy of Experts in Traumatic Stress (http://www.aaets.org/) Center for Early Childhood Mental Health Consultation (http://www.ecmhc.org/) Child Trauma Measures for Research and Practice (http://www.childtrauma.com/mezpost.html) International Society for Traumatic Stress Studies (http://www.istss.org/) Multiplying Connections (http://www.multiplyingconnections.org/) The National Child Traumatic Stress Network. (2010). Early childhood trauma. (http://www.nctsn.org/ trauma-types/early-childhood-trauma) The National Child Traumatic Stress Network. (n.d.). Psychological first aid. (http://www.nctsn.org/ content/psychological-first-aid) Substance Abuse and Mental Health Services Administration. (n.d.). Early childhood materials. (http:// www.samhsa.gov/children/earlychildhood_trauma_resources.asp) Treatment Collaborative for Traumatized Youth (http://www.tcty-nd.org/) United States Department of Veterans Affairs (http://www.ptsd.va.gov/professional/pages/ptsd_in_ children_and_adolescents_overview_for_professionals.asp) Zero to Three. (n.d.). Impact of trauma. (http://www.zerotothree.org/maltreatment/trauma/trauma. html) Publications Blaustein, M. E., & Kinniburgh, K. M. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. New York, NY: Guilford Press. Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York, NY: Guilford Press. Gasker, J. A. (1999). I never told anyone this before: Managing the initial disclosure of sexual abuse re- collections. New York, NY: Haworth Press. Journal of Child & Adolescent Trauma Lieberman, A. F., & Van Horn, P. (2005). Don’t hit my mommy: A manual for child–parent psychotherapy with young witnesses of family violence. Washington, DC: Zero to Three Press. Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York, NY: Guilford Press. Nader, K. (2007). Understanding and assessing trauma in children and adolescents: Measures, methods, and youth in context. New York, NY: Routledge. Osofsky, J. (2007). Young children and trauma: Interventions and treatment. New York, NY: Guilford Press. Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New York, NY: Norton. Saxe, G., Ellis, H., & Kaplow, J. (2009). Collaborative treatment of traumatized children and teens: The trauma systems therapy approach. New York, NY: Guilford Press. Webb, N. B. (2005). Working with traumatized youth in child welfare: Social work practice with children and families. New York, NY: Guilford Press. Phone Numbers The National Center for Trauma-Informed Care: 866-254-4819

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LEGAL AND POLICY PROFESSIONALS Websites Center for Children’s Law and Policy (http://www.cclp.org/) Models for Change (http://www.modelsforchange.net/index.html) National Council of Juvenile and Family Court Judges (http://www.ncjfcj.org/content/blogcategory/ 364/433/) Trauma Center at Justice Resource Institute (http://www.traumacenter.org/) Publications Buffington, K., Dierkhising, C. B., & Marsh, S. C. (2010). Ten things every juvenile court judge should know about trauma and delinquency. Reno, NV: National Council of Juvenile and Family Court Judges. Retrieved from http://www.ncjfcj.org/images/stories/dept/publications/trauma%20bulletin.pdf Igelman, R. S., Ryan, B. E., Gilbert, A. M., Bashant, C., & North, K. (2008). Best practices for serving traumatized children and families. Juvenile and Family Court Journal, 59 (4), 35–47. Justice Policy Institute. (2010). Healing invisible wounds: Why investing in trauma-informed care for children makes sense. Washington, DC: Author. Retrieved from http://www.justicepolicy.org/images/ upload/10-07_REP_HealingInvisibleWounds_JJ-PS.pdf The National Child Traumatic Stress Network. (n.d.). Juvenile justice system. Retrieved from http:// www.nctsnet.org/nccts/nav.do?pid=ctr_top_juv The National Crime Victims Research and Treatment Center. (2004). Child physical and sexual abuse: Guidelines for treatment. Charleston, SC: Author. Retrieved from http://academicdepartments. musc.edu/ncvc/resources_prof/OVC_guidelines04-26-04.pdf Films and Videos Insight Media (Producer). (1999). Understanding the six forms of emotional child abuse [DVD]. Insight Media (Producer). (2002). What is childhood trauma? [DVD]. Insight Media (Producer). (2004). Understanding the traumatized child [DVD]. Insight Media (Producer). (2006). Mandated reporting [DVD]. Insight Media (Producer). (2007). Recognizing child abuse [DVD]. Insight Media (Producer). (2008a). Bullying and peer harassment: Why does it start, and who is affected? [DVD]. Insight Media (Producer). (2008b). Recognizing the signs of child sexual abuse [DVD].

REFERENCES Ainsworth, M. D. (1964). Patterns of attachment behavior shown by the infant in interaction with his mother. Merrill-Palmer Quarterly, 10, 51–58. Bogat, G. A., DeJonghe, E., Levendosky, A. A., Davidson, W. S., & von Eye, A. (2006). Trauma symptoms among infants exposed to intimate partner violence. Child Abuse & Neglect, 30 (2), 109–125. Bowlby, J. (1982). Attachment (2nd ed.). New York, NY: Basic Books. Celebi Oncu, E., & Wise, A. M. (2010). The effects of the 1999 Turkish earthquake on young children: Analyzing traumatized children’s completion of short stories. Child Development, 81(4), 1161–1175. Chemtob, C. M., Nomura, Y., Rajendran, K., Yehuda, R., Schwartz, D., & Abramowitz, R. (2010). Impact of maternal posttraumatic stress disorder and depression following exposure to the September 11 attacks on preschool children’s behavior. Child Development, 81(4), 1129–1141. Cicchetti, D. (2004). An odyssey of discovery: Lessons learned through three decades of research on child maltreatment. American Psychologist, 59 (8), 731–741. Coates, S., & Gaensbauer, T. J. (2009). Event trauma in early childhood: Symptoms, assessment, intervention. Child and Adolescent Psychiatric Clinic of North America, 18 (3), 611–626. Cohen, J. A., Berliner, L., & Mannarino, A. (2010). Trauma focused CBT for children with co-occurring trauma and behavior problems. Child Abuse & Neglect, 34 (4), 215–224. Cohen, J. A., & Mannarino, A. P. (1993). A treatment model for sexually abused preschoolers. Journal of Interpersonal Violence, 8 (1), 115–131. Cohen, J. A., Mannarino, A. P., Murray, L. K., & Igelman, R. (2006). Psychosocial interventions for maltreated and violence-exposed children. Journal of Social Issues, 62(4), 737–766.

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Cohen, J. A. S., & Semple, R. J. (2010). Mindful parenting: A call for research. Journal of Child and Family Studies, 19 (2), 145–151. Crusto, C. A., Whitson, M. L., Walling, S. M., Feinn, R., Friedman, S. R., Reynolds, J., . . . Kaufman, J. S. (2010). Posttraumatic stress among young urban children exposed to family violence and other potentially traumatic events. Journal of Traumatic Stress, 23 (6), 716–724. Davies, D. (2004). Child development (2nd ed.). New York, NY: Guilford Press. De Bellis, M. D. (2001). Developmental traumatology: The psychobiological development of maltreated children and its implications for research, treatment, and policy. Development and Psychopathology, 13 (3), 539–564. Duncan, M. K. (2010). Creating bibliotherapeutic libraries for pediatric patients and their families: Potential contributions of a cognitive theory of traumatic stress. Journal of Pediatric Nursing, 25(1), 25–27. Erikson, E. H. (1968). Identity: Youth and crisis. New York, NY: Norton. Eyberg, S. M. (1988). PCIT: Integration of traditional and behavioral concerns. Child and Family Behavioral Therapy, 10, 33–46. Fantuzzo, J. W., & Fusco, R. A. (2007). Children’s direct exposure to types of domestic violence crime: A population-based investigation. Journal of Family Violence, 22(7), 543–553. Fantuzzo, J. W., Perlman, S. M., & Dobbins, E. K. (2011). Types and timing of child maltreatment and early school success: A population-based investigation. Children and Youth Services Review, 33 (8), 1404–1411. Ghosh Ippen, C., Harris, W. W., Van Horn, P., & Lieberman, A. F. (2011). Traumatic and stressful events in early childhood: Can treatment help those at highest risk? Child Abuse & Neglect, 35(7), 504–513. Graham-Bermann, S. A., Howell, K., Habarth, J., Krishnan, S., Loree, A., & Bermann, E. A. (2008). Toward assessing traumatic events and stress symptoms in preschool children from low-income families. American Journal of Orthopsychiatry, 78 (2), 220–228. Green, E. J., Crenshaw, D. A., & Kolos, A. C. (2010). Counseling children with preverbal trauma. International Journal of Play Therapy, 19 (2), 95–105. Herschell, A. D., & McNeil, C. B. (2005). Theoretical and empirical underpinnings of parent-child interaction therapy with child physical abuse populations. Education and Treatment of Children, 28 (2), 142–162. Hildyard, K. L., & Wolfe, D. A. (2002). Child neglect: Developmental issues and outcomes. Child Abuse & Neglect, 26(6–7), 679–695. Jack, S. J., & Ronan, K. R. (2008). Bibliotherapy: Practice and research. School Psychology International, 29 (2), 161–182. Levendosky, A. A., Huth-Bocks, A. C., Semel, M. A., & Shapiro, D. L. (2002). Trauma symptoms in preschool-age children exposed to domestic violence. Journal of Interpersonal Violence, 17(2), 150–164. Lieberman, A. F., Ghosh Ippen, C., & Van Horn, P. (2006). Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 45(8), 913–918. Lieberman, A. F., & Knorr, K. (2007). The impact of trauma: A developmental framework for infancy and early childhood. Psychiatric Annals, 37(6), 416–422. Lieberman, A. F., & Van Horn, P. (2008).Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York, NY: Guilford Press. Lieberman, A. F., & Van Horn, P. (2009). Giving voice to the unsayable: Repairing the effects of trauma in infancy and early childhood. Child and Adolescent Psychiatric Clinics of North America, 18 (3), 707–720. Lieberman, A. F., Van Horn, P., & Ghosh Ippen, C. G. (2005). Toward evidence-based treatment: Childparent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44 (12), 1241–1248. Markese, S. (2007). Taping together broken bones: Treatment of the trauma of infant physical and sexual abuse. Journal of Infant, Child, and Adolescent Psychotherapy, 6(4), 309–326. Milot, T., Ethier, L. S., St-Laurent, D., & Provost, M. (2010). The role of trauma symptoms in the development of behavioral problems in maltreated preschoolers. Child Abuse & Neglect, 34 (4), 225–234. National Research Council. (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.

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Nelson, C. A., & Bosquet, M. (2000). Neurobiology of fetal and infant development: Implications for infant mental health. In C. H. Zeanah (Ed.), Handbook of infant mental health (2nd ed., pp. 37–59). New York, NY: Guilford Press. Nuzzo, C. (2006). Together we play: Parent–child interaction coaching program: Building relationships to support development. Unpublished manuscript. Osofsky, J. D., & Lieberman, A. F. (2011). A call for integrating a mental health perspective into systems of care for abused and neglected infants and young children. The American Psychologist, 66(2), 120–128. Perlman, S., & Fantuzzo, J. (2010). Timing and influence of early experiences of child maltreatment and homelessness on children’s educational well-being. Children and Youth Services Review, 32(6), 874–883. Perry, B. D., Pollard, R. A., Blakley, T. I., Baker, W. L., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation, and “use-dependent” development of the brain: How “states” become “traits.” Infant Mental Health Journal, 16(4), 271–291. Piaget, J. (1952). The origins of intelligence in children (2nd ed.). New York, NY: Norton. Ringel, S. (2011). Attachment theory, infant research, and neurobiology. In S. Ringel & J. R. Brandell (Eds.), Trauma: Contemporary directions in theory, practice, and research (pp. 77–96). Thousand Oaks, CA: Sage. Rothbaum, F., Weisz, J., Pott, M., Miyaki, K., & Morelli, G. (2000). Attachment and culture. Security in the United States and Japan. American Psychologist, 55(10), 1093–1104. Scheeringa, M. S., Salloum, A., Arnberger, R. A., Weems, C. F., Amaya-Jackson, L., & Cohen, J. A. (2007). Feasibility and effectiveness of cognitive-behavioral therapy for posttraumatic stress disorder in preschool children: Two case reports. Journal of Traumatic Stress, 20 (4), 631–636. Scheeringa, M. S., & Zeanah, C. H. (1995). Symptom expression and trauma variables in children under 48 months of age. Infant Mental Health Journal, 16(4), 259–270. Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. W. (2005). Predictive validity in a prospective follow-up of PTSD in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 44 (9), 899–906. Schuder, M. R., & Lyons-Ruth, K. (2007). “Hidden trauma” in infancy: Attachment, fearful arousal, and early dysfunction of the stress response system. In J. D. Osofsky (Ed.), Young children and trauma: Intervention and treatment (pp. 69–104). New York, NY: Guilford Press. Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are. New York, NY: Guilford Press. Silverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. J., Kolko, D. J., Putnam, F. W., & Amaya-Jackson, L. (2008). Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. Journal of Clinical Child and Adolescent Psychology, 37(1), 156–183. Sparrow, J. D. (2007). From developmental to catastrophic: Contexts and meanings of childhood stress. Psychiatric Annals, 37, 397–401. Sroufe, L. A., Carlson, E. A., Levy, A. K., & Egeland, B. (1999). Implications of attachment theory for developmental psychopathology. Development and Psychopathology, 11(1), 1–13. Timmer, S. G., Ware, L. M., Urquiza, A. J., & Zebell, N. M. (2010). The effectiveness of parent-child interaction therapy for victims of interpersonal violence. Violence and Victims, 25(4), 486–503. Tortora, S. (2010). Ways of seeing: An early childhood integrated therapeutic approach for parents and babies. Clinical Social Work Journal, 38 (1), 37–50. True, M. M., Pisani, L., & Oumar, F. (2001). Infant-mother attachment among the Dogon of Mali. Child Development, 72(5), 1451–1466. U.S. Department of Health and Human Services. (2010). Child maltreatment 2008. Washington, DC: U.S. Government Printing Office. van der Kolk, B. A. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1(5), 253–265. Wenar, C., & Kerig, P. (2000). Developmental psychopathology: From infancy through adolescence (4th ed.). New York, NY: McGraw-Hill.

CHAPTER 9

Trauma Experienced in Adolescence ANDREA DOYLE AND STACI PERLMAN

INTRODUCTION Five million children are exposed to traumatic events yearly in the United States (Ruzek et al., 2007). Both children and adolescents are subject to extremely high rates of abuse and neglect, victimization, and intentional and unintentional injury (Centers for Disease Control and Prevention, 2009; Finkelhor, Ormrod, & Turner, 2009; McCaig & Nghi, 2002; McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green, 2006). By the age of 11, 11% of youth have experienced a traumatic event; by the age of 18, 43% of youth have experienced such an event (Eckes & Radunovich, 2007). This increased exposure to and experiencing of trauma during adolescence is partly tied to behaviors characteristic of this particular developmental stage. The purpose of this chapter is to outline particular consequences of trauma when it occurs during adolescence, as well as what one might expect subsequent to earlier childhood traumatic events that occurred. This aim is accomplished in the following sections: (a) Trauma-Relevant Issues in Adolescence and (b) Counseling Implications. These major sections are followed by a summary of the chapter and a detailed list of relevant resources.

TRAUMA-RELEVANT ISSUES IN ADOLESCENCE Stemming from the Latin adolescere “to grow up,” adolescence is the phase between childhood and adulthood, generally considered to be the ages between 13 and 19. Characterized by a rush of hormones and a budding sexuality that leads to fundamental physical changes, it is also a time of experimentation and risk taking. Because of this risk taking, adolescents have a high probability of experiencing traumatic events (Crane & Clements, 2005). They also are at risk of trauma that is related to bullying at school, violence in the home as well as the community, drug experimentation, and other dangerous situations (Shaw, 2000). In the course of defining who they are, many teens take risks and defy their parents in an effort to differentiate boundaries between parents and self (Hales & Yudofsky, 2003). Typical traumatic experiences specific to this stage include date rape, gang shootings (depending on community context), and teen suicide. This section presents discussions about the issues that are relevant to the discourse on trauma experienced in adolescence: Stages of Development, Effects of Trauma, Typical Responses to Trauma, Gender Differences, Age- and Stage-Appropriate Considerations, Multiple Diagnostic Categories, and Family Issues.

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Stages of Development Adolescence is a period of rapid cognitive development, characterized by the capacity for abstract thinking (Piaget, 1952). The development of the prefrontal cortex, associated with executive functioning, allows for more coordination and management of thinking and behavior (Choudhury, Blakemore, & Charman, 2006), necessary for the development of autonomy and engaging in relationships (Cook et al., 2005). Experiences during this developmental period play a major role in identity formation (Erikson, 1968) and personality, thus shaping adulthood (Smith & Handler, 2007). The developmental tasks of adolescence are as follows: ■ ■ ■ ■ ■ ■

Accepting the physical changes and sexual impulses brought on by puberty, Attaining independence from parents (economically, emotionally), Developing mature relationships with peers and adults outside the family, Developing the capacity for intimacy with a romantic partner, Establishing a set of moral values and ethical behavior, Consolidating a coherent social role (including gender, vocation, and ethnic identity), and ■ Pursuing a vocation or career (Becker et al., 2003; Havighurst, 1949). Although these stages are considered universal across cultures, for adolescents of color, ethnic identity has unique stages (Phinney, 1989). Ethnic identity–achieved adolescents demonstrate more solid ego identity and psychological adjustment (Phinney, 1989; Phinney & Ong, 2007). This period of development involves a search for an integrated and stable ego identity. This process proceeds as teens make sense of their current self-perceptions with their “self perceptions from earlier periods and with their cultural and biological heritage” (Brodzinsky, 1987, p. 37).

Effects of Trauma Following a particular type of trauma, namely disaster, children assume greater responsibilities and face several morally challenging situations that may lead to premature moral development (Goenjian et al., 1999). By the same token, posttraumatic stress disorder (PTSD) symptoms and negative self-schemas may lead to lacunae in moral functioning (Goenjian et al., 1999). Trauma associated with disaster may beget further trauma. For example, we know that in Haiti postearthquake, there is a growing prevalence of sexual assaults, with accounts of girls as young as 12 years old being treated for sexually transmitted infections resulting from rapes (Bayard, 2010). Within Erikson’s theory of development, adolescence falls in the stage of identity versus identity diffusion. At the extreme, dissociative identity disorder can result from early trauma (Sanders & Giolas, 1991). A more frequent reaction of traumatized adolescents is premature closure of identity formation (Figley, 1985) or entrance into adulthood. Posttraumatic “acting out” can include absences from school, early sexual debut, and delinquency (Filipas & Ullman, 2006; Finkelhor, 1990; Newman, 1976; Steiner, Garcia, & Matthews, 1997). Substance use is often a way of self-medicating in an effort to offset depressed mood, but what starts out as experimentation and a way of coping in the short term can lead to problems in brain development and later addiction if used regularly (Mayhew, Flay, & Mott, 2000). Adolescent survivors from the Jewish Holocaust of World War II, for example, experienced persistent identity diffusion, interpersonal distress, and difficulties with school and work (Koenig, 1964; Koenig, O’Leary, Doll, & Pequenat, 2004). Unlike younger

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children, who are likely to misinterpret the trauma as something that resulted as a consequence of their own behavior, adolescents possess the developmental capacity for abstract and contextual understanding of the sequential nature of events over time and how their choices might fit into the chain of events leading up to a trauma (Figley, 1985). Finkelhor (1995) distinguishes between localized versus developmental effects of trauma. The symptoms associated with PTSD are considered localized and will dissipate over time or with treatment. Developmental effects are more generalized and pervasive and challenge the attainment of age-appropriate tasks such as emotional regulation and development of positive self-esteem (Finkelhor, 1995). Similarly, traumatic events must be distinguished between a single event versus a chronic process (Shaw, 2000), the latter of which can have more generalized effects. Adolescents may withdraw and become less communicative subsequent to a trauma, whereas toddlers are likely to cry, and grade school children may experience disturbances in sleep or somatic complaints (Zubenko & Capozzoli, 2002). As children become teenagers, their symptoms resemble those of adults (Wolfe & Mash, 2006). There is some evidence that a person’s cognitive style may affect symptomatology. Moran and Eckenrode (1992) found that those with a higher internal locus of control were less depressed than those with a more external locus of control. Traditionally, the prevailing thinking in psychology has been that males externalize, whereas females tend to internalize negative life experiences, and this thinking has been subject to some debate as gender roles have changed with time. However, this notion of internalizing or externalizing is worthy of comment as it has implications for prognosis and treatment. Internalizing is an intrapsychic reaction to trauma that manifests itself as depression, anxiety, or low self-esteem (Feuer, Jefferson, & Resick, 2001). Externalizing or “acting out” usually manifests in aggressive ways such as seen in conduct disorders. Disorders of internalization and externalization represent a breakdown of the developmental path as a response to crisis.

Typical Responses to Trauma Research in the area of trauma demonstrates the primacy of human attachments in assessment, treatment, and adolescent development (Brown, 2008). Trauma undermines trust and human connections. When trust is damaged by adults failing to protect from or actually perpetrating trauma, basic worldviews and foundational aspects of relationships change (Nader, 2007). The inability to trust caretakers, God, or the universe makes it challenging to feel safe again following trauma (Nader, 2007). Fear and anxiety, reexperiencing of the trauma, increased arousal, avoidance, anger and irritability, guilt, shame, grief, depression, negative self-image and worldview, disinterest in sex, and abuse of substances are all common reactions to trauma (Foa, Hembree, Riggs, Rauch, & Franklin, 2011). Essentially, trauma is an assault to the brain (Berkowitz, personal communication, August 6, 2010), and this issue needs to be considered carefully in the context of the increased brain development during adolescence (Hales & Yudofsky, 2003). There is evidence that the stress associated with traumatic events can change major structural components of the central nervous system and the neuroendocrine system, leaving a lasting effect (Shaw, 2000; Spear, 2000).

Gender Differences Females are more at risk for victimization, especially sexual, in interpersonal relationships than are males, whereas males are at greater risk for physical abuse and assault (Feuer et al., 2001; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Yehuda, 2004).

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Young women and men tend to experience and process the distress associated with traumatic events differently (Briere & Scott, 2006). The counselor should be sensitive to ways in which traumatized adolescents display or suppress their emotional reactions based on gender expectations. Males are more likely to be exposed to traumatic stressors, but females are more likely to experience PTSD (Stuber, Resnick, & Galea, 2006). Gustafsson, Nilsson, and Svedin (2009) found no difference in occurrence of trauma by gender, but found differences by age, with older adolescents reporting more trauma events. Margolin and Gordis (2004) found that females and Caucasians were less likely to be victims or perpetrators, that middle adolescents were more likely to be perpetrators only, and that adolescents with substance-using peers were more likely to be victims and/or perpetrators of violence. In their juvenile detainee sample, Abram et al. (2004) found slightly higher rates of traumatic incidents in males. Horowitz, Weine, and Jekel (1995) propose the concept of “compounded community trauma” in their study of urban female adolescents and found that they experienced a mean of 28 violent events. Of these young women, 90% experienced hyperarousal, 89% had symptoms of reexperiencing, 80% used avoidance as a coping mechanism, and 67% met criteria for PTSD. Increased number of types of violent events was positively correlated with meeting PTSD criteria and with greater symptom severity. The young women endured prolonged and repeated exposure to multiple types of community as well as domestic violent events, via multiple modalities of contact, over time. The takehome message here is that the effects of trauma are cumulative.

Age- and Stage-Appropriate Considerations Evidence from studies of combat trauma, disasters, and rape results points to differential effects on adolescents. Adolescents who fought in Vietnam, for example, were more likely to develop PTSD than older soldiers; van der Kolk (1985) speculated that this differential effect was caused by the intensity of their attachment to their peer soldiers and the consequent magnitude of the loss that the young soldiers experienced when their friends were killed. When one considers that most young people are entering the military in their late teens and early 20s, and that PTSD as well as depression are serious problems for soldiers who return home from the war, it is important to keep in mind that the soldier is a developing adolescent. An average of 10% of returning soldiers from Iraq and Afghanistan suffer from PTSD and/or depression, with many displaying violent behavior as well (Thomas et al., 2010). Hardoff and Halevy (2006) note that the capacity for abstract thinking and planning for the future, typical of late adolescence, runs counter to the military demand for obedience, leaving family, and threats of physical injury and emotional stress. Upon discharge from the military, the chronologically mature young adult faces the questions of the late teen, normal adolescent growth having been forestalled by war (Hardoff & Halevy, 2006). The authors urge those who care for soldiers in their late teens and early 20s to consider the time of military service as an additional developmental stage of late adolescence. Additionally, adolescent children of deployed older soldiers also are affected by the trauma of war. In a study of stress levels among adolescents with family members serving in Iraq at the beginning of Operation Iraqi Freedom in March 2003 and at the end of the campaign in May of the same year, Barnes, Davis, and Treiber (2007) found that at both time points, adolescents of military parents experienced PTSD symptoms; this finding was especially true if a parent had been deployed. Davidson, Hughes, George, and Blazer (1996) found the greatest likelihood of later suicide attempts in those who were assaulted prior to age 16. Similarly, Breslau, Davis, Andreski, Peterson, and Schultz (1997) found that women who experienced

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trauma of any kind prior to age 15 were more vulnerable to developing PTSD than were those whose trauma occurred at a later age. Two years after the Buffalo Creek disaster, adolescents were found to have higher levels of distress than younger children (Green et al., 1991). A major factor contributing to this tragedy was a loss of community as well as a belief in duplicity on the part of the mining company whose carelessness led to the disaster. These may have been particularly traumatic stresses for the adolescents, for whom normal development would dictate orienting socially outside the family and a realization that adults in authority are fallible. Adolescents may be less vulnerable than children or adults to certain kinds of trauma. Studies of Holocaust survivors of World War II indicate that the most devastating effects were on those who were infants during this massive trauma (Kestenbaum & Brenner, 1996); adolescents who survived did relatively well, faring better than adult survivors. The separation from parents was most detrimental for the youngest children; the thinking here is that older children and adolescents had at least a period of earlier healthy development to sustain them. Resourcefulness, group cohesion, a sense of invulnerability, rebelliousness, and a willingness to take risks were protective factors and enhanced the likelihood of adolescents surviving. Similar findings emerged from Weine and colleagues’ (1995, 1998) studies of Bosnian survivors of ethnic cleansing, which indicated that adolescents were less traumatized than were adults. In their sample, however, younger survivors tended to experience less torture and other extreme conditions than did adults. The authors suggest that the relatively low rate of PTSD compared to adults and also in comparison to Cambodian adolescent survivors of the “killing fields” may be related to normal prior development, the time-limited nature of the trauma, adversity, lack of sexual or physical abuse, reuniting with family, or simply insufficient time for the development of delayed-onset PTSD. More optimistically, they suggest that these results may be owing to adolescent resilience. Terr and colleagues (1997) studied the reactions of children and adolescents who had witnessed the 1986 Challenger space explosion on television while at school, which was particularly relevant to school children because a teacher was among the crew members who all perished. In contrast to children who exhibited symptoms, teenagers had changes in their thinking. During the 14 months after the explosion, adolescents developed negative attitudes toward God, institutions, and the future.

Multiple Diagnostic Categories PTSD frequently co-occurs with other diagnostic categories (Giaconia et al., 1995; Kessler et al., 1995). Traumatic experiences can lead to disruptive behavior disorders, other internalizing disorders, personality disorders, and physical illnesses (Ohan, Myers, & Collett, 2001). Adolescents who have experienced trauma as children are more likely to develop anxiety-related disorders and fears and are more likely to show a pattern of risky sexual behaviors (Norwood, Ursano, & Fullerton, 2000). Different types of exposure to traumatic events lend themselves to different subsequent diagnoses. Children’s exposure to violence often goes unnoticed or unreported; therefore, symptoms often are diagnosed as maladjustment (Margolin & Gordis, 2004). In an epidemiological study of juvenile delinquents in detention, Abram and colleagues (2004) found that 11% of adolescents in jail met criteria for PTSD, and that 93% had experienced at least one trauma in their lifetime; the mean was 15 traumatic events. A history of family violence is the most significant difference between groups of delinquents and nondelinquent youth (National Center for Children Exposed to Violence [NCCEV], 2006). In a review of the relationships among eating disorders (EDs), trauma, and comorbid psychiatric disorders, with a particular focus on PTSD, Brewerton (2007) concluded

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the following: childhood sexual abuse (CSA) is a nonspecific risk factor for EDs, other forms of abuse and neglect besides CSA have been linked to EDs, trauma is more common in bulimia compared to other EDs, multiple traumatic events and/or specific types of trauma are associated with EDs, ED severity is not necessarily associated with trauma, trauma is associated with greater comorbidity (including and often mediated by PTSD) in research participants with ED, subthreshold PTSD also may be a risk factor for bulimia, and recovery from the ED and comorbid disorders is contingent on the trauma and PTSD symptoms being addressed. A range of posttraumatic responses does not necessarily meet full criteria for PTSD. Evidence from community samples suggests that partial syndromes are much more common than PTSD in the general population and also following a specific traumatic event such as a natural disaster. These subclinical conditions also can coincide with significant impairment. Adolescent posttraumatic symptoms can include avoidance, reexperiencing, and arousal that parallel those in adults who meet PTSD criteria (American Psychiatric Association [APA], 2000). Trauma-specific fears, depression and anxiety, and hostility are also common. Even though full PTSD criteria may not be met, a young person can experience significant distress that may interfere with daily functioning. Other disorders may follow trauma, even if posttraumatic symptoms are not immediately present. The ultimate outcome of experiencing trauma during adolescence may include increased sensitivity to loss and an increased vulnerability to anxiety and depression. More serious reactions include dissociation, ranging from chronic psychic numbing to dissociative identity disorders and interpersonal difficulty. Trauma-related psychopathology that is comorbid with depression, conduct disorder, or substance abuse markedly complicates treatment of the adolescent. Therefore, it is important to assess for a history of trauma and how the adolescent coped at the time of the event. PTSD itself is difficult to detect without systematic screening (Abram et al., 2004). PTSD and child abuse often are unrecognized in adolescents (Cohen, 1998). Symptoms of PTSD overlap with other disorders such that it may be missed. For example, ADHD may be the diagnosis ascribed to the interpersonal problems, hyperactivity, and distractibility that accompany PTSD; this type of presentation necessitates looking beyond the presenting symptoms to assess for early trauma (Wolfe & Mash, 2006). Greenwald (2002) has asserted that trauma mediates the development of conduct problems in adolescence; the trauma can account for the lack of empathy and for the impulsivity, anger, and acting out. Community violence is a significant risk factor for conduct problems in early adolescence (age 10–14) according to Pearce, Jones, Schwab-Stone, and Ruchkin (2003). Protective factors that offset conduct problems include a strong religious faith and parental involvement.

Family Issues The impact of a traumatic event may depend on the extent to which it disrupts family functioning. Gustafsson et al. (2009) found that interpersonal violence was more strongly associated with symptoms than with noninterpersonal violence. The major categories of violence are child maltreatment, aggression between parents, and community violence, and these often co-occur (Margolin & Gordis, 2004). Each year, more than 10 million children witness physical aggression between their parents (Margolin & Gordis, 2004). Exposure to violence very often occurs in familial settings. Possible consequences include break-up or relocation of family, family conflict, poverty, parental unemployment, parental substance abuse, and psychopathology. Thus, life stresses and trauma can become cyclical. Common short-term effects of exposure to violence are

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behavioral disorders such as aggression and delinquency, emotional and mood disorders, posttraumatic stress, health-related problems, somatic symptoms, and academic and cognitive problems (Margolin & Gordis, 2004).

COUNSELING IMPLICATIONS Adolescence is an opportunity to rework earlier traumas (Blos, 1962). The importance of this favorable period for therapeutic action cannot be underestimated, as earlier interventions bode well for better adaptation in later developmental stages. This section offers discussions on stage-appropriate interventions and present-day promising practices.

Stage-Appropriate Interventions Cognitive behavioral therapy is particularly effective in treating symptomatic adolescents exposed to trauma (Villalba & Lewis, 2007). Eye movement desensitization and reprocessing (EMDR) also can work with some traumatized individuals (Roth & Fonagy, 2005). Preliminary evidence suggests that propranonol may be useful in trauma recovery, although it was not specifically tested on adolescents (Brunet et al., 2008; Vaiva et al., 2003). Trauma can affect several developmental domains such as attachment systems, biology, affect regulation, disassociation, behavioral control, cognition, and self-concept. Bath (2008) examined trauma interventions for complex trauma, and specified three pillars upon which interventions should be based. This three-pronged interactive approach involves steps that caregivers can take to strengthen the three pillars: safety, connections, and managing emotional impulses. The outcome of complex trauma is often PTSD; however, because the PTSD criteria are meant for adults, many adolescents go undiagnosed and untreated. Unfortunately, according to Bath, adolescents often come to view adults as threats instead of supports. But all home, school, and community caretakers who interact with traumatized children potentially contribute to their maturation and healing. Bath argues that in order for healing to occur, safety, affect regulation, and coping and selfmanagement skills must be established. The first pillar, safety, represents a core developmental need (Bowlby, 1988; Erikson, 1950; Maslow, 1948). Therefore, when working with adolescents who have experienced trauma, it is essential to create a sense of safety (transparency, availability, consistency). The second pillar demands the development of comfortable connections between the adolescent and their caretakers. The author further argues that third-pillar interventions should teach adolescents the ability to manage emotions or self-regulate. Margolin and Gordis (2004) propose community interventions such as mentoring programs and structured school-based activities. Particularly for trauma symptoms stemming from community-based violence, community interventions without involving all of the community systems such as police and schools are less likely to succeed (Horowitz et al., 1995). Given the developmental shift to looking more toward peers than family, group interventions often are employed (Aronson & Kahn, 2004; van der Kolk, 1987). After the 1988 Armenian earthquake, trauma/grief-focused brief psychotherapy was employed in schools in order to mitigate PTSD symptoms and prevent aggravation of comorbid depression among young adolescents (Goenjian et al., 1997). The results support the broad use of such school-based interventions after major disasters and demonstrate the cross-cultural applicability of Western psychotherapeutic approaches.

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Promising Practices The Community Service Foundation & Buxmont Academy (CSF Buxmont) operates a Pennsylvania alternative school that uses restorative practices. A student confronts traumatic life challenges with the help of group problem solving with supportive peers (Lange, 2008). The use of peer groups at this developmental stage is a recurring thread among best practices for traumatized youth. The Sanctuary Model of Trauma-Informed Organizational Change (Bloom, 1997) builds respectful culture in community mental health organizations and schools so that troubled youth and their caregivers are not subject to victimization. The therapeutic community focuses on the needs of traumatized youth through a psychoeducational model called SELF, which addresses the challenges of Safety, Emotional management, Loss, and Future. The UCLA Trauma Psychiatry Program has developed a school-based intervention program for children and adolescents who have been exposed to trauma, and who are chronically distressed with resultant problems in school or with peer and family functioning (see Saltzman, Steinberg, Layne, Aisenberg, & Pynoos, 2001). The program includes a systematic approach to screening for trauma, a manual-based 16- to 20-week trauma/grief focused group psychotherapy protocol, along with individual and family therapy and measurement scales to determine any reduction in symptomatology as well as any increase in adaptive functioning. Miller Children’s Abuse and Violence Intervention Center (MCAVIC) in Long Beach, California created the Integrative Treatment of Complex Trauma for Adolescents (ITCT-A), which focuses on the treatment of multiply traumatized youth. This program is a comprehensive manual-based multimodal treatment (Briere & Lanktree, 2008), which is freely available to the public. Finally, it is worth noting that dialectical behavioral therapy (DBT) is being widely used in various residential programs for youth who cannot remain in the home of the family of origin. Although not always articulated, many of these youths are in residential care because of a history of trauma. DBT has been conceptualized as a trauma-based model for those with borderline personality disorder (BPD; Swenson, 2000). Originally developed for women diagnosed with BPD who exhibited suicidal and parasuicidal behaviors and very often had histories of trauma, DBT has since been used in state-run adolescent residential programs such as Echo Glen in Washington State (see Trupin, Stewart, Beach, & Boesky, 2002). Modest success has been reported with suicidal adolescents in reducing suicidal symptoms (Rathus & Miller, 2002; Sunseri, 2004) and hospitalization for self-injury (Sunseri, 2004). The symptoms of BPD are similar to those of a risk-taking adolescent who is just learning how to modulate emotions, such that the skills offered by this approach resonate with the tasks of this developmental phase. DBT treatment consists of individual behavioral treatment, skills coaching, and psychoeducational group work where cognitive and behavioral skills, including mindfulness, can be learned and practiced. What all of the sampling of available approaches discussed previously have in common are their multipronged, relational approaches with a strong peer group work component. This use of the mutual aid of peers is consistent with the importance of peers as well as self-determination at this stage of life. The use of cognitive behavioral procedures for identifying triggers and emotional responses is also a core component of these programs and consistent with traditional approaches to treating trauma in adults. Cognitive approaches promote exposure to and tolerance of the emotions that persons suffering from trauma often attempt to avoid (Lang & Sharma-Patel, 2011). Whatever the approach, there is some evidence that telling one’s story and being able to do so in a coherent narrative is a good prognostic sign (Briere & Scott, 2006; Pennebaker, 1993).

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The cognitive skills and motivation necessary for constructing a coherent narrative related to one’s life story normally develop during adolescence (Habermas & Bluck, 2000). Efforts in treatment are geared toward being able to face and articulate the trauma in a way that the adolescent can convey his or her experience without reliving it in the moment.

SUMMARY Adolescence is not only a time when there is increased risk for trauma because of the risk taking typical of this developmental stage, but it also offers an opportunity to rework earlier traumas. Intervention approaches typically include cognitive behavioral techniques to assist the young person in identifying triggers to deal with symptoms associated with PTSD; group interventions also are key during this developmental phase, when peers become much more important. Being able to tell one’s story in a linear coherent narrative, without the intrusion of posttraumatic stress symptoms, assists in the identity formation so crucial to this developmental stage of life.

RESOURCES Resource list for traumatized adolescents and their parents, teachers, and other helping professionals. YOUTH Websites It’s My Life (http://pbskids.org/itsmylife/emotions/index.html) MedicineNet Teen Center (http://www.medicinenet.com/teenagers/index.htm) The National Center for Victims of Crime. (n.d.). Teen tools: Crime, teens, and trauma. (http://www.ncvc. org/tvp/AGP.Net/Components/DocumentViewer/Download.aspxnz?DocumentID=45313) TeensHealth (http://kidshealth.org/teen/your_mind/mental_health/ptsd.html#cat20123) Teens’ Page (http://www.childgrief.org/teenspage.htm) YouthHealthTalk (http://www.youthhealthtalk.org/) Publications Anonymous. (1971). Go ask Alice. New York, NY: Simon Pulse. Dobson, J. (2000). Life on the edge. Nashville, TN: Thomas Nelson. Greenwald, R., & Baden, K. J. (2007). A fairy tale (comic book). Greenfield, MA: Child Trauma Institute. Holmes, M. M., & Mudlaff, S. J. (2000). A terrible thing happened: A story for children who have witnessed violence or trauma. Washington, DC: Magination Press. McNamee, G. (2000). Hate you. New York, NY: Laurel Leaf. Myers, D. W. (2001). Monster. New York, NY: Amistad. Pelzer, R. (2007). A teenager’s journey: Overcoming a childhood of abuse. New York, NY: Wellness Central. Pipher, M. B. (1994). Reviving Ophelia: Saving the selves of adolescent girls. New York, NY: Putnam. Thompson, G. (2008). Sunshine to the sunless. London, United Kingdom: Transworld Publishers. Phone Numbers Adolescent Crisis Intervention & Counseling Nineline: 1-800-999-9999 Girls and Boys Town National Hotline: 1-800-448-3000 National Youth Crisis Hotline: 800-442-HOPE (4673) Teen Helpline: 1-800-400-0900 Youth Crisis Hotline: 1-800-HIT-HOME (448-4663)

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PARENTS Websites Child Trauma Academy (http://www.childtrauma.org/) Learning Center for Child and Adolescent Trauma (http://learn.nctsn.org/course/category.php?id=3) National Center for PTSD (http://www.ptsd.va.gov/) The National Child Traumatic Stress Network. (n.d.). Youth and family partnerships. (http://www. nctsnet.org/nccts/nav.do?pid=ctr_top_youth) National Institute of Mental Health. (n.d.). Children and violence. (http://www.nimh.nih.gov/health/ topics/child-and-adolescent-mental-health/children-and-violence.shtml) Office of Population Affairs (http://www.hhs.gov/opa/familylife/tech_assistance/etraining/trauma/ index.html) Parents Trauma Resource Center (http://www.tlcinst.org/PTRCnottosay.html) Penn Center for Youth and Family Trauma Response and Recovery (http://www.med.upenn.edu/ traumaresponse/information.shtml) Publications Borgman, D. (2003). Hear my stories: Understanding the cries of troubled youth. Peabody, MA: Hendrickson Publishers. Carter, L. (2009). Putting Humpty Dumpty back together again: Parenting a distressed child. Waco, TX: Restoration Publications. Doctor, R., & Shiromoto, F. (2009). The encyclopedia of trauma and traumatic stress disorders. New York, NY: Facts on File. Levine, P. (2004). It won’t hurt forever: Guiding your child through trauma. Boulder, CO: Sounds True. Monahan, C. (1997). Children and trauma: A guide for parents and professionals. San Francisco, CA: Jossey-Bass. Phone Numbers Covenant House Hotline: 800-999-9999 Mental Health InfoSource: 1-800-447-4474 National Alliance on Mental Illness (NAMI): 1-800-950-NAMI (6264) Parent Hotline: 1-800-840-6537 TEACHERS Websites Child Safety Commissioner. (2007). Calmer classrooms: A guide to working with traumatized children. (http://www.ocsc.vic.gov.au/downloads/calmer_classrooms.pdf) The Impact of Trauma on Learning (http://www.sch-psych.net/archives/001169.php) The Language of Trauma and Loss (http://westernreservepublicmedia.org/trauma/) The National Child Traumatic Stress Network. (2008). Child trauma toolkit for educators. (http://www. nctsnet.org/nctsn_assets/pdfs/Child_Trauma_Toolkit_Final.pdf) The National Child Traumatic Stress Network. (n.d.). Responding to a school crisis. (http://www.nctsnet. org/nccts/nav.do?pid=ctr_aud_schl_crisis) Publications Ellison, K. (n.d.). Seven schools for troubled teens: From trauma to recovery. (http://www.greatschools.org/ parenting/behavior-discipline/slideshows/2745-troubled-teens.gs) Nickerson, A., Reeves, M., Brock, S., & Jimerson, S. (2010). Identifying, assessing, and treating PTSD at school: Developmental psychopathology at school. New York, NY: Springer Publishing. Pynoos, R. S. (1999). Dealing with tragedy and trauma in the school community: An overview. (http://www. nctsnet.org/nctsn_assets/pdfs/Overview_of_Trauma_in_School_Communities.pdf) MENTAL HEALTH AND CHILD WELFARE PROFESSIONALS Websites American Academy of Experts in Traumatic Stress (http://www.aaets.org/) Child Trauma Measures for Research and Practice (http://www.childtrauma.com/mezpost.html) International Society for Traumatic Stress Studies (http://www.istss.org/) The National Child Traumatic Stress Network. (n.d.). National Child Traumatic Stress Network empirically supported treatments and promising practices. (http://www.nctsnet.org/nccts/nav.do?pid=ctr_top_ trmnt_prom)

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Treatment Collaborative for Traumatized Youth (http://www.tcty-nd.org/) United States Department of Veterans Affairs (http://www.ptsd.va.gov/professional/pages/ptsd_in_ children_and_adolescents_overview_for_professionals.asp) Publications Blaustein, M. E., & Kinniburgh, K. M. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. New York, NY: Guilford Press. Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York, NY: Guilford Press. Journal of Child & Adolescent Trauma. Nader, K. (2007). Understanding and assessing trauma in children and adolescents: Measures, methods, and youth in context. New York, NY: Routledge. Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New York, NY: Norton. Saxe, G., Ellis, H., & Kaplow, J. (2009). Collaborative treatment of traumatized children and teens: The trauma systems therapy approach. New York, NY: Guilford Press. Webb, N. B. (2005). Working with traumatized youth in child welfare: Social work practice with children and families. New York, NY: Guilford Press. Phone Numbers National Center for Trauma Informed Care: 866-254-4819 LEGAL AND POLICY PROFESSIONALS Websites Center for Children’s Law and Policy (http://www.cclp.org/) Models for Change (http://www.modelsforchange.net/index.html) The National Child Traumatic Stress Network. (n.d.). Juvenile justice system. (http://www.nctsnet.org/ nccts/nav.do?pid=ctr_top_juv) National Council of Juvenile and Family Court Judges (http://www.ncjfcj.org/content/blogcategory/ 364/433/) Trauma Center at Justice Resource Institute (http://www.traumacenter.org/) Publications Buffington, K., Dierkhising, C. B., & Marsh, S. C. (2010). Ten things every juvenile court judge should know about trauma and delinquency. Reno, NV: National Council of Juvenile and Family Court Judges. (http://www.ncjfcj.org/images/stories/dept/publications/trauma%20bulletin.pdf) Igelman, R. S., Ryan, B. E., Gilbert, A. M., Bashant, C., & North, K. (2008). Best practices for serving traumatized children and families. Juvenile and Family Court Journal, 59 (4), 35–47. Justice Policy Institute. (2010). Healing invisible wounds: Why investing in trauma-informed care for children makes sense. Washington, DC: Author. (http://www.justicepolicy.org/images/upload/10-07_ REP_HealingInvisibleWounds_JJ-PS.pdf) The National Crime Victims Research and Treatment Center. (2004). Child physical and sexual abuse: Guidelines for treatment. Charleston, SC: Author. (http://academicdepartments.musc.edu/ncvc/ resources_prof/OVC_guidelines04-26-04.pdf) Phone Numbers National Center for Mental Health and Juvenile Justice: 1-866-9NCMHJJ Films and Videos Insight Media (Producer). (2006). Mandated reporting [DVD]. Insight Media (Producer). (2008a). Bullying and peer harassment: Why does it start, and who is affected? [DVD]. Insight Media (Producer). (2008b). Generation cyberbully: Bullying without borders [DVD]. Insight Media (Producer). (2011a). Bullying can be addressed through IEP [DVD]. Insight Media (Producer). (2011b). Sexual harassment at schools: Hostile environments [DVD]. Insight Media (Producer). Violence prevention strategies [DVD].

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Swenson, C. R. (2000). How can we account for DBT’s widespread popularity? Clinical Psychology: Science and Practice, 7(1), 87–91. Terr, L. C., Bloch, D. A., Michel, B. A., Shi, H., Reinhardt, J. A., & Metayer, S. (1997). Children’s thinking in the wake of Challenger. American Journal of Psychiatry, 154 (6), 744–751. Thomas, J. L., Wilk, J. E., Riviere, L. A., McGurk, D., Castro, C. A., & Hoge, C. W. (2010). Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry, 67(6), 614–623. Trupin, E. W., Stewart, D. G., Beach, B., & Boesky, L. (2002). Effectiveness of a dialectical behaviour therapy program for incarcerated female juvenile offenders. Child and Adolescent Mental Health, 7(3), 121–127. Vaiva, G., Ducrocq, F., Jezequel, K., Averland, B., Lestavel, P., Brunet, A., & Marmar, C. R. (2003). Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma. Biological Psychiatry, 54 (9), 947–949. van der Kolk, B. A. (1985). Adolescent vulnerability to posttraumatic stress disorder. Psychiatry, 48 (4), 365–370. van der Kolk, B. A. (1987). Psychological trauma. Washington, DC: American Psychiatric Press. Villalba, J. A., & Lewis, L. D. (2007). Children, adolescents, and isolated traumatic events: Counseling considerations for couples and family counselors. The Family Journal, 15(1), 30–35. Weine, S., Becker, D. F., McGlashan, T. H., Vojvoda, D., Hartman, S., & Robbins, J. P. (1995). Adolescent survivors of “ethnic cleansing”: Observations on the first year in America. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (9), 1153–1159. Weine, S. M., Vojvoda, D., Becker, D. F., McGlashan, T. H., Hodzic, E., Laub, D., . . . Lazrove, S. (1998). PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States. Journal of the American Academy of Child and Adolescent Psychiatry, 155(4), 562–564. Wolfe, D. A., & Mash, E. J. (Eds.). (2006). Behavioral and emotional disorders in adolescents: Nature, assessment, and treatment. New York, NY: Guilford Press. Yehuda, R. (2004). Risk and resilience in posttraumatic stress disorder. The Journal of Clinical Psychiatry, 65(Suppl. 1), 29–36. Zubenko, W. N., & Capozzoli, J. A. (Eds.). (2002). Children and disasters: A practical guide to healing and recovery. New York, NY: Oxford University Press.

CHAPTER 10

Treating Adult Trauma Survivors BARBARA PECK

INTRODUCTION The focus of this chapter is on the adult survivor of trauma. An underlying premise here is that many adult trauma survivors, who self-identify or are identified by service providers as trauma survivors, probably have traumatic histories that may include physical abuse, sexual abuse, emotional abuse, neglect, or attachment issues, that often have an early onset in childhood, and that typically are chronic in nature. Early onset can include birth through age 16. This chapter addresses survivors of interpersonal violence, severe early childhood neglect, and disrupted attachment. Some adult survivors present with an extensive history of multiple traumatic events across the developmental life span, whereby trauma has been repeated by the same perpetrator or the survivor has sustained many traumatic events sporadically over the lifetime; in either kind of multiple-event trauma, the survivor may have a chronic or complex type of posttraumatic stress disorder (PTSD). Survivors typically describe or present with symptoms that include lack of trust, sleep disturbances, dissociation, somatization, depression, dysregulated affect, shame, and relationship issues, any of which may extend beyond the criteria of PTSD as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revised (DSM-IV-TR; American Psychiatric Association, 2000; Courtois, Ford, & Cloitre, 2009; Herman, 1992; van der Kolk, 2005). With these clients, a psychiatric diagnosis often is comorbid with other disorders such as alcohol abuse or chemical dependency, eating disorders, or depression. The main purpose of this chapter is to address aspects of the therapeutic work that needs to be considered in treating adult survivors of trauma. This is accomplished by discussing pertinent issues in the following sections: (a) surviving severe and enduring trauma, (b) preparing trauma survivors for treatment, and (c) specific treatment approaches. These sections are followed by a discussion of the implications for counselors working with adult survivors and by resources that can assist clinicians in working with survivors of severe or complex trauma.

UNDERSTANDING SEVERE AND PROLONGED TRAUMA It is essential for clinicians to understand the phenomenological experiences of the lives of clients who have survived trauma and how their real-life situations have shaped their belief systems and worldviews. In this section, the following issues are

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elaborated: Knowing the Client, Multiple Diagnoses, Clinical Complexity, and Levels of Impaired and Delayed Development.

Knowing the Client The therapist needs to gain an understanding of how survivors perceive their own lived worlds, their relationships, and their sense of self. Additionally, the therapist needs to be aware of the client’s ability to self-regulate, which would include assessing for highrisk behaviors such as substance abuse, promiscuity, self-injury, and suicidality. Additionally, the therapist needs to be flexible in the way in which he or she works with survivors, being alert for transference issues in the client and countertransference reactions on the part of the therapist. Survivors’ life experiences have shaped their sense of self and the way in which they adapt and respond to others; they often misinterpret social cues in the present because of their traumatic experiences and attachment issues of the past. The client’s early history, the importance of trust, and the presentation of symptoms are discussed in the following section.

Early History Assessing the early attachment histories of trauma survivors helps in case formulation. Clinicians need to ask about early family disruption, absent caregivers, removal by child protective services (CPS), abandonment, death of a caregiver, neglect, violence, history of failure to thrive, and serious medical conditions requiring invasive medical procedures and longer hospital stays. Any of the aforementioned early history, alone or in combination, can contribute to emotional distancing and anxiety; in turn, this can create inability to bond or attach, relationship difficulty, and affect dysregulation (Pearlman & Courtois, 2005).

Importance of Trust Establishing a trusting therapeutic relationship is a basic tenet for therapy, in general. However, when working with trauma survivors, this can be a challenge because of the clients’ lack of trust, affect dysregulation, and unstable relationships (Chu, 1998; Herman, 1992; Pearlman & Courtois, 2005). The empathy, support, consistency, and attentiveness offered by the therapist are unfamiliar to many survivors and can be threatening to survivors precisely because these are often outside the realm of their experiences. They often may resist or test these qualities in the therapist (Pearlman & Courtois, 2005). The client’s lack of trust further complicates treatment, as trauma therapy involves the survivor thinking about his or her history, which typically is avoided so as not to experience the overwhelming feelings, sensations, and thoughts related to the traumatic past (Briere, 2006; Perlman & Courtois, 2005). Adult survivors frequently experience emotional dysregulation and a lack of balance in many areas of their lives. It is important to know that this is generally long-term treatment. Many survivors feel too much or feel too little (van der Kolk, 1994). This can appear like a volcano about to erupt in the therapy (hyperarousal) or, by contrast, like disappearing into the wall (hypoarousal), thus requiring the therapist to help the client to decrease the hyperarousal or increase the hypoarousal so that the therapeutic work can occur within the client’s “window of tolerance” (Ogden, Minton, & Pain, 2006, p. 38). This is the space in which a client can work, without becoming hyperaroused or hypoaroused, but this window initially is limited in therapy. Over time, and as a function of therapy, this window expands. Such growth can occur because the therapist offers psychoeducation

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to the client and demonstrates additional coping skills to help the client in managing the overwhelming feelings and sensations; this provides an increasingly larger window of tolerance, thus decreasing the potential for retraumatization. Establishing rapport with survivors takes extensive time and can be trying for the therapist.

Symptoms Working with adult trauma survivors necessitates attentiveness on the part of the therapist, especially in assessing and understanding the symptoms that the client is presenting. The therapeutic relationship is an attachment relationship and can contribute to improved emotional regulation in the client (Siegel, 2009). Additionally, the therapist needs to have a working understanding of how trauma can affect the mind as well as the body, and how trauma can have an impact on survivors’ overall functioning in multiple domains, including home, relationships, work, school, and community and even on survivors’ worldviews and core values/beliefs. Therapy with trauma focus particularly requires that the therapist have an awareness and understanding of dissociative symptoms and how these might manifest in the client. There are many ways in which dissociation can appear, and all nuances of the survivor’s presentation become important. It is imperative that the clinician have some comprehension of complex trauma disorders, yet this knowledge set goes beyond what the DSM-IV-TR currently details in PTSD criteria (Courtois et al., 2009; Herman, 1992; van der Kolk, 1996, 2005; Wheeler, 2007). Discussion regarding the need for a complex trauma diagnosis has been ongoing. Additional symptom clusters for complex traumatic stress disorders have been identified and include the following: (a) affect and impulse dysregulation; (b) biological self-regulation/somatization such as a physical symptom, like pain, that is not entirely medically explained; (c) alterations in consciousness, that is, pathological dissociation; (d) perception of the perpetrator, for example, a focus on revenge; (e) self-perception that includes shame or guilt; (f) relationships that lack trust or include revictimization; and (g) systems of meaning marked by hopelessness (Courtois et al., 2009; Herman, 1992; Luxenberg, Spinazzola, & van der Kolk, 2001; Pearlman & Courtois, 2005). Clinician competence in assessing the cognitive, emotional functioning, and body sensations is a complimentary adjunct to a sensorimotor approach to treatment. The current literature on trauma in the areas of development, attachment, and neuroscience address the importance of incorporating the cognitive, emotional, and somatic aspects of trauma in treating traumatized individuals. A sensorimotor approach centers on the physical as well as the psychological aspects of trauma. Survivors of trauma can be overwhelmed with sensorimotor symptoms “in such forms as intrusive images, sounds, smells, body sensations, physical pain, constriction, numbing, and inability to modulate arousal” (Ogden et al., 2006, p. xxix). Sensorimotor therapy emphasizes the importance of using body-centered approaches to decrease these reactions and allows for change in the client. Traumatic memories are not held in narrative form but in sensory fragments and are held in the neuropathways throughout the brain in the form of smells, sounds, touch, sensations, and images (Stein & Kendall, 2004; van der Kolk, 1996, 2005). These fragmented memories “take on a life of their own, able to intrude at any moment” (Ogden et al., 2006, p. 155). They can invade into the client’s awareness whenever the client encounters a trigger, that is, a reminder of the trauma, or when the client experiences a similar emotional reaction that was present at the time of the trauma (Stein & Kendall, 2004). Triggers can be subtle or more obvious; they can be situational, like when the survivor’s child reaches the survivor’s age of abuse, or they can consist of sounds,

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smells, or gestures, for example, which were a part of the trauma experience. Adult survivors may experience memories of the trauma as if they were happening in that given moment. They may be overwhelmed by the barrage of physical sensations, and may even lose a sense of the present, as they relive an experience from their specific past. These intrusions occur during consciousness and are known as flashbacks (Stein & Kendall, 2004; van der Kolk, 1996); survivors also can experience these intrusions as nightmares during sleep. Dissociation is also a hallmark symptom of traumatized individuals (Rothschild, 2000). Dissociation includes a disconnection from self to the extent that thoughts, feelings, and self-awareness are totally or partially outside of awareness. Chronic traumatization contributes to dissociation that can alter one’s perceptions, thoughts, and emotions and interferes with information processing (Briere, 2006; van der Kolk, 1996). Dissociation can occur at the time of the trauma or right after the event. Waelde, Silvern, Carlson, Fairbank, and Kletter (2009) indicate that “acute posttraumatic dissociation” occurs a week or two following the trauma, whereas “chronic dissociation” is ongoing for years after the trauma and can evolve into a frequent response to stressors in one’s daily life (p. 448). Therapists may notice dissociative symptoms in their clients during intense moments in therapy. Several types of dissociative symptoms can indicate a dissociative disorder, especially when symptoms are extreme. Depersonalization is a sense of being separated from one’s body; a client may describe this as “I can see myself from across the room” or “I see myself from the ceiling.” Derealization is a perception of the environment as being strange, unreal, or far away; a client may express this as “Everything is foggy,” or another may feel like “Everything is far away,” even when the person is aware of being in the room (DSM-IV-TR, 2004). Dissociative amnesia refers to one’s inability to recall or retain memory of personal information; the formulation of amnestic barriers is beyond normal forgetfulness. Someone experiencing a dissociative fugue may seem to wander, arriving at a location without awareness of how he or she arrived, having no memory of the past, and being confused about personal identity.

Multiple Diagnoses Clients with extensive trauma histories often arrive at community mental health agencies and at the office of private practitioners with a plethora of symptoms and diagnostic characteristics that can be perplexing to the therapist or treatment team. Adult survivors may present with a variety of Axis I disorders, including but not limited to bipolar disorder, major depressive disorder, PTSD, dissociative identity disorder (DID), adjustment disorder, generalized anxiety disorder (GAD), panic disorder, eating disorders, and substance abuse (Courtois et al., 2009; Resick, Monson, & Gutner, 2007). PTSD is often comorbid with other Axis I diagnoses (Ford & Courtois, 2009). Survivors also may have an Axis II such as borderline personality disorder (BPD), schizotypal disorder, and antisocial personality disorders (Keane, Brief, Pratt, & Miller, 2007). Not all people who experience trauma are traumatized or meet DSM-IV-TR criteria for acute stress disorder (ASD) or PTSD; however, some of these individuals can experience depression or an anxiety disorder directly linked to the traumatic event.

Clinical Complexity Since 1980, when PTSD initially was identified in the DSM as an anxiety disorder, an evolving theoretical and research literature has further identified a subset of traumatized individuals. The need has been postulated, by many leaders and experts in

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the traumatic stress field, for a diagnostic category for those who have endured early childhood trauma, neglect, abuse, and attachment issues as well as those with chronic traumatic histories. Herman (1992) was the first to conceptualize and define this paradigmatic concept as complex traumatic stress disorders under the diagnosis of disorders of extreme stress not otherwise specified (DESNOS; Herman, 1992; Ford & Courtois, 2009). Van der Kolk (2005) submitted the proposal of developmental trauma disorder (DTD) to the field trails committee for the DSM-V (not yet published) as a diagnosis for a trauma disorder that is based on criteria for children who have extensive trauma, neglect, and/or attachment issues. Van der Kolk’s attempt is significant, as the current PTSD diagnosis as in the DSM-IV-TR is based on adult criteria.

Levels of Impaired and Delayed Development The basis for complex trauma has its roots in severe and usually sustained abuse, neglect, and disorganized attachment in childhood. Trauma exposure occurring in infancy and early childhood, especially on the part of the primary caregivers, interferes with normal psychobiological development in children (Stein & Kendall, 2004; van der Kolk, 2005). Specifically, in infancy, right brain development is affected by and interferes with the maltreated child’s ability to regulate intense affect; this can further contribute to longterm effects of pathological dissociation (Schore, 2009). Although the right brain may be functional at birth, it requires ongoing emotional attunement from caregivers for children’s continued healthy development and growth; what occurs in the environment is extremely relevant to infants’ physiological development. The human stress response to trauma has been characterized as one of either fight, flight, or freeze (Herman, 1992; Perry, 1994; Putnam, 1997; van der Kolk, 1996). This response, based on biological changes in the child’s body and mind, is one over which the child has no control. Trauma can rob a child of the ability to self-protect: the younger the child, the less likely it is that the child can fight or flight, thus resulting in the child’s body going into a freeze mode. When in this state, the infant or young child is not able to respond in a self-protective manner, especially physically (Perry, 1994, 1999; Schore, 2002); experts do not yet fully understand the internalized psychological and emotional responses, an area requiring more research. According to Bloom (1997), traumatic events diminish the child’s ability to trust, and they deflate the child’s sense of empowerment. Perry (1994, 1999), Schore (2002), and van der Kolk (1996) have contributed to an increased understanding of the neurobiologic effects of trauma. Neurobiology refers to the manner in which neurons work, how the brain functions and develops, and the developmental aspect of “interpersonal relationships,” as these concern the developing brain (Siegel, 1999). To explain further, the infant–caregiver relationship is a gene– environment relationship in which “the mother mediates the external environment of the child, and in dyadic affective transactions she psychobiologically influences the infant’s production of hormones and neurohormones in the infant’s developing nervous system” (Schore, 1994, p. 526). Researchers (Putnam, 1996; van der Kolk, 1996) have identified a variety of neurobiological abnormalities in traumatized children and adolescents. In children with chronic trauma histories, it has not been uncommon for them to be unaware of their emotions, “. . . but they are there, often stored in bodily sensations” (Stein & Kendall, 2004, p. 113). Researchers in one study (De Bellis et al., 1999) found that abused and neglected children have brains that are as much as 7% smaller than the brains of the control groups of nonabused children. They also found abnormalities in the corpus callosum—a thick cord made up of fibers that connect the left and right hemispheres of the brain. These researchers also noted that in children who have

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endured longer periods of abuse, the cerebral volume in the brain was smaller, and the children displayed more trauma symptoms such as hyperarousal, avoidance, dissociation, and intrusive images or thoughts. Teicher, Andersen, Polcari, Anderson, and Navalta (2002) compared the brains of maltreated children with those of a control group of nonabused children. The researchers reviewed EEG coherence tests, MRI results, and medical records; they also administered neuropsychological testing in order to measure the capacities of both brain hemispheres. The results of this and other studies showed that the cortex in the left hemisphere was not fully developed; this, in turn, affects language and reasoning skills (Stein & Kendall, 2004; Teicher et al., 2002). Additionally, the reduced capacity of the left hemisphere causes the child to be at risk for developing depression. This group of researchers also found abnormalities in the corpus callosum. This results in the right and left hemispheres not working together and thus interfering with emotional and cognitive processing and lateralization occurs. Other researchers (Herman, 1992; Perry, 1994, 2002; Putnam, 1996; Schore, 2002) have determined that chronic trauma results in affect dysregulation, sleep disorders, startle reactions, sensory-motor dysfunction, dissociation, learning problems, relationship issues, anxiety and panic attacks, and avoidance of specific situations or events. These symptoms, individually or in combination, result from child maltreatment and negatively affect child development (Cicchetti & Toth, 1995; Perry, 1994; Putnam, 1997). Child maltreatment is the foundation from which trauma-related psychiatric disorders, including depression and separation anxiety, evolve over time and continue to affect and impair the adult survivor (Perry, 1994, 1997; Putnam, 1997; Schore, 2002; Siegel, 1999).

TREATING TRAUMA SURVIVORS The treatment of trauma requires an in-depth knowledge on the part of the therapist in understanding and being able to identify dissociation. It is imperative that clinicians have a strong understanding of the effects of traumatic events on clients and use best practices when treating trauma in order to avoid “therapeutic misadventures.” Trauma treatment-related issues are discussed in the following sections: Phases of Treatment, Principles of Treatment, and Inner Child or Ego State Therapy.

Phases of Treatment Trauma therapy typically covers three phases. The issues addressed in the first stage may resurface during each phase of treatment, making therapy a highly recursive process (Levers, 1997). The stages of trauma therapy are well documented in the trauma literature and were first outlined by Janet in the early part of the 20th century (Courtois et al., 2009; Ford, Courtois, Steele, van der Hart, & Nijenhuis, 2005; Herman, 1992; Ogden et al., 2006; van der Kolk, 1996). Safety is the focus of the first stage, and accurate assessment is critical. The client may outline various traumatic stressors, much like a grocery list, and may show minimal, if any, affect when recounting terrifying events. An untrained therapist may believe that the client self-disclosed without realizing the basis for the lack of affect (Herman, 1992; Ford et al., 2005). Like many stage models, the phase model in the treatment of PTSD and complex stress disorders has its basis in clinical experiences (Ford et al., 2005). The therapist must establish the framework from which the therapy will proceed, including a discussion of boundaries and limits. These typically need to be repeated at every phase of treatment and often are tested by the client. This can encompass the time frame of the sessions, the frequency, and how between-session phone calls can be

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managed. Explaining the nature of the therapeutic relationship to clients along with stressing that this is not a friendship is important. A discussion needs to transpire regarding how to manage crisis and whether a phone call is sufficient; a crisis team may be needed or inpatient care may need to be considered when a more intensive level of treatment is required, for example, a partial hospitalization program or an intensive outpatient program (International Society for the Study of Trauma and Dissociation [ISSTD], 2011). The use of expressive arts therapy including drawing, sculpting, painting, dance movement, music, writing, meditation, and exercise can tap into the creativeness and mindfulness of the individual. These activities work with other areas of the brain, sometimes enabling clients to express aspects of the trauma that have not been communicated verbally or on a cognitive level. They can be adapted to all three stages of therapy. Providing opportunities for clients to make choices is also important throughout the therapeutic process, as survivors often were not given much opportunity to make decisions. The three phases are detailed, in sequence, in the following subsections.

Safety and Stabilization Establishing a therapeutic alliance becomes challenging due to the lack of trust, which has been well ingrained in trauma survivors. This is further complicated by the fact that survivors feel unsafe in their bodies and in personal relationships (Herman, 1992). This phase takes as long as the client needs, and this can be an extensive period that depends on several variables (Chu, 1998; Herman, 1992). Of primary concern is the client’s safety. Safety refers to the physical safety of the environment where the therapy occurs as well as to emotional safety of the client. Safety also includes issues outside of the therapy session and between sessions. In this phase, the therapist can expect that crises will arise. Therefore, the therapist needs to anticipate this and to give the client clear direction on how a particular crisis needs to be handled between sessions and outside of therapy. It is important to review the boundaries and limits of the therapeutic relationship. Typically, clients test the genuineness of the therapist to ascertain that, no matter what, the therapist will not reject them or “throw them to the curb.” The therapist can expect transference issues within this phase. These can be emotionally charged and overwhelming for the client. They also can have an impact on the therapist who becomes the object of the client’s negatively charged affect; this is one of the reasons why therapists working with trauma survivors must remain vigilant about countertransference issues and must ensure that they have access to supervision. Client transference is related to the level of mistrust that the client has learned, as well as to the betrayal the client experienced at the hands of those who were supposed to be protective and caring, but who were not. This reaction can be noted when a therapist may call out for an illness or goes on vacation; some clients personalize such normal life activities of the therapist, and clients with attachment issues may experience counselor absence as abandonment. It is at such times, in this first stage, when clients may act out. One example of acting out is client self-harm. Therapy in this phase includes efforts to stabilize a client’s urges to self-injure and to manage suicidal thoughts, eating disorders, and substance abuse. Engaging the client in writing a safety plan, signed by both the client and the therapist, is a helpful way to engage both in promoting safety. The signed contract needs to include high-energy activities such as exercising, biking, jogging, walking, dancing and kicking, or throwing a ball. Less intense actions also are helpful, such as calling someone on the person’s support person list, writing in a journal, drawing, taking a bath, or listening to music. The contract spells out a variety of alternatives for the client to decrease the intensity of the stressor, including both passive and more aggressive activities. It also needs to list at least three support people whom

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the client can call before calling the therapist. While trying to manage a self-injury urge, a client may not be able to think clearly about what to do, but may be able to look at the safety contract that has a list of the possible actions the he or she could consider to decrease the urge. Learning ways to calm the body down and decrease hyperarousal states are essential for survivors during the safety phase (Herman, 1992). Safety also refers to the pace of the therapy, and the therapist needs to educate and encourage the client on how and when to “put on the brake” (Rothschild, 2000). The brakes are needed when trauma symptoms escalate; the goal then becomes allowing the client to regroup by calming the body, temporarily ignoring self-depreciating words or feelings, and letting the sensation decrease (Ogden et al., 2006). The therapeutic relationship is pivotal in working with adult survivors; this requires learning and then using the client’s strengths and internal and external resources, as well as areas where they struggle or are lost. The therapist teaches and demonstrates coping daily skills that address overreactive functioning, also encouraging the client to learn more adaptive responses that can lead to self-confidence and more productive emotional functioning in the client. This may include improved sleep patterns, better personal hygiene, increased exercising, nutritional eating patterns, and mindfulness/meditation (Courtois et al., 2009; Herman, 1992). Psychoeducation is also another aspect of the first phase. Explaining the effects of traumatic stress, including its biological and psychosocial ramifications, is one option that can contribute to reducing fear and normalizing the client’s symptoms and reactions. The therapist can begin to provide education during the first few sessions. This forms the basis for teaching the grounding and containment skills required in improving affect regulation (Ford et al., 2005; Wheeler, 2007). Even with ongoing skill building and teaching self-soothing techniques, there is a percentage of survivors, particularly among those with dissociative disorders, who will not move from this phase, as they cannot tolerate trauma reprocessing. However, their levels of functioning and self-regulation may continue to improve with an enhanced sense of safety and grounding and containment skills (Courtois et al., 2009; Wheeler, 2007).

Processing the Trauma The stabilization that was established and the coping, grounding, and containment skills that were developed in the safety phase are essential for the client to be able to process the traumatic memory. Productive trauma processing only can occur when the following conditions are present: the therapeutic alliance must be solid; the client needs to have developed a firm sense of safety and competent skill management; and the client and therapist must be willing to engage in the difficult trauma work of managing the flood of traumatic material on somatic, emotional, cognitive, and spiritual levels (Rothschild, 2000, p. 83). The client must have active input as to whether he or she wants to do this work; while remembering the trauma may be essential to continued therapy, a client should never be pushed when not ready or led by the therapist in revealing memories. Currently, there is no clear research indicating that it is an absolute necessity to do memory work for treatment of trauma to be effective (Ford et al., 2005); however, the theoretical literature emphasizes that remembering is an important aspect of moving forward (Herman, 1992). The focus in the second phase is to incorporate the traumatic memory into a narrative about the survivor’s life. The traumas are then framed as experiences in the life of the client and are no longer the basis for personal identity (Herman, 1992; van der Kolk, 1996). Along with an expression of related cognitive schemata, the narrative needs to include the imagery and sensory aspects of the event(s), including body sensation and emotion; otherwise, the narrative is not complete (Herman, 1992).

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It is essential that the therapist is attentive to the individual survivor’s ability to self-regulate, which will vary. Attunement with the client allows for adjustments to the way the therapist intervenes, offers support, and guides the therapeutic process with the client; this enables the client in “operating the brakes” (Rothschild, 2000). If the survivor becomes hyperaroused or experiences intense trauma symptoms, the session needs to slow down, thereby reinforcing the importance of the collaboration between client and therapist (Herman, 1992; Rothschild, 2000). Stabilization with the use of previously learned coping skills needs to be implemented when the survivor experiences an increase in hyperarousal during this phase of processing. The therapist needs to be aware of the client’s ability to self-regulate in each session, as well as noticing the increasing ability of the client to regulate over time (Ogden et al., 2006). Clients may choose to write or draw at different points in the trauma processing, and it is the role of the therapist to remind the client that reading a journal entry or describing a drawing can have a powerful healing impact when shared together in session (Herman, 1992). This has a pendulum effect, going from the past to the present, and can be helpful in titrating the intensity of the trauma processing. At times, the client and/or the therapist may notice hyperarousal or intensification of other symptoms. When this occurs, from a sensorimotor perspective, the therapist may encourage the client to stop the words and focus only on the body sensations until the arousal calms down. In this way, as the therapy continues, the cognitive and emotional aspects of the memory can then be titrated at a level that meets the capacity of the client in dealing with the traumatic memories (Ogden et al., 2006). The goal is to avoid retraumatizing the client and to integrate the memory as part of the trauma narrative. In this phase of treatment, the therapist becomes a witness to the trauma (Herman, 1992). The therapist needs to reassure the client that all memories do not need to be processed and that one memory can be representative of several. It is important to reinforce the client’s efforts, to reaffirm his or her capability in working through the overwhelming emotions and memories, and to encourage the client in rebuilding a sense of self.

Reconnection and Integration During the third phase of therapy, the focus is to move the client on the path of creating a normal lifestyle, with a view toward the future that may include school, work, a career, formulating new relationships, intimacy, and a renewed sense of self; the aim is to enable the survivor to reengage in life in an emotionally regulated manner. The challenge for the client is to work on these goals with a different perspective—from the stance of a survivor, no longer dwelling in the victim role (Herman, 1992; Luxenberg et al., 2001). This is not merely a semantic issue; this transformation can lead to survivors’ awareness that out of their trauma experiences, they have discovered new meanings for themselves. For many survivors, the concept of pleasure is foreign, as their lives have been centered on negativity and overwhelming situations. The ability to have positive experiences is limited because typically elevated emotions, positive or negative, are reminders of past trauma. During this phase, clients are encouraged to participate in positive activities; however, this can create a dilemma, as many clients have little idea as to what would be fun, and therapists may need to provide positive challenges in order to increase client tolerance for positive emotions (Ogden et al., 2006). Boundary issues are well integrated at this point, the need to respect the boundaries of others is clear, and the client’s ability to maneuver boundary issues effectively has been established. The crises experienced by clients in this phase of therapy tend to be minimal. Clients have developed or redeveloped their capacities to trust others, and

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they also are more keenly aware that, in certain situations, it is appropriate not to trust people or situations that may cause harm. In this final phase of treatment, the client often shows insight as they begin to comprehend the level of chaos and dysfunction that they have experienced. Empowerment has extended meaning for the client in this stage. As an example, a survivor can look at interpersonal relationships and recognize that he or she can have a voice and can make healthy decisions for self and the family or support system. In this way, clients learn that they have a voice and are able to make choices for themselves in many domains. Realizing that silence is no longer the only choice is powerful for the survivor, as the theme of “not to tell” was so embedded in the client’s mind. No matter what, how, or whether the family of origin responds, it is a victory for the survivor; he or she finally can name what he or she experienced, initially in therapy, but with the therapist as a witness (Herman, 1992). Thus, in this stage, the survivor is able to determine whether to discuss the trauma openly with his or her family; this is a profound and individual decision. If the decision is made to share familial trauma, it is not uncommon for clients to express hurt and frustration toward the nonoffending caregiver for not protecting them. In some instances, especially those having the potential for transgenerational trauma, the adult survivor may choose to enlighten his or her own children regarding his or her history (Herman, 1992) as a matter of instruction and safety.

Principles of Treatment Trauma treatment requires a multidimensional approach that includes body awareness and processing, creative expression, grounding and containment, assessment, psychoeducation, cognitive adjustment, and medication (these issues are covered in other chapters in this book). There are several organizations that define and outline certain necessary principles for trauma treatment, including the American Psychiatric Association (2004) and the ISSTD (2011). In addition, the American Psychological Association (2006, 2007) offers guidelines for evidence-based practice and guidelines for women and girls. Several concerns have been identified in working specifically with complex trauma disorders (Ford et al., 2005). Therapists need to assist clients in the following ways: developing coping skills in order to manage hyperarousal; increasing self-awareness to assess the intensity of arousal; encouraging the maintenance of a level of functioning high enough to manage individual daily life responsibilities; managing triggers and trigger situations, rather than avoiding them; and increasing the client’s personal control and efficacy (Cloitre et al., 2009; Steele & van der Hart, 2009; van der Hart, Nijenhuis, & Steele, 2005).

Treatment Limitations Several concerns have been identified in working specifically with complex trauma disorders (Ford et al., 2005). Clients with histories of complex trauma can be volatile, and the therapist needs to be attentive and to educate clients in specific trauma-related areas. The most fragile survivors may leave therapy prematurely or may need to reenter counseling several times before attaining the level of trust and affect regulation that is required to work through their traumatic past. Chronically traumatized clients, due to an abusive past, may have a strong need to control the therapist. At times, they may be disrespectful and act out emotionally or reenact aspects of past traumatic relationships; at such times, they may need further stabilization before they can continue to process their traumatic past. Additionally, the survivor may act on internal reactions by relying on chronic addictive behaviors such as chemical misuse, eating disorders, self-injury, or suicidality. Due to the client’s paucity of interpersonal resources, a decision to focus

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on skills training may be the preferred path of treatment, and trauma processing thus would not be a focus of treatment or postponed for a more appropriate time. Therapists need to assist clients in the following ways: developing coping skills in order to manage hyperarousal; increasing self-awareness to assess the intensity of arousal; encouraging the maintenance of a level of functioning high enough to manage individual daily life responsibilities; managing triggers and trigger situations, rather than avoiding them; and increasing the client’s personal control and efficacy. Therapists must be vigilant about transference and countertransference issues that are sure to arise (Cloitre et al., 2009; Steele & van der Hart, 2009).

Inner Child or Ego State Therapy Children tend to dissociate when coping with overwhelming traumatic stress that is chronic and repetitive. Dissociation allows traumatized children a way to avoid the pain and terror of abuse (Stein & Kendall, 2004). In fact, some clinicians consider dissociation to be a creative coping strategy, initially. However, severely maltreated children are faced with a double bind; they need to survive the abuse inflicted on them, often by parents or caregivers, while they are dependent on perpetrator parents/caregivers (Herman, 1992; Stein & Kendall, 2004). Some children develop a false sense of self that tells the world that all is good, even though their worlds are in chaos (Paulsen, 2009). At the same time, a steel curtain of amnesia is created; behind this curtain lays the knowledge, sensory elements, and secrets of the abuse. This contributes to the functional belief held by the child that the trauma is happening to someone else. An impressive body of research suggests that, over time, early dissociation changes the child’s personality and actually interferes with the integration of the trauma in the neurological pathways in the child’s brain. In the absence of appropriate intervention, the trauma becomes neurologically encoded and has consequences for the adult survivor (Ford & Courtois, 2009). While this actually contributes to psychopathology, the child becoming an adult appears to be functioning within a normal or socially expected manner (Ford & Courtois, 2009). This phenomenon has to do with ego states. Ego states represent aspects of one’s personality. Nondissociative people often speak about parts of the self, and they have an awareness of the various aspects of themselves, such as the part of the self who goes to work versus the parent part of the self, as the latter entails adaptive and separate ways of functioning. Many survivors have more of a separation or barrier between or among various ego states. There may be a slight awareness, such as in adult-onset PTSD. However, in more profound instances of severe and early traumatization (e.g., as is the case with DESNOS), there appears to be distinct ego states that are separated by thick amnestic barriers, where some parts are not known by all the other parts, and each holds the intense emotional content associated with its formation. It is important that therapists reinforce and educate the client about the principle that the ego state—the part of the personality also referred to as “alter,” “alter state,” or “part”—is not actually separate from the original self; that there is only one body. It would not be unusual for the client with a dissociative disorder to challenge this concept on several levels, and do so for a length of time, depending on the level of amnesia. In the old nomenclature, the implications of the diagnostic term “multiple personality disorder (MPD)” contributed to a distorted understanding of fragmented ego states in severely traumatized individuals; unfortunately, while the newer term, DID, presents clearer terminology, many of the old myths concerning MPD remain in the popular mindset. In order to grasp the concept of ego state therapy, it is important to consider the structure of the self. Van der Hart, Nijenhuis, and Steele (2005) present the ideas of the apparently normal personality (ANP) and the emotional personality (EP). The ANPs are geared to manage the routine of daily life and to avoid any reminders of the trauma; the

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EPs are fixated on some aspect of the trauma, including “vehement emotion” (Steele & van der Hart, 2009, p. 149). The EP may be referred to as “the angry one,” “the sad one,” “the wimp,” and so forth. The goal is for integration of the parts into a functioning self. The therapist needs to work with the “system” of parts or ego states to work as a cohesive unit. Watkins and Watkins (1997) developed the ego state concept and have advocated that therapists use an integral group and family approach to resolve internal conflicts among the ego states. In this self-system, there are barriers that hide the emotion, body sensations, and thoughts from the self and the other ego states (Paulsen, 2009). The intentional therapist, then, strategically and carefully attempts to increase the awareness of the various ego states within the client’s internal system, eventually revealing these states to the self—referred to as coconsciousness. It is then important that the therapist work with the client to build on the newly evolving coconsciousness, thus promoting internal cooperation by increasing communication among the ego states or EPs.

TREATMENT APPROACHES Several treatment approaches have been identified as best practices for use with survivors of trauma, including eye movement desensitization and reprocessing (EMDR; e.g., American Psychiatric Association, 2004; ISSTD, 2011), dialectical behavior therapy (DBT; e.g., Resick et al., 2007; Wagner, Rizvi, & Harned, 2007), cognitive behavioral therapy (CBT; e.g., American Psychiatric Association, 2004; Ford et al., 2005; Resick et al., 2007), and psychodynamic (e.g., American Psychiatric Association, 2004; ISSTD, 2011). Treatment for complex trauma needs to incorporate and recognize the attachment problems that are so apparent in this population. Relevant treatment interventions are discussed briefly in the following sections on EMDR, DBT, CBT, and Psychodynamic approaches.

Eye Movement Desensitization and Reprocessing EMDR is an eight-phase treatment approach developed by Francine Shapiro in 1989 that focuses on the brain’s information processing system and the way memories are held. EMDR additionally includes an adaptive information processing (AIP) model that is based on the ways that trauma affects the brain and on the way that healing may occur (Shapiro, 2001; Wheeler, 2007). The AIP model emerged concomitantly as EMDR was being used and researched. Research has indicated that bilateral stimulation (BLS)—left or right tapping, auditory tones, specifically recorded music, or certain movement—is not just limited to eye movement; hence, BLS that activates the right and left hemispheres of the brain may access traumatic memory. EMDR processes many aspects of the images, thoughts, body sensations, and emotions associated with the traumatic memory. EMDR is a structured approach and uses a past, present, and future template. The dual attention has the client focusing on the distressing material and simultaneously on the BLS. Between sets of BLS, clients use free association to grasp further information and make sense of associated memories (Wheeler, 2007). The client processes the overwhelming material and is able to integrate new information. This approach to the treatment of trauma disorders is evidence based and requires extensive training on the part of already experienced therapists. EMDR is used for strengthening the client’s internal resources and is thought to bring about fast and long-lasting change (Nebrosky, 2003).

Dialectical Behavior Therapy DBT is a relational skills treatment approach developed by Marsha Linehan. DBT initially was specifically designed for working with BPD and with a focus on issues of

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emotional and affect dysregulation that accompanies this disorder in various intensities. Since its conception, DBT is used along with other trauma-related disorders such as substance abuse, eating disorders, and anxiety (Resick et al., 2007). Many clients who have issues with affect dysregulation and relationship problems or who thrive on crisis also have complicated trauma histories; for this reason, DBT or selected components of DBT may be useful in helping adult survivors of trauma in the healing process. This treatment approach was designed to “treat a complex and heterogeneous group” as well as to calm down the chaos in clients’ lives (Wagner et al., 2007, p. 399). DBT includes a series of structured group sessions consisting of skills training; these are not process groups. The DBT approach requires that for this to be effective, clients must work simultaneously with an individual therapist. The structured groups often are offered in mental health agencies and partial hospitalization programs. DBT covers four skill sets with a focus on affect regulation, mindfulness, interpersonal interactions, and distress tolerance (Wagner et al., 2007). The affect regulation skill set offers clients adaptive methods to develop and maintain better control over reactive emotions associated with trauma or distress. Mindfulness teaches clients to be in the present moment in a nonjudgmental manner, and at the same time, encourages body awareness. The third skills set provides clients with ways to interact more effectively with people in their lives, and the final set emphasizes the development of better coping strategies intended to improve affect regulation. This approach encourages clients to stay in the present and to pay attention to what is helpful. It can aid in decreasing anxiety levels and self-destructive behaviors like selfinjury, which then can assist in decreasing the overreactive responses often displayed by this population. DBT is an adjunctive treatment that can complement other therapeutic modalities. It can be implemented efficaciously during the safety stage of trauma work based on its focus on safety and self-regulation (Ford et al., 2005).

Cognitive Behavioral Therapy CBT operates on the premise that clients can learn to regulate their feelings by changing their thoughts and behaviors, and that new ways of thinking, behaving, and feeling can affect change (Jackson, Nisseson, & Cloitre, 2009). CBT is a structured therapy approach, incorporating skills training, which can lessen the client’s level of anxiety as it helps in preparation for future intensive work. This approach can be used in individual and group therapy. In CBT, the sessions have agendas with goals and offer predictability about what happens next when there are target aims. Distortions in thinking or catastrophizing are addressed, and clients are taught to reframe such distortions to more adaptable and accurate ways of thinking. Homework is used in this therapeutic approach; clients keep a journal of their thoughts, feelings, and behaviors and process this information with their counselors. This approach encourages telling the trauma narrative, and the therapist titrates the pace and intensity, so that the client effectively can manage thoughts, feelings, and behaviors. This approach has a strong emphasis on containing affect, thereby allowing clients to experience more intense affect during stage two of trauma processing, when they are more ready because they are safer.

Psychodynamic Approch Psychodynamic therapy is an insight-oriented treatment approach that focuses on the interpersonal relationships of a client, including the therapeutic relationship with the therapist. As stated throughout this chapter, clients with complex trauma histories often experience difficulties in affect regulation and misinterpretation of social cues. The psychodynamic therapist uses the therapeutic alliance to assist the client in gaining insight

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about relationship issues by making interpretations that are related to the client’s past childhood and current life experiences (Schottenbauer, Glass, Arnkoff, & Gray, 2008). The ISSTD guidelines (2011) recommend employing a psychodynamic approach for treating DID in ways that can incorporate techniques from other approaches. The American Psychiatric Association’s practice guidelines also support this approach for PTSD, as it accounts for the ways in which the client copes and manages traumatic memories. It further encourages the client to establish a sense of self in order to strengthen a sense of trust, and this then assists the client in identifying the subjective aspects of the trauma (American Psychiatric Association, 2004).

COUNSELING IMPLICATIONS The long-term effects of abuse, neglect, and disordered attachment are well documented in the trauma literature and research. Recent neuroscience research continues to provide new insight and understanding about the negative effects that result from chronic and prolonged trauma. This underlines the importance of therapists in keeping current by reading peer-reviewed journals, staying abreast of the most recent literature, and attending trainings and conferences in the area of trauma effects. It is essential to keep in mind that trauma therapy needs to be multidimensional and that “one size does not fit all.” It is widely held that problems with affect regulation are right brained, and therefore, nonverbal in nature (Nebrosky, 2003). This offers a partial explanation as to the relevance of why verbally based talk therapies alone often fail; they are unable to restore normal affect regulation (Nebrosky, 2003) and ignore the neurobiological aspects of trauma. Expressive arts, dance, yoga, meditation, and music are additional aspects of treatment. In working with trauma, it is important to consider that information processing is multidimensional and occurs on cognitive, emotional, and sensory levels. In closing, in the final stages of trauma treatment, clients can begin to comprehend that “the events they endured have not changed, but the negative effects on mind and body have been transformed” (Ogden et al., 2006, p. 300). Not only is dealing with and healing from trauma transformational for clients; the healing process also has an impact on clinicians. Working with survivors of trauma is not for all therapists, and as Chu (1998, p. 204) insightfully suggests about counselors who choose to work with trauma, “The important and serious work with traumatized patients requires honesty, flexibility, integrity, and humor.”

CONCLUSION This chapter has offered an overview of complex trauma disorders, an important concept for therapists to understand when working with adult trauma survivors. I have focused on the three commonly endorsed phases of trauma therapy when working with this population: safety and stabilization, trauma processing, and reconnection and integration. These have been well documented in the trauma literature and across various treatment approaches as a blueprint for treatment; I have illuminated how the use of this model can help to structure and guide therapy with adult survivors. I have emphasized how inner child work can begin to normalize aspects of trauma effects and can help in the healing process, including the implementation of coping and affect regulation skills to affirm the sense of safety that many survivors lack as they enter therapy. Such best practices accentuate the therapeutic relationship between the therapist and client, which goes a long way in the stabilization process.

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It is essential that therapists keep in mind that a multidimensional approach is necessary in working with adult survivors due to the wide variety of trauma effects and symptoms that survivors present. It is important to consider the amount of courage that it takes, on the part of survivors, to sit in therapy, and to take the immense risk of trusting a therapist with their sometimes unspeakable but nearly always hidden worlds. The adult survivor deserves the utmost respect and support in doing this most difficult work. It also is important that therapists support one another, as the work is strenuous and can be overwhelming at times. New information regarding the effects of long-term trauma is more prevalent at this time than ever before, and it is our collective responsibility to remain current with evolving theory and new research and knowledge about working with adult survivors of trauma.

RESOURCES Websites BookShoppe. (n.d.). Trauma & posttraumatic stress disorder. (http://www.therapist4me.com/Book%20 Shoppe%20Trauma.htm) CBS News. (2009). 60 minutes on Tyler Perry and his traumatic childhood. (http://www.cbsnews.com/ video/watch/?id=5419931n&tag=contentMain;contentBody) Courtois, C. A. (n.d.). Understanding complex trauma, complex reactions, and treatment approaches. Heal my PTSD. (http://healmyptsd.com/2010/12/understanding-complex-trauma-complex-reactions-andtreatment-approaches-part-4.html) Gift From Within (http://www.giftfromwithin.org/html/articles.html) International Society for the Study of Trauma and Dissociation. (2011). Treatment guidelines. (http://www. isst-d.org/education/treatmentguidelines-index.htm) Mental Health America (http://www.nmha.org/reassurance/ptsd.cfm) Sidran Foundation (http://www.sidran.org) Trauma Central (http://www.traumacentral.net/) Publications Levine, P. A., & Frederick, A. (1997). Waking the tiger: Healing trauma: The innate capacity to transform overwhelming experiences. Berkeley, CA: North Atlantic Books. Mason, P. T., & Kreger, R. (1998). Stop walking on eggshells: Taking your life back when someone you care about has borderline personality disorder. Oakland, CA: New Harbinger. Schiraldi, G. R. (2000). The post-traumatic stress disorder sourcebook: A guide to healing, recovery, and growth. New York, NY: McGraw-Hill. Williams, M. B., & Poijula, S. (2002). The PTSD workbook: Simple, effective techniques for overcoming traumatic stress symptoms. Oakland, CA: New Harbinger.

REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., Text Rev.). Washington, DC: Author. American Psychiatric Association. (2004). Treating patients with acute stress disorder and posttraumatic stress disorder: A quick reference guide. Retrieved from http://psychiatryonline.org/content.aspx?b ookid=28§ionid=1663338 American Psychological Association. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285. American Psychological Association. (2007). Guidelines for psychological practice with girls and women. American Psychologist, 62, 949–979. Bloom, S. L. (1997). Creating sanctuary: Toward the evolution of sane societies. New York, Routledge.

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Briere, J. (2006). Dissociative symptoms and trauma exposure: Specificity, affect dysregulation, and posttraumatic stress. Journal of Nervous and Mental Disease, 194, 78–82. Chu, J. (1998). Rebuilding shattered lives. New York, NY: John Wiley & Sons. Cicchetti, D., & Toth, S. L. (1995). Developmental psychopathology and disorders of affect. In D. Cicchetti & D. Cohen (Eds.), Developmental Psychopathology--Volume 2: Risk, Disorder, and Adaptation (pp. 369-420). New York: John Wiley & Sons. Cloitre, M., Stolbach, B. C., Herman, J. L., van der Kolk, B., Pynoos, R., Wang, J., & Perkova, E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22(5), 399–408. doi:10.1002/jts.20444 Courtois, C., Ford, J., & Cloitre, M. (2009). Best practices in psychotherapy for adults. In C. A. Courtois & J. D. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 82–103). New York, NY: Guilford Press. De Bellis, M. D., Keshaven, M. S., Clark, D. B., Caseey, B. J., Giedd, J. B., Boring, A. M., . . . Ryan, N. D. (1999). Developmental traumatology. Part 2: Brain development. Biological Psychiatry, 45, 1271–1284. Ford, J., & Courtois, C. A. (2009). Defining and understanding complex trauma and complex traumatic stress disorders. In C. A. Courtois & J. D. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 13–30). New York, NY: Guilford Press. Ford, J., Courtois, C. A., Steele, K., van der Hart, O., & Nijenhuis, R. (2005). Treatment of complex postraumatic self-dysregulation. Journal of Traumatic Stress, 18 (5), 437–447. Herman, J. (1992). Trauma and recovery. New York, NY: Basic Books. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision: Summary version. Journal of Trauma & Dissociation, 12(2), 188–212. Jackson, C., Nisseson, K., & Cloitre, M. (2009). Cognitive behavioral therapy. In C. A. Courtois & J. D. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 243–263). New York, NY: Guilford Press. Keane, T. M., Brief, D. J., Pratt, E. M., & Miller, M. W. (2007). Assessment of PTSD and its comorbidity in adults. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 497–520). New York, NY: Guilford Press. Levers, L. L. (1997). Counseling as a recursive dynamic: Relationship and process, meaning-making and empowerment. In T. F. Riggar & D. R. Maki (Eds.), Rehabilitation counseling: Profession and practice (2nd ed., pp. 170–182). New York, NY: Springer Publishing. Luxenberg, T., Spinazzola, J., & van der Kolk, B. (2001). Complex trauma and disorders of extreme stress (DESNOS) diagnosis, part one: Assessment. Directions in Psychiatry, 21(4), 373–393. Nebrosky, R. J. (2003). A clinical model for the comprehensive treatment of trauma using an affect experiencing-attachment theory approach. In M. F. Solomon & D. J. Siegel (Eds.), Healing trauma: Attachment, mind, body and brain (pp. 282–321). New York, NY: Norton. Nijenhuis, E. R. S., van der Hart, O., & Steele, K. (2004). Trauma-related structural dissociation of the personality: Traumatic origins, phobic maintenance. Retrieved from http://www.trauma-pages.com/a/ nijenhius-2004.php Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York, NY: Norton. Paulsen, S. (2009). Looking through the eyes of trauma and dissociation: An illustrated guide for EMDR therapists and clients. Charleston, SC: Booksurge Publishing. Pearlman, L., & Courtois, C. (2005). Clinical applications for the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress, 18 (5), 449–459. Perry, B. D. (1994). Nurobiological sequelae of childhood trauma: Post traumatic stress disorders in children. In M. Murburg (Ed.), Catecholamine function in post traumatic stress disorder: Emerging concepts (pp. 253–276). Washington, DC: American Psychiatric Press. Perry, B. D. (1997). Incubated in terror: Neurodevelopmental factors in the’cycle of violence’ [Electronic verison]. In J. Osofsky (Ed.), Children, youth and violence: The search for solutions (pp. 124–148). New York: Guilford Press. Perry, B. D. (1999). Memories of fear: How the brain stores and retrieves physiologic states, feelings, behaviors and thoughts from traumatic events [Electronic version]. In J. Goodwin & R. Attias (Eds.), Splintered refelections: Images of the body in trauma. New York: Basic Books.

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Perry, B. D. (2002). The vortex of violence: How children adapt and survive in a violent world [Booklet]. Houston, TX: The Child Trauma Academy. Putnam, F. W. (1996). Special methods for trauma research with children. In E. B. Carlson (Ed.), Trauma reserach methodology (pp. 153–173). Lutherville, MD: Sidran Press. Putnam, F. W. (1997). Dissociation in children and adolescent: Adevelopmental perspective. New York: Guilford Press. Resick, A. P., Monson, C. A., & Gutner, C. (2007). Psychosocial treatments for PTSD. In A. J. Freidman, A. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD (pp. 330–358). New York, NY: Guilford Press. Rothschild, B. E. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New York: W. W. Norton. Ryan, J. (2010). New developments in trauma therapy. Therapy Today, 21(5), 1–9. Schore, A. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale, NJ: Lawrence Erlbaum Associates. Schore, A. (2002). Dysregulation of the right brain: A fundamental mechanism of traumatic attachment and the psychopathogenesis of posttraumatic stress disorder. Australian and New Zealand Journal of Psychiatry, 36(1), 9–30. Retrieved from http://www.trauma-pages.com/a/schore-2002.php Schore, A. (2009). Attachment trauma and the developing right brain: Origins of pathological dissociation. In P. A. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-V and beyond (pp. 107–144). New York, NY: Routledge. Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., & Gray, S. H. (2008). Contributions of psychodynamic approaches to treatment and trauma: A review of the empirical treatment and psychopathology literature. Psychiatry, 71(1), 13–34. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed.). New York, NY: Guilford Press. Siegel, D. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York, NY: Guilford Press. Siegel, D. J. (2009). Emotion as integration: A possible answer to the question, what is emotion? In D. Fosha, D. J. Siegel, & M. F. Solomon (Eds.). The healing power of emotion: Affective neuroscience, development & clinical practice (pp. 145–171). New York, NY: W. W. Norton. Steele, K., & van der Hart, O. (2009). Treating dissociation. In J. D. Ford & C. Courtois (Eds.), Treating complex traumatic stress disorders (pp. 145–165). New York, NY: Guilford Publications. Stein, P., & Kendall, J. (2004). Psychological trauma and the developing brain: Neurologically based interventions for troubled children. New York, NY: Haworth Press. Teicher, M. H., Andersen, S. L., Polcari, A., Anderson, C. M., & Navalta, C. P. (2002). Developmental neurobiology of childhood stress and trauma. Psychiatric Clinics of North America, 25(2), 397–426. van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2005). Dissociation: An under-recognized feature of complex PTSD. Journal of Traumatic Stress, 18, 413–424. van der Kolk, B. A. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review Psychiatry, 1(5), 253–265. van der Kolk, B. A. (1996). The body keeps the score: Approaches to the psychobiology of posttraumatic stress disorder. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 214–241). New York, NY: Guilford Press. van der Kolk, B. A. (2005). The developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35, 401–408. Waelde, L., Silvern, L., Carlson, E., Fairbank, J., & Kletter, H. (2009). Dissociation in PTSD. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-V and beyond (pp. 447–4456). New York, NY: Routledge. Wagner, A., Rizvi, S., & Harned, M. (2007). Applications of dialectical behavior therapy to the treatment of complex trauma-related problems: When one case formulation does not fit all. Journal of Traumatic Stress, 20 (4), 391–400. Watkins, J. G., & Watkins, H. H. (1997). Ego states: Theory and therapy (2nd ed.). New York, NY: W. W. Norton. Wheeler, K. (2007). Psychotherapeutic strategies for healing trauma. Perspectives in Psychiatric Care, 43 (3), 132–141.

CHAPTER 11

Intimate Partner Violence NANCY N. FAIR AND FRANK M. OCHBERG

INTRODUCTION The Strange Case of Kristin In August of 1973, a Swedish bank teller in Stockholm was taken hostage and held in a bank vault for several days by an armed assailant named Olsson. By the end of her captivity, the young bank teller, Kristin, had become enamored with Olsson to the point where she broke off her engagement to her fiancé and spoke vigorously in defense of her captor to the Swedish prime minister. Shortly after the incident in Sweden, one of the authors of this chapter (F. M. O.) was the psychiatrist on the National Task Force on Terrorism and Disorder and became intrigued by the case, which was one of a rash of hostage events that occurred in the 1970s. Law enforcement officials and behavioral scientists were just beginning to collaborate intensely on cases like Kristin’s, which involved an unexpected bond forming between captive and captor. Kidnap and hostage experts had already been aware of such cases, and psychoanalyst Anna Freud had described similar situations in Nazi concentration camps as “identification with the aggressor.” Interviews in the Stockholm case and many others afterward, however, did not support the idea that captives were identifying with an aggressor; rather, the hostages described being stunned, shocked, and certain they would die. A human being in such a situation then becomes like an infant—dependent on captors for food, water, and other basic necessities. In each one of these cases, small acts of kindness by the captors gradually began to evoke feelings much deeper than relief. As one Dutch ex-hostage stated about the men who chose not to kill him, “We knew they were killers, but they gave us blankets, cigarettes.” What the hostages seemed to experience was more like an infant’s primitive feelings of security, calm, and, in a way, gratitude, when basic needs are met. These are the feelings that eventually develop and differentiate into varieties of affection and love (Ochberg, 1988). The attachment goes both ways, with the captor often developing reciprocal feelings toward the hostage. When this occurs, both captive and captor have usually developed a distrust of outsiders, including the rescuers, who then become the common enemy. The dynamics of hostage situations that involve the formation of a bond between captor and captive was identified as a pattern (Ochberg, 1975, private papers) that later came to be known as the Stockholm syndrome. Although the syndrome was identified for the purpose of assisting negotiators in developing effective strategies for facilitating

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hostage release in rare situations like Kristin’s, it is also especially useful for helping clinicians to understand the bonds of attachment that often exist in abusive intimate partner relationships (Martinez, 2001; Ochberg, 1998). As Graham, Rawlings, and Rigsby (1994) summarize, the four conditions of the syndrome include (a) the victim’s perception of threat to survival; (b) the victim’s perception of some kindness, no matter how small from the abuser; (c) the victim’s isolation from others who might offer an alternative perspective to the abuser’s; and (d) the victim’s perception that there is no escape. In addition to applying the lessons learned from hostage situations to the trauma of intimate partner violence (IPV), this chapter examines various effects, social costs, contextual theories, and implications for counseling regarding survivors of IPV. This is achieved in the following sections: defining relevant terms, offering background statistics, discussing the trauma associated with IPV, outlining the theoretical contexts for understanding IPV, identifying the implications, and summarizing the salient points. This chapter concludes with a listing of helpful resources for instructors, clinicians, students, and clients.

DEFINITIONS IPV as a topic has been studied in several academic disciplines and has been described using a variety of terms. To enhance the reader’s understanding of IPV in this chapter, some of the terms and constructs are defined in the following subsections.

Victims and Abusers Violence is an unfortunate fact of our human existence. The cruelty of war, sexual assault, revenge and honor-motivated killings, bullying, and hate crime assault our senses on a daily basis. Efforts to identify root causes have produced volumes of theoretical and research data that have added to the public understanding of the social, biological, and emotional origins of violence, but have not reduced the prevalence of victimization. IPV (a relatively new term) is an area that has been the subject of copious research under a variety of names, including domestic abuse, wife beating, and domestic violence. Recent IPV research has begun to include studies of female violence against male partners (Straus, Gelles, & Steinmetz, 1980); however, most partner abuse victims have been, and continue to be, overwhelmingly female. The historic roots of spousal abuse run deep. Women have been bought, sold, and traded as chattel for centuries, denied education, land ownership, and are not yet considered fully independent human beings in many cultures. Politically, even in the industrialized West, women’s rights have been nominally granted but continue to be undermined or ignored by certain male groups, and often in their own homes by their partners (Ochberg, 1998). Estimates from the National Crime Victimization Survey (NCVS) indicated that, in 1998, about 1 million violent crimes qualifying as IPV were committed against individuals. Of that 1 million, 876,340 or about 85% were against women. Tjaden and Thoennes (2000) studied the prevalence and consequences of maleto-female and female-to-male IPV, finding that women experienced higher rates of violence by marital/opposite sex partners than did men. Women reported more frequent, longer lasting violence, as well as more threats and fear of bodily harm. Women victims of IPV were significantly more likely than men to report that they had been injured, had received medical care and mental health counseling, had lost time from work, and had sought legal intervention. Thus, male and female experiences of violence at the hands of an intimate partner appear to differ both quantitatively and qualitatively.

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Based on the statistics that indicate women are victimized more often by partners and more seriously affected by IPV than men, references to abusers in this chapter use the pronoun “he,” whereas victims are referred to as “she.” However, the authors fully acknowledge the presence of victims and perpetrators in both genders, particularly as they appear in the context of same-sex couples, a subject that is explored in detail in later sections of this chapter.

Intimate Partners Intimate partners are defined by the U.S. Department of Justice (Rennison & Welchans, 2000) as “current or former spouses, boyfriends, and girlfriends,” and the term assumes that the partnerships may be either heterosexual or homosexual. Statistics regarding violence in transgender partnerships are not included in the U.S. Department of Justice report but are addressed in a later section of this chapter.

Intimate Partner Violence The U.S. Department of Justice (Rennison & Welchans, 2000) lists the following crimes in their description of IPV statistics: homicide, rape, sexual assault, robbery, aggravated assault, and simple assault. Other studies have expanded the definition to include psychological violence, defined as “put-downs, name calling, and controlling behavior” (Thompson et al., 2006, p. 4). The Leadership Council on Child Abuse and Interpersonal Violence, a nonprofit independent scientific organization, uses the term, “Domestic Violence by Proxy,” coined by Patterson (2009) to describe the behavior of some batterers who continue to perpetrate their abuse on their former partner through the couple’s children. This may occur even after separation or divorce, by manipulating the child’s feelings about the other parent, usually the mother. Such tactics are primarily used in the context of divorce and custody disputes in which the batterer continues to have contact with his children.

STATISTICS The numbers of individuals affected by IPV, including victims, family members, and society as a whole, are staggering. The following statistics are the results of studies quantifying reports of IPV, both in the United States and abroad.

Prevalence in the United States The U.S. Department of Justice, Bureau of Justice Statistics (2000) reported the following IPV statistics for the year 1998: ■ ■ ■ ■

1,830 murders (1,320 female victims; 510 male victims) 63,490 rapes/sexual assaults (63,490 female victims; 0 male victims) 187,970 aggravated assaults (140,050 female victims; 47,920 male victims) 676,440 simple assaults (569,650 female victims; 106,790 male victims)

IPV made up 22% of violent crime against women between 1993 and 1998. By contrast, intimate partners committed 3% of the violence against men during the same period. Thompson et al.’s (2006) study of a group of 3,568 women, aged 18 to 64 who were enrolled in a U.S. Health Maintenance Organization, reported an IPV adult lifetime

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prevalence of 44%, with 10.7% to 21% having been abused by more than one partner. Most respondents also had experienced more than one type of IPV.

Findings From a Multicountry Study Garcia-Moreno, Jansen, Ellsberg, Heise, and Watts (2006) interviewed 24,097 women about IPV in 15 sites in 11 countries, including Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia, Montenegro, Thailand, and the United Republic of Tanzania as part of the World Health Organization (WHO) project on women and domestic violence. The findings indicated a lifetime prevalence of physical and/or sexual partner violence from between 15% and 71%, with two sites having a prevalence of less than 25%, seven between 25% and 50%, and six between 50% and 75%. In all but one of the sites, women were at much greater risk of violence by a partner than from violence by other people. The findings confirmed that physical and sexual violence against women is a worldwide problem, with the variations in prevalence indicating that risk factors vary by culture and that these factors can be addressed.

Sexual Minorities Although IPV has been studied extensively in heterosexual couples, much less has been written about IPV between same-sex and transgender partners. Turell’s (2000) study of 499 ethnically diverse gay men, lesbians, bisexuals, and transgendered people revealed that physical violence was reported in 9% of current and 32% of past relationships. One percent of the study participants had experienced forced sex in their current relationship. Nine percent reported this experience in past relationships. Emotional abuse was reported by 83% of the participants, with women reporting higher frequencies than men for physical abuse, coercion, shame, threats, and use of children (Domestic Violence by Proxy). Balsam, Rothblum, and Beauchaine (2005) compared gay, lesbian, and bisexual (GLB) adults to their heterosexual siblings’ experiences with multiple types of violence across the life span, and found that sexual orientation was a significant predictor of most of the victimization variables, including partner psychological and physical victimization in adulthood. A study conducted by Freedner, Freed, Yang, and Austin (2002) focused on the IPV experiences of GLB adolescents, revealing that the prevalence of dating violence among this group is similar to that of heterosexual teens. Although GLB youth have been the target population of very few studies to date regarding IPV, the findings of Freedner et al. add to our understanding of the scope of the IPV problem in all segments of the population, independent of sexual orientation.

THE TRAUMA OF INTIMATE PARTNER VIOLENCE A poster produced by the San Francisco District Attorney’s Family Violence Project and appearing in the medical journal, The Lancet (2002), displays an x-ray of a fractured skull, along with the statement “A bad relationship can hurt more than your feelings.” The message is shockingly direct in its ability to draw our attention to the often-tragic results of IPV. The broken bones leave no room for ambiguity in the mind of the reader as to the real and permanent damage that can be caused by IPV. Not visible in the poster, and less easily conveyed to an observer, are other serious long-term consequences of IPV. These include physical health effects not visible on x-rays, mental health problems such as chronic posttraumatic stress disorder (PTSD), and the subsequent social issues that inevitably occur in cultures where violence and trauma are common events.

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The Traumatic Consequences of Intimate Partner Violence on Individuals The traumatic consequences of IPV are numerous and far reaching. Some of the physical and psychological effects are detailed in the following sections of this chapter.

Physical Effects The physical effects of IPV are often first discovered in medical settings, such as emergency rooms, physicians’ offices, or clinics. These effects can manifest as poor health status, poor quality of life, and frequent use of medical care for a wide variety of physical injuries. According to Campbell (2002), battered women are more likely to have been injured in the head, face, neck, thorax, and abdomen than women hurt in nonbattering incidents. Campbell also describes the long-term consequences of battering, such as fear and stress that can result in chronic conditions like headaches, neck pain, and back problems. The connection between these common conditions and their antecedent causes is often unclear to health care providers, as well as to victims themselves, resulting in neglect for those patients who repeatedly seek medical care for vague and persistent symptoms while the traumatic origins of the problem remain unaddressed. Large-scale research conducted by Felitti et al. (1998) establishes the connection between adverse childhood experiences (ACE Study) and problems in adulthood, ranging from chronic physical health issues to long-term psychiatric disorders. Studies (Campbell, 2002; Coker et al., 2002; Diez et al., 2009) show that battered women report higher than average gastrointestinal, cardiac, and immune system symptoms and disorders. Further research is warranted to establish a cause and effect relationship. Campbell notes that gynecological problems related to forced sex by intimate partners are “. . . the most consistent, longest lasting, and largest physical health difference between battered and non-battered women” (p. 1332). Campbell’s findings among heterosexual women are extended by Heintz and Melendez (2006), who report an increased risk of HIV/STDs among gay, lesbian, bisexual, and transgendered (GLBT) individuals as a result of forced sex by intimate partners. Members of sexual minorities also report a higher incidence of battering as a direct consequence of asking their partners to practice safe sex. The identification and treatment of IPV-related injury and illness often is hindered by the reluctance of victims to report their partners’ violence to medical personnel. They fear that police and legal intervention may follow, further jeopardizing their physical safety and financial security. In addition, the shame and social stigma attached to being battered by a partner or spouse prevent many victims from seeking medical help for all but the most severe injuries, which then, often, are attributed to falls or other accidents. If the victim is also a member of a minority population, the personal experience of racism and prejudices realistically may contribute to an individual’s reluctance to seek help for physical problems associated with IPV.

Psychological Effects A meta-analysis of studies of the psychological effects of IPV (Golding, 1999) reveals that depression and PTSD, which have a high degree of comorbidity, are the most prevalent mental health problems associated with intimate partner trauma, with the occurrence of PTSD in battered women statistically much higher than in nonabused women. Diez et al. (2009) observed psychological health indicators such as antidepressant intake, sleep disorders, lack of concentration, loss of energy, and difficulties making decisions to be higher in abused women. Coker et al. (2002) confirmed that behaviors that may have an adverse effect on mental well-being, such as alcohol consumption and drug use, tend to be more prevalent in female victims of IPV.

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Although most people have become familiar with the concept of combat-related PTSD, few are likely to associate the same constellation of symptoms with IPV. The reasons for this perceptual gap are many, including the public attention given to military trauma and the conspiracy of silence surrounding abuse within the family. Historically, the relationship between intimate partners has been considered private, particularly in cultures that tacitly or overtly condone men’s domination of women. In many heterosexual marriages, women are subject to the control of their husbands; a situation that is often supported through selective interpretation of religious teachings. Law enforcement personnel have been reluctant to intervene in domestic violence situations because attempts to separate the abuser from the victim often result in the formation of a united front against the police—a phenomenon that leads us back to the Stockholm syndrome principle of alliance between abuser and victim that was introduced in the beginning of this chapter. Misunderstanding of the complex dynamics involved in IPV relationships has led to general skepticism about the abused person’s status as a victim or as a sufferer of traumatic stress, although social science research has begun to change these misperceptions. PTSD was defined as applying equally to military trauma, criminal violence, and natural disaster. Ochberg (1988), however, has proposed that victims of deliberate cruelty such as IPV are likely to suffer from symptoms from the following list, which represents “victimization” rather than “traumatization”—a distinction that recognizes the perpetrator’s behavior rather than the victim’s reaction as the source of deleterious effects associated with IPV. 1. 2. 3. 4. 5. 6. 7. 8. 9.

Shame: embarrassment, humiliation Self-blame: exaggerated feelings of responsibility Subjugation: feeling belittled, dehumanized Morbid hatred: obsessions with vengeance Paradoxical gratitude: positive feelings toward victimizer (Stockholm syndrome) Defilement: feeling dirty, disgusting, or evil Sexual inhibition: reduced capacity for intimacy Resignation: a state of broken will or despair Second injury or second wound: revictimization by legal, medical, or mental health systems 10. Socioeconomic status downward drift: reduction of opportunity or lifestyle

The Consequences of Intimate Partner Violence on Society The consequences of IPV on individual victims, as we have detailed earlier, can be measured in the lives of those who suffer its effects. The following subsections describe the less quantifiable but pervasive social costs of IPV.

The Cycle of Violence In the previous section of this chapter, we examined some of the physical and psychological effects of IPV on individual victims. This section explores some of the consequences of IPV on society, including its likely contribution to the intergenerational transmission of violence, termed the cycle of violence by Widom (1989) in her critical examination of the literature linking IPV, child abuse, and other social stressors. In discussing the cycle of violence, it is important to recognize that most individuals who have been abused as children do not go on to become abusers as adults (Kaufman &

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Zigler, 1987; Lisak, Hopper, & Song, 1996). However, it is equally important to know that studies have clearly identified childhood abuse as a crucial risk factor for later violence (Lisak & Miller, 2003; Maxfield, Weiler, & Widom, 2000; Weeks & Widom, 1998; Widom, 2000). These seemingly contradictory statistics are more easily understood if we are able to picture victims of abuse as a relatively large group of individuals, while recognizing that victimizers represent only a small number of those who have been abused and may not belong to the victimized group at all, but generally victimize more than one person. Among victimizers, however, as stated earlier, studies have shown that a large percentage of this group has been victimized, thus implicating childhood victimization as a risk factor for becoming a violent adult. Widom’s (1989) review of research on the impact of observing and witnessing violence between parents cites studies reporting that 53% of habitually violent offenders had observed their parents engaged in physical combat (Bach-y-Rita & Veno, 1974); similarly, Lewis, Shanok, Pincus, and Glaser (1979) noted that 79% of the violent children they studied reported having witnessed extreme violence between their parents. Heyman and Slep (2002) found that frequency of family-of-origin violence predicted adulthood child and partner abuse. Whitfield, Anda, Dube, and Felitti (2003) confirmed that girls exposed to family aggression and violence have a substantially higher risk of becoming victims, whereas boys have a substantially higher risk of becoming perpetrators as adults. Along with its multigenerational aspects, the notion of a cycle of violence also characterizes perpetrator/victim dynamics that can be expressed as three phases including tension, abuse, and relief or “honeymoon” phase (Walker, 1980). During the tension phase, the abuser may become tense or irritable, prompting the victim to “walk on eggshells.” In the abuse phase, the perpetrator acts violently (physically, sexually, and/or emotionally) toward the victim, during which time the victim may leave home or seek help. The relief or honeymoon phase is characterized by abuser behaviors that include apologies, remorse, and promises to change, all of which serve to keep the victim hopeful for the future and enmeshed in the relationship.

Social Costs and Multiple Losses The social costs of IPV can be expressed in several ways. Societal resources are required to evaluate and treat the victims of violence; these resources include victim service organizations, child welfare agencies, mental health services, and medical facilities. The willingness of taxpayers and governments to fund resources is not commensurate with the need. Anyone who has ever worked in an agency involved with the treatment of victims of violence knows that the work is rewarding but difficult; the pay is low, and budget cuts are an ever-looming threat to continued services. The most damaging effect of IPV is its impact on succeeding generations of human relationships and its profound reduction of quality of life. Lisak and Beszterczey (2007) reviewed the life histories of 43 death row inmates, finding that more than 80% of the men had witnessed IPV in their childhood homes and 100% had experienced some form of neglect, along with other forms of abuse. The authors also found that subjects who had been abused were likely to have come from families with multigenerational histories of abuse. Although the study sample represented the extreme end of the continuum of long-term effects of familial violence, the consequence for the lives of the participants gives us a glimpse of the pervasive effects of IPV. The losses suffered by victims of IPV include and exceed those of individuals who have been traumatized by non-IPV events (Koss et al., 1994). Loss of health, financial security, home, children, pregnancies, and even life itself are tragic legacies of victims of IPV.

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Less easily observable losses can include decreased ability to assess one’s situation caused by shock, grief, and despair. Koss et al. (1994) point out that as victims deploy more internal coping strategies (e.g., denial, dissociation, numbing), there is often a decrease in external activity that would be more likely to change the IPV situation. Symonds (1978) speculated on a “state of terror” experienced by victims, which can contribute to a sense of loss of control or agency within one’s life and seriously impair the victim’s ability to appraise her own situation. We once again are reminded of Ochberg’s (1988) list of complex symptoms seen in survivors of intentional cruelty. The presence of any or all of these difficulties implies a loss to the individual as well as a loss to society. We may consider the following: 1. Shame: Implies an impairment of a person’s ability to relate to self and others accurately, thereby depriving society of the full benefit of that individual’s selfhood and gifts. 2. Self-blame: Implies that the victim carries a sense of being somehow responsible for her own victimization, thereby diverting attention from the perpetrator’s culpability. 3. Subjugation: Implies that the victim’s sense of powerlessness may prevent her from effectively protecting herself and her children, thus perpetuating the cycle of violence. 4. Morbid hatred: Implies that the victim’s life energy may be diverted from selfactualization to obsession with rage/revenge, increasing the possibility of mental illness, addiction, and legal problems. 5. Paradoxical gratitude: Implies that the victim will employ a survival strategy that keeps her in an abusive relationship. 6. Defilement: Implies that the sense of being “damaged” by the abuse will be likely to affect the victim’s sense of self and may contribute to problems with eating disorders, body image, and identity. 7. Sexual inhibition: Implies that the victim will be less able to engage in healthy intimate relationships and may live out a pattern of choosing battering partners. 8. Resignation: Implies loss of the victim’s ability to persevere, resulting in lifelong struggles with depression and unfulfilled potential. 9. Second injury or second wound: Implies the likelihood that the victim will experience retraumatization at the hands of those agencies and individuals charged with helping victims, thus creating multiple layers of wounding and dysfunction. 10. Socioeconomic status downward drift: Implies that the victim’s situation may result in a decreased ability to work and care for herself and children, resulting in dependence on welfare, foster care, or disability funds for survival. We have examined the characteristics, prevalence, individual, and social costs of IPV so far in this chapter. In the following section, we present relevant literature for the purpose of identifying theoretical contexts for understanding IPV.

THEORETICAL CONTEXTS FOR UNDERSTANDING INTIMATE PARTNER VIOLENCE According to Koss et al. (1994), early literature on the subject of IPV tended to speculate on possible psychopathological characteristics of the victims rather than social contributions to the problem or perpetrator characteristics (Kleckner, 1978; Shainess, 1977; Snell, Rosenwald, & Robey, 1964). Women’s verbal and emotional aggression against their partners was seen as a precipitant to male violence, whereas other studies (Straus, 1993) sought to evaluate IPV from a gender-neutral standpoint, asserting that males were victims of IPV as often as females. Koss et al. compared this methodology to an investigation

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of automobile accidents without regard to the make and size of the vehicle and the speed at the time of the collision. As stated in previous sections of this chapter, the vast majority of IPV incidents are perpetrated by males on their female partners, with altercations identified as “mutually assaultive” far more likely to be damaging to women than to men. The following subsections identify and describe some of the most frequently studied issues, regarding risk factors for IPV, and include perspectives from feminist and family systems theory, the biomedical model, and conclude with more comprehensive paradigms such as Bronfenbrenner’s (1979) ecological development model and attachment theory. Disciplines represented in this literature review range from psychology and counseling to nursing, medicine, and criminal justice.

Feminist Theory Feminist theories of IPV originated with the upsurge in attention brought to the victimization of women in the 1970s, defining IPV as primarily a social problem to be corrected by empowering women and reeducating men. Feminist theories identify gender-based power differentials as central to the issue of IPV, citing the domestic relationship’s structure as a parallel process mirroring the patriarchal pattern of society’s organizational structures (Healy, Smith, & O’Sullivan, 1998).

Strengths and Criticisms of Feminist Theory We need only to look at the history of batterer intervention programs in the United States to recognize the impact of feminist theory on the subject of IPV. Healey, Smith, and O’Sullivan (1998) note that treatment programs for batterers were established as a result of feminist activism and focused on changing sex role attitudes, which claim that women’s behavior provokes men’s violence. Support for the feminist model comes from observations that most batterers are able to control their violent behavior when “provoked” by authority figures such as bosses, police officers, and judges. Some theorists have claimed that feminist theory relies too heavily on a social model of IPV to the exclusion of other factors, such as childhood abuse and personality disorders (Dutton & Painter, 1993a). Dutton also has described the translation of the feminist social model into offender treatment practices as too focused on reeducation and lacking in attention to the psychodynamics of the abuser. According to critics, feminist theory fails to predict which men will become violent, assuming that all men are exposed to similar patriarchal values.

Family Systems Theory The family systems theory assumes that all individual problems are a manifestation of the dysfunction present in the family unit, with each family member contributing to the problem (Giles-Sims, 1983). This theory predicts that either partner may resort to violence if conflict escalates beyond verbal and emotional abuse. Partners are seen as neither victim nor perpetrator of IPV, even if only one partner becomes violent, because it is the interaction that is deemed to be violent rather than the person. Family systems theory promotes a treatment strategy that includes improving communication rather than focusing on the individual pathology of either partner.

Strengths and Criticisms of the Family Systems Theory The family systems theory provides a treatment framework for IPV couples who may want to remain together while working to eliminate the violence from their relationship.

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The model’s emphasis on relationship strengths rather than pathology is cited by some as a useful approach, particularly in light of statistics indicating that more than half of IPV couples remain together (Sirles, Lipchik, & Kowalski, 1993). Predictably, most criticisms of the model’s use with IPV couples cite concern for victim safety, speculating that speaking honestly in the presence of the batterer is inherently dangerous, particularly if the couple continues to live together. Other critics note the potential for victim blaming while the victimizer is not held responsible for the violent act (Healey et al., 1998).

The Biomedical Model The biomedical model is a framework in which victims’ psychological symptoms are catalogued and the individual is then assigned a diagnosis. The connections between symptoms displayed and antecedent trauma are deemed secondary, if not irrelevant to patient treatment. Treatment is founded upon the assumption that many psychological disorders arise from faulty brain chemistry that requires psychiatric medication for correction, with or without adjunctive psychotherapy (Greenberg, 2010). As a result of the identification of trauma-based disorders, particularly PTSD, research into the origins of trauma as well as its connection to common mental health diagnoses has made a purely biomedical model less relevant in working with IPV (Herman, 1992; van der Kolk, McFarlane, & Weisaeth, 1996). Problems such as anxiety, dissociation, depression, and personality disorders have all been the subjects of extensive study, linking them to traumatic antecedent events in the life of victim, perpetrator, or both (van der Kolk et al., 1996).

Strengths and Criticisms of the Biomedical Model The primary utility of the biomedical model is its acceptance as the prevailing paradigm by which diagnosable mental difficulties are understood, and upon which insurance payments to providers are based. Consumer-based organizations such as the National Alliance on Mental Illness (NAMI) have lobbied for equal insurance reimbursement for treatment of mental and physical illness. Destigmatization of mental illness depends on its inclusion in the cultural understanding as just another form of medical illness, on par with heart disease and diabetes. The downside of this view is that medicalization of the symptoms suffered by trauma survivors requires the sufferer to accept her symptoms as an illness rather than to understand them as the natural outcome of traumatic experience. The medical model may result in the secondary wounding and decreased credibility of the victim described earlier in this chapter (Ochberg, 1998).

Ecological Development and Attachment Models In attempting to understand the complexity of IPV, the reader may wish to consider comprehensive models of human development and behavior that take into account the biological, developmental, and psychosocial factors that contribute to the creation of an IPV relationship. Bronfenbrenner’s (1979) ecological development model and Bowlby’s (1969) attachment model offer broader developmental and relational models for conceptualizing IPV. Bronfenbrenner’s (1979) ecological development model, when applied to a framework for understanding IPV, implies an acknowledgment of the biological characteristics with which humans are endowed, along with developmentally mediated psychological factors, as seen within a multifaceted social context. Bronfenbrenner’s reference to

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micro-, meso-, exo-, and macrosystem structures in an individual’s life acknowledges the impact of multiple layers of the relational environment upon an individual’s experience at any given moment. The ecological model, coupled with attachment theory (Bowlby, 1969), which focuses predominantly on the impact of children’s early relationships with caregivers, provides a more balanced view of the factors associated with IPV. Attachment theory is a framework upon which extensive enhancements have been constructed by social scientists from a variety of disciplines. Bowlby (1969) based his theory on his observations and belief that human infants have a biologically driven developmental need to be cared for by a person who is older and wiser (usually the mother) for purposes of safety and survival as well as regulation of affect. The quality of this initial attachment bond acts as a template for future adult attachments. If early attachment is disrupted by separation, illness, or trauma, the child’s ability to soothe herself in the presence of stress may be underdeveloped; this is a deficit that has particular relevance to IPV because attachment-seeking behavior continues throughout the life span (Bowlby, 1984). Based on Bowlby’s (1984) work, Fonagy (1999) proposed that adult relationship violence is an exaggerated response of the attachment system. As stated previously, seeking solace through close relationships is a normal human behavior and one that may erupt into intimate partner discord if early dysfunctional attachment patterns are experienced as being present in the adult romantic relationship. Bronfenbrenner (1979) emphasizes experience as a word of key importance, as it is the experience of the individual in a particular context that takes precedence over any objective observations that may be made regarding the situation. An emotional experience template forged in a childhood of abuse and domestic violence has been implicated in the prevalence of IPV in adulthood (Fonagy, 1999). Studies on the neurobiology of attachment (Schore, 1999; Siegel, 1999) have provided support for attachment theory by demonstrating the link between biological and psychological models of development, thereby deconstructing artificial barriers that historically have existed between the two. The advances in this area of study have provided new dimensions to our understanding of traumas such as IPV as the result of a complex interplay of biological, psychological, social, and cultural risk factors for both victim and perpetrator.

Risk Factors—The Victim As we demonstrated earlier in this chapter, the Stockholm syndrome pattern of attachment between captive and captor is echoed in many IPV situations where the cycle of tension, abuse, and relief is lived repeatedly, with the relief phase offering intermittent moments of hope and optimism that may keep the victim in the relationship (Ochberg, 1998). Dutton and Painter (1993b), in fact, cite the intermittency of abuse as a factor in the level of stress experienced by women who chose to leave their batterers, with extremes of negative and positive batterer behavior associated with the most postseparation distress. In other words, women whose abusers were extremely violent, but who also displayed the most kindness and remorse during the relief phase of the IPV cycle, had the most difficulty separating from their batterers. Bornstein (2006) cites economic and emotional dependency as risk factors in the etiology of IPV relationships, for both women and men. For women in particular, the cultural traditions of economic dependency and social disempowerment contribute to the possibility of victimization by a male partner, as does her partner’s excessive emotional dependency. Cunradi, Caetano, Clark, and Schafer (2000) found that couples living in impoverished neighborhoods are at increased risk for IPV, particularly if the couple is African American. Wallace (2007) reminds us that most women in IPV relationships are looking for signs that the perpetrator is not all bad. The woman has much invested in the relationship

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and hopes for a future, for herself, and for any children she might have with the perpetrator. Wallace also lists the following beliefs and behaviors that may result from the conditions imposed by the Stockholm syndrome-type pattern of perceived threats and social isolation imposed by batterers: ■ ■ ■ ■

She develops an overwhelming need to pacify the batterer to survive She adopts the batterer’s perspective of the world She feels intense feelings of gratitude toward the batterer She rejects offers of help or rescue, which she may believe could aggravate the batterer

Kearney (2001) reported the following rationalizations for staying in IPV relationships given by U.S. women in a study of domestic violence: 1. 2. 3. 4. 5.

A salvation ethic (need to care for the abuser) A commitment to the higher loyalties of religion or tradition Denial that abuse was controllable Denial that their injuries were real or that they were blameless The inability to see practical or emotional alternatives

Kearney’s (2001) list supports the argument for a multifactorial model of IPV, in that it includes influences from social and cultural institutions (religions, traditional expectations of women) as well as factors that possibly could be connected to attachment patterns or childhood experiences of witnessing domestic violence (e.g., caretaker role, use of denial). The women in Kearney’s study also reported that changes in their relationships (for the worse) had occurred over time, with most of the women endorsing a definition of love that included a need to endure. Draucker (1999) and Hage (2000) provide phenomenological support for women’s strategies of enduring, monitoring, and rationalizing within abusive relationships. Thus, we can conclude that women’s interpersonal relational style (Gilligan, 1982), combined with attachment experiences and viewed within an IPV context, may make them vulnerable to a pattern of coping strategies that often is misunderstood by those outside the relationship who may focus on the perceived shortcomings of the victim rather than the actions of the perpetrator.

Risk Factors—The Perpetrator Fonagy (1999) suggests that many men who commit violent acts against women lack the ability to mentalize, that is, to imagine their attachment figure’s thoughts. This is a state that Fonagy attributes to a childhood rendered so physically or emotionally unsafe that the child copes by refusing to imagine the state of mind of a parent who wishes to harm him. This pattern, persisting into adulthood, may form the basis for IPV relationships between batterers and their partners (who may also be attachment disordered). Similarly, Meloy (2002) believes that men who fail to develop secure attachments in childhood are at greatest risk for IPV, basing this hypothesis on a growing body of research that empirically supports the connection between insecure attachments and adult (often intergenerational) relationship violence. A study by Mauricio, Tein, and Lopez (2007) found that both antisocial and borderline personality disorders were related to attachment styles that served as mechanisms for both physical and psychological violence in a sample of male batterers referred for treatment. The authors state that their findings suggest that intervention programs may need to address batterers’ personality disorders more directly to improve outcomes.

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Continuing in the cycle of violence risk factor theme, Heyman and Slep (2002) found that the frequency of family of origin violence predicted adulthood child and partner abuse in a retrospective study of more than 6,000 participants in a national family violence survey. As a possible prequel to this finding, Israel and Stover (2009) studied distress levels in children exposed to violent father figures and reported significantly more symptoms in these children, leading us to speculate on the interconnectedness of the two studies’ findings as well as the implications for society.

Operating from an Ecological and Attachment Paradigm with IPV Specific features of the ecological model and attachment theory offer a broad context for understanding IPV. For this reason, a succinct discussion of the strengths and criticisms of this paradigmatic approach is far more complex than in the previously described models; it would require greater comprehensive theoretical explication, and therefore is beyond the scope of this chapter. However, there are several reasons why this paradigm merits further investigation by therapists working with IPV and trauma: 1. The ecological model provides a multilevel social systems framework that accommodates strengths from the feminist and family systems theories. 2. Attachment theory includes elements from both the biomedical model and family systems theory. 3. The ecological model and attachment theory combined offer social and individual developmental dimensions to the study of IPV and trauma.

COUNSELING IMPLICATIONS Given the prevalence of IPV in our culture, professional counselors are likely to encounter victims and perpetrators among their clientele over the course of their careers. Depending on the focus of a counselor’s practice, whether at an agency devoted to a particular client base, an institution, or a private venue, the counselor may have contact with a few or perhaps many individuals affected by IPV. To work effectively with these clients, the counselor can benefit from increasing her or his knowledge base about IPV. The following subsections refer to aspects of IPV with which professional counselors may want to become familiar.

Treatment for Victims Given that there are many forms, facets, and stages within the IPV cycle, generalizations about victim interventions should be avoided. Those still in physical danger will need physical safety, financial assistance, and legal protection. Providers of these services include security specialists, the staff of shelters, lawyers, victim advocates, and others with relevant experience and resources. It is only after basic needs have been met that the victim may be able to address the effects of trauma and any self-defeating patterns of her own in therapy with a trauma-competent counselor (Ochberg, 1998). Counselors should be aware that shelters are often the safest refuges for victims because the family of origin may represent another source of betrayal and abuse for the battered individual. Shelters offer protection from the abuser and have the added benefit of esteem-building groups for residents. Careful discussion about what constitutes supportive behavior can help counselors and their clients identify trustworthy contacts (Ochberg, 1998).

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Once the client’s safety is established and the therapy process begins, it is important for counselors to use an empowerment approach, in which the client is given as many choices as possible in determining the course of her own life. Counselors also need to be prepared to encounter the depression and often-contradictory behavior patterns of abused women. These behavior patterns may confuse the therapist that the client is frequently labeled “borderline,” due to the frequent limit-testing and emotional demands (Walker, 1991). Maintaining a professional relationship without implying friendship beyond appropriate boundaries is the most helpful response (Ochberg, 1998).

Treatment for Batterers The Duluth model (Pence & Paymar, 1993), a group model based on a sociocultural feminist perspective of male patriarchy and relationship violence, once was considered to be the best approach for treating batterers. More recent research studies have found this model to be ineffective in decreasing male violence toward women (Babcock, Green, & Robie, 2004). What has been found to be more efficient is an approach that blends attachment theory and cognitive behavioral therapy, taking into account the early childhood risk factors mentioned earlier in this chapter (Bowen, n.d.). Lawson, Barnes, Madkins, and Francois-Lamonte (2006) have reported significant changes in abuser attachment styles as well as decreased violent behavior in men who participated in a 17-week course of integrated cognitive behavioral/psychodynamic group treatment. Renn (2009) advocates for couple therapy, in certain cases, following a careful risk assessment. Renn states that Couple violence . . . is a complex phenomenon and has both relational and individual origins. Understanding the traumas and adult attachment styles that people bring to their intimate relationships in the context of their early attachment histories may help us to assess whether or not, and under what specific circumstances, couple violence is more likely to occur. (p. 2) Regardless of the model applied in the treatment of batterers, true personal change that generalizes into societal change can only be accomplished by holding batterers and social institutions accountable for the damage they inflict or fail to prevent. The cost to society is too great to be ignored.

Multicultural Considerations Although most studies regarding IPV have focused on heterosexual couples in the United States, the statistics presented in earlier sections of this chapter show that samesex and transgender partnerships are affected as well. Brown (2008) reminds us, for example, that in order for counselors to acknowledge same-sex violence, it is necessary to first address our own biases and myths about same-sex relationships. For IPV victims from different cultural backgrounds, service providers may need to work with clients to understand the meaning of victimization within that individual’s group and how treatment issues may be affected.

Prevention Strategies The focus of this chapter has been on defining and identifying IPV, and its sequelae that present major public health and social problems for the entire culture, as well as for individuals. To date, most research and intervention strategies have been directed

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to the problem of IPV on a tertiary level, addressing the needs of victims and holding perpetrators accountable. Wolfe and Jaffe (1999) describe an emerging public health model that targets prevention on primary and secondary levels as well, proposing that tertiary crisis intervention models, although useful, cannot alone address the complex dynamics of IPV. The authors define primary prevention as efforts to reduce the incidence of IPV in a population before it occurs, whereas secondary prevention targets individuals to decrease prevalence of IPV by minimizing or reducing its severity and the continuation of its early signs. Primary and secondary prevention programs currently are being mandated by the Centers for Disease Control and Prevention (CDC), with funding and implementation responsibilities assigned to domestic abuse shelters and rape crisis centers in an ongoing effort to change the culture of violence that promotes IPV. The burden of effecting this change, however, cannot and should not be borne by victim service agencies alone. Placing primary responsibility for ending IPV on the shoulders of such agencies perpetuates an institutionalized version of a deeply ingrained philosophy that holds victims responsible for their own abuse. True cultural change requires public acknowledgment of the problem by political forces, as well as action by governmental agencies responsible for defining needs, allocating funds, and upholding the rights of women, children, and other marginalized populations. To date, most politicians and government officials have been reluctant to address IPV and sexual abuse for fear of being associated with topics found repugnant by society in general. Personal and professional activity that holds public officials accountable for initiating and supporting measures that protect vulnerable members of the population may be one of the most important ways in which counselors can advocate for their clients, as well as for their work, and for society as a whole.

The Importance of Education and Self-Reflection In closing this chapter, the authors wish to acknowledge the critical need for graduate education that addresses IPV trauma and its effects on individuals and society. Few professional counseling programs offer classes that teach students how to identify and work with trauma, and those that do so usually offer them as elective courses (Kitzrow, 2002). Based on the statistics presented in this chapter, the likelihood of a counselor’s encountering clients affected by IPV is high. Therefore, the following suggestions are offered: 1. Seek out and use continuing education to learn how to deal effectively and compassionately with IPV and trauma in general. Such advanced training should include the use of self-reflection as a professional development strategy, enabling the counselor to identify his or her own biases, feelings, and values. 2. Utilize supervision, preferably from a professional who understands and works with IPV or other types of trauma. 3. Find like-minded colleagues with whom you can share the challenges and rewards of working with IPV clients. 4. Finally, and perhaps most importantly, develop a system of self-care that acknowledges the secondary stress that comes with working with trauma survivors. Counseling victims of IPV is difficult, but rewarding work, requiring not only an understanding of the complex dynamics of the individuals involved, but also awareness of the multiple factors that enter into the creation of an IPV social environment. As Gold (2000) so aptly states, referring to childhood abuse survivors, “Their best hope,

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and consequently that of the rest of us, is to recognize that although they have been abandoned and feel alienated and alone, their destiny, and that of society as a whole, are in actuality inextricably intertwined” (p. 244).

CONCLUSION In this chapter, we have presented the concept of IPV as trauma experienced mainly by females at the hands of males, but one that exists as a form of power differential that can include same-sex couples as well. We introduced this chapter with the case of Kristin, the Swedish bank teller, whose paradoxical bonding with her kidnapper became known as the Stockholm syndrome—a pattern of primitive attachment that is echoed in the lives of many victims of IPV. Although viewed by the world as strange initially, Kristin’s survival strategy has been rendered more understandable through research that identifies the connections between PTSD and victimization of all types. The effects of trauma are reflected in the physical, psychological, emotional, and social aspects of the victim’s life and are often intricately entwined in the individual’s earliest development due to the intergenerational transmission of violence. The losses associated with IPV are many—for the victim and for society. The interdependent nature of human existence dictates that individual trauma does not truly happen in isolation, but affects the entire culture through subsequent generations of traumatized children, who may grow up to be traumatized adults who, in their turn, create traumatized societies (DeMause, 2002). The risk factors associated with IPV may originate from within social, biological, or developmental contexts, or, most likely, a combination of all three. Just as individual trauma exists within a larger cultural context, the environment of IPV is created within that same complex contextual framework. IPV is part of the tapestry of our culture; no single thread representing IPV can be followed from beginning to end, or can it be removed from the larger picture into which it has been interwoven without changing the prevailing pattern, all of which imply serious challenges for counselors involved in the change process.

APPENDIX 11.1 Case Study Valerie (not her real name) Valerie was born to Ray and Betty, an upper middle-class couple, in an affluent suburb of a major U.S. city. Ray, an account executive with a Fortune 500 company, and Betty, a former executive secretary and subsequent stay-at-home mom, raised their daughter in the best environment money could buy: private schools, designer clothing, and a stone house on a tree-lined street. From the outside, Valerie’s home life appeared to be idyllic. Inside their home, however, all was not well. Ray was a self-made man who had risen above his brutal and neglectful upbringing by working his way through college and attaining an MBA, eventually securing his lucrative job in finance. Unfortunately, he had not been able to transcend the emotional effects of his parents’ abandonment, and his constant fear of rejection played out consistently in his relationship with his wife, Betty. Quiet and shy, Betty was raised (continued)

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APPENDIX 11.1 (continued) to believe that a woman’s highest achievement was her marriage to a successful man. When Betty married Ray, she felt relieved and happy to have met her parents’ expectations and looked forward to life as a successful wife. Despite Betty’s best efforts, the marriage soon encountered problems. Ray became increasingly controlling of Betty, dismissing her attempts at homemaking and accusing her of being unfaithful. Mystified by Ray’s behavior, Betty thought that having children might prove her value to Ray. While Betty was pregnant with Valerie, Ray slapped Betty for the first time, blaming her for making him angry. The violence continued to escalate over the years after Valerie was born, resulting in several serious injuries to Betty, which she hid out of shame and fear of being seen as a failure as a wife. Valerie grew up watching her mother’s efforts to please her father and witnessing his emotional and physical outbursts toward her. Sometimes Valerie would become the target of her father’s rage, especially if she tried to defend her mother. She grew up fearing her father, while loving and pitying her mother. Valerie vowed to escape her violent home as soon as possible after high school and left to study chemistry at a college far away from her hometown. As part of her plan to avoid a relationship like her parents, Valerie dated only men whom she judged to be unlike her father, men who did not aspire high-powered business careers, and who lacked the aggressiveness to which Valerie attributed her father’s angry outbursts. When Valerie met Steve at a bar near her college, he seemed to embody all the qualities Valerie’s father lacked. Steve was quiet and polite, and usually deferred to Valerie’s opinions on topics they discussed on weekend evenings when they met for drinks. Valerie also saw Steve’s major in law enforcement as a refreshing change from her father’s emphasis on big-money careers and was not concerned when Steve told Valerie that he was on academic probation in his program. Valerie herself was an honor student, and Steve seemed proud to be associated with her and her achievements. Although Valerie saw her relationship with Steve as promising, her friends were not as enthusiastic about the match. Valerie defended Steve’s academic failures and lack of ambition on numerous occasions, citing his quiet demeanor and gentleness as the causes of his being misunderstood by faculty as well as friends. When Steve was suspended from the law enforcement program, Valerie decided to help him by asking him to share her apartment until he got back on his feet financially and academically. To Valerie’s surprise, Steve grew sullen and angry and seemed to lose all motivation to do more than meet friends at the bar for drinks after he moved in with Valerie. She felt even more betrayed when Steve’s former pride in her academic achievements evolved into jealousy and dismissal of her work, eventually leading to screaming fights that often ended with Steve’s pushing and shoving her around the apartment. The first time Steve pushed Valerie to the floor, Valerie reluctantly called her mother for advice. Valerie’s mother’s first words were, “What did you do to make him get so angry?” Shocked and ashamed, Valerie began to question her own perceptions about the interaction and came to the conclusion that she had not been supportive enough of Steve in his life crisis. After all, she reasoned, he was not like her father. Steve was struggling to find himself and needed her to be there for him and not nag him to help around the apartment. Valerie stopped going to class and seeing her friends, devoting all her time to Steve’s needs. Steve responded to Valerie’s sincere (continued)

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APPENDIX 11.1 (continued) efforts to be a “better partner” by showering her with gratitude and bragging about her to his friends. Valerie began to hope that this behavior heralded the coming of a real change in their relationship. EPILOGUE: As readers might have guessed, the relationship did not improve, but rather, it evolved into a cycle of violence similar to the one that Valerie endured as a child; although her belief that Steve was “different” from her father—quieter, less violent, and periodically loving—he kept her isolated and hopeful that the situation would change, if only she tried harder. Valerie was eventually able to separate from Steve with help from friends and a counselor at a women’s shelter, but she still struggles with feelings of love and guilt about Steve, who periodically begs her to rekindle their relationship.

RESOURCES Websites Gift From Within (http://www.giftfromwithin.org) Contains resources relating to PTSD, trauma, and IPV for survivors and caregivers. National Coalition Against Domestic Violence (http://www.ncadv.org) Contains resources and information. Publications Buzawa, E. S., & Buzawa, C. G. (2003). Domestic violence: The criminal justice response. Thousand, CA: Sage. Roberts, A. R. (2002). Handbook of domestic violence intervention strategies: Policies, programs, and legal remedies. New York, NY: Oxford University Press. Sokoloff, N. (2005). Domestic violence at the margins: Readings on race, class, gender and culture. Pistacaway, NJ: Rutgers University Press. Walker, L. E. A. (2009). The battered woman syndrome (3rd ed.). New York, NY: Springer Publishing. Films Beauty and the Beast (Disney animated version). Classic tale of a woman who is held captive by a beast and eventually cures him of his cruel ways through her love. This fi lm can be used to illustrate the dangerous message to girls and women that abusive men can be changed by women’s actions. The Burning Bed. (1984). Stars Farrah Fawcett in the true story of a woman who doused her abusive husband with gasoline and set him on fire. The Color Purple. (1985). Stars Whoopi Goldberg as a woman of color living in the South who is transformed by her friendship with two women, despite the presence of her abusive husband. Fried Green Tomatoes. (1991). Several subplots, one of which involves a battering husband who mysteriously disappears. Gaslight. (1940). Portrays the mental abuse and crazy-making behavior by a husband toward his wife where no actual physical abuse occurs. Videos Insight Media (Producer). (2011a). Family violence: The impact on children: Vol. 1. For caregivers and educators [DVD]. Insight Media (Producer). (2011b). Family violence: The impact on children: Vol. 2. For parents [DVD].

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CHAPTER 12

Elder Abuse ERIKA FALK

INTRODUCTION Dubbed the “Silver Tsunami,” the United States is beginning an unprecedented demographic shift. The number of people age 65 and older will double between 2011 and 2050, and the number of people age 85 and older will increase fourfold (Administration on Aging, 2010).While it is predicted that aging baby boomers will experience health, vitality, and longevity unknown to previous generations of elders, it also is forecast that many will live with greater levels of disability, frailty, and sadly, vulnerability to abuse. For many years, advocates in the field of elder abuse prevention have pointed out that public awareness about elder abuse has lagged behind other types of family and interpersonal violence such as child abuse and domestic violence. Ageism, defined here by Butler (1969), is frequently cited as one of many potential reasons for the relative lack of recognition of elder abuse, “Age-ism reflects a deep seated uneasiness on the part of the young and middle-aged – a personal revulsion to and distaste for growing old, disease, and disability; and fear of powerlessness, ‘uselessness’ and death.” However, there are hopeful signs that interest in identifying and treating elder abuse and its traumatic aftermath is increasing among clinicians, researchers, law enforcement and policy makers. The purpose of this chapter is to give an overview of the nature and effects of abuse in later life and how counseling interventions can help. This is accomplished by the discussion of relevant information in the following sections: (a) Definitions and Types of Abuse, (b) Identification and Reporting, (c) General Considerations for Counseling Older Adults, (d) Counseling and Interventions for Older Victims of Abuse, (e) Counseling Implications, and (f) Conclusion. This is followed by a list of resources related to working with victims of elder abuse.

DEFINITIONS AND TYPES OF ABUSE Elder abuse, sometimes also referred to as elder mistreatment, is a complex phenomenon. According to the website of the National Center on Elder Abuse (NCEA, 2011), elder abuse is a term referring to any “knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult.” However, definitions of what constitutes elder abuse, and when a person may meet eligibility criteria for intervention from Adult Protective Services (APS), vary widely between

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jurisdictions. Some states have enhanced penalties for crimes committed against older adults and in others, “elder abuse” is not considered a crime, but rather an abusive behavior toward an older adult can be prosecuted only if it fits within the definition of another crime such as assault, theft, or fraud (U.S. Government Accountability Office [GAO], 2011). Nerenberg (2008) summarizes some of the differences and controversies, including whether any of the following are requirements for an act to be considered elder abuse: (a) the victim must have a debilitating illness or condition that compromises his or her independence and judgment; (b) a “special relationship” of trust, confidence, or dependency with the abuser; (c) the act is intentional (thus excluding acts that are passive, reckless, or committed by persons considered incapable of intent); (d) the conduct results in injury, physical pain, or impairment; and (e) an ongoing versus a single instance of abuse. Table 12.1 provides a general overview of the types of elder abuse as defined by the NCEA. More than one type of abuse can occur at the same time. For example, financial exploitation may co-occur with neglect and/or psychological abuse (GAO, 2011). Selfneglect, which can be thought of as behavior on the part of an older adult that threatens his or her own health and safety, such as not providing for adequate nutrition, shelter, or medical care (NCEA, 2011), is not listed in Table 12.1. However, situations that initially appear to be the result of self-neglect may, with further investigation, actually be the result of active abuse by others. For example, an elder who is not going to the doctor or taking appropriate medications may be having those medications stolen and be prevented from seeking care.

The Extent of Elder Abuse The precise number of older adults who are being harmed, neglected, and exploited is unknown. Collection of this data has been hampered by the lack of a national data collection system and by variability in definitions of abuse and even the age at which one is considered an “elder,” which in some states is age 55 and in others age 60 or 65. One study estimates that between 1 and 2 million Americans aged 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection (Bonnie & Wallace, 2003). For every case of elder abuse that is reported to APS, it is estimated that five go unreported (NCEA, 1998).

Risk Factors for Abuse Elder abuse, like other types of interpersonal violence, is extremely complex. Generally, a combination of psychological, social, and economic factors, along with the mental and physical conditions of the victim and the perpetrator, contribute to the occurrence of elder maltreatment. Although the factors listed in the sections that follow cannot explain all types of elder maltreatment because different types of abuse and each unique incident involve different causal factors, the following are some of the risk factors researchers think are related to elder abuse.

Age According to the National Elder Abuse Incidence Study (National Incidence Study), the oldest elders (those older than 80 years of age), who made up about 19% of the U.S. elderly population at the time of the study, were far more likely to be the victims of all categories of abuse, with the exception of abandonment (NCEA, 1998). They accounted for more than half the reports of neglect (51.8%), 48.0% of financial/material abuse,

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Table 12.1 Types of Elder Abuse Type

Description

Examples

Physical abuse

Use of physical force against an older adult that may result in bodily injury, physical pain, or impairment.

Striking (with or without an object), hitting, beating, pushing, punching, shoving, shaking, slapping, kicking, pinching, burning, inappropriate use of drugs and physical restraints, force feeding, and physical punishment of any kind

Sexual abuse

Nonconsensual sexual contact of any kind with an older adult. Sexual contact with any person incapable of giving consent also is considered sexual abuse.

Unwanted touching and all types of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photographing

Psychological abuse

Infliction of anguish, pain, or distress on an older adult through verbal or nonverbal acts.

Verbal assaults, insults, threats, intimidation, and humiliation; treating an older person like an infant; isolating an older person from his or her family, friends, or regular activities; giving an older person the “silent treatment”; and enforced social isolation

Financial exploitation

Illegal or improper use of an older adult’s funds, property, or assets.

Cashing an older person’s checks without authorization or permission; forging an older person’s signature; misusing or stealing an older person’s money or possessions; coercing or deceiving an older person into signing any document (e.g., contracts or will); and the improper use of conservatorship, guardianship, or power of attorney

Neglect

Refusal or failure to fulfill any part of a person’s obligation or duties to an older adult. May also include failure of a person who has fiduciary responsibilities to provide care for an older (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care.

Refusing or failing to provide an older adult with such necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials

Abandonment

Desertion of an older person by an individual who has assumed responsibility for providing care for an older or by a person with physical custody of an elder.

Desertion at a hospital, nursing facility, or shopping center with no identifying information

Note. From “Major Types of Elder Abuse,” by The National Center on Elder Abuse, n.d.

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43.7% of physical abuse, and 41.3% of emotional/psychological abuse. In all types of abuse and neglect, elderly victims in the 60–64 and 65–69 age groups accounted for the smallest percentages. Thus, age is one of the strongest predictors of vulnerability to abuse. This is particularly salient when the relationship between age and dementia, discussed later in this section, is considered.

Gender The National Incidence Study found that female elders were more likely to be the victims of all categories of abuse, except for abandonment (NCEA, 1998). While making up about 58% of the total national elderly population in 1996, women were the victims in 76.3% of emotional/psychological abuse, 71.4% of physical abuse, 63% of financial/ material exploitation, and 60% of neglect, which was the most frequent type of maltreatment. A majority of the victims of abandonment were men (62.2%).

Health and Functional Impairment The term functional impairment refers to any reduction in the person’s ability to perform essential activities of everyday life. A person’s functional abilities usually are assessed according to their ability to perform “activities of daily living” (ADLs) such as dressing, bathing, feeding, ambulating, and toileting, as well as higher level “instrumental activities of daily living” (IADLs) such as cooking, shopping, bills paying, and using the telephone. These activities are necessary to maintain health independence and quality in an elderly individual’s life (University of Nebraska Medical Center [UNMC], 2011). The National Incidence Study has found that elders who are unable to care for themselves are more likely to suffer from abuse (NCEA, 1998). Approximately one half (47.9%) of the substantiated incidents of elder abuse has involved elderly persons who are not able to care for themselves, 28.7% who are somewhat able to do so, and 22.9% who are able to care for themselves. In a 1997 study of older adults in Connecticut, Lachs, Williams, O’Brien, Hurst, and Horwitz have found that those who cannot perform ADLs, such as bathing or dressing themselves, are left more vulnerable to abuse (as cited in GAO, 2011). Because neglect involves elders who depend on others for care, neglect victims tend to be in poor health and have functional limitations (Nerenberg, 2008).

Cognitive Impairment/Dementia Persons with cognitive impairment are at risk of abuse because they may be unaware of the abuse or unable to defend themselves (GAO, 2011). There are many reasons that an older person may have cognitive impairment, including potentially reversible conditions such as delirium or adverse reactions to medication and nonreversible conditions such as a progressive dementia. The term dementia describes a progressive, degenerative decline in cognitive function that gradually destroys memory as well as the ability to learn, reason, make judgments, communicate, and carry out daily activities. While it often includes memory loss, memory loss by itself does not mean that a person has dementia. There are many different causes of dementia, but the most common cause in persons aged 65 and older is Alzheimer’s disease, which accounts for 47% of all dementias (University of California San Francisco [UCSF], 2010). In the National Incidence Study (NCEA, 1998), approximately 6 of 10 substantiated elder abuse victims have experienced some degree of confusion (31.6% have been very confused or disoriented, and 27.9% sometimes have been confused). More recent research has

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indicated that people with dementia are at greater risk of elder abuse than those without (Cooney, Howard, & Lawlor, 2006). Approximately 5.4 million Americans older than 65 have Alzheimer’s type dementia, and of those, 66% or 3.4 million are women. One of eight Americans has Alzheimer’s disease, and close to half of all people older than 85 years, the fastest growing segment of the U.S. population, has Alzheimer’s disease (Alzheimer’s Association, 2011). A recent study by Wiglesworth et al. (2010) has found that 47% of participants with dementia have been mistreated by their caregivers. Specifically, 42% have experienced psychological abuse, 10% physical abuse, and 14% caregiver neglect. The study has concluded further that the best combination of factors for predicting which people with dementia have been mistreated is their own behavior toward their caregiver. In other words, when a person with dementia is combative or verbally aggressive with their caregiver because the person’s disease renders him or her unable to regulate behavior, it increases the chances that the caregiver may respond with abusive behavior. These findings suggest that dementia is a strong risk factor for abuse, and that caregivers need to be asked about the behavior of those in their care and their own responses to those behaviors, possibly bringing to light a mistreatment situation.

Mental Health Conditions According to the National Incidence Study (NCEA, 1998), about 44% of all substantiated abused elders were gauged to be depressed at some level, with about 6% of them severely depressed. One study (Dyer, Pavlik, Murphy, & Hyman, 2000) found that victims of elder abuse who had been referred to a Houston area hospital had higher levels of depression than older patients referred for other reasons (as cited in GAO, 2011). Another study of older adults in Pennsylvania (Beach, Schultz, Castle, & Rosen, 2010), found that risk of clinical depression was a consistent predictor of financial and psychological abuse. Low self-esteem and substance abuse also were cited as possible risk factors. The loss of a spouse or other family member has been viewed as a factor that may increase elders’ need for care and may result in neglect if there is not an adequate response (Nerenberg, 2008). Acierno et al. (2010) found that the experience of previous traumatic events—including interpersonal and domestic violence—increased the risk for emotional, sexual, and financial mistreatment.

Social Support, Resources, and Living Conditions Social support is a key factor in the prevention of, and recovery from, elder abuse (Nerenberg, 2008). Research suggests that those who lack ongoing, caring connections are at greater risk of abuse. A recent study by Acierno et al. (2010) has indicated that low social support among those older than age 60 is a predictor of most forms of abuse, and that high social support can help prevent abuse. The study has suggested that addressing low social support might have significant public health implications. Those with fewer financial resources may be more dependent on others for their care, have fewer options, and be at higher risk for abuse and neglect. Residents of nursing homes are at high risk for abuse due to frailty and greater cognitive and physical impairments. An estimated 10% of the complaints, or about 20,000 complaints received by the National Long-Term Care Ombudsman Resource Center during fiscal year 1998, involved allegations of abuse, gross neglect, or exploitation (Hawes, 2002). A study conducted by the GAO (2008) has revealed that state surveys understate problems in licensed facilities: 70% of state surveys miss at least one deficiency, and 15% of surveys miss actual harm and immediate jeopardy of a nursing home resident.

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Abuser Characteristics In order to develop effective interventions to prevent and stop incidents of elder abuse, it is crucial to understand the vulnerabilities, stresses, and motivations of those who commit acts of abuse against elders. Several characteristics can be associated with perpetrators of elder abuse. These are discussed briefly in the following subsections.

Relationship to Victims According to the National Incidence Study (NCEA, 1998), 90% of perpetrators of abuse are family members. Adult children of elder abuse victims have been the most likely perpetrators of substantiated maltreatment (47.3%). Spouses have represented the second largest group of perpetrators (19.3%). In addition, other relatives and grandchildren, at 8.8% and 8.6%, respectively, have been the next largest groups of perpetrators. Nonfamily perpetrators have included friends/neighbors (6.2%), in-home service providers (2.8%), and out-of-home service providers (1.4%). Research (NCEA, 2005) has indicated that many abusers tend to be dependent on their victims for financial support, housing, transportation, and sometimes care.

Mental Health and Behavioral Problems Family members who abuse drugs or alcohol, who have a mental/emotional illness, and who feel burdened by their caregiving responsibilities have abused at higher rates than those who have not (Schiamberg & Gans, 1999). A review article of 21 studies published between 1988 and 2000 about abusers was conducted by the NCEA (2005). Many studies showed that a significant number of abusers had impairments, including substance abuse, mental illness and depression, or cognitive impairments. There also were suggestions that abusers have problems with relationships, may be more isolated, and lack social supports. Further, there were indications that abusers with personal problems may be more physically abusive and that perpetrators may minimize or deny their abusive behavior.

Gender According to the findings in the National Incidence Study (NCEA, 1998), overall, men were the perpetrators of abuse and neglect 52.5% of the time. Of the substantiated cases of abuse and neglect, males were the most frequent perpetrators for abandonment (83.4%), physical abuse (62.6%), emotional abuse (60.1%), and financial/material exploitation (59.0%). Only in cases of neglect were women slightly more frequent (52.4%) perpetrators than men. The NCEA (2005) reviewed articles about abusers and found the majority of perpetrators to be male, with sexual abusers almost exclusively male; only older men (not women) perpetrated homicide–suicide in later life. A few studies found more female perpetrators than male, particularly as regard neglect, where women tend to exhibit higher rates of abuse than men (possibly because women provide more care than men).

Age The age category with the most perpetrators was the 41–59 age group (38.4%), followed by those in the 40 years or less group who were perpetrators in more than one quarter of reports (27.4%). About one third of perpetrators (34.3%) were elderly persons themselves (age 60 and older). Perpetrators of financial/material exploitation were

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particularly younger compared to other types of abuse, with 45.1% being 40 or younger and another 39.5% being 41–59 years old. Approximately 85% of the perpetrators of financial/material exploitation were younger than age 60.

Effects of Abuse Research has indicated that elder abuse affects victims’ health and longevity. For example, one study (Fisher & Regan, 2006) found that older women in the Midwest who were psychologically abused once, repeatedly, or in conjunction with other forms of abuse, also reported higher rates of bone or joint problems, digestive problems, depression or anxiety, chronic pain, and high blood pressure or heart problems than older women who had not been abused. A 2010 study by Mouton, Rodabough, Rovi, Brzyski, and Katerndahl found a relationship between exposure to abuse and poorer psychological health. They also found that exposure to verbal abuse, even without physical abuse, had a strong effect on psychological health. In a qualitative study of 64 women, aged 50 and older, who were interviewed about their experiences of violence and abuse, several of the respondents spoke of ongoing health and mental health problems (Hightower, Smith, & Hightower, 2006). A longitudinal study (Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998), comparing abused and nonabused community-dwelling older adults in Connecticut, found that only 9% of those abused at some point between 1982 and 1992 were still alive in 1995, compared to 40% of those who had not been investigated for abuse during that same period. In another study (Dong et al., 2011), community-dwelling older adults in Chicago who had been reported to social services agencies for abuse faced an increased risk of mortality compared to those who had not been reported for abuse. Furthermore, it was found that those with the highest levels of depression and the lowest levels of social support had the highest mortality risk. Although underreported, the annual financial loss by victims of financial elder abuse is estimated to be at least $2.6 billion (MetLife Mature Market Institute, 2009). Unlike younger victims of financial crimes, older victims may not have the ability to recoup losses over time, and restitution, if any is forthcoming, may not arrive before the elder victim has died (MetLife Mature Market Institute, 2009). Loss of fi nances can result in restricted choices regarding care and services and may result in loss of independence. Deem (as cited in MetLife Mature Market Institute, 2009) indicates that financial losses can result in shame, guilt, or general mistrust, escalating into paranoia or depression. Some victims report that being the victim of financial abuse is akin to being the victim of a violent crime. Depression that is undetected or untreated can cause death by passive or active suicide.

IDENTIFICATION AND REPORTING Elder abuse often is called a hidden crime. Victims may be reluctant to report because of shame, particularly as family members are overwhelmingly the perpetrators. Victims also may be unable to report abuse because they are isolated or cognitively and/or functionally impaired (NCEA, 2011). Because of these barriers, it is important that any person who suspects that an elder is being abused or neglected attempts to get help by contacting someone who can respond to the alleged abuse (e.g., physician, APS, law enforcement). Many states have laws that designate mandated reporters of elder abuse. There is wide variability across the United States as to who is a mandated reporter, with some states requiring everyone to report suspected abuse and other states specifying some combination of physicians, home health care providers, mental health service

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Table 12.2 Common “Red Flags” for Abuse Type of Abuse Physical abuse

Possible Indicators ■ ■

Neglect

■ ■ ■ ■ ■ ■ ■ ■ ■

Financial abuse

Inadequately explained fractures, bruises, welts, cuts, sores, and burns Untreated pressure wounds or “bed” sores Lack of basic hygiene Lack of adequate food Lack of medical aids (glasses, walker, teeth, hearing aid, medications) Lack of clean appropriate clothing Demented person left unsupervised Bedbound person left without care Home cluttered, filthy, in disrepair, or having fire and safety hazards Home without adequate facilities (stove, refrigerator, heat, cooling, working plumbing, and electricity) Hoarding

■

Lack of amenities victim could afford Elder “voluntarily” giving inappropriate financial reimbursement for needed care and companionship ■ Caregiver has control of elder’s money but is failing to provide for elder’s needs ■ Caretaker “living off” elder ■ Elder has signed property transfers (power of attorney, new will, etc.) when unable to comprehend the transaction ■

Psychological abuse

■

Sexual abuse

■

Caregiver isolates elder (does not let anyone into the home or speak to the elder) ■ Caregiver is aggressive, controlling, addicted, or uncaring Unexplained anal or vaginal bleeding Torn or bloodied underwear or bruises around the breasts or genitals ■ Unexplained genital infection ■

Note. From “Red Flags of Elder Abuse,” by The University of California Irvine Center of Excellence on Elder Abuse and Neglect, n.d.

providers, law enforcement officers, and financial institutions (GAO, 2011). A handful of states do not have mandated reporting requirements. Table 12.2 outlines some of the most common indicators or “red flags” of potential abuse.

The Role of Adult Protective Services According to the National Adult Protective Services Association (NAPSA, 2004), APS are those services provided to older people and people with disabilities who are in danger of being mistreated or neglected, are unable to protect themselves, and have no one to assist them. The guiding value of APS is that every intervention should balance the duty to protect vulnerable adults and their right to self-determination. Interventions provided by APS include, but are not limited to, the following: receiving reports of adult abuse, exploitation, or neglect; investigating these reports; and case planning, monitoring, and evaluation. In addition to casework services, APS may provide or arrange for the provision of medical, social, economic, legal, housing, law enforcement, or other protective, emergency, or supportive services (NAPSA, 2004). Eligibility criteria for receiving APS services are determined by state law and therefore vary from

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state to state. Eligibility criteria may individually, or in some combination, include age of the victim, type of alleged elder abuse, victim’s vulnerability or dependence, and the victim’s relationship with the perpetrator. For example, in California, an individual must be either 65 or older, whereas in Florida, an individual must be at least 60 and unable to care for or protect himself or herself; the alleged perpetrator must be a caregiver, family member, or household member (GAO, 2011). One of the aspects that make APS work so complex is that adults have the right to refuse services and are presumed to have decision-making capacity unless adjudicated otherwise in court (NAPSA, 2004).

The Role of the Long-Term Care Ombudsman Under the federal Older Americans Act, every state is required to have an ombudsman program that addresses complaints and advocates for improvements in the longterm care system. The ombudsman program is administered by the Administration on Aging (AoA, 2010). According to the National Long-Term Care Ombudsman Resource Center (NORC, n.d.), the network has 8,700 volunteers certified to handle complaints and at least 1,300 paid staff. The long-term care ombudsman advocates for residents of nursing homes, board and care homes, and assisted living facilities. Ombudsmen provide information about how to find a facility and what to do to get quality care. They are trained to resolve problems, but the consent of a resident is required to share concerns beyond the confidential resident–ombudsman relationship. The types of complaints that ombudsmen handle include violation of residents’ rights or dignity; physical, verbal, or mental abuse; deprivation of services necessary to maintain residents’ physical and mental health or unreasonable confinement; poor quality of care, including inadequate personal hygiene and slow response to requests for assistance; improper transfer or discharge of a patient; inappropriate use of chemical or physical restraints; or any resident concern about quality of care or quality of life (NORC, n.d.).

GENERAL CONSIDERATIONS FOR COUNSELING OLDER ADULTS Counseling older victims of abuse requires an understanding of the basic principles of trauma treatment (discussed elsewhere in this volume) and an understanding of some basic issues unique to older adults. The American Psychological Association (APA, 2011) produced a brochure to guide practitioners on working with older adults. The following considerations for persons counseling older adults have been adapted from that brochure. Many psychological interventions used with younger and middle-aged adults also are effective for older adults, but it is important to understand problems specific to later life and how to adapt interventions for older adults for treatment to be maximally effective.

Accommodating Sensory/Mobility Deficits The counselor needs to understand whether the client has hearing and/or vision loss that may make communication more difficult. Accommodations include ensuring adequate lighting, ambient temperature, larger print written materials (e.g., consent forms), and reduced background noise. For clients who have assistive devices such as hearing aids and glasses, some may need reminders or encouragement to use them. The counselor may want to have an amplification device (e.g., a “Pocket Talker”) or magnifying glass on hand. Prior to the initial appointment, it is helpful for the counselor to make sure that the counseling setting can accommodate wheelchairs or walkers, if needed, and to minimize fall risks for the client (e.g., carpets that slide).

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Stigma/Unfamiliarity About Mental Health Treatment Many older adults are referred for mental health services by a third party, often a spouse, adult child, or service provider. The counselor needs to assess what the older adult understands about why he or she is meeting with the counselor, and the possible expectations and motivations for treatment. Because the older adult may have been influenced by historical experiences in which mental illness was more stigmatized than today, the elder may feel embarrassment or shame about receiving mental health services. Some older adults may harbor fears about a forced psychiatric institutionalization if they admit to any psychological difficulties. It can be helpful, therefore, to delineate clearly the voluntary and confidential nature of counseling as well as to explain the circumstances under which disclosure of protected health information could occur. Older adults may require more education regarding what counseling is and how it may be beneficial.

Coordination With Other Providers A high level of coordination with other service providers is often necessary because older adults referred for counseling often have concurrent physical or social problems. Underlying medical problems or medications often can mimic or exacerbate psychological symptoms (e.g., depression, anxiety). When needed, counselors should obtain permission from older adults or their legal guardians to contact other service providers. Coordination with other professionals in inpatient medical, rehabilitation, or psychiatric settings often needs to be timely because there are increasingly abbreviated lengths of stay as well as other contingencies related to insurance or Medicare.

Working With Cognitive Impairment Many older adults with mild or even moderate cognitive impairment can benefit from counseling. In general, an older client must have the capacity to interact with the counselor, understand what is discussed in counseling sessions, and retain the basic issues and themes of the counseling session. Some older adults may be slower in the processes of problem solving, learning, and behavior change than younger adults. With some cognitively impaired older adults, interpersonal support and environmental/behavioral modification may play a greater role than with other older people.

Counselor Attitudes and Flexibility In general, counselors need to be mindful of their own negative biases or stereotypes about older people, including their suitability for counseling. Because many late-life mental disorders are recurrent or chronic, treatment goals that emphasize managing symptoms, preventing relapse, and enhancing functional capacity rather than completely eliminating presenting problems may be more appropriate. Mental health services may be provided to older adults in diverse settings, including in their own homes; outpatient and inpatient medical, rehabilitative, or psychiatric settings; assisted living facilities; senior centers; day care centers; and nursing homes. Independent practitioners need to be flexible about missed or rescheduled appointments because of acute medical crises, responsibility for care of ill relatives, or reluctance to travel during inclement weather.

Working in Long-Term Care Facilities Providing services in long-term care facilities may require the counselor to be especially mindful of maintaining focus on the needs and best interests of the client because

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facility staff may have priorities that sometimes run counter to those of the client (e.g., not wanting a client to complain about conditions). In these settings, it may take considerable effort to maintain privacy because older residents often have roommates, and separate, quiet places to talk may be difficult to find. The counselor must ensure that the client consents to sharing the contents of any psychotherapeutic session with other staff. It may sometimes be necessary to intervene on behalf of the client with facility staff to change institutional routines, reduce environmental stresses, and decrease maladaptive behavior on the part of staff toward the patient. Maintaining collaborative communication with nursing home staff is critical.

COUNSELING AND INTERVENTIONS FOR OLDER VICTIMS OF ABUSE Each older victim of abuse is unique and requires a good assessment of his or her individual strengths and needs. However, the following sections offer some basic ways to approach counseling and other interventions with older adults.

National Clearinghouse on Abuse in Later Life—Tips on Working With Victims The following are tips on working with older survivors of abuse as developed by the National Clearinghouse on Abuse in Later Life (NCALL, 2003). It is important to ask about abuse. Questions about abuse might be prefaced with a statement such as “Because many of the people I work with are hurt by family members, I ask questions about relationships and abuse.” Open-ended questions are inviting and are an essential part of a good assessment. Examples of open-ended questions include “How are things going with your spouse (or adult child)?” “Are you getting out with your friends?” “Are you afraid of your spouse (or other family member)?” “Have you ever been hit, kicked, or hurt in any way by a family member?” “Does anyone threaten you or force you to do things you do not want to do?” It is important to give a victim a sense of hope by believing the account of the abuse; telling the victim that he or she is not to blame and that abuse can happen to anyone; planning for safety; offering options and giving information about resources; allowing the victim to make decisions about next steps (returning power to the victim); keeping information shared by the victim confidential; and documenting the abuse with photographs, body maps, and victim statements. The counselor needs to avoid doing anything that further isolates, blames, or discourages victims, such as telling the victim what to do (e.g., “You should leave immediately”), judging a victim who returns to an abusive relationship, threatening to end or ending services if a victim does not do what is wanted, breaking confidentiality by sharing information with the abuser or other family members, and blaming the victim for the abuse (“If only you had tried harder or done this, the abuse might not have happened”). Mandated reporters need to tell the victim what they are doing and why. Counselors can help the victim with safety planning if needed, and by documenting only facts (e.g., observed bruising about the face and neck) not opinions (e.g., “He’s drunk and obnoxious” or “She’s hysterical and overreacting”), because they can be used against a victim in court. Counselors must not collude with the abuser and give him or her more power and control by accepting excuses from the abuser and supporting the violence (“I can understand how much pressure you are under; these things happen”); blaming alcohol/drug use, stress, anger, or mental illness for the abuse; or minimizing the potential danger to the victim or the counselor if help is offered. Counselors can arrange for appropriate security for the victim, as well as agency or facility staff when working with a potentially lethal batterer (e.g., has made homicidal/suicidal threats or plans, owns weapons).

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Other Services and Interventions for Victims Nerenberg (2008) outlined six overarching goals as a way to conceptualize services and interventions for elder victims of abuse: maximizing independence; resolving crises and emergencies; ensuring victim safety; healing, empowering, and supporting victims; preserving, protecting, and recovering assets; and ensuring justice. Maximizing independence may include interventions such as enlisting support services (e.g., home-delivered meals) and specialized case management services (e.g., mental health or medically focused case management). Resolving crises and emergencies may require assessment through home visits by APS or “well-being” checks by law enforcement; resolution also may necessitate the use of emergency funds for food, rent, or in-home attendant care. Ensuring victim safety might entail safety planning, use of shelters (or specialized elder shelters), and protective orders (e.g., emergency protective orders). Healing and empowerment of victims may include individual or group counseling sessions that focus on psychoeducation; trauma processing; reducing isolation; and increasing social skills, grief work, or substance abuse. Strategies for preserving and recovering assets might include the use of representative payee services, psychoeducation about fraud prevention, building in safeguards when designating powers of attorney, and working with APS and law enforcement to “freeze” assets to stop financial loss while an investigation occurs. Ensuring justice involves accessing a broad spectrum of civil and criminal remedies, guardianships through the probate system and alternative remedies such as mediation.

COUNSELING IMPLICATIONS Several implications arise from the practice of counseling elder victims of abuse. In many ways, addressing the mental health needs of older victims of abuse requires overcoming three layers of invisibility and stigma: (a) the general societal stigma regarding mental health needs; (b) the fact that the mental health needs of older adults, in particular, often are missed or undertreated; and (c) that elder abuse is often an invisible phenomenon. It is therefore crucial that counselor training programs go beyond simply relaying information about any elder abuse mandated reporting requirements; preservice training programs need to develop counseling curricula targeted toward identifying and assisting older victims of abuse. Even counselors who primarily work with children can benefit from more training on elder abuse identification and response because so many children are being raised by grandparents or are living in intergenerational households. There is a compelling need for more research about elder abuse, in general, and specifically about the mental health needs of those who have suffered abuse. There are many opportunities for developing, piloting, and building the evidence base for effective interventions for elder victims of abuse. There is also a need to develop interventions for abusers, perhaps modeled on batterer intervention programs in domestic violence. An important implication for those counseling older victims of abuse is to take heed that issues of vicarious traumatization and burnout are risks that require practitioners to reflect, use collegial and supervisory supports, and exercise self-care. Finally, working with elder victims of abuse can be particularly rich and rewarding for counselors. Older adults bring with them a lifetime of experiences, perspectives, and often wisdom. The complexity of the medical, legal, familial, and societal interplay with each client can be intellectually and professionally challenging and stimulating.

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CONCLUSION There is a demographic imperative for all clinical practitioners to better understand the needs of older adults. Those most at risk of abuse in later life are the “oldest old,” socially isolated elders, and persons with dementia and concomitant behavioral problems. Understanding the warning signs of abuse and resources for reporting and intervening in abuse is critical to preventing, stopping, and ameliorating the impact of abuse. Effective counseling for this older adult population takes into account the unique needs of older adults, incorporates effective strategies from domestic violence treatment, and builds in awareness of resources specific to older adults.

APPENDIX 12.1 Case Study: Mrs. C. Mavis C. is an 89-year-old African American woman who came to the attention of Adult Protective Services (APS) after a neighbor became worried that she had not seen Mrs. C. in several days. When the social worker from APS went to Mrs. C.’s residence, Mrs. C.’s daughter, Beatrice, opened the door and was very suspicious and reluctant to let APS speak with her mother. The APS social worker was able to convince Beatrice to let her interview Mrs. C. privately. Mrs. C. was in bed and appeared frail and malnourished. Mrs. C. was initially reluctant to talk to the social worker and needed reassurance that it was not APS’s goal to put her in a nursing home. Mrs. C. told the social worker that she had heart disease, diabetes, and arthritis that made it increasingly difficult for her to get around. Mrs. C. let APS arrange home-delivered meals but refused to go to the doctor. The APS social worker made several visits before Mrs. C. disclosed that her daughter, who was her paid caregiver, had hit her on several occasions and was taking her pension checks. Mrs. C. eventually agreed to see her doctor but did not want to press charges against her daughter. APS was able to have a representative payee handle Mrs. C.’s fi nancial matters and got part-time care by an outside provider who was to Mrs. C.’s liking. Mrs. C. is now seeing a counselor, developing a safety plan, and discussing how her daughter’s behavior affects her.

RESOURCES Websites National Center on Elder Abuse (http://www.ncea.aoa.gov/) The National Center on Elder Abuse (NCEA) serves as a national resource center dedicated to the prevention of elder mistreatment through online educational resources and operation of a popular LISTSERV forum for professionals. National Clearinghouse on Abuse in Later Life (NCALL) (http://www.ncall.us) NCALL provides information about programming, outreach, collaboration, and policy development related to abuse in later life and elder abuse. Many resources are available to download at no cost on NCALL’s website.

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University of California Irvine Center of Excellence on Elder Abuse and Neglect (http://www.centeronelderabuse.org) The Center of Excellence serves as a central source of technical assistance, best practice information, multidisciplinary training, useful research, and relevant policy issues. Call Center Eldercare Locator 1-800-677-1116 To report suspected abuse, call the national Eldercare Locator, a public service of the U.S. Administration on Aging.

REFERENCES Acierno, R., Hernandez, M., Amstadter, A., Resnick, H. S., Steve, K., Muzzy, W., & Kirkpatrick, D. G. (2010). Prevalence and correlates of emotional, physical, sexual, and fi nancial abuse and potential neglect in the United States: The national elder mistreatment study. American Journal of Public Health, 100 (2), 292–297. Administration on Aging. (2010). Profile of older Americans: 2010. Retrieved from http://www.aoa.gov/ aoaroot/aging_statistics/Profile/2010/Index.aspx Alzheimer’s Association. (2011). 2011 facts and figures. Retrieved from http://www.alz.org/documents_ custom/2011_Facts_Figures_Fact_Sheet.pdf American Psychological Association. (2011). Practitioners working with older adults: What practitioners should know about working with older adults: APA working group on the older adult brochure. Retrieved from http://www.apa.org/pi/aging/resources/guides/practitioners-should-know.aspx Beach, S., Schultz, R., Castle, N., & Rosen, J. (2010). Financial exploitation and psychological mistreatment among older adults: Differences between African Americans and non-African Americans in a population-based survey. The Gerontologist, 10 (6), 744–757. Bonnie, R. J., & Wallace, R. B. (Eds.). (2003). Elder mistreatment: Abuse, neglect and exploitation in an aging America. Washington, DC: National Academies Press. Butler, R. (1969). Age-ism: Another form of bigotry. The Gerontologist, 39 (4), 243–246. Cooney, C., Howard, R., & Lawlor, B. (2006). Abuse of vulnerable people with dementia by their carers: Can we identify those most at risk? International Journal of Geriatric Psychiatry, 21(6), 564–571. Deem, D. (2000). Notes from the field: Observations in working with the forgotten victims of personal financial crimes. Journal of Elder Abuse & Neglect, 12(2), 33–48. Dyer, C., Pavlik V., Murphy, K., & Hyman, D. (2000). The high prevalence of depression and dementia in elder abuse or neglect. Journal of the American Geriatrics Society, 39 (2), 205–208. Dong, X., Simon, M., Beck, T., Farran, C., McCann, J., Mendes de Leon, C., . . . Evans, D. (2011). Elder abuse mortality: The role of psychological and social wellbeing. Gerontology, 57(6), 549–558. doi: 10.1159/000321881 Fisher, B., & Regan, S. (2006). The extent and frequency of abuse in the lives of older women and their relationship with health outcomes. The Gerontologist, 46(2), 200–2009. Hawes, C. (2002). Elder abuse in residential long-term care facilities: What is known about prevalence, causes, and prevention. Testimony before the U.S. Senate Committee on Finance. Retrieved from http://finance. senate.gov/hearings/testimony/061802chtest.pdf Hightower, J., Smith, M., & Hightower, C. (2006). Hearing the voices of abused older women. Journal of Gerontological Social Work, 46(3), 205–227. doi:10.1300/J083v46n03_12 Lachs, M., Williams, C., O’Brien, S., Hurst, L., & Horwitz, R. (1997). Risk factors for reported elder abuse and neglect: A nine-year observational cohort study. Gerontologist, 37(4), 469–474. Lachs, M., Williams, C., O’Brien, S., Pillemer, K., & Charlson, M. (1998). The mortality of elder mistreatment. Journal of the American Medical Association, 280 (5), 428–432. MetLife Mature Market Institute. (2009). Broken trust: Elders, family and finances. Retrieved from http://www. metlife.com/assets/cao/mmi/publications/studies/mmi-study broken-trust-elders-family-finances.pdf

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Mouton, C., Rodabough, R., Rovi, S., Brzyski, R., & Katerndahl, D. (2010). Psychosocial effects of physical and verbal abuse in postmenopausal women. Annals of Family Medicine, 8 (3), 206–213. doi:10.1370/afm.1095 National Adult Protective Services Association. (2004). Ethical principles and best practice guidelines. Retrieved from http://www.apsnetwork.org/Resources/docs/Ethical%20Principles.pdf National Center on Elder Abuse. (1998). The national elder abuse incidence study, final report. Washington, DC: Author. National Center on Elder Abuse. (2005). Domestic abuse in later life: Abusers. Retrieved from http:// www.ncea.aoa.gov/ncearoot/main_site/pdf/research/abusers.pdf National Center on Elder Abuse. (2011). Frequently asked questions. Retrieved from http://www.ncea .aoa.gov/NCEAroot/Main_Site/FAQ/Questions.aspx National Clearinghouse on Abuse in Later Life. (2003). Domestic abuse in later life: Tips on working with victims. Retrieved from http://www.ncall.us/docs/Tips_Older_Victims.pdf National Long-Term Care Ombudsman Resource Center. (n.d.). About ombudsmen. Retrieved from http://www.ltcombudsman.org/about-ombudsmen Nerenberg, L. (2008). Elder abuse prevention: Emerging trends and promising strategies. New York, NY: Springer Publishing. Schiamberg, L., & Gans, D. (1999). An ecological framework for contextual risk factors in elder abuse by adult children. Journal of Elder Abuse & Neglect, 11(1), 79–103. U.S. Government Accountability Office. (2008). Nursing homes: Federal monitoring surveys demonstrate continued understatement of serious care problems and CMS oversight weaknesses (GAO Publication No. 08-517). Washington, DC: U.S. Government Printing Office. U.S. Government Accountability Office. (2011). Elder justice: Stronger federal leadership could enhance national response to elder abuse (GAO Publication No. 11-208). Washington, DC: U.S. Government Printing Office. University of California, Irvine, Center of Excellence on Elder Abuse and Neglect. (n.d.). Red flags of elder abuse. Retrieved from http://www.centeronelderabuse.org/education_overview.asp University of California, San Francisco. (2010). UCSF memory and aging center: Education overview. Retrieved from http://memory.ucsf.edu/education/overview University of Nebraska Medical Center. (2011). Geri pearls: Functional disability assessment. Retrieved from http://webmedia.unmc.edu/intmed/geriatrics/reynolds/ pearlcards/functionaldisability/ functionaldisability_prlcard.htm Wiglesworth, A., Mosqueda, L., Mulnard, R., Liao, S., Gibbs, L., & Fitzgerald, W. (2010). Screening for abuse and neglect of people with dementia. Journal of the American Geriatrics Society, 58 (3), 493–500.

CHAPTER 13

Addiction and Psychological Trauma: Implications for Counseling Strategies PATRICIA A. BURKE AND BRUCE CARRUTH

INTRODUCTION There are several ways to conceptualize addiction. There is the popular culture idea of addiction that has broad meanings, ranging from the use of substances in a way that causes harm to hoarding junk to the point of being the subject of a reality television show. This broad definition of addiction contains two elements related to compulsion: (a) a pattern of obsessive thinking about engaging in a behavior that elicits a feeling of being high or intoxicated or that reduces anxiety or hyperarousal and (b) compulsive engagement in that behavior. In addition, addiction is characterized by loss of control over the behavior, yet continued engagement in the behavior, in spite of harmful consequences to the individual (Coombs, 2004). Types of behaviors that fit this definition of addiction include compulsive use of substances like alcohol, prescription, and illicit drugs, as well as “process addictions” such as anorexia/bulimia, compulsive overeating, sex addiction, compulsive gambling, internet addiction, self-harming behaviors like cutting, “workaholism,” and compulsive buying. In addition, there is evidence to suggest that many people who have been traumatized “neutralize their hyperarousal by a variety of addictive behaviors, including compulsive reexposure to situations reminiscent of the trauma” (van der Kolk, 1989, p. 401). This broad definition of addiction has value in helping clinicians understand the essential components of psychological dependence, which include obsessive thinking, compulsive behavioral expression of that dependency, and loss of control of those behaviors. The Diagnostic and Statistical Manual IV-Text Revised (DSM-IV-TR) does not refer to addiction as a diagnosis but uses terminology such as substance abuse and dependence (American Psychiatric Association [APA], 2000). Substance abuse refers to using illegal drugs like heroin, marijuana, and cocaine; using legal drugs like alcohol and nicotine; or using prescription drugs. People may abuse these substances in ways that (a) can cause harm to or interferes with their health or their ability to function in the areas of work, school, family/relationships, and finances; or (b) can create legal problems, like arrests for driving under the influence of such substances. When an individual takes a prescription drug for reasons other than for which the drug was prescribed or when taking more than the prescribed amount and this causes harm, this also is considered substance abuse. Substance dependence manifests as impaired control or compulsive use of a substance (whether legal or illegal); continued use despite harm, physical craving, tolerance to the drug (i.e., using more to get the same effect); and withdrawal symptoms

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when the person stops using the drug. In the clinical literature, substance abuse and dependence are collectively referred to as substance use disorders or SUDs. In the realm of process addictions, the DSM-IV-TR uses terminology like pathological gambling, eating disorders, and so forth (APA, 2000). DSM-IV-TR diagnostic criteria for substance abuse and dependence as well as process addictions are specific and reflect clinical formulations of the construct of addiction. DSM-IV-TR terms are used for research and clinical assessment and diagnosis. The common elements in both the popular and clinical definitions of addiction include obsession/compulsion, loss of control, and continued use of substances or engagement in the compulsive behavior despite harm.

PRESENTATIONS OF TRAUMA AND ADDICTION The relationship between the psychological/emotional aftereffects of trauma, including depression, anxiety, panic, posttraumatic stress disorder (PTSD), eating disorders, and addiction is complex. Like all co-occurring conditions, trauma-related disorders and addictions can present themselves in several ways. For example, the development of an addiction can be an adaptive strategy for managing the emotional and psychological responses to trauma, and addiction to substances can make people more vulnerable to trauma, including rape and other kinds of violence that can cause trauma complications like PTSD. Although the research indicates that there is a strong association between trauma complications and SUDs, clinicians should not make assumptions about causal relationships. Najavits et al. (2008) suggest that co-occurring conditions like PTSD and SUDs can precede each other, follow each other, contribute to the development or course of each other, or arise independently of one another. Recent research suggests that “having PTSD greatly increased the risk of developing a subsequent SUD, but exposure to a traumatic event that did not result in PTSD did not increase the risk of developing a subsequent SUD. Thus, it appears to be the development of PTSD, not exposure to trauma per se, which increases the risk of developing an SUD” (Chilcoat & Breslau as cited in Brady, Back, & Coffey, 2004, p. 206). A good example of how SUD and PTSD each have an impact on the course of the other is illustrated in the case of Jan,1 a 27-year-old woman with a history of childhood sexual trauma and PTSD, who becomes abstinent from alcohol, cocaine, and marijuana after 10 years of heavy use. Once she stops using, her PTSD symptoms worsen. Jan becomes suspicious and mistrusting. She begins to have panic attacks, flashbacks, and night terrors. In order to cope with the physiological hyperarousal, she begins drinking again. This worsens her insomnia, depression, and suicidal ideation. Jan then begins smoking marijuana and overeating. Najavits (2006) suggests that the abuse of substances in people with trauma histories “is often construed as a reenactment of trauma. Substance use may represent harm to the body that symbolizes familiar traumatic experiences; living the role of the marginalized; or not caring about oneself after violation by others” (p. 229). In this regard, substance abuse can be viewed as a type of self-harming behavior that often is associated with people who suffer from trauma. This self-harming behavior can become a kind of addiction that exhibits the components of obsession, compulsion, and loss of 1

All identifying information and some clinical details in the clinical anecdotes and case examples in this chapter have been disguised, fictionalized and/or combined from several individuals in accordance with professional standards in order to protect the individual’s identity and confidentiality.

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control. The paradox of self-harming behaviors is that people with histories of trauma often initiate this behavior in order to gain a sense of control, while eventually losing control over the self-harming behavior. Regardless of how trauma-related conditions and addiction present themselves and in what order, both disorders must be addressed simultaneously in treatment. As Najavits (2006) states, “Regardless of how they enter treatment, clients need attention to both disorders. Split systems, wherein a client who uses substances is rejected from mental health treatment until abstinent, or the client with mental health problems is rejected from SUD treatment until stabilized, are believed less effective than concurrent or integrated treatment” (p. 229).

SEQUENTIAL, PARALLEL, AND INTEGRATED TREATMENT OF ADDICTION AND PSYCHOLOGICAL TRAUMA Treatment for co-occurring trauma-related disorders and addiction can occur along three treatment trajectories: sequential, parallel, and integrated therapy. These are described briefly as ■ sequential treatment, in which one disorder is defined as “primary” and is treated

first, followed by treatment of the “secondary” disorder; ■ parallel treatment, in which the disorders are treated concurrently but in separate

treatment systems or by separate clinicians, generally without much coordination between the two treatments; and ■ integrated therapy treatment, in which both disorders are treated concurrently by the same clinician or treatment system, with recognition of how each disorder impacts the recovery from the other and with a high degree of coordination within the treatment system. Almost everyone would agree that the third option is the most efficacious; unfortunately, however, this often is not what happens in practice. First, the treatment system for substance use often does not interact with mental health treatment systems that typically address trauma-related disorders (and vice versa). Such lack of communication is not conducive for sequential treatment. Clinicians in addiction treatment settings focus on getting people sober first, assuming that the trauma symptoms may subside or can be dealt with later by a mental health clinician. Clinicians in mental health treatment settings focus on managing trauma-related symptoms first, assuming that the alcohol and drug use or other addictive behaviors may subside or can be treated later by substance abuse professionals or self-help recovery groups. In parallel treatment situations, a person may be getting services simultaneously from a substance abuse counselor and a mental health professional. However, when clinicians in psychological trauma treatment systems are not trained in addictions treatment and clinicians in addictions treatment are not “trauma informed,” the treatment can work at cross purposes. Not only is a working knowledge of both disorders required for truly integrated treatment, but clinicians also must be aware of treatment methods and community resources available for both disorders. Many mental health, addictions, social service, and public health agencies simply are not organized in a way that allows resources for both disorders to be available under one roof. This situation is exacerbated by the separation of funding streams by state and Federal governments for the substance abuse and mental health treatment delivery systems. The impact of this separation of services is that clients are often left to navigate the maze of treatment services on their own.

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For integrated treatment to occur, an individual with a co-occurring SUD and trauma-related condition needs to receive treatment for both simultaneously, through one treatment delivery system. This does not mean that all clinicians need to be experts in the treatment of both disorders. A clinician with a strong clinical background working with one disorder can treat the co-occurring disorders of an individual with good support and clinical supervision from a clinician experienced in treating the other disorder. It is hoped that more and more treatment programs will have a “specialist” trained in treating the other disorder. Ideally, a program (whether in the context of an addiction treatment or mental health service) needs to have special services designed for treating people with both disorders. Some community-based addiction and mental health treatment programs now have specialized tracks for treating clients with cooccurring trauma-related and addiction disorders. Three levels of “qualification” can be identified for clinicians working with clients with co-occurring trauma and addiction disorders. At the least, all clinicians should be aware of the symptoms, course, and impacts of both addiction and trauma-related conditions. They need to be able to screen for both disorders, to recognize the symptoms that might be presented, to feel comfortable talking with the client about both disorders, to help the client understand how the two disorders interact and have an impact on treatment and recovery, and finally, to be capable of making an effective referral for treatment. Clinicians at this level, under the supervision of a more qualified clinician, might be qualified to lead psychoeducational groups in which clients can learn about symptoms of both disorders, learn more about treatment approaches and recovery options, and be in a position to make more informed choices about how to initiate treatment. Clinicians with more training and experience might be considered trauma and addiction informed. Clinicians who are trauma and addiction informed should be capable of providing certain integrated treatment interventions under clinical supervision. Trauma- and addiction-informed clinicians also should be able to coordinate parallel treatment when integrated treatment is not possible. They should be able to develop an effective treatment protocol and plan that recognizes the client’s unique needs and goals and considers the range of recovery resources that are available. In particular, they should be capable of recognizing and addressing initial resistance of the client to engaging in treatment. For instance, it would not be uncommon for many trauma survivors who have a strong undercurrent of shame to resist addiction recovery efforts that involve sharing and emotional vulnerability. Informed clinicians should have the skills to help the client recognize and transcend this resistance and engage in beneficial treatment. At the same time, a clinician would need to recognize when a particular treatment is either too stressful or is simply inappropriate for a specific client. In effect, the trauma- and addiction-informed clinician should be able to individualize treatment and not simply apply “cookie-cutter” approaches to care. Finally, an individual clinician may be sufficiently trained in both trauma and addiction treatment to be considered a specialist, that is, one who is capable of providing care to individuals affected by both disorders. Specialists are capable of practicing independently within their realms of competence. They also are aware of other treatment approaches, appreciate their efficacy, and understand when those approaches are best used. Specialists also may be competent in providing clinical supervision to others less skilled in either trauma or addictions treatment. This presumes that the specialist also is trained, formally, in clinical supervision. Not all services require the skill of a specialist in both arenas. The following are examples of services that can be provided by clinicians with less training and experience: psychoeducational programs, screening, supportive counseling, case management,

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motivational enhancement, follow-up care, and aftercare. It is essential that all clinicians have an appreciation for the impact of both disorders, know how important it is to address both in treatment, and maintain sensitivity to the needs of clients affected by addiction and by trauma-related disorders.

TREATMENT APPROACHES AND COUNSELING STRATEGIES There is no single treatment approach or strategy to address such a broad-based and complex issue as psychological trauma and co-occurring SUDs. Counselors have to consider the unique needs of the client, the context in which services are provided, and the counselor’s own level of training and skill in treating these co-occurring conditions. In this next section, we will examine some overarching approaches and specific strategies for integrated treatment of SUDs and trauma.

Treating the Symptom Versus Treating the Problem A basic dilemma in both addiction and trauma treatment concerns symptom management versus treating the underlying dynamic. The primary symptoms of SUDs are obsession, compulsion, and harm caused by drug use. The primary symptoms of trauma are interpersonal withdrawal, hypersensitivity, and intrusion. Treatment systems addressing trauma-related disorders and addiction generally favor short-term, symptom-management approaches. This approach deems treatment successful if symptoms subside. In effect, no symptom, no problem! SUD treatment programs tend to put their personnel and financial resources into helping people get “clean and sober,” rather than focusing on the more costly strategy of helping people change a way of life. Most clinical resources go into the first 30 to 90 days of substance abuse recovery. The result is that many people are left without long-term assistance at a critical time in their recovery when they are most likely to have a resurgence of trauma-related symptoms and, thus, are prone to relapse back into alcohol/drug use or addictive behaviors. These people then end up becoming the “walking wounded”; perhaps they are not using drugs, but they may continue to live a limited life. Likewise, in trauma treatment, the bulk of clinical resources go into reducing symptoms of hyperarousal, interpersonal withdrawal, and intrusion (often through psychopharmacology). But this simply creates short-term relief for many clients who continue to experience the underlying symptoms of trauma: disturbed interpersonal relationships, low self-esteem, a lack of hope and optimism, diminished self-efficacy, and difficulty experiencing the joys of life. It should be noted that clients with both disorders can become willing coconspirators in ending treatment too quickly. For instance, when clients are no longer experiencing intrusive nightmares or have not had a drink in 30 days, they may be only too willing to declare themselves “cured” and no longer in need of treatment. Few people voluntarily wish to explore their painful inner functioning and past to understand how these wounds manifest in their current lives and interfere with self-esteem, relationships, and a sense of belonging. For some, adult traumas, particularly “single-event” traumas such as a rape, an armed robbery, a near-death health crisis, or the death of a spouse, it may be appropriate to address only the trauma symptoms and not “delve deeper” unless the client signals that such exploration might be useful. They might signal the need to delve deeper, for instance, by suggesting that the single event activates other traumas in their history or by reports of long disavowed affects emerging when ego defenses are down,

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such as upon awakening in the morning. When higher-functioning people go through a traumatic time, the risk of significant wounding at the level of self-functioning is lower than with a person who does not have very good coping skills. However, even for higher-functioning people, it might be wise to see if symptoms of a self-wound appear before probing. In a similar vein, some people can, with positive support from others (and sometimes strong sanctions against continuing the behavior), cease a destructive compulsive pattern such as alcohol or drug use, compulsive sexual behavior, shoplifting, or gambling and not need additional treatment. But anecdotal evidence suggests that these clients are the exception, not the norm. Many clients with SUDs can look—and are—remarkably improved after 30, 60, or 90 days of abstinence. But, a part of what is clinically relevant in this circumstance is that the psychological defense that individuals have employed—and continue to employ— to look “good enough” to self and others may be hiding enormous underlying pain. Not every client with co-occurring trauma-related and addiction disorders needs long-term treatment. Some clients can benefit from relatively short-term intensive treatment, followed by supportive counseling or self-help programs. However, it is critically important to be cognizant of the fact that many, and perhaps a majority of this particular category of clients, need more. Finally, these additional services have to be matched to the specific needs of the clients. No one treatment protocol effectively can address the wide range of treatment and recovery needs of people with such diverse presentations of trauma and addiction disorders.

Staging Treatment It is helpful to think of both trauma and addiction treatment as occurring in stages. The symptoms presented in early treatment are not necessarily the symptoms that become evident later on. Likewise, treatment needs vary depending on the phase of treatment. Finally, the role of the clinician may differ significantly depending on where the client is in his or her recovery. This subsection focuses on early treatment, because this is the point at which the interaction of trauma symptoms and addiction symptoms are most likely to be prominent. Once a client has stabilized in recovery, it is often more common for the client to be able to separate symptoms of one disorder from the other. Likewise, in more extended recovery, symptoms like low self-esteem, relational difficulties, lowered self-efficacy, repression of specific emotions, and overreactivity to environmental stressors often blend; it becomes more difficult, in these later stages, to describe a symptom as specific to trauma or to addictive illness. In general, early treatment is focused on goals such as symptom management, reducing triggers and cues, stabilizing the psychosocial environment, learning about trauma and about addictive illness, developing a better understanding of recovery, and developing hope that life can be better. As clients master these tasks, other dynamics in a second stage of treatment may begin to be more prominent. The latter are marked by some of the following: being able or unable to manage success; continuing or not continuing relational patterns that are self-destructive or unfulfilling; and confronting problems that arose during the process of addiction or have evolved as a result of trauma such as bad decisions about jobs or careers, patterns of family relations that are limiting or retraumatizing, or decisions about the future of a marriage or other important relationships. These are most often problems that predated entering treatment, but it is only after a period of stabilization that they emerge to the forefront. These dilemmas for the client require different treatment strategies and change the therapeutic stance of the clinician. In earlier treatment, the clinician might have been more directive, more

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focused on therapeutic boundaries, and more structured in the therapeutic endeavor, thus allowing the client to develop a dependent therapeutic relationship. As treatment progresses, the clinician might elect to focus more on the client’s affect, encouraging insight and supporting the client in making his or her own decisions; at this point, the therapist begins to appear less confrontational. In an even later stage of treatment, the clinician might take on more of the role of an advisor, walking alongside clients as they make their own decisions. A final stage of treatment involves the client’s separation from the clinician, allowing the client to “let go” of a resource that has been a significant part of his or her lifeline for the duration of therapy. Being able to achieve this separation healthily can, in and of itself, be a major therapeutic step for people who have experienced significant abandonment or attachment trauma.

Counseling Strategies in the Early Stages of Treatment There are several specific counseling strategies that are useful in the early stages of treatment of trauma aftereffects, SUDs, and process addictions. Perhaps the most important strategy is to create a safe working relationship, balancing the client’s need for control and therapeutic relationship boundaries. While clients need clear boundaries to establish safety in the therapeutic relationship, when working with people with trauma-related disorders and addiction, the clinician also must recognize that the client needs to feel a sense of control in the relationship—a sense of control that was shattered during the trauma experience. Trauma has an impact on how people perceive the world: their thoughts, judgments, intuition, and their relationship to their emotions and physical experience. People sometimes shrink their world of experience in an effort to make it controllable, while simultaneously and paradoxically feeling out of control. Addiction also can have an impact on how people perceive the world—their thoughts, judgments, intuition, and their relationship to their emotions and physical experience. Obsessive thinking and compulsive behaviors associated with addiction are actually coping strategies (or responses to trauma) and are employed by traumatized people to gain a sense of control; however, this paradoxically may increase their experience of being out of control. The person who suffers from trauma complications and addiction is dancing this dance of control in a vicious circle. The goal of the clinician is to dance with the client in a mutual process of following and leading, in order to enhance the client’s sense of empowerment in the context of a safe relationship. Unfortunately, the rhythm of the dance is rendered “less than smooth” by some of the differences between “standard” trauma and SUD treatment. For example, in traditional SUD treatment programs, it is often a goal to get clients to “admit” that they are alcoholics or addicts and to confront those who do not. For trauma survivors, the shame associated with feelings of loss of control that is engendered by this “admission” may activate the shame of the trauma experience and become overwhelming or the push to make an admission may feel like another violation of personal boundaries. In the Seeking Safety model of treating the co-occurring conditions of trauma aftereffects and addiction, Najavits (2006) states that “the heavily confrontational style of some SUD group therapies [should be] avoided to maintain the safety of a traumafocused treatment. Accountability, but not harsh confrontation, is emphasized” (Najavits, 2006, p. 245). It is more useful in the context of SUD and trauma-focused treatment not to focus on confronting clients about making an identity declaration of addiction but rather to use collaborative counseling strategies that facilitate agreement about which addictive behaviors the client is willing to change and how those changes can occur. One such

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collaborative method is motivational interviewing, which is a value-centered approach to helping people change health risk behaviors (Miller & Rollnick, 2002). Although the ultimate goal of addiction treatment is abstinence from substance use, harmful compulsive behaviors, and process addictions, this collaborative approach to counseling recognizes that stabilization and harm reduction are important intermediate goals. Such an approach enhances a mutually agreed upon agenda of behavior change between client and clinician. The client can regain a sense of control over his or her life and can manifest a sense of empowerment by retaining a measure of control over the treatment agenda. Other counseling strategies essential to successful treatment of SUD and trauma involve employing supportive psychotherapy to explore the relationship between trauma aftereffects like PTSD and SUDs, along with psychoeducational methods to address the role substance use and compulsive behaviors have in reducing the heightened anxiety, hyperarousal, and flashbacks that frequently occur when people stop using substances and/or engaging in compulsive behaviors. The key here is to educate people about the effects of trauma and how substance use and addictive behaviors are understandable responses to the trauma aftereffects. An implicit subtlety here is for clinicians to emphasize that harmful behaviors such as cutting, drinking to pass out, and compulsive overeating are not to be dismissed or excused but are to be understood in the context of the client’s traumatic experience. Supportive psychotherapy and psychoeducation can help clients to understand that they have choices about the strategies they employ to cope with trauma. These approaches also reinforce that although substance use may provide temporary relief from some of the intensity of the trauma effects, in the long run, it leaves them feeling more out of control than in control. Processing of trauma memories needs to be delayed until a client’s SUD and compulsive behaviors are stabilized and he or she has established sufficient coping strategies to manage intense affect. Much of the clinical literature indicates that clients run the risk of increased substance use, or relapse back into substance use after a period of abstinence, if specific trauma memories are processed prematurely in treatment. According to Najavits (2006): Opening up the “Pandora’s box” of trauma memories may destabilize clients when they are most in need of stabilization. Clients themselves may not feel ready for trauma processing early in SUD recovery; others may want to talk about the past but may underestimate the intense emotions and new disturbing memories. (p. 244) Traumatic experiences can overwhelm people’s sense of control, connection, and meaning; they then tend to engage in a defensive strategy of disconnection that serves to protect them, superficially, from further threat, whether actual or perceived (Herman, 1992). People with SUDs and process addictions also tend to become isolated and disconnected from meaningful relationships with family, friends, coworkers, and others. For a person suffering from addiction, the drug or the compulsive behavior becomes like a capricious lover, and the relationship to that love object takes precedence over all other relationships. Therefore, an essential counseling strategy—especially in the early stages of treatment and recovery, when clients give up or dramatically change their relationship to the drug or compulsive behavior and are feeling isolated, alone, anxious, and depressed—is to work collaboratively with clients to replace this unhealthy relationship with healthy social supports. Such supports include recovery support groups like Alcoholics Anonymous (AA), Narcotics

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Anonymous (NA), Overeaters Anonymous (OA), Women for Recovery, Self-Management And Recovery Training (SMART), and so forth. Engagement in social support networks helps clients to reestablish meaningful connection to others and to decrease isolation. A renewed sense of connection can help reduce the hyperarousal that people with trauma complications suffer; however, this is true only if they feel safe. One client, Leslie, a 35-year-old lesbian who grew up in an alcoholic home that was emotionally chaotic and suffered from traumatic losses as a child, reports that in the fi rst 6 months of recovery, when she attends lesbian and gay AA meetings where she feels safe, she often experiences a reduction in anxiety even when she does not speak to anyone. She reports that it is enough just to listen to people’s voices; even if she is unable to hear what they say, she immediately calms down. Project MATCH, a multisite study conducted by the National Institute of Alcohol Abuse and Alcoholism, investigated the effectiveness of three types of individual psychotherapy delivered to alcohol-dependent clients. The study found that the Twelve Step facilitation therapy, that is, encouraging clients to participate actively in AA and monitoring and exploring their reactions to meetings, was “associated with significant and substantial reductions in both drinking behavior and alcohol-related negative consequences over a 12-week therapy delivery period and a 1-year follow-up” (Donovan, Kadden, DiClemente, & Carroll, 2002, p. 292). Project MATCH clients, including those in the Twelve Step facilitation therapy group, also showed significant decreases in depression and improvements in social functioning (Project MATCH Research Group, 1998, p. 592). This strategy of encouraging clients to attend and participate fully in communitybased support groups can be an extremely important part of the early treatment process for people with co-occurring trauma and addiction issues.

Recovery Support Groups as an Adjunct to Counseling As noted earlier, recovery support groups can be an important adjunct to individual counseling for people with co-occurring conditions of SUDs and trauma-related conditions. Most recovery support groups are patterned after AA, which is based on the Twelve Steps of recovery. The Twelve Steps are principles for living that accomplish the following: emphasizing powerlessness over the substance or addictive behavior; making amends with people harmed as a result of destructive, addictive behavior; and developing a spiritual connection to self, others, and something greater than the self. Types of Twelve Step support groups that might be useful for people with co-occurring addiction and trauma-related conditions include AA, NA, Cocaine Anonymous (CA), OA, Gamblers Anonymous (GA), and Emotions Anonymous (EA). Other recovery support groups that are not based on the Twelve Step model include Women for Sobriety, which includes a spiritual component and SMART and Secular Organizations for Sobriety (SOS), which do not include spiritual components. In addition to social support, recovery support groups also provide cognitive reframing functions that are consistent with cognitive behavioral therapy (CBT), which have been demonstrated to be effective in treating SUDs and PTSD. For example, AA slogans, which are often hung on banners in meeting locations, such as “one day at a time,” provide people with a kind of reminder to return to the present moment when their minds project into the future or get obsessively stuck in ruminating about the past. The spiritual component of many recovery support groups can be helpful to clients who have suffered the devastating effects of trauma by helping people reconnect to meaning in their lives. In addition, numerous studies have shown that alcohol or other

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drug abuse is associated with a lack of meaning in life, and those without an active religious or spiritual life are more likely to fill this void with alcohol or drugs (National Council on Alcoholism and Drug Dependencies [NCADD], 1999). Although the spiritual aspects of recovery support groups is not for everyone, it is important to explore this potential resource with clients in counseling. Facilitating active involvement in recovery support groups is an important aspect of the counseling process with people who suffer from addictions and trauma complications. This counseling strategy involves exploring clients’ understanding of recovery support groups, dispelling myths and misunderstandings, educating clients about the benefits and potential risks of participation, helping clients resolve ambivalence about attendance, helping clients decide on and locate appropriate meetings, and monitoring clients’ reactions to meetings. Many clients feel ambivalent and anxious about attending recovery support groups. Many feel ashamed about being identified as an “alcoholic” or “addict,” and others simply are uncomfortable in groups. Clients with histories of trauma may feel overstimulated by the environment and experience a reactivation of trauma memories. It is important to work collaboratively with clients to resolve their initial ambivalence about attendance at meetings and develop a desensitization plan. A clinical example of this involves a 38-year-old female, Lois, who has a history of multisubstance abuse issues, including alcohol, compulsive overeating, and childhood trauma related to a gas explosion and fire in her elementary school. She is wary about attending AA meetings. Her trauma reactions are reactivated by watching news reports of the 9/11 attacks on the World Trade Center towers, and she is anxious about being in a closed space with a large group of people. The clinician explores the cognitive links she has made between her childhood trauma, witnessing the 9/11 attacks on video, and her anxiety about attending AA. Once she agrees to try AA as an experiment, the clinician and client develop a plan that involves finding a meeting, driving to the meeting location, sitting in the parking area to get acclimated, finding out where the entrance to the meeting is, and then returning to the meeting location at the time of the meeting. Lois agrees to go into the meeting location, sit in the back of the room near the door, and stay for 5 minutes. She repeats this process until she is able to stay for the entire meeting. The clinician and client process her experience after each meeting. Finding the right support group for each client is also a part of this collaborative counseling strategy. For example, women who have been sexually traumatized by men often find the predominantly male atmosphere of AA, NA, CA, and other recovery support groups, to be anxiety provoking. Women’s AA and/or Women for Sobriety meetings might be more acceptable for these clients. It is important for clinicians to respect clients’ experience with trauma and encourage them to investigate meetings that are acceptable. Miller and Rollnick (2002) suggest that any plan, developed in collaboration with clients to help them change health risk behaviors, needs to be accessible, acceptable, and appropriate for each individual. It is possible for some individuals to find that the support group environment is inadvertently retraumatizing. Consider Ben, a 36-year-old man with an 18-year history of substance abuse and dependence, who was sexually abused from age 8 to 11 by a leader in his church. Two older men, who participated in a local Twelve Step group to which Ben had been referred, showed interest in and concern for him, invited him to have a cup of coffee and talk after the meetings, and encouraged him to telephone them if he needed support. Ben reacted to both men with anger and withdrawal. He began to have memories of the abuse, fueling low self-esteem, and a sense of feeling trapped. He began to have a sense of dread but was not able to identify what initiated the dread. Ben confronted one of the men and questioned his motivation for wanting to support

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him. Both men withdrew and shunned Ben, adding to his discomfort. Ben quit going to meetings, and only after several weeks, was he willing to talk with his clinician about his experience. The clinician was able to help Ben identify the source of the feelings and begin to develop a plan for how to cope with the memories, his feelings, and the situation at hand. The plan included Ben finding a new meeting and “hanging” with others with whom he felt safe. Retraumatization can occur in various ways in self-help support groups. For instance, hearing other participants openly describe trauma events in their lives can open memories and disavowed affects for some individuals, particularly those new to the program. Individuals with weak interpersonal boundaries may misinterpret the interest and attention given to them by others and then feel rejected and abandoned. Some individuals can become prematurely involved in sexual relationships with other support group members and unconsciously “reenact” their trauma experiences. As in the case of Ben, it is very important that clinicians monitor a client’s participation in self-help environments, supporting the person’s involvement, helping the individual to integrate his or her learning in different recovery environments, and being observant for signs of potential retraumatization. Being able to handle the potential retraumatization in a positive and productive way can be particularly therapeutic for individuals in early recovery, especially for those who have a limited repertoire of coping skills. Self-help programs offer the potential for powerful therapeutic growth through the process of identification, sharing, and belonging. This is particularly true for clients who have experienced abandonment trauma, thereby interfering with their ability to bond with others. Self-help programs can aid clients to experience intimate sharing in a safe environment and especially to have a sense of belonging; such programs can offer significant therapeutic gains that may not be available in individual counseling settings. Clients in self-help programs can proceed at their own pace, have the opportunity for meaningful feedback from others, and can learn to modulate their own sharing and involvement. The role of the “sponsor” in Twelve Step self-help environments can be particularly therapeutic. A sponsor is another member of the group with more experience in recovery, who acts as a mentor and coach for newly recovering individuals. The role of a safe, nurturing parent figure as a client moves through the recovery process cannot be underestimated. It is not uncommon to hear an individual say, for example, “My sponsor in AA was like the father I never had.”

Spirituality in Trauma and Addiction Treatment An additional counseling strategy, which can be employed at all stages of the treatment process, is to work collaboratively with clients to enhance hope and resilience through the exploration of their own understanding of spirituality. The purpose of such spiritual exploration is to counteract the hopelessness associated with both trauma and addiction. Spirituality is primarily concerned with the personal search for meaning and a felt sense of connection with some ultimate or transcendent reality. The search for meaning is also an integral part of the traumatized person’s efforts to cope with helplessness and vulnerability (Turner, McFarlane, & van der Kolk, 1996). When a person experiences a severe trauma, whether it is psychological trauma, childhood sexual abuse, domestic violence, or a natural disaster, this individual often struggles with existential questions of meaning. Why me? Is the world a just or unjust place? Is there some greater meaning or purpose to my life? Much of the clinical literature suggests that traumatic experiences often provoke a kind of “crisis of faith” (Herman, 1992), and that spirituality can

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help heal this shattering of trust in a just world by “providing a sense of purpose in the face of terrifying realities by placing suffering in a larger context and by affirming the commonality of suffering across generations, time, and space” (McFarlane & van der Kolk, 1996, p. 25). Engaging in a search for meaning can help trauma survivors place their traumatic experience into the larger context of their lived experience and lessen its negative impact on their lives. In addition, spirituality can enhance a person’s vitality and sense of interconnectedness with all existence (Carroll, 1998), thus combating the pervasive sense of disconnection that traumatized people experience (Herman, 1992). Recent research has demonstrated that alcohol/drug use also is associated with a lack of meaning in life and that active spiritual involvement can reduce the risk of substance abuse, contribute to the formation of a resilient worldview, enhance long-term recovery, increase coping skills and resilience to stress, enhance hope, and act as a protective factor in preventing alcohol and drug abuse (Burke, 2006). Exploration of spirituality in counseling needs to be inclusive; it needs to honor the client’s own experience and to assist the client in understanding the broader meaning of personal trauma. For example, instead of getting caught in discussions about religious beliefs, which often can become impersonal debates, it is important to ask clients about their spiritual practices, such as walking in nature, praying, or meditating, which might be considered helpful during times of high anxiety or when there is a temptation to drink, use drugs, or engage in addictive behaviors. It also is important to explore spiritual experiences, values and ethical principles, relationships to spiritual teachers, connection to sacred space, and how spiritual communities (whether a meditation, church, AA group, etc.) have been or could be a resource to help people stay sober and reconnect with social supports (Burke, 2005). A clinical example is Cindy, a 48-year-old divorced mother of two, who had been sexually abused by her minister when she was a teenager. She started drinking again after one of her daughters was raped. She had been sober for 5 years and attended AA briefly but stopped going because she did not like all the “God talk.” It reminded her of church. She said that she stopped going to church after the incident with the minister; she missed the connection to people but could not go back because of what had happened. She reported that she wanted to stop drinking again, but she found it difficult to deal with all of the stress on her own. The following are some questions that helped shape the conversation about spiritual community with her: ■ What do you mean by community? ■ How might your sense of belonging to a community shape a sense of meaning

in your life? ■ How might your feeling of connection to the people in a community support

program help you take a stand against the drinking or drug use? (adapted from Burke, 2005) As a result of this exploration, Cindy decided to join a quilting group. Cindy remembered quilting with her mother when she was young, and the conversation with the clinician had ignited a feeling of warmth and safety when linked to the idea of quilting with other women. For Cindy, participation in AA was not an option that was acceptable to her but joining a quilting group of women who might provide company, a sense of spiritual connection and belonging, social support, and an alternative to drinking to alleviate stress was acceptable. The exploration of spiritual community, in an inclusive and collaborative way, supported this client with SUD and trauma

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complications; it helped her find hope, rebound from adversity, connect with a greater meaning and purpose, and reconnect with social supports that had been lost to her after the original trauma.

COUNSELING IMPLICATIONS Because of the complexity of working with clients with co-occurring issues of psychological trauma and SUDs and the demands on clinicians in high-stress treatment environments, clinicians are at risk for developing secondary trauma (signs of PTSD related to exposure to clients’ trauma material), vicarious traumatization also known as compassion fatigue (a negative shift in worldview and self-identity), burnout (the general psychological stress of working with difficult clients), and intense countertransference reactions (Burke, Carruth, & Prichard, 2006). To prevent and/or reduce the impact of secondary trauma, vicarious traumatization, burnout, and intense countertransference reactions, it is essential for clinicians to develop comprehensive personal and professional self-care plans that include a relapse prevention plan for those who are themselves in recovery from SUDs or process addictions. “Personal self-care strategies should address the mental, emotional, psychological, physical, relational, creative, and spiritual needs of the individual and professional self-care plans must include relationally based trauma therapy supervision/consultation with a focus on resolving countertransference issues” (Burke, Carruth, & Pritchard, p. 298). Although personal responsibility is important, the clinical and research literature suggests that a team approach, where members of the treatment team or supervision group share in the responsibility of caring for complex and challenging clients, can prevent or lessen the impact of secondary trauma, and intense countertransference reactions by clinicians (Burke et al., 2006). The literature also suggests that treatment agencies can support clinicians in their efforts by adopting a trauma-informed approach that normalizes secondary trauma reactions and vicarious traumatization, validates and encourages clinician self-care, and creates an atmosphere of empowerment and respect for both the client and the counselor (Arledge & Wolfson, 2001).

CONCLUSION There is a complex relationship between psychological trauma and addictive disorders. Although not every clinician who works with people with these co-occurring conditions needs to be an expert in the treatment of both, it is essential to be able to recognize the expression of both in clients and to be trauma and addiction informed. This means being able to recognize that trauma-related conditions—such as PTSD, clinical depression, and anxiety as well as symptoms like hyperarousal, interpersonal withdrawal, and intrusive reexperiencing of trauma memories—arise in treatment for SUD and process addictions once the client is no longer using such substances. These trauma-related symptoms need to be addressed in early recovery from addiction. In addition, the longterm psychological impact of trauma also must be addressed in order for people to move beyond being a “survivor” or a “recovering addict” to living satisfying and meaningful lives. A spiritually sensitive focus in counseling can aid in this meaning-making function, enhance resilience, and provide hope and reconnection to community. Hope and connection are what make life meaningful and are essential ingredients in recovery from both trauma and addictions.

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APPENDIX 13.1 Women’s Recovery Program: A Model for Women’s Treatment Maureen Keating Director of Women & Family Services, Community Health Center, Akron, OH In 1986, Community Health Center (a Northeast Ohio nonprofit organization providing substance abuse and behavioral health services to people in need) embarked on a journey to develop gender-specific treatment for women. The Women’s Recovery Program (WRP) was a groundbreaking treatment model focused on eliminating barriers to treatment that, at the time, were not even associated with the recovery process, let alone seen as affecting the success of recovery. By casting an outreach net to the homeless, to the incarcerated, and to addicted women with co-occurring disorders, the WRP was able to engage women and their children in treatment in a sustainable manner. After 3 years of operating this program, the results were staggering: the agency had a 16% increase in women treated by 1989. Fifty-two percent of the agency population was women versus only 36% the year the program began in 1986. Additionally, the WRP was serving more young women in need; 90% were younger than 34 years of age, and 78% had a family income of less than $5,000 per year (Levers & Hawes, 1990). This evidence, exhibited during the infancy of the program, solidified the WRP as the best way to treat the women who entered the agency. Fast-forward 25 years and the WRP at community health center maintains these high rates of outreach and treatment among addicted women. Practitioners in the field agree that addiction is a multifaceted issue, especially in women. Two glaring issues that women experience are the lack of healthy relationships and trauma. The WRP mission is to reach out to women and offer them a safe place to begin the process of recovery. Each staff member in the WRP is part of this “safe place” and is committed to the principles of the program. The ideals that make the WRP successful include: collaboration with the client, empowerment, self-expression, and the freedom to define what they need. Our staff believes that they can be catalysts in the treatment process by inviting the women into a team that supports them and connects them to others. A core component to WRP is outreach. We focus primarily on women of childbearing age and prioritize pregnant women. Approximately 63 pregnant women have been served in 2010, with about 90 women delivering babies free of illicit drugs in their systems. Almost half of all pregnant women served in the program are opiate addicts, and their babies are born drug affected because of medication-assisted therapy using methadone or buprenorphine, yet they are free of alcohol and illicit drugs. Our outreach specialist is known in the community by our local crisis/detox center, hospitals, high-risk clinics, pregnancy care centers, child protective services, domestic violence shelters, the courts, and many more human service agencies. Referrals also come through regular intake and word of mouth. After an initial meeting, prospective clients are invited to become consumers and are given information on how to be successful. Case management services are extended to support consumers in the engagement process as well as in continuing needed services. Case managers provide assistance for referrals to health care, family services, employment, and housing. We follow an integrated treatment model and use cognitive and affective models, depending on the client’s individual needs. Services that are provided by the WRP include first- and second-step support groups, empowering-women-in-relationship groups, (continued)

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APPENDIX 13.1 (continued) individual counseling (for substance abuse, mental health, and co-occurring disorders), and intensive outpatient treatment. Most recently, trauma-centered care has moved to the forefront of behavioral health care treatment. WRP recognized many years ago that this was a missing piece of the puzzle, because without treating the trauma in the client’s life, relapse usually was inevitable. We operate under the assumption that everyone experiences some trauma at one time or another, and that the women entering our doors are at the high end of the spectrum, either through adverse childhood events (Felitti, 2004) or the emotional or physical baggage from their lives (assault, rape, homelessness, etc.). In fact, our office is located in a separate building, keeping in mind that (a) entering into treatment itself may be a traumatic experience, and (b) when entering the main facility, there is a chance of running into drug dealers, old boyfriends/abusers, and so forth. Our WRP lobby is more like a living room, and clients are greeted in a very warm and welcoming manner. Clinicians are trained to conduct psychoeducational groups on trauma, and a specific trauma treatment group has been established. This type of women’s programming has been supported by Substance Abuse and Mental Health Services Administration (SAMHSA) through set-aside monies since 1986. Ohio has used these dollars to build a network of 69 affiliates known as the Ohio Women’s Network, Inc. (www.ohiowomensnetwork.org). Thousands of women and their children, who would have fallen between the cracks of the mental health system on one side and the addictions system on the other, have found recovery and healing in the gender-specific programs in our state. The network assists program providers in offering places of safety, sisterhood, support, learning, and empowerment. Unfortunately, economic hard times are challenging a cost-effective intervention that uses program alumnae, self-help communities, and dedicated professionals to enhance the status of women.

RESOURCES Websites National Center for PTSD (http://www.ptsd.va.gov/index.asp) The Center, funded by the US Department of Veteran’s Affairs is dedicated to research and education on the prevention, understanding, and treatment of PTSD. National Center for Trauma-Informed Care (http://www.samhsa.gov/nctic/) SAMHSA’s National Center for Trauma-Informed Care (NCTIC) is a technical assistance center dedicated to building awareness of trauma-informed care and promoting the implementation of trauma-informed practices in programs and services. National Trauma Consortium (http://www.nationaltraumaconsortium.org/) The mission of NTC is to raise public awareness about trauma and its wide-ranging impact on people’s lives. The website includes articles on substance abuse and trauma recovery and links to other resources. PILOTS (Published International Literature on Traumatic Stress) Database (http://www.ptsd.va.gov/ professional/pilots-database/pilots-db.asp) The Published International Literature on Traumatic Stress (PILOTS) database is an electronic index to the worldwide literature on post-traumatic stress disorder (PTSD) and other mental-health consequences of exposure to trauma. It is free and available to the public.

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Seeking Safety (http://www.seekingsafety.org/) Seeking Safety is a present-focused therapy developed by Lisa Najavits to help people attain safety from trauma/PTSD and substance abuse. This website includes articles and training materials on the Seeking Safety model. Substance Abuse and Mental Health Services Administration (SAMHSA) (http://www.samhsa.gov) SAMHSA’s goal is to improve the quality and availability of substance abuse prevention, alcohol and drug addiction treatment, and mental health services. This website includes links to support groups, information resources, events, and articles. Films and Videos Insight Media (Producer). (2000). Substance abuse [DVD]. Insight Media (Producer). (2006). Addiction and the human brain [DVD]. Insight Media (Producer). (2006). Understanding addictions [DVD].

REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed., Rev. ed.). Washington, DC: Author. Arledge, E., & Wolfson, R. (2001). Care of the clinician. In M. Harris & R. D. Fallot (Eds.), Using trauma theory to design service systems (pp. 91–98). San Francisco, CA: Jossey-Bass. Brady, K. T., Back, S. E., & Coffey, S. F. (2004). Substance abuse and posttraumatic stress disorder. Current directions in psychological science, 13 (5), 206–209. Burke, P. A. (2005, May). Circle of meaning: A narrative tool for exploring the multi-dimensional nature of spirituality. Counselor: The magazine for addiction professionals, 6(3), 22–28. Burke, P. A. (2006). Enhancing hope and resilience through a spiritually sensitive focus in the treatment of trauma and addiction. In B. Carruth (Ed.), Psychological trauma and addiction treatment. New York, NY: Haworth Press. Burke, P. A., Carruth, B., & Prichard, D. (2006). Counselor self-care in work with traumatized, addicted people. In B. Carruth. (Ed.), Psychological trauma and addiction treatment. New York, NY: Haworth Press. Carroll, M. M. (1998). Social work’s conceptualization of spirituality. Social thought: Journal of religion in the social services, 18 (2), 1–13. Coombs, R. H. (2004). Handbook of addictive disorders: A practical guide to diagnosis and treatment. Hoboken, NJ: Wiley. Donovan, D. M., Kadden, R. M., DiClemente, C. C., & Carroll, K. M. (2002). Client satisfaction with three therapies in the treatment of alcohol dependence: Results from project MATCH. The American Journal on Addictions, 11(4), 291–307. Felitti, V. J. (2004). The origins of addiction: Evidence from the Adverse Childhood Experiences study. Retrieved from http://www.acestudy.org/files/OriginsofAddiction.pdf Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New York, NY: Basic Books. Levers, L. L., & Hawes, A. R. (1990). Drugs and gender: A women’s recovery program. Journal of Mental Health Counseling, 12, 527–531. McFarlane, A. C., & van der Kolk, B. A. (1996). Trauma and its challenge to society. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 24–46). New York, NY: Guilford Press. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York, NY: Guilford Press. Najavits, L. M. (2006). Seeking safety: Therapy for posttraumatic stress disorder and substance use disorders. In V. M. Follette & J. I. Ruzek (Eds.), Cognitive-Behavioral therapies for trauma (2nd ed., pp. 228–257). New York, NY: Guilford Press. Najavits, L. M., Ryngala, D., Back, S. E, Bolton, E., Mueser, K. T., & Brady, K. T. (2008). Treatment of PTSD and comorbid disorders. In E. B. Foa, T. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed., pp. 508–535). New York, NY: Guilford Press.

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National Council on Alcoholism and Drug Dependencies. (1999, January 19). Religious involvement reduces substance abuse. NCADD News. Project MATCH Research Group. (1998). Matching patients with alcohol disorders: Clinical implications from Project MATCH. Journal of Mental Health, 7(6), 589–602. Turner, S. W., McFarlene, A. C., & van der Kolk, B. A. (1996). The therapeutic environment and new explorations in the treatment of posttraumatic stress disorder. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth. (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 537–558). New York, NY: Guilford Press. van der Kolk, B. A. (1989). The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatric Clinics of North America, 12(2), 389–411.

CHAPTER 14

Criminal Victimization LAURENCE MILLER

INTRODUCTION Although almost any kind of violence can happen to anyone, certain types of criminal victimization appear to be relatively common in the clinical practice of trauma counselors. These are discussed briefly in the following sections: Criminal Assault; Sexual Assault; Theft and Robbery; Crime in the Community; and Real Crime, Fear of Crime, and The “Mean World Syndrome.”

Criminal Assault Each year, more than 25 million Americans are victimized by some form of crime. Rapes, robberies, and assaults account for 2.2 million injuries and more than 700,000 hospital stays annually. Although the most violent crimes are committed by family members or close associates of the victim (Bidinotto, 1996; Herman, 2002; Kirwin, 1997; Miller, 2008c, in press-b), what most people fear most is an attack by a malevolent stranger. Several diagnosable psychiatric syndromes may be seen following criminal assault. Depression, anxiety, posttraumatic stress disorder (PTSD), and substance abuse are common psychological disorders found in victims of robbery, rape, and burglary, and a high proportion of panic attacks trace their onset to some traumatically stressful experience. About half of crime-induced PTSD cases persist after 3 months, and clinical experience suggests that such traumatic effects may last for years or longer in some victims. Men appear to be subject to economic assaults, such as muggings and robberies, in similar situations as women but are far less likely to be subject to sexual assault. However, it may be more difficult for a man to report any kind of assault for fear of shame, ridicule, or disbelief (Breslau, Davis, Andreski, & Peterson, 1991; Breslau et al., 1998; Davis & Breslau, 1994; Falsetti & Resnick, 1995; Frank & Stewart, 1984; Hough, 1985; Kilpatrick & Acierno, 2003; Norris, 1992; Resnick, Acierno, & Kilpatrick, 1997; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993; Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992; Saunders, Kilpatrick, Resnick, & Tidwell, 1989; Uhde et al., 1985). One of the realities of doing crime victim work is the realization that perpetrators and victims do not come in neat, separate, and diametrically opposed packages. Whereas some victims are targeted through no fault of their own, others may lead questionable or marginal lifestyles that all too often put them in the wrong place at the wrong time. Women who work in the adult entertainment industry may be targeted for sexual assault by males who feel “entitled” to have sex with women in these trades. People

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looking to buy or sell drugs may be assaulted and robbed. Members of a rival gang may be assaulted for straying into alien territory or in retaliation for real or imagined aggression of their own. In such cases, counselors may have to negotiate the delicate task of suspending moral judgment in order to form a successful treatment relationship, while at the same time forthrightly addressing the risky behavior to prevent (as much as possible) a repeat of the victimization (Miller, 2008c, in press-b).

Sexual Assault Sexual assault affects one fourth of women and up to 7% of men, and is associated with significantly increased risk of anxiety, depression, substance abuse, and PTSD (Elliott, Mok, & Briere, 2004; Resick, 1993). As with all traumas, individual differences account for the severity of PTSD symptoms after sexual assault (Bowman, 1997, 1999). In particular, the PTSD symptoms of women who perceive negative events as uncontrollable tend to be more severe than women who believe that they have some ability to predict and control what happens to them (Kushner, Riggs, Foa, & Miller, 1993). In addition to the general effects of crime victim trauma, some authorities have characterized the relationship between sexual violence and health as the radiating impact of violent victimization (Macy, 2007; Riger, Raja, & Camacho, 2002). In this conceptualization, violence influences women’s physical and mental health, as well as radiating out to affect careers, friendships, families, and whole communities. Despite this impact, a surprisingly small number of sexual assault victims seek mental health services for problems related to their assault (George, Winfield, & Blazer, 1992; Golding, Siegel, Sorenson, Burnam, & Stein, 1989; Ullman, 2007).

Theft and Robbery Although typically not lethal, to steal something from another person constitutes a fundamental violation of that person’s dignity and bespeaks a callous disregard for his or her rights as a human being. This is why most of us react with that burning sting of outrage upon being tricked or strong armed out of what we believe is rightfully ours. Theft refers to the illicit appropriation of resources that rightfully belong to someone else—in other words, someone taking what is not theirs. Although technically frowned upon in all cultures and considered a crime in societies with formal legal systems, it is nevertheless a cultural universal, occurring frequently in all human groups, as well as in many other animal species (Kanazawa, 2008). More than 90% of theft and robbery crimes are committed by men, especially those who are poor, less intelligent, and have less education (Herrnstein & Murray, 1994; Kanazawa, 2004, 2008; Kanazawa & Still, 2000; Miller, in press-b; Wilson & Herrnstein, 1985). Burglaries involve breaking into a structure to steal something, usually without physical confrontation, although some burglaries can turn violent if the thief is surprised by the occupants. Some criminals also combine burglary with rape. Burglaries make up 11% of all thefts, and burglars are typically young males of low educational and socioeconomic status, with histories of substance abuse and other criminal behavior. The skill level of burglars can range from rank amateurs, such as bored teens breaking into a private residence to professionals who hit wealthy homes or businesses that contain valuable items or large amounts of cash. Most private dwellings are burglarized during the day when occupants are likely to be out, whereas businesses are typically struck at night. Some burglars report experiencing a thrill or rush at breaking into a dwelling and stealing items. This thrill may take on a frankly sexual nature in the case of fetish burglaries in which intimate items are stolen, or in more violent cases, where

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rape accompanies the burglary. Some burglars may urinate, defecate, or masturbate in the burgled dwelling or otherwise vandalize the premises. Where the criminals force their way into the dwelling by overpowering the occupants, this is referred to as a home invasion (Bureau of Justice Statistics, 2003, 2006; Conklin, 1992; Miller, in press-b; Palermo & Kocsis, 2005; Pitts, 2001).

Crime in the Community The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association [APA], 2000) recognizes that posttraumatic stress reactions can occur in persons who observe terrible events happening to others, even if they are not directly affected, including witnessing crimes of violence or threats of violence against others. Indeed, certain segments of the population may be exposed to traumatically stressful events on a fairly regular basis, for example, residents of crime-ridden and socioeconomically depressed inner-city neighborhoods. Precipitating events include sudden injuries, serious accidents, physical assaults, and rape, as well as having one’s life threatened, receiving news of the death or injury of a close friend or relative, narrowly escaping injury in an assault or accident, or having one’s home destroyed in a fire. Many of these individuals experience anxiety, depression, cognitive impairment, medical symptoms, and PTSD that persist for a year or longer. Furthermore, this appears to produce a vicious cycle—the so-called “cycle of violence”—with victims of aggression showing more aggression toward others (Breslau & Davis, 1992; Breslau et al., 1991, 1998; Garbarino, 1997; Scarpa, 2001; Scarpa & Haden, 2006; Scarpa et al., 2002).

Real Crime, Fear of Crime, and the “Mean World Syndrome” Inasmuch as most of the general public have little direct experience with crime, our beliefs about crime and the criminal justice system are largely based on what we see on TV and read in the newspapers or online, where sensational and violent crimes are often overrepresented, leading to a type of media-induced trauma known as mean world syndrome (Budiansky, Gregory, Schmidt, & Bierk, 1996). This may have the paradoxical effect of oversensitizing people to nonexistent or insignificant threats, while at the same time numbing the public’s understanding of the true impact of crime victimization when it does occur (Miller, 1995, 2008c; Miller & Dion, 2000; Miller, Agresti, & D’Eusanio, 1999).

THE PSYCHOLOGY OF CRIME VICTIMIZATION Russell and Beigel (1990) conceive of crime victimization as comprising several layers in relation to a person’s core self: property crime, like burglary and vandalism, generally hurts victims at the outermost self-layer, that is, their belongings, although the theft or destruction of certain meaning-laden family heirlooms can have a much greater emotional impact. Armed robbery, which involves personal contact with the criminal and threat to the physical self of the victim, invades a deeper psychological layer, while assault and battery penetrates still deeper, injuring the victim both physically and psychologically. Rape goes to the very core of the self, perverts the sense of safety and intimacy that sexual contact is supposed to have, and affects the victim’s basic beliefs, values, emotions, and sense of security in the world. Society’s response to crime also plays a role in how supported or abandoned victims feel (Russell & Beigel, 1990). For example, society often regards victimization

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as contagious. In modern American culture, with its emphasis on fierce competition for limitless success and the perfect life, victims are often equated with losers. Most of us want to believe that crime victimization is something that happens to somebody else. The victim must have done something to bring it on himself or herself, otherwise, “I’m just as vulnerable too, and who wants to believe that?” We may thus be reluctant to empathize or associate with crime victims for fear that their bad luck will “rub off.” All of these beliefs and reactions further contribute to the feelings of blame and shame that many crime victims experience (Miller, 1996a, 1998a, 1998b, 2001a, 2007b).

CRIME VICTIMIZATION: THERAPEUTIC AND COUNSELING GUIDELINES Proper psychological intervention with crime victims ideally takes place at three levels and at three points in time: (a) at or close to the crime scene itself, involving crisis intervention and short-term psychological stabilization; (b) intermediate-level stress management and symptom-reduction strategies to allow the crime victim to achieve a sense of normalcy and control; and (c) more extensive counseling and therapy to help the victim work through the traumatic event and regain a sense of existential groundedness (Miller, 1998a, 1998b, 2008c).

On-Scene Crisis Intervention: Guidelines for First Responders Ideally, effective mental health intervention for crime victims begins the moment the first responders arrive. For most crimes, this consists of police and paramedics, sometimes accompanied by a special mental health trauma clinician. In other cases, the first mental health contact occurs in the emergency room if the victim is taken to a hospital. Whoever the first responders are, they need to be aware that they are in a unique position to help the crime victim deal with the impact of his or her ordeal and to help restore a sense of safety and control to an otherwise frightening and overwhelming situation (Herman, 2002; Miller, 2000, 2008c, 2010). First responders may face a confusing scenario when arriving at a crime scene. Traumatized victims may be in a state of shock and disorientation during the initial stage of the crisis reaction, feeling helpless, vulnerable, and frightened. Other victims may manifest fight-flight-or-freeze panic, and some may actually try to flee the crime scene. Some victims may be confrontational or combative with arriving police or paramedics, adding to the confusion as to who is the victim and who is the offender; this is most likely to occur in cases of barroom brawls, domestic disturbances, or neighbor disputes. In some instances, virtual physical and emotional paralysis may occur, rendering the victim unable to make rational decisions, speak coherently, or even move purposefully, much less seek medical attention or report the incident to the police. Balancing concern for victim welfare and the need to obtain detailed information thus becomes a delicate dance and requires some degree of interpersonal skill on the part of the interviewer. The following subsections offer some practical recommendations for first responders who have to deal with crime victims on scene (Clark, 1988; Frederick, 1986; Miller, 1998a, 1998b, 2006b, 2010; Silbert, 1976).

Introduce Yourself As soon as you arrive, identify yourself by name and full title to the victim and bystanders. Even with a uniform or ID tag, you may need to repeat the introduction several times; victims who are still in shock may respond to you as if you are the criminal, especially if you arrived quickly on the scene, unintentionally heightening

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their shock and disorientation. Children traumatized by adults may respond with fear to any new adult in their environment.

Apply Medical First Aid It is typically the job of paramedics to render emergency medical care. But even as a mental health counselor, if you are one of the first responders on the scene, you may be the only one available to apply basic first aid until further medical help arrives. For whoever carries out this task, calmly explain to the crime victim what you are doing, especially when you are touching the victim or doing an otherwise intimate procedure, such as applying a breathing mask or removing clothing. If possible, encourage the victim to help you treat her, if she is capable and wants to, by having her hold a bandage or letting her undo her own clothing in order to afford some sense of control.

Respect the Victim’s Wishes When feasible, allow a requested family member or friend to remain with the victim during medical treatment or questioning by the police. If the present officer makes the victim uncomfortable, try to have a less threatening backup officer fill in for the questioning (e.g., a female officer for a rape victim; an ethnically or culturally familiar officer for a minority victim).

Validate the Victim’s Reactions Always try to normalize and validate the traumatic ordeal the victim has just been through and, as realistically as possible, reinforce his or her resilience and coping efforts thus far. In general, build on the victim’s own resources to increase his or her feelings of self-efficacy and control, for example: “I can see this must have been a terrible experience for you; most people would be feeling pretty much like you are under these circumstances, but I’m glad to see you’re handling it as well as you are.”

Investigate Sensibly and Sensitively Police typically prefer to interview crime victims as soon as possible to obtain fresh information that can be used to apprehend and prosecute the offender. Mental health clinicians who are on scene can assist and advise law enforcement personnel in these actions. This includes avoiding even unintentional accusatory or incriminatory statements, such as “What were you doing in that building so late at night?” A sympathetic, supportive, and nonjudgmental approach to law enforcement interviewing can do much to restore the crime victim’s trust and confidence and thereby facilitate all aspects of the criminal investigation (Miller, 2006b, 2008c, 2010).

Present a Plan Related to the issue of restoring control is having some kind of clear plan to provide further structure and order to an otherwise overwhelming situation. Such a plan needs to be backed up with concrete suggestions for action: “We’re going to move to a safe area and have the medics take care of these cuts; then I’m going to ask you a couple of questions, if that’s all right. After I’m done, I’m going to explain what happens next in the police process and legal area, and then I’ll give you a card with some phone numbers of Victim Assistance agencies you can contact. I’m also going to give you my card, and you can contact me at any time for any reason. Do you understand? Do you have any questions?”

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Employ Humor Judiciously A well-placed witticism may put some perspective on the crisis and ease an otherwise tense situation, but traumatized people tend to become very literal and concrete under stress, and well-meaning humor may be mistaken for mocking or lack of serious concern. As with all such recommendations, use your clinical judgment.

Utilize Interpersonal Calming and Coping Techniques Never overlook the interpersonal power of a reassuring presence, both verbally and physically. Project a model of composure for the victim to emulate. Eye contact should be neither a detached glance nor a fixed glare, but more of a concerned, connected gaze. Stand close enough to the victim to provide proximal contact comfort, but do not crowd or intimidate by invading the victim’s personal space. Use physical touch carefully. Sometimes, a brief pat on the shoulder or comforting grasp of the hand can be very reassuring, but it may frighten a victim who just has been physically assaulted. Take your cue from the victim.

SYMPTOM MANAGEMENT AND SHORT-TERM MENTAL HEALTH STABILIZATION Clinicians often wonder, “When does crisis intervention end and ‘real’ psychotherapy begin?” However, the border between short- and long-term therapies is a fluid one, as is the line between so-called superficial and deep therapies. Much depends on the client. For example, helping a crime victim gain control of his or her bodily reactions—panic attacks, churning gut, and so forth—in the days and weeks following a physical beating, armed robbery, hostage scenario, or sexual assault may be an essential first step toward tackling the issues of safety and predictability that are raised in more extensive traditional trauma therapy. For other victims, even a cursory attempt to deal with symptoms must await the achievement of some degree of therapeutic confidence and stability. For many clients, this is a reciprocal cycle, with small increments in confidence permitting small steps toward symptom control, which in turn produce greater confidence and further attempts at mastery, and so on. Still in other cases, clients may come to understand that although symptoms may be managed and controlled, they may never completely disappear but can be relegated to the background of consciousness, like “mental shrapnel” that only aches on occasion (Everstine & Everstine, 1993; Matsakis, 1994; Miller, 1994b, 1998b).

Modulating Arousal The following sections present a flexible menu of cognitive behavioral symptom-control techniques that I have culled from diverse areas of practice and have used with diverse clinical populations, including crime victims, accident victims, law enforcement critical incident stress, military psychology, sports psychology, and others (Miller, 1989a, 1989b, 1994a, 2006a, 2006b, 2008a, 2008b, 2008c, in press-a). More extensive descriptions of these strategies may be found in Miller (2006b, 2008b, 2008c).

Progressive Muscle Relaxation For more than half a century, the technique of progressive muscle relaxation (Jacobson, 1938) has been the standard recipe of stress management and is by now so well-known that it only needs to be summarized here. The basic rationale is that much of what we

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experience as uncomfortably heightened arousal arises out of feedback from tensed muscles and other bodily signals of arousal. Essentially, then, the progressive relaxation exercise focuses on one muscle group or body area at a time and guides the subject through an alternate tense-and-relax sequence until all major muscle groups are in a state of relative physiological quiescence. This is typically combined with slow, steady, and diaphragmatic breathing (deep stomach breathing as opposed to shallow chest breathing) and one or more mental cuing or imagery techniques (see on the following texts) to further induce a state of psychophysiological calm. The technique is first practiced in a peaceful, stress-free environment, such as in the therapist’s office or in stress management class, guided by the clinician’s or instructor’s soothing words or by the use of a commercially prepared or custom-made relaxation tape or CD. Later, with continued practice in a variety of settings and conditions, the traumatized crime victim should be able to self-induce the relaxed state on his or her own, in his or her natural environment, without external prompting, and without having to go through the whole tense-and-relax sequence each time. As an example, he or she can use it while sitting in traffic or at his or her desk at work.

Cued Relaxation Once the progressive relaxation procedure has been practiced and mastered, many individuals are able to employ a kind of instant relaxation or cued relaxation technique. By voluntarily reducing muscular tension, taking a calming breath, and using a cue word, the subject learns to lower his or her physiological arousal immediately and thereby induce a more calm and focused mental state. The cue word or phrase may range from the spiritual (“God is with me”; “Om”) to the mundane (“Chill”; “Okay, I’m good”) and is basically any word or phrase that the subject has learned to associate with the full relaxation response and that he or she can now say to himself or herself to signal his or her body to relax. Similarly, a cue image is any mental scene the subject can invoke that has a calming effect, especially by virtue of having been paired with the initial relaxation response practice. Have your client pick the modality or technique that works best for him or her: the key is to invoke some cue that enables the client to quickly and voluntarily lower his or her arousal level to a degree that is appropriate for the situation he or she is in (Hays & Brown, 2004; Miller, 1994a, 2006a, 2008b, 2008c).

Centering This is a technique derived from Eastern meditation (Asken, 1993) that involves combining diaphragmatic breathing with a centering cue image. The instruction to the client is as follows: “Begin by taking a slow, deep diaphragmatic breath. As you breathe out, slowly let your eyes close (or remain open if this is more comfortable for you) and focus your awareness on some internal or external point, such as your lower abdomen or an imaginary spot on the wall. Repeat this process until you feel yourself becoming calmer.” As with all of these techniques, increased practice yields greater proficiency.

Mindfulness For some people, “trying to relax” is a contradiction in terms: the more they try to force themselves to relax, the more tense they get. That’s because, by definition, relaxation is something you have to learn to let happen, not something you can make happen, and some individuals are just too challenged by the process to allow this to take place comfortably, especially following a traumatic crime victimization, where “relaxation”

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may connote letting one’s guard down and becoming more vulnerable. In mindfulness training (Kabat-Zinn, 1994, 2003; Marra, 2005), the individual makes no conscious effort to relax, but simply allows himself or herself to take in the sensations and images in the surrounding environment without trying to control them. Eventually, by taking the demand element out of the process, relaxation often will occur as a beneficial side effect. This technique may be especially useful with crime victims who already have enough to feel ashamed about without having to face the prospect of “failing” a relaxation assignment. Mindfulness training allows productive engagement with a therapeutic exercise that has as little demand as possible, thus allowing whatever small progress occurs to be counted as a step in the right direction.

COUNSELING AND PSYCHOTHERAPY OF CRIME VICTIMS Effective as they are, therapeutic symptom-reduction strategies have their limitations in dealing with the full cognitive and emotional range of posttraumatic stress reactions and bringing about a reintegrative healing of the personality after crime victimization. For many victims, some form of constructive confrontation with the traumatic experience and its meaning has to take place in order to achieve a workable degree of mastery and resolution (Miller, 1998b, 2008b). Bear in mind that symptom-oriented therapies and reintegrative therapies are not mutually exclusive; in fact, they reinforce each other, that is, sometimes, sufficient therapeutic trust, ego bolstering, and self-mastery through self-control must take place to lay the groundwork for more detailed direct exploration of the traumatic event itself (Brom, Kleber, & Defares, 1989; Everstine & Everstine, 1993; McCann & Pearlman, 1990).

Counseling and Therapeutic Strategies As used here, a therapeutic strategy refers to an overall approach or game plan for addressing a problem or therapeutic issue, whereas a therapeutic technique is the actual nuts-and-bolts practical application of that strategy. For example, one strategy may be to help a victim feel more comfortable interacting with coworkers from the same ethnic group as his or her attacker by increased positive interaction with these peers. Specific techniques would include relaxation training, rehearsal and role-playing exercises, and gradually increasing time spent in interaction with these coworkers. In general, the effectiveness of any therapeutic strategy is determined by the timeliness, tone, style, and intent of the intervention. Effective psychological interventions with crime victims include the components discussed briefly in the succeeding subsections (Blau, 1994; Fullerton, McCarroll, Ursano, & Wright, 1992; Miller, 1994b, 1998a, 1998b, 2006b, 2008c; Wester & Lyubelsky, 2005).

Create a Sanctuary One essential component of the therapeutic environment should be to provide a feeling of safety. The crime victim should be assured that what he or she says will be used only for the purposes of his or her healing and strengthening. Indeed, once the initial wariness passes, many victims report that they find the counselor’s office a refuge— perhaps the only refuge—from the legal and family stresses that swirl around them in the wake of the crime, the only place where they can be “real.” Of course, the limits of confidentiality must be carefully explained to the client, as she probably will be involved in legal proceedings, and the counselor’s records may be subpoenaed or the counselor may be called to testify in court (Miller, 1996b, 2001b, 2007a, 2009).

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Focus on Critical Areas of Concern As with the general emphasis on quick mobilization of therapeutic gains and the client’s sense of self-control, crime victim psychotherapy initially should be goal directed. It should remain focused on resolving specific adaptation and recovery issues related to the crisis at hand, which is a corollary of the next principle.

Specify Desired Outcomes In the beginning, the clinician needs to help the crime victim to operationalize these therapeutic objectives, in line with the emphasis on achieving practical goals. For example, the patient might state, “I’d like to feel more at ease with my work and my family.” The therapist can help him to objectify this general desire to more specific and achievable goals, such as, “I want to reduce the number of intrusive thoughts about the attack to a level where I can ride to work without panicking at each red light,” or “I’d like to be able to step back for a few seconds to regain my composure before I blow up at my wife and kids again over nothing.” Of course, few distraught clients will come to the first session with a preset list of concrete goals; indeed, traumatized victims often are confused initially about what they hope to accomplish in therapy (e.g., “I just want the pain to go away,” “I just want to be able to sleep,” “I just want to think clearly.”). In the early phases, then, it is primarily the counselor’s task to help the victim sort out, focus, and operationalize his or her goals so that there can be a way of assessing if the therapy process is accomplishing them. Once again, without being overly rigid, specifying a doable goal and then setting to work on it, can serve to focus and empower the out-of-control client.

Develop a General Plan From the first session, after one or more workable goals have been elaborated, develop an initial game plan that can be modified as you go along. All the details need not be worked out at this point, and most likely, the plan will be revised as new information comes in. But you have to start somewhere, so develop a general road map that allows you to identify implementation and self-efficacy strategies.

Identify Practical Initial Implementations Hit the ground running: begin interventions as soon as possible. This induces confidence quickly, motivates further progress, and allows you to get valuable feedback from initial treatment efforts thus far that can guide further interventions.

Review Assets and Encourage Self-Efficacy Consistent with the overarching aim of posttraumatic psychotherapy as a strengthening, not weakening, process, it is as important to know what personal strengths and resources the client has as it is to understand his or her vulnerabilities. Always strive to capitalize on strengths to overcome or work around weaknesses.

Counseling and Therapeutic Techniques Adapted and expanded from psychological work with public safety personnel, the following therapeutic intervention techniques also have been found effective in working with traumatized crime victims (Blau, 1994; Miller, 1998b, 2000, 2006b, 2008b, 2008c;

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Miller & Dion, 2000; Silva, 1991). As always, clinicians should adapt and improvize these guidelines to the specific needs of their individual patients.

Attentive Listening Attentive or active listening is a basic counseling skill. It includes good eye contact, appropriate body language, genuine interest, and interpersonal engagement, without inappropriate comment or unnecessary interruption.

Empathic Presence Empathic presence is a therapeutic attitude that conveys availability, concern, and awareness of the disruptive emotions being experienced by the traumatized, distressed crime victim. Several victims have commented that they were put off by their counselor’s detached, clinically aloof demeanor and did not feel as if the clinician really was prepared to engage them. Some of this may have to do with countertransference, vicarious traumatization, and emotional contagion issues on the part of the counselor (McCann & Pearlman, 1990; Pearlman & MacIan, 1995). Alternatively, some victims may be unusually demanding of the counselor’s time and devotion, necessitating the setting of realistic limits, while still retaining empathic engagement.

Reassurance In acute stress situations, this should take the form of realistically reassuring the crime victim that routine matters will be taken care of, deferred responsibilities will be handled by others, and that the victim has the support of his or her family, the mental health clinician, and the criminal justice system. It is also helpful to let the victim know in a nonalarming manner what he or she is likely to experience in the days, weeks, and months ahead. How much information is to be imparted, at what pace, and at what stages in the treatment process, should be carefully calibrated to the patient’s recovering ego strength in order to avoid retraumatization. The key is to balance realism with reassurance.

Supportive Counseling This includes active listening, restatement of content, clarification of feelings, and validation. It also may include such concrete services as community referral and networking with liaison agencies, if necessary.

Interpretive Counseling This type of intervention should be used when the crime victim’s emotional reaction is significantly greater or reaches into wider areas of the subject’s life than the circumstances of the critical incident seem to warrant. In appropriate cases, this therapeutic technique can stimulate the victim to explore underlying emotional, personality, or psychodynamic issues that may be intensifying a naturally stressful traumatic event (Horowitz, 1986). In a few cases, this may lead to continuing, ongoing psychotherapy for broader life issues. Be careful, however, that you do not reflexively attribute any atypical reaction of the crime to his or her criminal victimization as stemming from “unresolved” childhood issues. These may well be important, but be sure you understand what is happening in the here-and-now before delving into past dynamics.

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Humor Humor has its place in many forms of psychotherapy (Fry & Salameh, 1987) but may be especially useful in working with some traumatized crime victims (Fullerton et al., 1992; Henry, 2004; Miller, 1994b, 1998a, 1998b, 2006b, 2008c; Silva, 1991). In general, if the therapist and client can enjoy a laugh together, this may lead to the sharing of more intimate feelings. Humor serves to bring a sense of balance, perspective, and clarity to a world that seems to have been warped and polluted by malevolence and horror. “Show me a man who knows what’s funny,” Mark Twain said, “and I’ll show you a man who knows what’s not.” However, it is usually wise to maintain proper boundaries regarding destructive types of self-mockery or inappropriate projective hostility on the patient’s part. This may occur in the form of sleazy, cynical, or mean-spirited sniping, character assassination, or self-deprecation. Also remember that many traumatized individuals tend to be quite concrete and suspicious at the outset of therapy, and certain well-intentioned kidding and cajoling may be perceived as insulting to the crime victim or dismissive of the seriousness of his or her plight; always know your client and take your cue from him or her.

Utilizing Cognitive Defenses In psychology, defense mechanisms are the mental stratagems the mind uses to protect itself from unpleasant thoughts, feelings, impulses, and memories. Although the normal use of such defenses enables the average person to avoid conflict and ambiguity and maintain some consistency to his or her personality and belief system, most mental health clinicians would agree that an overuse of defenses to wall off too much unpleasant thought and feeling can lead to a rigid and dysfunctional approach to coping with life. Accordingly, much of the work in traditional psychotherapy involves carefully helping clients to relinquish their pathological defenses so that they can learn to deal with internal conflicts more constructively. However, in the face of acutely traumatizing experiences, the last thing the affected person needs is to have his or her defenses stripped away. For an acute psychological trauma, the proper use of psychological defenses can serve as an important “psychological splint” that enables the person to function in the immediate posttraumatic aftermath and eventually be able to productively resolve and integrate the traumatic experience when the luxury of therapeutic time can be afforded (Janik, 1991). In many cases, the clinician discovers that traumatized crime victims need little help in applying defense mechanisms on their own (Durham, McCammon, & Allison, 1985; Henry, 2004; Taylor, Wood, & Lechtman, 1983). Examples of common defenses— all of which can have both constructive and maladaptive effects, depending on how they are used—include the following. Denial: “I’m just going to put it out of my mind, focus on other things, and avoid situations or people who remind me of it.” Rationalization: “I had no choice; things happen for a reason; it could have been worse; other people have it worse; most people would react the same way I am.” Displacement/ projection: “It was my boss’s fault for sending me down to the basement so late at night; the police took forever to respond to the 911 call; the district attorney is going soft on this case because of politics.” Refocusing on positive attributes: “This was an isolated event—I’m usually a cautious, capable person. I’m a smart, strong person; I can get through this.” Refocusing on positive behaviors: “Okay, I’m going to follow safety procedures more carefully and talk to management about getting better security around here. I’m going to advocate for more safety training so nothing like this happens to anyone here again.”

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Where necessary, at least in the short term, counselors should know when to actively support and bolster psychological defenses that temporarily enable the traumatized crime victim to continue functioning (Janik, 1991). Only when defenses are used inappropriately and for too long, when they begin to hold the crime victim back from facing his or her fears and reentering the world, should we gently confront the now-maladaptive aspects in an atmosphere of safety and support (Miller, 1998b, 2008c).

Existential Issues, Therapeutic Integration, and Closure In virtually every case of significant trauma, the victim struggles with shattered assumptions and fantasies about fairness, justice, security, and the meaning of life, and it is part of the essential task of psychotherapy to help him or her come to terms with these existential issues. Some clients obsess over what they did or should have done to avoid or escape more serious harm or to help other people, and with these individuals, the therapeutic task becomes one of reorienting these clients to a more realistic state of self-acceptance. Many clients need to pass the anniversary date of the traumatic event, especially when their trauma was severe, before they can begin to bring the trauma response to closure. The process of simultaneously externalizing and integrating the crime trauma allows the last stages of recovery to take place. As the client approaches closure, the therapist can help him or her form a newly realistic and adaptive self-image, which becomes the foundation for a healthy future (Calhoun & Tedeschi, 1999; Everstine & Everstine, 1993; Rudofossi, 2007; Tedeschi & Calhoun, 2004; Tedeschi & Kilmer, 2005). Indeed, the diversity of human personality and the variation in severity and circumstances of the traumatic event virtually guarantee that different victims will have different reactions and that the therapeutic outcomes will vary as well. Thus, posttraumatic integration can be approached from one or more of three main perspectives (Everly, 1994, 1995), and these are described briefly on the following texts.

Trauma Integrated Into the Client’s Existing Worldview The message here is that these things happen—people do hurt other people—but that the victim is not helpless or hopeless because there are certain precautions one can take to minimize the risk of this happening in the future. Such a message allows the person to feel reasonably safe again.

Trauma Understood as a Parallel Aspect of the Existing Worldview That is, an “exception to the rule.” According to this interpretation, society sets up laws and structures to keep most of us safe most of the time, so this tragedy, while certainly awful, is really an isolated incident that, most likely, never will happen to the same person again. Of course, this must be realistically based; as noted earlier in some communities, risk of repeated exposure to crime is a grim reality that must be respected.

Trauma Illustrates the Need to Create a New and Modified Worldview The trauma can be used to demonstrate the invalidity of the client’s existing perspective and the need to construct an alternative one in which the trauma more readily fits. For example, the assault shows the victim that the world is not entirely filled with good people, that justice does not always work out, and that sometimes the innocent suffer and the guilty go free. But you can fashion a new way of looking at things that encourages both realism and cautious optimism; you can learn to be clear headed, even skeptical, about human nature and motives but without allowing yourself to turn into a soul-shriveled cynic.

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I have found that the subject’s personality has a strong effect on which integrative strategy is most effective. For example, predominantly externalizing clients seem to adhere to the once-in-a-lifetime “lightning does not strike twice” type of explanation, putting their trust in fate or God or sheer statistical improbability. The “what can I personally do to keep this from happening again” type of reframe appeals more to clients who already possessed a degree of self-efficacy before the trauma and are therefore willing and able to try to solve problems by their own efforts once the therapist shows them the way. Still, others may blend various perspectives together. Finally, counselors must be mindful of victims who suffer from enhanced integration of the traumatic theme into their self-concept and life narrative (Berntsen & Rubin, 2007). For these individuals, the crime victimization becomes the exclusive focal point of their entire existence, and their lives become a ceaseless search for validation of their martyrdom. For such clients, the therapeutic emphasis must be on emotionally decoupling from the traumatic victimization and finding non-crime–related activities that encourage these individuals to resume a “civilian” life. In such circumstances, these clients may subtly or overtly shift gears to another alleged source of their woundedness and betrayal, such as family traumas, illness, or disability. Alternatively, they may quit treatment with you and start over with another, more sympathetic, counselor, until that relationship sours as well, and so on. Existential treatment strategies that focus on a quest for meaning may productively channel the worldview conflicts generated by the trauma event, such as helping the client to formulate an acceptable “survivor mission” (Shalev, Galai, & Eth, 1993). Indeed, in the best cases, the rift and subsequent reintegration of the personality leads to an expanded self-concept and even a new level of psychological and spiritual growth (Bonanno, 2005; Calhoun & Tedeschi, 1999; Tedeschi & Calhoun, 1995, 2004; Tedeschi & Kilmer, 2005). Some trauma survivors are thus able to make positive personal or career changes out of a renewed sense of purpose and value in their lives. Of course, not all crime victims are able to achieve this successful reintegration of the ordeal, and many may struggle with at least some vestige of emotional damage for a long time, perhaps for life (Everstine & Everstine, 1993; Matsakis, 1994; McCann & Pearlman, 1990). Therefore, the main caution about these transformational therapeutic conceptualizations is that they be presented as an opportunity, not an obligation. The extraction of meaning from adversity is something that ultimately must come from the crime victim himself or herself and not be foisted on him or her by the therapist. Such forced existential conversions are usually motivated by a need to reinforce the therapist’s own meaning system, or they may be part of what I call a therapeutic “Clarence-the-angel fantasy” (Miller, 1998b), wherein the enlightened counselor swoops down and, by virtue of the clinician’s brilliantly insightful ministrations, rescues the client from his or her darkest hour and gives him or her a proverbial new lease on life. Realistically, we can hardly expect all or even most of our traumatized clients miraculously to transcend their tragedy and thereby acquire a fresh, revitalized outlook on life—how many counselors would respond this well? But human beings do crave meaning (Yalom, 1980), and if a philosophical or religious orientation can nourish the client in his or her journey back to the land of the living, then our therapeutic role must sometimes stretch to include some measure of guidance in affairs of the spirit.

COUNSELING IMPLICATIONS Psychotherapy with traumatized crime victims must span the range from concrete, supportive, and directive approaches to the most abstract, and even—in the broadest

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sense—spiritual modalities. Short-term crisis intervention can help restore a feeling of stability and control early in the trauma evolution process and possibly prevent the development of more disabling posttraumatic manifestations down the road. Psychophysiological and cognitive-behavioral symptom-reduction strategies can help break the vicious cycle of escalating distress leading to greater helplessness, more severe distress, and so on. Psychologically integrative therapy and counseling approaches can help crime victims put their experiences into a narrative context to regain a sense of order and meaning in the world. Counselors who work with crime victims should master the fundamental skills of trauma therapy but be knowledgeable and flexible enough to allow each client’s individual personality and recovery trajectory to guide intervention efforts.

CONCLUSION Psychotherapeutic work with crime victim survivors often forces the clinician to confront the effects of human callousness and cruelty in all of its flesh-and-blood starkness. Working with these patients requires skill, dedication, patience, perseverance, flexibility, tolerance of partial solutions, and sometimes, a strong stomach. But in many cases, the clinician will have the satisfaction of knowing that he or she has made a substantial impact, not just on the crime victim himself or herself, but on the larger radiating orbit of family, coworkers, and community.

RESOURCES Websites Miller, L. (2008). Counseling crime victims: Practical strategies for mental health professionals. New York, NY: Springer. (http://www.springerpub.com/product/9780826115195) National Center for Victims of Crime (http://www.ncvc.org) National Organization for Victim Assistance (http://www.trynova.org/) Office for Victims of Crime (http:www.ojp.usdoj.gov/ovc/help/)

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CHAPTER 15

Traumatic Aftermath of Homicide and Suicide TUMANI MALINGA-MUSAMBA AND TAPOLOGO MAUNDENI

INTRODUCTION More and more people worldwide die due to physical violence. For this reason, violence has emerged as a public health priority. In fact, in 1999, the 49th World Health Assembly declared violence as a major and growing public health problem across the world (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). These deaths are those related to suicide, homicide, and war. About half of the estimated 1.7 million violent deaths that occurred in the world in 2000 were the result of suicide, about one third resulted from homicide, and one fifth were from war-related injuries (Mercy, Krug, Dahlberg, & Zwi, 2003). The World Health Organization (WHO) defined violence as the “intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, and deprivation” (WHO, as cited in Krug et al., 2002, p. 5). Violence has been reported to have both short- and long-term effects on individuals, families, communities, and countries (Reza, Mercy, & Krug, 2001). Violence has been categorized by Krug et al. (2002) into three types: self-directed violence, which involves suicidal behavior (suicidal thoughts, attempted suicide, and completed suicide); interpersonal violence, which covers forms of violence such as child abuse, intimate partner violence, and elderly abuse; and collective violence, which can be political, social, and economic violence. However, Murray and Lopez (1996) categorized violence into four categories, which included suicide, homicide, war-related deaths, and overall violence. Mercy et al. (2003) report that suicide, interpersonal violence, and war-related deaths are the fourth, fifth, and 10th leading causes of death, respectively, among 15–44 year olds throughout the world. Rando (1993) and Armour (2006) argue that grieving a violent death is different from “normal” mourning behavior. This is because the death is caused by human intent or negligence rather than an internal disease, old age, or natural disasters like flood, tornado, and fire. The previous statement does not, in any way, minimize the mourning of the survivors left after other kinds of death. However, it should be noted that after suicide and homicide, those left behind experience a particular type of trauma that may be more existentially soul searing than those who experienced death due to other causes. A sudden and unexpected—often violent—death leaves the surviving family members in turmoil, with tasks like reassessing the meaning of the world and suddenly

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needing to reconstruct a new world without the victim (Clements, DeRanieri, Vigil, & Benasutti, 2004). Survivors are left in extreme shock and struggle emotionally, physically, socially, and financially. These responses include feelings of rage, fear, sleep disturbance, exaggerated startle behavior, phobic anxiety, intense shame, horror, and guilt. Survivors of violent death often are left with incomplete information about what may have happened and may be plagued by a multitude of “what ifs.” As a result, the bereaved may feel the need to assign blame and responsibility, search for reasons, or dwell on the missing details in an attempt to make sense of the death (Armour, 2006). Armour argues that the coexistence and interplay between the trauma reactions and the need to grieve create a synergy that delays recovery. According to Armour, there is greater current recognition of the co-occurrence of trauma and grief as a “normal” response to violent death. It is worth noting that the way grief affects individuals who experienced the death of a loved one, through suicide or homicide, cannot be generalized. As such, the aim of this chapter is first to distinguish between the lived experiences of survivors (i.e., usually family and friends, but sometimes strangers or casual acquaintances who witness the violence) who experienced death through suicide and homicide. Second, it aims to point out the important aspects upon which counseling professionals should focus during their interactions with grieving clients. Finally, it aims to identify and discuss the counseling implications and resources associated with suicide and homicide. These aims are accomplished through discussions in the following sections: definition of key concepts, background information, the trauma of suicide and homicide, and associated counseling implications. This chapter concludes with a summary of relevant issues, followed by a list of useful resources.

DEFINITION OF KEY CONCEPTS The WHO (1977) defines suicide as fatal, self-inflicted injuries, which are specified as intentional. Suicide often has been defined as “the human act of self-inflicting one’s own life cessation” (Encyclopedia Britannica, as cited in Krug et al., 2002, p. 185). Suicide and suicidal attempts are major worries for mental health practitioners (Bhugra, 2004). Giddens (1996) reports that suicide is “a purely personal act, appear[ing] to be entirely the outcome of extreme personal unhappiness” (p. 707). On the other hand, Durkheim indicated that social factors have a fundamental influence on suicidal behavior, reporting that anomie is a strong influence (Giddens, 1996). Another term that needs to be defined is homicide. The WHO (1977) defines homicide as fatal injuries inflicted by another person, with the intention to injure or kill by any means. Clements and Burgess (2002) portray it as sudden, unexpected, and always violent. It is the purposeful “snuffing out” of one life by another. The victim may be tortured prior to death, the body may be mutilated, the victim may suffer for hours before the actual homicide, or the victim may die instantly as a result of mortally inflicted trauma. Regardless of the manner and timing of the homicide, the victim’s pain and suffering ends in death (Clements & Burgess, 2002, p. 2). A more comprehensive definition of homicide has been provided by Brookman (2005, p. 6), who asserts that “homicide refers to the killing of a human being, whether the killing is lawful or unlawful.” According to Brookman, examples of lawful homicide include the killing of another human being during wartime combat, the implementation of the death penalty, or the accidental killing of a boxer by his opponent. On the other hand, examples of unlawful homicide include murder, manslaughter, or infanticide. Existing literature (e.g., Brookman, 2005) suggests that many homicides

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occur among family members, particularly spouses or cohabiting partners who are not genetically related. Therefore, this chapter largely focuses on the effects of this type of homicide. It is also critical to understand the term trauma. Trauma is a personal experience of interpersonal violence including sexual abuse, physical abuse, severe neglect, loss, and/or witnessing of violence, terrorism, and disasters (Gillece, 2009). Finally, the term survivor refers to living family members and friends of the murder or suicide victim, and victim refers to the deceased individual.

BACKGROUND INFORMATION ABOUT SUICIDE AND HOMICIDE Homicide and suicide have prevailed in many societies from time immemorial. In primitive societies, death (particularly a self-inflicted one) has always been a taboo subject. However, in the 19th century—when the sociopolitical effects of rising capitalism began to isolate people socially, and when cities grew larger, and individuals thus grew more solitary— attitudes toward suicide changed, and scientific writing on suicide began to appear (Farberow, 1975). Existing literature shows that various forms of violence prevail between people involved in intimate relationships. These forms include physical violence, emotional or psychological violence, economic violence, and sexual violence. Violence between people in intimate relationships has been categorized broadly as gender-based violence and as violence against women (VAW). Existing literature from various countries shows that domestic violence is a major risk factor for murder of women. In Papua New Guinea, almost 73% of adult women murdered between 1979 and 1982 were killed by their husbands (Bradley, 1988). In Canada, 62% of women murdered in 1987 died at the hands of an intimate male partner (Canadian Centre for Justice Statistics, 1988). These findings do not rule out the fact that sometimes women themselves commit homicide. However, there is abundant data from countries such as Canada, Papua New Guinea, and the United States that show that women who kill men often do so in self-defense and usually after years of persistent and escalating abuse (Bradley, 1988; Browne, 1987; Canadian Centre for Justice Statistics, 1988; Kelermann & Mercy, 1992; Walker, 1989). A review of spousal homicide in the United States, published in the American Journal of Public Health, reports that Studies of homicides between intimate partners show that they are often preceded by a history of physical abuse directed at the women and several studies have documented that a high proportion of women imprisoned for killing a husband had been physically abused by their spouses. (Mercy & Saltzman, 1989, p. 597) According to Pokorny (1965), homicide and suicide are closely related. He reports that suicide is a kind of inverted or retroflexed homicide. Pokorny asserts that people who commit suicide may have instinctual destructive tendencies, which can be directed inward or outward. A commonly reported hypothesis is that a person commits a homicide, and then kills himself because of the resulting anger. Suicide, therefore, can be viewed as an attempt to escape punishment. Following the work of Durkheim, Quinney (1965) suggests that the relationship between suicide and homicide is that of two opposing phenomena. Durkheim concluded that “suicide sometimes coexists with homicide; sometimes they are mutually exclusive; sometimes they react under the same conditions in the same way, sometimes in opposite ways” (as cited in Quinney, 1965, p. 401).

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TRAUMA OF SUICIDE AND HOMICIDE The WHO (2009) highlighted that almost one million people die from suicide annually, making suicide the 10th leading cause of death globally. However, among people aged 15 to 44 years suicide is one of the three leading causes of death. In the last 45 years suicide rates have increased by 60% worldwide. Krug et al. (2002) reported that suicide evokes direct reference to violence and aggressiveness. Suicide represents an unexpected, traumatic, and violent death that poses numerous challenges to the bereaved (Ratnarajah & Schofield, 2007; Sakinofsky, 2007). Ratnarajah and Schofield went on to report that risk factors of suicidal behavior include age, sex, the environment, and factors related to an individual’s life history, including social, biological, psychiatric, intellectual, and emotional aspects. These factors also can include personal loss, interpersonal conflicts, and legal or work-related problems (Krug et al., 2002). Moreover, Williams (2001) reports that the issues that surround suicide and attempted suicide involve the feeling of being trapped by circumstances, as well as one’s personal feelings and thoughts. Homicide, on the other hand, is unplanned. Douglas, Burgess, Burgess, and Ressler (as cited in Vigil & Clements, 2003) note that homicide may occur in many situations, having various motives and using differing manners of execution. These may include any of the following: brutal killings during domestic quarrels, skillfully calculated crimes as a method of personal or gang-related revenge, those carried out for financial or personal gain, and murders that are committed in retaliation for a previous or perceived injustice. Homicides happen with no warning, and the reasons for their occurrences often remain obscure; as such, survivors of these events often have great difficulty in explaining them (Wall & Levy, 1996). Survivors experience changes in stability of the family unit, family developmental issues, changes in communication patterns, and changes in role functioning (Asaro & Clements, 2005). Suicide and homicide not only raise issues of mortality, they often cause survivors to question life itself. Such intensely existential issues lead to immediate shock. The way that grief affects individuals cannot be generalized. Some individuals experience discomfort and avoid discussing the pain that survivors experience (Clements et al., 2004). Armour (2003) also reports that impact from violent death remain hidden because of social norms that stigmatize the bereaved and silence their pain. The health and social consequences of violent deaths are much broader. The repercussions of a homicide and suicide are also felt on the victim’s loved ones, who become victims themselves and suffer psychologically (mourning the loss of a loved one, shock, sorrow, emotional reactions) as well as financially (loss of income, funeral costs, and problems related to legal proceedings). Homicide and suicide inflict massive injury on the intrapsychic and interpersonal realities of the surviving kin (Masters, Friedman, & Getzel, 1988). In the remaining parts of this section, we explore the intense trauma associated with suicide and homicide in the following discussions: Experience of Violence by Family Survivors, Emotional and Psychological Experiences, Social Experiences, Physical Experiences, and Multiple Losses.

Experience of Violence by Family Survivors Homicide is often an unplanned and impulsive act. It involves a high level of unpredictability, resulting in sudden loss and trauma, which exacts a heavy toll on the mental health of the survivors (Clements & Burgess, 2002). Asaro and Clements (2005) note

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that after a murder, the surviving members of the family may experience similar reactions to their loss such as sadness, rage, guilt, shame, blame, and helplessness, but at varying times. However, in many cases, survivors are not always willing to talk about these feelings (Asaro & Clements, 2005). Wall and Levy (1996) argue that family members grieve differently as they may ascribe different meanings to the victim and to the event. Just as homicide leads to sudden loss and trauma, people who commit suicide leave behind their loved ones, family, and friends in a state of sudden loss, trauma, and often, disbelief. These people’s lives are profoundly affected emotionally, economically, socially (Krug et al., 2002), and in many other ways. Those left behind experience tumult in their lives. Suicide survivors can have both positive and negative experiences and may be categorized as social, physical, emotional, and psychological.

Emotional and Psychological Experiences Some emotional and psychological experiences that survivors go through can be characterized by reactions of shame, stigma, and self-blame, as was outlined by Begley and Quayle (2007) in their study on the lived experience of adults bereaved by suicide. In addition to these responses, individuals also are reported to experience feelings of rejection and abandonment, guilt, anger, and distress (Ratnarajah & Schofield, 2007). Sakinofsky (2007) also reports that survivors perceive suicide as an aggressive act directed at the survivor. Moreover, survivors of suicide deaths struggle to make sense of the reasons why individuals took their lives. Rando (1993) suggests that individuals may experience prolonged intrusive images, disorganized thinking, and increased vulnerability. Family members also can experience disruptive grieving, which Vigil and Clements (2003) argue is due to anger, obsession and rumination, the need to assign blame, attempts to regain control, feelings of victimization and unfairness, and a search for meaning. There are several factors that can influence the nature of family members’ grieving. These include previous experiences with losses and sociocultural factors such as ethnicity, religious beliefs, and gender (Wall & Levy, 1996). On the other hand, individuals struggling to deal with a homicide death try to make sense of the death, and they may blame themselves for the victim’s fate (Miller, 2009). Family members tend to stick to blaming themselves as a way to take psychological control of the situation (Miller, 2009). Miller argues that, at times, the internalized anger of family survivors is directed at the criminal justice system. Sakinofsky (2007) reports that individuals experiencing such intense emotions are prone to depressive illness and posttraumatic stress disorder (PTSD). Depression can be prolonged and is more likely to recur. Some of the psychological problems associated with PTSD, which is described in detail in other chapters of this book, may include internalizing feelings, hyperarousal, withdrawal, somatic complaints, and anxiety. Depression and PTSD symptoms may occur among children (Ratnarajah & Schofield, 2007) and adults. Dyregrov (2002) reports that individuals may go through a “traumatic experience which might lead to psychological reactions, like existential crisis, and complicated grief reactions” (p. 648). Rando (1993) identified several ways that individuals go through the grieving process, referring to these as the six “R” processes. These include the following: recognize loss, react to separation, recollect and reexperience, relinquish old attachments, readjust to move adaptively into the new world without forgetting the old, and reinvest. In addition, the trauma of the death can provoke unresolved traumatic experiences from the past. When this happens, some aspects of the survivor’s life can be frozen (Miller, 2009). Asaro (2001a) reported that the loss of a loved one through murder even may spark a

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questioning of one’s faith. Goals of dealing with the trauma, therefore, are to reduce symptoms and to minimize secondary losses (Rando, 1993).

Social Experiences Another experience that survivors face is that involving relationships. The death of loved ones can severely affect people’s relational systems, academic functioning, and developmental progress, especially for young people (Rando, 1993). Survivors experience difficulties with social functioning at work, school, with friends, and in the family. Some individuals reportedly withdraw emotionally and socially and are not willing to accept offers of assistance (Dyregrov, 2002). These kinds of behaviors are exacerbated by the emotional and psychological problems that people may experience, which can include withdrawal from social networks because of feelings of stigma and shame (Ratnarajah & Schofield, 2007). When we consider the multiple systems in which people are engaged, across multiple environments, the ripple effects of such social withdrawal can be devastating. This is best explained by the ecological model, which views survivors as having transitional problems and needs due to loss of loved ones, hence needing to adjust (Zastrow, 1996). Zastrow suggests that “[t]he ecological model views people not as passive reactors to their environment but rather as dynamic and reciprocal interactors with those environments” (p. 55). Bard (1982) noted that relationships with others often change after a murder. Some individuals may be seen as supportive, whereas others can be viewed as nonsupportive and uncaring. Therefore, new relationships may form, and some existing ones may break up. In other cases, within families, coping strategies used by individual family members may vary. This can create friction, anger, frustration, and misunderstanding between or among family members (Asaro & Clements, 2005). The interpersonal relationship, therefore, influences factors that create risk as a result of relations with peers. On a different note, individuals who participated in a study by Sakinofsky (2007) reported that suicide actually can be a relief from extended periods of living with individuals who have problem behaviors; thus, suicide may be viewed as liberation from unsupportive situations. Sakinofsky reported that suicide may drive already shaky family dynamics to dysfunction. While Ratnarajah and Schofield (2007) reported that suicide can be highly disruptive to family communication, Sakinofsky suggested that families can become more united during such times of crisis. Suicide bereavement is shaped by the bereaved individual’s life experiences with the deceased and also his or her perceptions following social interactions after the event. In their study, Begley and Quayle (2007) identified themes that indicated that the early months of loss were characterized by attempts to “control the impact of the death,” by the need to “make sense of the death,” and by an increase in marked “social uneasiness”; however, after working through these processes, participants had an eventual realization of a sense of “purposefulness” in their lives following the suicide death. Miller (2009) argues that some individuals may be numb and silent, whereas others can reach a near hysterical state. Survivors report that they often experienced feelings of loneliness and isolation, reacted with anger, and felt disenfranchised from their right to grieve (as cited in Asaro, 2001a). Besides the trauma that comes with bereavement, family members may experience a shift in roles (Miller, 2009); they may find themselves with new roles and responsibilities. Miller (2009) argues that the stress that comes with role shifts needs to be acknowledged and addressed. Wall and Levy (1996) argue that, due to all the emotions that survivors go through, it is difficult to integrate these events in a coherent manner. Homicides, thus, can pose a profound challenge to the veracity of individuals’ worldviews. As a result of all this, it is critical that therapists pay attention

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to families’ preoccupation with the details that surround the homicide and the concomitant sense of personal loss, as these are critical factors that concern families in the aftermath of homicides (Wall & Levy, 1996).

Physical Experiences Individuals need to develop personal coping strategies as a part of surviving the loss of a loved one to suicide or homicide. Asaro (2001b) identifies some of these strategies as staying busy, physical exercise, reading, and other types of engagement; these coping strategies are viewed as positive. However, some individuals report engaging in negative coping strategies, which includes drinking alcohol and using drugs to numb the pain of the loss.

Multiple Losses Asaro (2001a) contends that homicide survivors not only grieve the loss of their relationship with the victim, but they also grieve over their reactions to the sudden, traumatic, and violent death. While the primary loss resulting from murder is the loss of the victim, Asaro argues that other aspects of grief include lost expectations for a future life with the victim, who was perhaps a mate, a family member, a best friend, or the one significant person with whom the survivor shared problems with. The death also precludes the possibility of resolving past disagreements or angry feelings, which might have been settled over the course of time. Such experiences are not immune to survivors who lost loved ones due to suicide. It should be underscored that individuals, family members, and friends who lose loved ones due to violent deaths such as suicide and homicide all have lost a unique loved one, and the experiences that they go through, due to the sudden death, cannot be sufficiently differentiated and compared. Within this constellation of bereavements, there is no one loss that can be claimed to be more significant than the others. Aside from the loss of the victim, some individuals experience intrapersonal loss, interpersonal loss, and extrapersonal loss. Intrapersonal loss involves questioning of one’s faith, values, and deepest beliefs. Asaro and Clements (2005) add that families going through homicide bereavement are likely to have their daily routines repetitively disturbed and disrupted. In addition, Asaro (2001a) posits that individuals at times are unable to go to work due to court proceedings, which adds up to the additional stressor of lost income and perhaps even lost employment. These disruptions also can have a negative impact on one’s trajectory of growth and development. Freitag (as cited in Asaro & Clements, 2005) observed that after a sudden death, “. . . we are not only cut off from the one who is lost, but also from parts of ourselves” (p. 31). This occurs partly because recovery is prolonged, but mainly vis-à-vis the knowledge that the perpetrator is usually alive, and in some cases unpunished, and by the multiple losses endured: loss of a family member, loss of illusions of safety and invulnerability, loss of a sense of trust in the surrounding community, and loss of a belief system. Effective help to survivors requires interventions that respond to all aspects of the survivors’ losses (Masters et al., 1988). When individuals experience interpersonal losses, it feels like once-secure (or perhaps not-so-secure) family structures are breaking apart under the stress of the murder. For example, family members can take sides against one another in cases where the victim and killer were in a relationship or were related. This can cause families to disintegrate, thus complicating the grief with the additional loss of family support. Individuals also may experience a loss of social support and, hence, feel isolated and alone (Asaro, 2001a). In cases of suicide loss, if the victim left a suicide note, information

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in the note has the potential to further break the family apart, thus further isolating individual survivors. In addition to interpersonal and intrapersonal losses, individuals may face the consequences of extrapersonal losses. These can include the loss of the victim’s income or the loss of financial security because of medical bills that resulted in an effort to save the victim’s life. In turn, such changes in the survivor’s financial status might easily end in the loss of home and/or accustomed lifestyle (Asaro, 2001a).

COUNSELING IMPLICATIONS OF HOMICIDE AND SUICIDE Asaro (2001b) reports that the loss of a loved one through murder or suicide is a traumatic experience that leaves pain and anguish. These kinds of deaths are untimely and unfair, and people have intensifying feelings of disbelief, shock, and anger (Clements et al., 2004). Clements and colleagues also report that when a family member dies due to a sudden traumatic death, survivors go through shock and pandemonium. Armour (2006) argues that when an individual is undergoing the bereavement-related shock, normal feelings of loss and sadness may be interrupted, and the reflective and integrative processes that accompany grieving become disrupted. Remorse and sorrow may become despair. Vigil and Clements (2003) add that death due to negligence, carelessness, or interpersonal violence causes many responses in survivors that may interfere with their adaptive coping. As a result of all these complications, survivors may experience complicated grief and bereavement (Clements et al., 2004) mainly because death creates discomfort in many individuals. Acts of homicide and suicide carry negative stereotypes about those who die in this manner (Clements & Burgess,2002). Survivors may experience a sort of “contagion effect” as a result; they also may adopt a “don’t ask, don’t tell” attitude toward deaths that are particularly sudden and violent in nature (Clements et al., 2004). Vigil and Clements (2003) argue that it is evident that the survivors are victims of the homicide and suicide in their own way. These perspectives are important to understand because of the issues and problems the grieving process can present. Knowledge of “normal mourning,” as well as of the factors that complicate mourning, is necessary for mental health professionals because almost every survivor of a homicide will encounter complicated mourning issues (Vigil & Clements, 2003). Survivors of both suicide and homicide experience changes in their physical, physiological, emotional, and psychological functioning. For example, survivors can experience anxiety, dizziness, headaches, sleep disorders, panic attacks, and stomach distress. People who are experiencing trauma also have difficulty concentrating and impaired memory (Miller, 2009). Rando (1984) described 28 psychological, social, and physiological factors that may affect the grieving process after a loss. Among these are the meaning of the loss to the individual, the role of the deceased in the family, and the mourner’s prior coping skills and mental health. These, together with an understanding of the nature of the death and the reactions of survivors, are central to the therapeutic strategies. Wall and Levy (1996) report that it is critical to address the way families and children negotiate the initial aftermath of the event, as this can set the direction for the course of their adaptations to the death. This indicates that having an understanding of the dynamic within the family is critical, as the loss of a family member can result in many challenges to the stability, development, communication, and role functioning of the family system (Asaro & Clements, 2005). Asaro and Clements (2005) emphasize that it is critical for counseling professionals to have an understanding of the usual coping strategies used within a family. If the

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counselor employs strategies that are different from those typically used by the family, the counselor needs to ensure that this is made clear to the other family members, and that they are apprised that the survivors are doing what they need to do for their own personal grief work. It is therefore critical that the counselor assist all family members in exploring ways to understand why some survivors may be engaged in a different set of strategies. This can enable family members to curb the potential anger, arguments, hard feelings, and perhaps ongoing family conflict that otherwise might be provoked by engaging in different strategies. A number of specific implications arise from the aforementioned discussions. These are identified and listed in the following categories: implications for counseling professionals, implications for law and policy makers, implications for society at large and communities, and implications for researchers.

Implications for Counseling Professionals The following discussion of the implications of homicide- and suicide-related trauma regards the needs of service providers to be effective in this arena. There is need to empower social workers, counselors, psychologists, and other human service providers to deal with survivors of homicide and suicide. Providers need to be educated on how to deal with the survivors by focusing on intrapersonal loss, interpersonal loss, and extrapersonal loss. Hertz, Prothrow-Stith, and Chery (2005) report that people do not need to witness the murder of a friend or family member directly to be impacted, that children may exhibit different symptoms than adults, and that symptoms may be present for years after the murder. Professionals therefore should be trained on these issues to enable them to effectively help survivors. The ecological model emphasizes that professionals should focus on individuals going through the trauma; professionals need to help survivors with coping strategies and how to deal with the loss. The model indicates that individuals should be helped to articulate transitional problems and needs (Zastrow, 1996) to help them cope with the trauma. Besides focusing on individuals going through the trauma, there is need to explore how they cope with other systems in their lives. The ecological model emphasizes that individuals have systems with which they interact; hence, professionals should be sensitized to the importance of also focusing on other systems when dealing with survivors. The ecological model guides the professional to focus on maladaptive interpersonal problems and needs. Zastrow (1996) suggests that the model helps professionals to identify interpersonal obstacles and to apply appropriate intervention strategies. Counseling professionals should understand the need to reach out beyond clinical settings to connect patients to resources (Hertz et al., 2005). Hertz et al. assert that during their preservice training, professionals should be encouraged to establish and maintain partnerships with community-based organizations, including churches. Most importantly, as much as counseling professionals are trained to help survivors to cope, they also should be trained in preventive measures. This is critical because the literature indicates that people mourning the death of a person who has committed suicide are at risk of committing suicide themselves. In addition, for those mourning the death of a person who was killed, they also may be at risk of committing homicide due to the anger they may have toward the people who have killed their loved one, and eventually could commit suicide. There is thereby a great need to have anger management programs that can be offered to all survivors to curb anything violent happening. The WHO (2009) reports that “[t]here is compelling evidence indicating that adequate prevention and treatment of depression and alcohol and substance abuse can reduce suicide rates, as well as follow-up contact with those who have attempted

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suicide” (Effective Interventions, para. 2). Counseling professionals should therefore be made aware of some of the triggers of suicide and homicide to enable them to deal with likely causes before an individual is disposed to commit homicide and/or suicide. Programs that assist people in coping with homicide and suicide, as well as to prevent them, should embrace all people who have been affected and exposed by these experiences, including people living with disabilities, the elderly (some of whom are illiterate), children, and people living in rural and remote areas.

Implications for Law and Policy Makers The following implications of homicide- and suicide-related trauma regard legislative and policy issues in this arena: ■ Governments of countries that have not domesticated all international conven-

tions dealing with gender-based violence should be lobbied to do so. ■ There is need to strengthen existing laws to adequately address gender-based

murder by the removal of the discretion to be lenient, as such discretion still exists in some countries around the world, with perpetrators of femicide and other “hate murders,” like the killing of gay, lesbian, and transgendered persons or the killing of people based on race or ethnicity.

Implications for Societies and Communities at Large The following implications of homicide- and suicide-related trauma regard social and community needs in this arena: ■ The need for appropriate socialization and teaching of proper values to girls

■

■

■

■

and boys, allowing for independence emotionally, economically, spiritually, and so forth. The need to revisit songs, and the messages that are imparted as songs, that have lyrics that continue to degrade women. This implication is applicable across societies. For example, there is an English song that says “ain’t no romance without finance.” Such songs may encourage lovers to spend a lot of money on each other, to the extent that the party who feels he or she has been financially ripped off may resort to homicide when the other partner wants to end the relationship. In addition, communities at large need to be educated about the roles of social workers, counselors, and psychologists, so that people can know where to go whenever they feel overwhelmed by their problems, instead of taking their lives or the life of another. This is crucial because a major dilemma faced by many people, especially in developing countries, is that they do not realize the importance of psychologists, social workers, and counselors who are knowledgeable about mental health issues and relevant community resources. Curriculum and training materials on domestic violence as well as training of trainers who would implement the curriculum should be developed in countries where there are none. Effective systems for educating men on gender-based violence and involving them in advocacy and speaking out against violence against women should be put into place. This recommendation is crucial, particularly taking into account that efforts to combat gender-based violence have from time immemorial been spearheaded by women; yet, research shows that most perpetrators of this crime are men.

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Implications for Researchers The following implications of homicide- and suicide-related trauma regard the need for more evidence-based research in this arena: ■ The need for extensive research to explore the root causes of homicides and sui-

cides. This can help professionals who are dealing with people with problems to know what to focus on when providing preventive counseling. This also can enable them to focus on critical issues when educating the community. ■ In addition, research is needed to explore the experiences of those who have lost loved ones through suicide and homicide. Such information can be useful when providing counseling to the grieved. ■ Finally, all of the helping professions need the advantage of data-driven research to be able to develop the best practices for dealing with homicide- and suiciderelated trauma. One of the ways to achieve this is to devise mechanisms for collating country-specific data, which portray figures on various types of violence on an annual basis. The authors are aware that some countries have made considerable progress on this issue, while others still have a long way to go.

CONCLUSION This chapter has explored issues of suicide and homicide at a global level. It has shown that these problems are not peculiar to any one country, but rather that they prevail across the world. This chapter has further shown that these problems have complex, multifaceted, and far-reaching consequences for the emotional, social, spiritual, economic, and physical well-being of survivors. This chapter concludes by highlighting implications for counseling, for law and policy, for societies and communities at large, as well as for researchers. It is clear that suicide and homicide prevention and treatment require holistic interventions from both health and other sectors to come up with innovative, comprehensive, and multisectoral approaches to address these problems. It is hoped that the implementation of the suggested recommendations may go a long way to make this world a safer place to live.

APPENDIX 15.1 Suicide and Femicide in One Developing African Country (Republic of Botswana) In Botswana, with a population of approximately 1.7 million, suicide is currently the third leading cause of death, following road traffic accidents and HIV/AIDS. On average, six people commit suicide every week, accounting for more than 203 deaths reported to the Botswana Police Service since the beginning of 2010 until early August 2010 (Baaitse, 2010). In 2009, there were only 184 cases of suicide reported for the same period (Baaitse, 2010). This indicates that there is an alarming increase in the number of people who commit suicide. Pinielo and Botlhoko (2010) reported that the leading methods of suicide in Botswana include hanging, firearms, and the use of toxic substances. (continued)

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APPENDIX 15.1 (continued) Suicide cases are a growing problem in the country, as is indicated by recent newspaper headlines. For example, on a weekly basis, the headlines are as follows: ■ Mmegi (Pinielo & Botlhoko, 2010), “The Shock of Suicide Tragedies Among

Teenagers”; ■ The Voice (Baaitse, 2010), “Our Pain”; ■ The Botswana Gazette (Ontebetse, 2010), “Police Record 10 Suicide Deaths in

a Week”; ■ The Monitor (Ngakane, 2010), “Police Investigate Suicide Case”; ■ The Voice (Baraedi, 2010), “Man Hangs Self After Being Ignored by Girlfriend”; and, ■ Botswana Press Agency (BOPA, 2010), “Suicide Cases Worry Police.”

This sample is indicative that suicide is increasing at an alarming rate and that public health measures have to be put into place to try to curb the problem. Ironically, when the award-winning Botswana photojournalist, Mogakolodi Nelson Boikanyo, held a photo exhibit at the capital city’s (Gaborone) major art gallery, Thapong Visual Arts Centre, in an attempt to facilitate greater public awareness of a spate of suicides at the time, the exhibit created controversy, shock, and denial (Bakwena, 2004; Edwards, 2004; Nermark, 2004). In 2007, 101 women were killed by their intimate partners, and thus, on average, a woman was murdered every third or fourth day. These murders are inappropriately labeled in police records as “passion killings.” Some of the factors that contribute to femicide include promiscuity; failure to deal with rejection, materialism, or competition; and identity crisis. Another factor that has been associated with these crimes relates to men’s feelings that women are undermining their authority. The fact that women in developing African countries are increasingly becoming independent and are demanding higher economic status seems to be putting more pressure on men, who by tradition have been the dominant partners over their female counterparts. Dikobe (2008) links the increasing rates of femicides to socialization. She argues that boys often are encouraged to be providers, whereas girls are socialized to be provided for. These messages are transmitted through various modes of socialization including songs. Therefore, when men are unable to fulfill their roles as providers, they tend to retrieve their egos by killing, which is a manifestation of their power over women. A United Nations report on the “Situation of Gender-Based Violence” (2009, p. 4) acknowledges that “[p]hysical violence against women and children within the family usually takes place on an ongoing basis, rather than a once only basis—and in some cases leads to the murder of the woman (femicide).” In his 2009 public Christmas message, the commissioner of the Botswana Police reported that “[l]ove-related murders continued to dominate the list of homicides recorded in this country. Between January and December 6th 2009, the police have dealt with 89 cases that ended the lives of 82 women and seven men” (Botswana Government Portal, 2009, Preamble, para. 8). Residents have been reeling in shock, and parents, relatives, and friends struggle to come to terms with tragedies brought about by suicide and murder cases (Pinielo & Botlhoko, 2010). Although femicide continues to take place in the country, it should be noted that stakeholders such as the police are trying hard to address the problem. However, they are confronted with challenges that have an adverse impact on the effectiveness of their services. These include the failure of victims to report crimes of abuse, threats to kill, or domestic violence, which are the early signs of “passion killings”; the withdrawal of cases by victims due to intimidation or financial dependence on the accused (continued)

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APPENDIX 15.1 (continued) or due to family pressure; the absence of witnesses in cases where the incident ended in loss of life; victims’ poor access to support services; and, a backlog of cases in the courts (Kapinga, 2008). Along with femicide, there are also many cases of ritual murder. Ditsheko (2010) reported that ritual murder cases are now a common occurrence in Botswana, and that they happen in both urban and rural areas. As people go missing, there is always the possibility that they may never be found or that they may be found dead, with suggestions that they have been killed for ritual purposes (Ditsheko, 2010). According to police reports, at least 500 people have been reported missing since the beginning of 2010. Murder cases have been common around Botswana. For many reported cases, bodies are found abandoned in thickets and other hidden places. In a number of these instances, body parts such as brains, genitals, tongues, and eyes have been removed; hence, the police have concluded that the killings were ritualistic (Ditsheko, 2010).

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Hertz, M. F., Prothrow-Stith, D., & Chery, C. (2005). Homicide survivors: Research and practice implications. American Journal of Preventive Medicine, 29 (5 Suppl. 2), 288–295. Kapinga, K. (2008). Challenges of protecting intimate partners from each other. Paper presented at a Youth Dialogue Era Conference on Crimes of Passion. University of Botswana, Gaborone. Kelermann, A. L., & Mercy, J. A. (1992). Men, women, and murder: Gender-specific differences in rates of fatal violence and victimization. Journal of Trauma, 33 (4), 1–5. Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A. B., & Lozano, R. (Eds.). (2002). World report on violence and health. Geneva, Switzerland: World Health Organization. Masters, R., Friedman, L. N., & Getzel, G. (1988). Helping families of homicide victims: A multidimensional approach. Journal of Traumatic Stress, 1(1), 109–125. Mercy, J. A., Krug, E. G., Dahlberg, L. L., & Zwi, A. B. (2003). Violence and health: The United States in a global perspective. American Journal of Public Health, 93, 256–261. Mercy, J., & Saltzman, L. (1989). Fatal violence among spouses in the United States, 1976–1985. American Journal of Public Health, 79, 595–599. Miller, L. (2009). Family survivors of homicide: I. Symptoms, syndromes and reaction patterns. American Journal of Family Therapy, 37(1), 67–79. Murray, C. J., & Lopez, A. D. (1996). Estimating cause of death: New methods and global and regional applications for 1990. In C. J. Murray & A. D. Lopez (Eds.), The global burden of disease (pp. 117–200). Cambridge, MA: Harvard University Press. Nermark, U. (2004, December 1). Editorial. Artifacts: Magazine for the Arts in Botswana. December, p. 1. Ngakane, G. (2010, February 8). Police investigate suicide case. The Monitor, 27(19). Retrieved from http://www.mmegi.bw/index.php?sid=1&aid=157&dir=2010/February/Monday8 Ontebetse, K. (2010, January 13). A police record 10 suicide deaths in a week. The Botswana Gazette. Retrieved from http://www.gazettebw.com/index.php?option=com_content&view=article&id =5107%3Apolice-record-10-suicide-deaths-in-a-week-&catid=18%3Aheadlines&Itemid=2 Pinielo, I., & Botlhoko, P. (2010, February 26). The shock of suicide tragedies among teenagers. Mmegi. Retrieved from http://www.mmegi.bw/index.php?sid=6&aid=465&dir=2010/February/ Friday26 Pokorny, A. D. (1965). Human violence: A comparison of homicide, aggravated assault, suicide, and attempted suicide. Journal of Criminal Law, Criminology, and Police Science, 56, 488–497. Quinney, R. (1965). Suicide, homicide, and economic development. Social Forces, 43, 401–406. Rando, T. A. (1984). Grief, dying and death. Champaign, IL: Research Press. Rando, T. A. (1993). Treatment of complicated mourning. Champaign, IL: Research Press. Ratnarajah, D., & Schofield, M. J. (2007). Parental suicide and its aftermath: A review. Journal of Family Studies, 13 (1), 78–93. Reza, A., Mercy, J. A., & Krug, E. (2001). Epidemiology of violent deaths in the world. Injury Prevention, 7, 104–111. Sakinofsky, I. (2007). The aftermath of suicide: Managing survivors’ bereavement. Canadian Journal of Psychiatry, 52(1), 129S–136S. United Nations & Republic of Botswana. (2009). Situational analysis on gender based violence in Botswana. Gaborone: United Nations Botswana. Vigil, G. J., & Clements, P. T. (2003). Child and adolescent homicide survivors: Complicated grief and altered worldviews. Journal of Psychosocial Nursing & Mental Health Services, 41(1), 30–39. Walker, L. (1989). Terrifying love: Why battered women kill and how society responds. New York, NY: Harper & Row. Wall, J. C., & Levy, A. J. (1996). Communities under fire: Empowering families and children in the aftermath of random homicide. Clinical Social Work Journal, 24, 403–414. Williams, A. (2001). Suicide and attempted suicide. New York, NY: Penguin Books. World Health Organization. (1977). Manual of the international statistical classification of diseases, injuries, and causes of death. Geneva, Switzerland: Author. World Health Organization. (2009). Suicide prevention (SUPRE). Retrieved from http://www.who.int/ mental_health/prevention/suicide/suicideprevent/en/ Zastrow, C. (1996). Introduction to social work and social welfare. Boston, MA: Brooks/Cole.

Section III: Intolerance and the Trauma of Hate CHAPTER 16

Existential Perspectives on the Psychology of Evil ALISON L. DUBOIS, LISA LOPEZ LEVERS, AND CHARLES P. ESPOSITO

Evil is unspectacular and always human and shares our bed and eats at our own table. —W. H. Auden, Herman Melville I happen to think that the singular evil of our time is prejudice. It is from this evil that all other evils grow and multiply. In almost everything I’ve written there is a thread of this: a man’s seemingly palpable need to dislike someone other than himself. —Rod Serling, Los Angeles Times, 1967

INTRODUCTION This chapter examines the phenomenon of “evil” in contemporary society. Western philosophical thought on the formation of the “self” is explored in an effort to understand the development of an individual’s self-identity. Dispositional and situational forces are discussed to address the concepts of “othering” and “scapegoating,” in addition to the role that group dynamics play in the self-regulation process of moral decision making. These themes are relevant to the perpetration of violence and the experience of traumatic events, and by illuminating them we begin to understand better how it is that one person is capable of committing an abomination against another. Human beings seemingly have an innate tendency toward projecting our own inner darkness and fear onto others. This is the territory examined by Conrad (1899/2004) in his novel, Heart of Darkness. He delves precisely into the darkest spaces of human nature that have challenged our understandings about ourselves since time immemorial. Conrad offers the following description in his exposé of European colonization of parts of Africa: It was unearthly, and the men were—no, they were not inhuman. Well, you know, that was the worst of it—the suspicion of their not being inhuman . . . They howled and leaped, and spun, and made horrid faces; but what thrilled you was the thought of their humanity—like yours—the thought of your remote kinship with this wild and passionate uproar. Ugly, yes it was ugly enough;

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but if you were man enough you would admit to yourself that there was in you just the faintest trace of a response to the terrible frankness of that noise, a dim suspicion of there being a meaning in it which you—so remote from the night of first ages—could comprehend. And why not? (Conrad, 1899/2004, p. 34) Marlow, the main character, is at once intrigued and yet repulsed by the “inhuman” indigenous natives he is observing. Given his own life experiences and inner sense of self, he views this behavior as aberrant, yet he finds himself experiencing an inner kinship with what he perceives to be “savage.” This belies the transformation into his own psychological descent, what psychologist James Garbarino (2008) references as the dark side of human experience. In an effort to understand how seemingly “good” individuals commit heinous acts, we must first explore the concept of “evil.” What is evil? Zimbardo (2007) defines evil as “. . . intentionally behaving in ways that harm, abuse, demean, dehumanize, or destroy innocent others—or using one’s authority and systemic power to encourage or permit others to do so on your behalf” (p. 5). We tend to dichotomize evil in the following ways: good versus bad, moral versus immoral, right versus wrong, and white versus black. Many religions of the world reinforce this dichotomous thinking, and in doing so, we remove the responsibility of an evil act from good people. Thus, good people do not have to consider the ways in which they have contributed to, enabled, or maintained the conditions that have led to evil action. Humans tend to view evil as an essentialized quality that is inherent in some people and not in others (Zimbardo, 2007), as if this essence of evil is simply something that a person is born with, simply his disposition, and over which he or she has little control. If this in fact is true, what explanation can be given when seemingly good people do bad things? This dispositional view discounts the impact of environment and experience, which shape an individual’s development. Counselors and psychologists often take a dispositional view, asking “Who is responsible?” when trying to understand deviant behavior instead of examining “What factors contributed to this behavior?” (Zimbardo, 2007). If evil is believed to be incremental, it can be viewed from a lens through which evil is seen to have the capacity to evolve, as a result of a person’s circumstances and experiences (Zimbardo, 2007). From the earliest revelation in the book of Genesis, the Judeo–Christian understanding of the human person, and of the whole universe, is that all is created by God and is essentially good. This message is also consistent with the teachings of Islam in the Quran. Teachings regarding the human person in the monotheistic world faiths hold that we are created by God and are, therefore, essentially good and made for goodness. What distinguishes evil from a theological–existential perspective is the abuse of human freedom. Evil thoughts, words, actions, and apathy are seen as inauthentic human behavior. Authenticity and reality are two sides of the same coin. This is why according to Dubay (1997), the saints are the most real people in all existence. The human person is sustained in a community where one is called to choose to be one’s authentic self in a way that contributes to the community and enables others to do the same. For centuries, philosophy has asked essential questions regarding man’s existence. Current atrocities such as rape, torture, and genocide have existed for millennia; however, questions still abound regarding the capacity of human nature to commit such acts. Freudian psychoanalytic theory, for example, does not view man as essentially good or essentially evil, but rather, as driven by contradictory forces or urges. According to Fromm (1947), Freud’s theory accounts for the goodness of man in addition to man’s destructive behavior. Fromm further discusses this duality as an alternative between “destructiveness and productiveness, potency and impotence, between virtue and vice.

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For humanistic ethics all evil strivings are directed against life and all good serves the preservation and unfolding of life” (p. 214). The underpinnings that drive human beings to strike out against one another are rooted in their survival instinct. In this innate quest for survival, human beings have long devised myriad ways to rank one another in an effort to ensure the continuity of the group. This self-segregation is rooted in an inherent survival instinct, driven by fear. It distinguishes differences by gender, race, religion, social class, intelligence, sexual orientation, age, ability, and political party. As a result of this tendency toward self-imposed classification, prejudices and discrimination against an individual or a group develop. If a person is different from us, they embody otherness, and his or her moral compass or worldview orientation must be different; his or her behaviors then take on negative connotations, and our own sense of loathing constitutes the negative attributes that we project onto the Other. Systems of power often have exploited this dynamic to retain influence. By segregating a group as the enemy, leaders can achieve control quite effectively through othering. The employment of this dynamic, separating us from them, whether conscious or unconscious, can be observed in a number of systems, ranging from schools to corporations, and it creates the context for prejudice and discrimination.

THE OTHER Regardless of our perceptions about the progress of Western civilization in the modern era, and in spite of our assertions of a postmodern ethos, we all too often continue to operate in an either/or world. Lakoff and Johnson (1980, 1999) have explored the everyday metaphors by which we live, thus providing a framework for understanding the uncritical metaphor of the “other.” In this section, we offer a discussion of the existential perspectives concerning the other, and we examine the historical context of human nature.

Existential Perspectives Humans have classified one another over the ages based on multiple variables. Philosophers have long sought to gain awareness and make meaning of human beings’ existence. Additionally, theologians have struggled with the deontological aspects of evil regarding the concepts of free will and determinism. Many would assert that it is plausible to believe in a moral good as well as the existence of an individual’s capacity for evil. Human beings long have struggled to make meaning of human suffering. Is evil found in an individual’s disposition, or do situations arise to create a singular course of evil action? Presuming the existence of free will, individuals then would have the capacity to choose an ethical course of action for the greater good. Forensic psychologist Stephen Diamond (1996) posits that “it is we who are responsible for much of the evil in the world; and we are each morally required to accept rather than project that ponderous responsibility” (p. 85). The construct of evil is difficult to conceptualize philosophically, precisely because it brings many metaethical questions to light. Questions probing the existence of God and the purpose of human suffering are but a few that probe the psyches of humans in the face of adversity. Reflecting on the reality of evil in the world is always both an observation of the actions, words, and apathies of those around us and an observation of ourselves related to our hidden thoughts and motives, as well as to our outward behaviors. In the Judeo–Christian understanding of human life, we are to be just and kind and to react with compassion and advocacy when others are hurting or in need.

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In the fourth chapter of the book of Genesis, Cain kills his brother Abel out of jealousy. Afterward, when God asks him about Abel, Cain responds, “Am I my brother’s keeper?” Here, we witness a manifestation of evil in an absence of the bond that we are intended to have with one another. Hegel and Kierkegaard (Hannay, 1986) both maintain that actions undertaken by the individual on his own behalf lack a moral dimension unless they can be linked, in intention or fact, to the well-being of society as a whole. The way of linking the realities of sin and death in the Abrahamic religions of Christianity, Islam, and Judaism speaks to the human power to perceive that we are acting in accord with the fullness of life when we are ethically centered; conversely, when we choose to embrace evil we are, to whatever degree of our choices, depriving ourselves of our humanity. Death, being linked with a turning away from Yahweh, throws light on what such separation entails (Auer & Ratzinger, 1988). While it is beyond the scope of this chapter to delve into and examine the full magnitude of this entire discourse, in the remainder of this section, we offer a rudimentary exploration of the philosophical construct of evil as it relates to othering. Many philosophers and social scientists have examined the concept of othering, thus developing a broader understanding of the phenomenon. We are particularly concerned here with connections between othering and power. As early as the 16th century, Machiavelli (trans. 1992) outlined in The Prince how the dynamics of power struggles relate directly to the moral nature of humankind. The “constitutive other,” a major concept in continental philosophy, has relied on a construction of the self in relationship to other. Hegel (1807/1977), the first to raise this notion of other in this manner, asserted that humans are social beings reliant on the construction of the other to make them fully aware of their own consciousness; individuals interacting with their environment and others in the environment create such conscious awareness through recognition of the other. Philosophers such as Heidegger, Husserl, Derrida, and Sartre, to name a few, have explored the existential phenomenology of the self and other. It is beyond the scope of this chapter to detail this complex area of existentialism. However, some specific parts of this corpus of knowledge relate directly to an understanding of othering and the implications of this dynamic for contemporary psychotherapists. Derrida, for example, explicated language as a mechanism of power, and by extension, abuse of power (Lawlor, 2011). Husserl’s (1983) concept of an inner monologue (“hearing one speak”) and Heidegger’s (1978) being in the world inform a counselor’s need for acute reflexivity. Communication has been a powerful tool used in gaining conscious awareness. Verbal and nonverbal cues have had the capacity to alter and change individuals’ perceptions of themselves and their relationships to the world. The interactions of environment and individual experiences have continued to have a profound impact on human development, thus supporting the view that situational factors can play an important role. Heidegger advanced an emphasis on listening as a means to understand fully, suggesting that “Language [is] more likely to be an effect of what we intended than a cause . . . . Language could hide such reality as reveal it” (Heidegger, as cited in Howard, 2000, p. 331). To Heidegger, the self was an ever-evolving, intricate phenomenon. Our identities, then, have become a creation of our authentic and intentional actions and interactions, from which we define and make meaning of our existence. As we continue to examine the underpinnings of how good people can commit evil acts, we note that the construction—or destruction—of one’s identity has become a central feature. We also have seen, in the course of human history, that language can be used as a powerful weapon, one that can be effective in planting the seeds of destruction for the benefit of the few. This tool creates and sustains willful compliance and passive complicity among people, often to their detriment. However, language also can be used

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to connect with one another for the purpose of a greater good, to build relationships, and foster empathy. The demonstration of compassion and understanding for others’ suffering is a construct that is instrumental to what it means to be human, and language can foster tolerance and empathy, in addition to promoting human dignity and social justice (Freire, 1970). Parallel to this transactional or situationalist perspective, Fromm (1947) asserts that We have shown that man is not necessarily evil but becomes evil only if the proper conditions for his growth and development are lacking. The evil has no independent existence of its own, it is the absence of the good, the result of the failure to realize life. (p. 218) With a theological–existential lens, evil can be measured as a depravity of the essential human goodness, just as cold is a deprivation of heat. How does one go about understanding the diametrically opposing forces that face human beings daily? Kant (1960) argues against searching for proofs of humanity’s propensity to evil, maintaining that moral laws exist in society with degrees of incentives for individuals to uphold them, but character is shaped by a choice. Human behavior, he says, “must be apprehended a priori through the concept of evil, so far as evil is possible under the laws of freedom (of obligation and accountability)” (p. 31). By acknowledging a situationalist perspective, one which presupposes that environmental interactions have a profound impact on human development, we can begin to comprehend the underpinnings rooted in the evils occurring in contemporary society. Introspection is a central component of counseling. In an effort to understand the why, humans turn inward to examine the essence of a phenomenon. This approach can shed light on an individual’s beliefs, values, and motivations. However, it does not consider the role that environmental forces play on the formation of a person’s worldview.

Historical Context of Human Nature The role of values plays a significant part in an individual’s belief system. A person’s values consist of a combination of beliefs and attitudes regarding individual or group differences, which in turn can generate an action, or conversely, inaction (Koppelman & Goodhart, 2008). Humans make decisions daily, which are based on the particular value systems that they have created or assumed, and these decisions, over time, can have an influence on the evolution of the society. Human differences come into play, as we each possess a different set of values; consequently, stereotyping, prejudice, bigotry, and discrimination occur. When humans experience fear or frustration, negative stereotypes develop against a particular individual or group and reinforce negative biases. According to Bond (2007), an individual is acculturated to become a contributing member to his group, thereby mobilizing the group’s ability to achieve dominance and promote the group’s ideologies, thus ensuring the group’s survival. Consequently, group members are constantly assessing individual and group needs and potential threats posed by other groups. As a result, prejudices about this individual or group develop, thus leading to negative or detrimental actions being taken against the other. As discussed previously in this chapter, humans classify one another based on several factors, ranging from appearance to cultural practices and beliefs; eventually, people uncritically create dominant and subordinate groups. Born out of this practice, derisive labeling occurs that reflects a “sense of contempt or ridicule based on factors such as race, class, disability, sexual orientation, and gender” (Koppelman & Goodhart, 2008, p. 16). The concept of prejudice reinforces the belief system that members of one group must fear

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and mistrust members of another group, thus leading to discrimination. Bond (2007) asserts that a “group’s ideologies are inculcated by the group’s institutions—familial, educational, occupational, and religious—becoming shared and helping to define what an acceptable member of that group believes and should endorse” (p. 42). Discrimination can take many forms, ranging from verbal abuse and physical assaults to institutionalized discrimination. When discrimination reaches extreme levels, hate crimes and genocide can occur. A more passive form of discrimination also can develop when individuals deny its existence or go out of their way to avoid members of a certain group. This passive complicity is discussed later in this chapter. The pervasiveness of discrimination is grounded in the purpose and benefit that it serves in society. Some studies link prejudicial attitudes and discriminatory practices to an individual’s longing for power. Levin and Levin (1982) identified four primary causes of prejudice that include the following: (a) personal frustration; (b) uncertainty about an individual or group; (c) threat to an individual’s self-esteem; and (d) competition for the achievement of goals in relation to power, status, or wealth. When people experience frustration in relationship to an individual or group about whom they are uncertain or fearful, they may take aggressive action, either verbally or physically. Humans tend to view themselves in dichotomous terms of either good or bad. Consequently, most believe in their innate goodness and seek to justify and rationalize their aggressive actions. This justification leads to scapegoating, which arises when an individual or group is blamed, uncritically, for problems, real or manufactured; it ultimately also can lead to rationalizing negative action against the scapegoated individual or group. Prejudicial behaviors are perpetuated on several levels. Because individuals tend to rationalize their behavior, a vicious cycle occurs as the negative discriminatory behaviors fuel future behaviors. When members of one group believe that members from another are attaining more power, wealth, and status, feelings of hostility and anger can emerge and create resentment. By the late 19th century, methods emerged for classifying human beings according to desired versus negative attributions. Systems of power developed, wielding their influence. Out of this period, the eugenics movement was born. Eugenics is described as “the study of agencies under social control that may improve or repair the racial qualities of future generations, either physically or mentally” (Koppelman & Goodhart, 2008, p. 94). Several well-respected scholars at the time supported the movement in the early 20th century, thus giving it traction, and thereby perpetuating the stereotype that Whites were superior. Eugenics advocates sterilized more than 65,000 Americans during the 1920s through the 1940s (Zimbardo, 2007). This immoral measure was believed to purify the human race by eliminating all undesirable traits from a targeted group. Perhaps as equally immoral as the action was the systemic pervasiveness of the underlying ideology. Within a consenting system, a vast ideological network evolved, in which individuals were taught the perverse morals and values of racism and other types of prejudicial “isms,” and not just by caregivers but also by teachers, religious leaders, and community members alike. This pervasive, structural influence created the foundation for a pseudoscientific and racist worldview and belief system. Classism and racism in all their cultural, individual, and institutional forms have been by-products of the human need to group and classify others as less than. Bond (2007) has made the point that a “cultural system is a particular solution . . . arising out of the interplay between its historical legacy, including traditions, and its current ecological-historical niche” (p. 33), with members being socialized to function as a part of this solution. In Western cultures, most biases take on an egocentric role. From a social– emotional perspective, this serves as a protective buffer for developing one’s identity and maintaining one’s self-esteem. Fear of rejection is a powerful motivator within a power-based

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system. When individuals do not recognize biases that are brought to the surface by situational factors, they underestimate the power that a system can exert. Zimbardo (2007) offers the following explanation: Situational power is most salient in novel settings, those in which people cannot call on previous guidelines for their new behavioral options. In such situations the usual reward structures are different and expectations are violated. Under such circumstances, personality variables have little predictive utility because they depend on estimations of imagined future actions based on characteristic past reactions in familiar situations. (p. 212)

THE PSYCHOLOGY OF EVIL In this chapter, we have discussed two different viewpoints regarding influences on moral behavior: situational and dispositional factors. Cultures that emphasize individualism are more likely to believe in a pathology-oriented, dispositional reason for the deviant behavior residing within an individual. The presumption has been that people simply are born with the capacity to commit moral or immoral actions. This view has narrowed our capacity to understand how good people can be capable of performing heinous acts. However, by examining what conditions or circumstances might have contributed to the action, we reasonably can determine if perhaps situational or environmental factors played a role. In addition to considering the importance of situational and dispositional forces, the role of systemic ideology has been powerful in educating individuals and sustaining a belief system. Zimbardo (2007) has asserted that power systems “create mechanisms that translate ideology” (p. 9). He offers the following assessment: Over time, Systems come to have a historical foundation and sometimes also a political and economic power structure that governs and directs the behavior of many people within its sphere of influence. Systems are the engines that run situations that create behavioral contexts that influence the human action of those under control. At some point, the System may become an autonomous entity, independent of those who initially started it or even of those in apparent authority within its power structure. Each System comes to develop a culture of its own, as many Systems collectedly come to contribute to the culture of society. (Zimbardo, 2007, pp. 179–180) Continuing our emphasis on the relevance of situational and dispositional forces and the systemic mechanisms of ideology, we have outlined a psychology of evil through the following discussions in the remaining parts of this section: the dialectic of dehumanization, the Stanford prison experiment, the banality of evil, and the evil of inaction.

The Dialectic of Dehumanization The first step in the process of marginalizing another is to identify the group to be targeted and then to construct negative, stereotyped perceptions of that group. The intention is to dehumanize members of the group, assigning or inferring identities to them so that they are perceived as worthless or as a threat to the fundamental values and beliefs of the assignees. Devaluing of the other’s personhood occurs gradually and

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works to strip away an individual’s or a group’s self-identity. As an example of this, in Night, Elie Wiesel (1960) discusses how the German soldiers at first assimilated into his village cordially; however, personal freedoms eventually were taken away. Wiesel states that “[t]he first step: Jews would not be allowed to leave their houses for three days—on pain of death . . . . A Jew no longer had the right to keep in his house gold, jewels, or any objects of value . . . every Jew must wear the yellow star” (p. 8). Dietrich Bonhoeffer (1995), a Lutheran pastor and theologian, was a part of the German resistance against Hitler’s Nazi regime. He was martyred for this cause just 23 days before the Nazi’s surrender. The Nazi regime used parts of Friedrich Nietzsche’s philosophy to buttress their pursuit of the übermensch, or genetically ideal human being. Seeing evil in the racism and xenophobic judgment used to justify this attempt at genetic engineering through genocide, Bonhoeffer protested. He asserted that the Nazi’s presumptuous misjudgment would lead either to the most mendacious hypocrisy or else to madness (Bonhoeffer, 1940/1995). He connected his experience of attempting to uphold human rights against the Nazi worldview with Christ’s conflict with the Pharisee through the theological drama recorded in the four gospels. Attempting to resist the propaganda of the Third Reich, Bonhoeffer (1940/1995) stated the following: All these facts must not, however, be allowed to distort the true picture; the passing of judgment does not spring from these vices of the human heart or from its wickedness, be they ever so rebellious; on the contrary, the passing of judgment is the origin of all these psychologically intelligible phenomena. It is not, as Nietzsche supposed, because it arises from these dark motives that judgment is wrongful; judgment is evil because it is itself apostasy, and that is also why it brings forth evil fruit in the human heart. (p. 36) Tracing the development of the Nazi regime to this source was, for Bonhoeffer, a study of the evil human attitude of judging one’s peers; how, unchecked, it can deteriorate a whole society.

The Stanford Prison Experiment In the early 1970s, Phillip Zimbardo, a social psychologist at Stanford University, wanted to examine the unique behavioral characteristics and group dynamics that occurred in prisons. He initiated the Stanford county prison experiment to “create” the conditions for these behavioral dynamics so that the behaviors could be observed and analyzed. The prison was located in the basement of the building where the psychology department was housed. A large pool of heavily screened participants was carefully narrowed down to 18— nine prison guards and nine prisoners—with two alternates, in case the need arose. The similarities among the participants were significant; the only factor separating one group from the other was fate, as their roles were randomly assigned. After each prisoner’s arrest, conducted in real time by actual police, they were taken physically to the Stanford County Jail, stripped of their personal possessions, and assigned a prisoner number. This number became each inmate’s new name. The prison guards controlled all aspects of prison life, including when the prisoners could speak; an example of this from the “seventeen rules” (Zimbardo, 2007, pp. 44–45) was that “[p]risoners must remain silent during rest periods . . . during meals, and whenever they are outside the prison yard” (Zimbardo, 2007, p. 44). The rules also dictated when they could eat and use the restroom. Prisoners were not permitted to operate lighting and were required

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to participate in all prison activities. Additionally, many daily activities were viewed as privileges, including mail, visitors, and smoking. The prisoners were not allowed to address each other by name, but rather, only by their assigned numbers. After less than 3 days, prisoners began to show signs of depersonalization; as a result of losing personal freedoms, the prisoners experienced a loss of personal identity. The constant subjugation experienced by the prisoners, as a result of having all aspects of their behavior controlled, contributed to the demonstration of passive, dependent, and depressive behaviors resembling learned helplessness (Zimbardo, 2007). The latter occurred when individuals experienced repeated failure or punishment, regardless of their own actions; they then demonstrated passive resignation or depression (Zimbardo, 2007). In her work on trauma and recovery, Herman (1997), explained that the psychological impact of subordination to coercive control demonstrates similarities within a number of realms, ranging from a public power system (e.g., politics) to a private system (e.g., home and family); by systematically and repeatedly inflicting psychological trauma on an individual, as in the Stanford study, a method of control can be established. The Stanford prison experiment illustrated how methods of psychological control can instill anxiety and fear, leading to feelings of helplessness and the destruction of a person’s identity and connection to others. A more recent example of such methods has been seen in the incidences of prisoner abuse at Abu Ghraib. As with the guards in the Stanford experiment, when the perpetrator’s outbursts have been inconsistent and unpredictable, fear is increased exponentially, as the targeted recipient of the outbursts finds himself in a novel setting, with little experiential knowledge on which to rely or to dictate his future behavioral options. A parallel also can be drawn here to the chaos and lack of predictability caused by the behavior of perpetrators in homes where extreme domestic violence and child maltreatment occur. Through the use of the rules, the Stanford prison experiment effectively stripped away personal freedoms; fear and anxiety increased, and the next step in devaluing the personhood of the inmates was to eliminate all feelings of autonomy. As this process unfolded, the inmates became more and more isolated. According to Herman (1997) in a discussion of other types of captivity, any objects that symbolized a connection to others were removed, and dependency on the perpetrator grew for basic bodily needs to be met, as well as for “outside” information and emotional sustenance. She explained that “[a]ll of the psychological structures of the self have been invaded and systematically broken down . . . the captive’s name is replaced with a nonhuman designation, a number” (Herman, 1997, p. 93). In the Stanford experiment, the creation of roles (guard and prisoner), rules, stripping of identity, and pressures to conform to the system all contributed to the creation of new group identities. These new identities distracted most of the participants from listening to their own internal dialogue, thus enabling them to succumb more readily to the newly established norms created in each respective group.

The Banality of Evil The legal scholar and philosopher Hannah Arendt coined the phrase “banality of evil” when observing that “moral conduct . . . seems to depend primarily on the intercourse of man with himself” (Arendt, 2003, as cited in Ludz, 2007). Arendt’s (1964) seminal work, Eichmann in Jerusalem: A Report on the Banality of Evil, was the first to introduce the possibility that individuals do not necessarily have to possess a pathological defect to commit an act of evil; environmental forces can affect behavior, allowing people to perform acts of evil in an uncritical fashion. It is the unquestioning moral acceptance of routine or everyday wrongs that has comprised Arendt’s notion of a banality of evil. The idea of disposition, she posited, begins with a commonly held assumption that

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there exists a right and wrong, and that this concept is absolute. However, when the forces are situational or environmental, those who presume an absolute moral dualism, and elect to ignore their moral compasses, can fall subject to the creep of everyday evil. Arendt’s work on the banality of evil has resonated to this day, as we are bombarded regularly with images of genocide from the Darfur region and testimonials of vicious gang rapes in the Congo. Arendt (1994/1951) also examined the concept of totalitarianism. In The Origins of Totalitarianism, she illuminated the powerful system of government and its capacity to affect large numbers of human beings. She asserted the possibility that a transnational ideology can emerge, promoting the interests of an individual or group in power, at the great expense of the people and nation (Arendt, 1994). Such a system no longer would be concerned with the common good; instead, it would use terror to propel its agenda. The totalitarian regime would not wish to seek compliance or even compromise, but rather, to eliminate those deemed inferior. Just as Heidegger examined language as a tool that could be used for good or evil, communication would be an important component used to further the totalitarian agenda. According to Arendt’s notion of totalitarianism, limited access to relevant information could create and sustain a sense of isolation, causing individuals to accept a transnational ideology and discouraging the free discourse that may challenge it. Collective violence relies on its contemporary culture to perpetuate it; the scope of the violence depends on the systemic control of the dominant group. As mentioned earlier, the men participating in the Stanford prison experiment were carefully screened, identified as being without “pathological defects” (Arendt’s term), and were viewed as “psychologically identical” (Bond’s term). When the researchers created a prison culture encouraging a particular type of behavior, they instituted situational controls that further perpetuated the system of dominance or passivity and provided the participants with roles; thus, a toxic web was woven. The transformation of these seemingly well-adjusted young men, into prison guards capable of committing a number of unspeakable acts and inmates with learned helplessness, happened quickly. Within 3 days, each group fully embraced their respective roles: that of prison guard or that of prisoner. One of the prison guards remarked, Once you put a uniform on, and are given a role, I mean, a job . . . then you’re certainly not the same person if you’re in street clothes and in a different role. You really become that person once you . . . take the night stick, and you act the part. (Zimbardo, 2007, p. 213) The assimilation of a character, once the mask had been donned, was a powerful reinforcement for the other guards, as well, and enabled the scapegoating of prisoners. A guard stated, “As I got angrier and angrier, I didn’t question this behavior as much . . . so I started hiding myself deeper behind my role” (Zimbardo, 2007, p. 86). The guards frequently blamed, and subsequently punished, the prisoners for circumstances out of the prisoners’ control, such as adequate bathing and restroom facilities. Many of the guards reported purposeful intent in perceiving the prisoners as subhuman. They believed that it made their jobs easier if they stripped the prisoners of their humanity, thus employing victim-blaming rationalizations to justify the unethical actions they demonstrated. According to Koppelman and Goodhart (2008), individuals who use this form of rationalization recognize that prejudice and discrimination exist; however, they believe that the problems reflect the flaws or deficiencies found in members of the dominated group. As time wore on in the Stanford prison experiment, the guards developed the belief that their shift would go smoothly if the prisoners would simply

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“follow the rules.” Victim blamers do not believe that they need to alter their behavior; it is the subjugated group that needs to change.

Evil of Inaction Not all of the guards in the Stanford prison experiment participated in heinous actions to dehumanize the prisoners. What makes human beings conform to the powerful practices of a system? Zimbardo posited two reasons for this occurrence. The first is driven by a human being’s need for information. We are driven to acquire information from others regarding views, perspectives, and knowledge to help us navigate the happenings in our world. The other reason, he asserts, is a normative need. Earlier in this chapter, we discussed a human’s fear of rejection. Zimbardo’s second assertion for passive complicity is connected to this fear. People want to fit in with a peer group, and in order to do this, they often are willing to yield their own beliefs and worldviews in order to align with the desired group membership. Kant (1960/1793) discusses this human capacity for evil as a weakness of the human heart or the frailty of human nature (p. 24). Social scientists have conducted numerous studies demonstrating that the greater the number of people who witness a tragic event or an emergency, the less likely it is that any of them will intervene. The presence of others seems to alleviate the sense of responsibility that might otherwise compel them to act. This type of group think was experienced by everyone involved in the Stanford prison experiment—from the researchers to the guards and prisoners. Even though several of the prison guards disagreed on a personal level with the behaviors of their fellow guards regarding the treatment of prisoners, none of them spoke up to improve conditions for the prisoners. Instead, the passive guards chose to keep themselves busy, doing other tasks that were nonprisoner related, or they conducted favors for the prisoners outside of the purview of the aggressive guards. Koppelman and Goodhart (2008) discussed ways in which individuals justify prejudicial, morally questionable actions. The group of guards demonstrated two different types of rationalizations; they either employed the use of avoidance rationalizations or denial rationalizations (Koppelman & Goodhart, 2008). Avoidance rationalizations have acknowledged that prejudice and discrimination exist in current society; however, the individual demonstrates reluctance to address the issue or willingness only to examine one small part of the problem, in other words, avoiding its totality. The guards using avoidance rationalizations recognized that there was a problem, but rationalized a way to avoid addressing it; these passive guards exercised denial rationalizations, refusing to recognize that there was a problem, which resulted in prejudices and discrimination. Sometimes denial rationalizations can appear as benign, such as “It is natural that women do some things better than men.” Several of the guards convinced themselves that they were engaging in nothing more than an experiment, and surely, the prisoners also kept this thought in mind throughout the process. Denial rationalizations can exact a high psychic cost, such as circumstances involving torture, genocide, and mass geopolitical rape. In cases of torture, using Abu Ghraib as an example, individuals can attribute human emotions to their particular in-group, denying these same traits to those in the out-group (Leyens et al., 2000). This recent phenomenon is rooted in a form of emotional prejudice. Feelings of conformity are powerful, stemming from a human need to belong. Group dynamics can alter behavior because their influence often is indirect. Human beings imitate what they see; by doing so, personal autonomy diminishes, limiting an individual’s potential to choose a path that is individually appropriate for the sake of the majority. To highlight the nature of such limitations, in

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the remaining parts of this section, we briefly examine the role of authority and the passive complicity of victims.

Role of Authority Stanley Milgram’s groundbreaking work on obedience in the early 1960s helped to shape how social scientists have come to view the impact of authority and passive complicity. Milgram (1974) examined the role that obedience played in conforming to a group dynamic. A person resembling a scientist in a lab coat addressed the participants, who were divided into two groups or roles: the learner and the teacher. Using euphemistic language, the scientist was able to manipulate how the teachers viewed their role in the experiment. By doing so, an environment was created, whereby the teacher would choose to comply, despite what inner thoughts he or she experienced regarding the request. The scientist also provided the teachers with justifications, which would support the behavioral options that the teachers subsequently would choose. In the experiment, the teachers were told that the goal of the study was to determine the impact of stress on memory. The learner was a confederate in the study, who would be given a series of word pairings to memorize. The teacher was then asked to administer a series of shocks to the learner when the learner answered a question incorrectly. The shocks ranged from “strong” to “danger, severe shock.” Of all the teachers, 65% went the whole way to the maximum shock level, despite the learners’ pleas to stop. Milgram’s data showed that almost anyone could be compelled to comply with authority when situational variables were manipulated. The percentages of compliance increased when certain group dynamics were instituted among the teachers. Important to note was that the teachers were composed of various age groups and occupations and included both genders. The role of an authority figure increased the likelihood that individuals would comply blindly with directives, despite internal misgivings regarding the request. The implications of this study were astounding, especially as they may relate to matters ranging from peer pressure, to fraternity hazing and bullying, to torture.

Passive Complicity in Victims The toll of bias-related rationalizations also can be experienced by the subjugated group. Originally defined by psychiatrist Frank Ochberg, MD, this identification with the captor or perpetrator has come to be known as Stockholm syndrome (see Chapter 11 of this book). Elie Wiesel (1960) reported an instance of the conflicting thoughts and feelings that he experienced while captive in a concentration camp, recalling the following story: The gypsy looked (my father) up and down slowly, from head to foot. As if he wanted to convince himself that this man addressing him was really a creature of flesh and bone, a living being with a body and a belly. Then, as if he had suddenly woken up from a heavy doze, he dealt my father such a clout that he fell to the ground, crawling back to his place on all fours. I did not move. What had happened to me? My father had been struck before my very eyes, and I had not flickered an eyelid. I had looked on and said nothing. (p. 37) The humiliation that is experienced by the subjugated individual perpetuates the feelings of helplessness and dehumanization. Wiesel’s realization of his failure to act demonstrates the impact that the prison guards had on Wiesel’s inner self, after only a short time in the camp. Mere survival relies on the individual’s ability to shut down feelings, emotions, and belief systems, thus stripping away the essence of the person.

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COUNSELING IMPLICATIONS The implications for counselors of understanding the psychology of evil and the dynamics of othering are enormous. Mental health practitioners are faced with the complexities of human nature on a daily basis. Counselors must clarify their personal belief systems in a process of reflection, especially because of the way that clients’ experiences may test or enlighten these beliefs. Cashwell and Young (2011) assert that although counselor education programs have “traditionally emphasized such core conditions as unconditional positive regard, genuineness, congruence, empathy, and warmth (including respect for others), the attention given to multicultural awareness factors such as race, gender, ethnicity, sexual orientation, and spiritual and religious issues is still developing” (p. 73). Human intricacies are a part of the fabric of everyday living, and therapists are tasked with helping others to navigate difficult and morally complex situations. The duality that seemingly exists in human beings, ostensibly driven by the need to preserve life and influenced by several circumstances, cannot be explained, easily, in absolutes. Fear, which is the basis of prejudice, has an impact on individuals, altering their existence and forcing them to evolve constantly, so as to adapt to the environment. Examining situational and environmental factors that play a role in an individual identity and moral development can enlighten practitioners about the clients’ worldviews and belief systems. Clients’ religious practices and spirituality also can be valuable resources in the therapeutic process. The pervasive influence of the Abrahamic faiths of Christianity, Islam, and Judaism on world cultures creates a potentially valuable bridge between practitioners and clients’ assumptive worldviews, regardless of personal affiliation. Situational power is especially influential in new settings, in which the individual has little experiential knowledge. As a result, the individual may not have a comprehensive understanding of behavioral expectations or reward structures, and decision making thus may become impaired (Zimbardo, 2007). By conducting a situational analysis (Zimbardo, 2007), counselors can understand clients’ fear-based behaviors and offer guidance. Throughout the process of sorting through biases and prejudices, language is a powerful tool used by practitioners to uncover a client’s thoughts, feelings, and perceptions. Conversely, language also can be used as an agent to create misunderstandings and induce harm. Although language is important, examining what an individual does can illuminate motivations that underlie a particular phenomenon. Early identification of prejudicial and discriminatory language and behavior is critical for both counselors and clients. Implementation of self-reflection techniques to explore thoughts that are discriminatory can create a deeper understanding and a more meaningful relationship with humanity. Kant (1960/1793) has offered that “the highest moral good cannot be achieved merely by the exertions of the single individual toward his (sic) own moral perfection, but requires rather a union of such individuals into a whole toward a common goal” (p. 89). By increasing one’s self-awareness, one can identify the perceptions and actions that lead to prejudicial acts. This can enable both the client and counselor to take active steps to alter client beliefs and to make decisions that have a positive impact on others. Self-awareness goes hand in hand with the development of empathy. Empathy enables individuals to encounter authentically the experiences of another. Expanding a person’s worldview to include the understanding of others’ experiences increases compassion and restores the “humanity” to the human. With a rise in school violence related to bullying, for example, social skills development and empathic communication skills are essential components in assisting students to expand social consciousness. College counselors and military counselors also must address issues such as hazing and torture, respectively, as these affect their clientele.

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Mental health therapists need to encourage clients to self-reflect on their inner monologue without external interference, thereby reducing the possibility of influence that is driven by peer pressure or groupthink. Helping clients to realize that they have choices is also a powerful factor in this process. Viktor Frankl (1959), a Holocaust survivor, instructs us that “[t]he experiences of camp life show that man does have a choice of action. There were enough examples, often of a heroic nature, which proved that apathy could be overcome” (p. 65). Passive complicity also can be acknowledged proactively through self-reflection. Counselors can touch on these themes to mediate, decrease, or even prevent trauma-inducing events.

CONCLUSION Cultural values, social mores, and human nature all influence the environment and are capable of transforming it in several ways. Human behavior cannot be reduced to such absolutes as good versus evil and moral versus immoral. Human beings are social creatures driven by their need to belong and their fear of rejection. As a result, an individual’s value system and worldview are shaped by the social actions and interactions among the diverse beliefs and values that the person has and experiences within the environment over time. The influence of a group is powerful and can hold positive or negative ramifications, based on an individual’s worldview. This chapter elucidated themes central to understanding the underpinnings of evil, forcing us to ask how or what factors enable good people to perform evil acts. Viewpoints from philosophers and social scientists were discussed in an effort to increase awareness of this phenomenon through early identification, self-awareness, and increased moral decision making. Human beings’ developmental pathways are dynamic and constantly evolving due to environmental and situational factors that force individuals to adapt. Using authentic means of communication can decrease discriminatory behaviors, such as scapegoating and othering, in addition to increasing self-awareness, moral development, and constructive decision making. Throughout this chapter, examples illuminated various aspects of human behavior. Each behavior, taken individually, appears small in nature, thus exacting a minute ripple effect; when examined in their totality, however, one can see the constructive or destructive ramifications of such a ripple effect. Individuals must be cognizant of their motivations and intentions and reminded of the consequences of their actions, no matter the nature and no matter how small the scale.

APPENDIX 16.1 Bandura and Moral Development In the mid-70s, Bandura, Underwood, and Fromson (1975) conducted an experiment that led to the development of a moral development model. They wanted to examine how individuals developed moral standards as a result of their environmental and socialization experiences. Bandura et al. (1975) believed that an individual was heavily influenced by his or her family, community, and society at large, thus providing the foundation for either prosocial or antisocial behaviors. The model posits that individuals develop selfidentity and self-worth as a result of reinforced thoughts and actions that have been influenced by positive social interactions within their environment. Based on how an (continued)

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APPENDIX 16.1 (continued) individual is treated by others, the social environment has a direct impact on the development of an individual’s identity. The implementation of self-regulatory behaviors is viewed as a fluid, evolving process that determines appropriate, acceptable moral conduct. Individuals can choose to disengage from this self-regulatory behavior based on group or environmental situations. Bandura (1986) elucidated four outcomes that can lead an individual to disengage morally from universally acceptable conduct. The first outcome posits that individuals disengage from reprehensible behavior by attaching a moral justification to it. This can be done by comparing one act to another that is more reprehensible. Individuals also can disguise the act, using euphemistic language that can conceal their thoughts as much as reveal them. The second outcome involves individuals’ ability to distance themselves psychologically from the act itself in order to alleviate the sense of personal responsibility. Individuals also may harbor the capacity to minimize or distort the way they perceive the action. In this third outcome, people have the option to ignore what they have done. Finally, individuals have the power to reconstruct their perceptions of the act, using rationalizations such as avoidance, denial, and victim-blaming justifications.

RESOURCES Website The Centre for Studies in Otherness. (http://www.otherness.dk/) Films and Videos Films for the Humanities & Sciences (Producer). (2008). Zimbardo speaks: The Lucifer effect and psychology of evil [DVD]. Pakula, A. (Producer), & Mulligan, R. (Director). (1962). To kill a mockingbird. United States: Universal International Pictures. Zimbardo, P. G. (Producer). (2004). Quiet rage: The Stanford prison experiment [DVD].

REFERENCES Arendt, H. (1964). Eichmann in Jerusalem: A report on the banality of evil (2nd ed.). New York, NY: Penguin Books. Arendt, H. (1994). The origins of totalitarianism. San Diego, CA: Harcourt. (Original work published 1951) Auer, J., & Ratzinger, J. (1988). Eschatology: Death and eternal life. Washington, DC: The Catholic University of America Press. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A., Underwood, B., & Fromson, M. E. (1975). Disinhibition of aggression through diffusion of responsibility and dehumanization of victims. Journal of Research and Personality, 9, 253–269. Bond, M. H. (2007). Culture and collective violence: How good people, usually men, do bad things. In B. Drož dek ¯ & J. P. Wilson (Eds.), Voices of trauma: Treating psychological trauma across cultures (pp. 27–57). New York, NY: Springer Publishing. Bonhoeffer, D. (1940/1995). Ethics. New York, NY: Touchstone/Simon & Schuster.

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Cashwell, C., & Young, S. (2011). Integrating spirituality and religion into counseling: A guide to competent practice (2nd ed.). Alexandria, VA: The American Counseling Association. Conrad, J. (2004). Heart of darkness. Whitefish, MT: Kessinger. (Original work published 1899) Diamond, S. A. (1996). Anger, madness, and the daimonic: The psychological genesis of violence, evil, and creativity. New York, NY: SUNY Press. Dubay, T. (1997). Authenticity: A biblical theology of discernment. San Francisco, CA: Ignatius Press. Frankl, V. (1959). Man’s search for meaning. Boston, MA: Beacon Press. Freire, P. (1970). Pedagogy of the oppressed. New York, NY: The Seabury Press. Fromm, E. (1947). Man for himself. New York, NY: Henry Holt. Garbarino, J. (2008). Children and the dark side of human experience: Confronting global realities and rethinking child development. New York, NY: Springer Publishing. Hannay, A. (Translator). (1986). Introduction. In S. Kierkegaard, Fear and trembling (pp. 7–37). New York: Penguin Classics. (Original work published 1843) Hegel, G. W. (1977). Phenomenology of spirit (A. V. Miller, Trans.). Oxford, United Kingdom: Oxford University Press. (Original work published 1807) Heidegger, M. (1978). Being and time. London, United Kingdom: Blackwell Publishing. Herman, J. (1997). Trauma and recovery. New York, NY: Basic Books. Howard, A. (2000). Philosophy for counseling and psychotherapy. New York, NY: Palgrave. Husserl, E. (1983). Ideas first book (F. Kersten, Trans.). Dordrecht, Netherlands: Kluwer Academic. Kant, I. (1960). Religion within the limits of reason alone. New York, NY: Harper & Brothers. (Original work published 1793) Kierkegaard, S. (1985). Fear and trembling: Dialectical lyric by Johannes de Silencio (A. Hannay, Trans.). London, United Kingdom: Penguin Books. (Original work published 1843) Koppelman, K. L., & Goodhart, R. L. (2008). Understanding human differences: Multicultural education for a diverse America (2nd ed.). New York, NY: Pearson. Lakoff, G., & Johnson, M. (1980). Metaphors we live by. Chicago, IL: University of Chicago Press. Lakoff, G., & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and its challenge to Western thought. New York, NY: Basic Books. Lawlor, L. (2011). Jacques Derrida. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy. Retrieved from http://plato.stanford.edu/archives/sum2011/entries/derrida/ Levin, J., & Levin, W. (1982). The functions of discrimination and prejudice (2nd ed.) New York, NY: Harper & Row. Leyens, J. P., Cortes, B., Demoulin, S., Dovidio, J., Fiske, S., Gaunt, R., . . . Vaes J. (2000). The emotional side of prejudice: The attribution of secondary emotions in-groups and out-groups. Journal of Personality and Social Psychology, 89, 186–197. Ludz, U. (2007). Arendt’s observations and thoughts on ethical questions. Social Research, 74 (3), 797–810. Machiavelli, N. (1992). The prince (R. M. Adams, Trans.). London, United Kingdom: Norton. Milgram, S. (1974). Obedience to authority: An experimental view. New York, NY: HarperCollins. Wiesel, E. (1960). Night. New York, NY: Bantam Books. Zimbardo, P. (2007). The Lucifer effect: Understanding how good people turn evil. New York, NY: Random House.

CHAPTER 17

Racial and Ethnic Intolerance: A Framework for Violence and Trauma EMMA MOSLEY

INTRODUCTION There can be no doubt that intolerance, of all sorts, still exists in the United States of America, as well as throughout the world. Intolerance in America is so deeply rooted that it often goes unnoticed except by its victims, who often have their lives dramatically altered by discrimination based on race, gender, age, color, country of origin, sexual orientation, religion, family status, economic level, education, and physical and mental disability. It is beyond the scope of this chapter to provide a detailed account of the history of the development of these various forms of intolerance. Yet, at the same time, it is a disservice to ignore the relevant historical events that have led to the formation and entrenchment of intolerance and that have created widespread discrimination directed toward a variety of people. It is often difficult to understand the attitudes and feelings of oppressed people if we are ignorant of or insensitive to the history of such discrimination. At the same time, we need to understand that, for many people, the historical legacy is reflected in current unfair and discriminatory practices. The past could be relegated to ancient history, were it not for the fact that the past is, very often, reflected in contemporary attitudes. The nature of intolerance and discrimination is detailed in this chapter, along with the historical development of such intolerance. Mental health practitioners, when working with people whose cultural histories include prejudicial treatment, need to consider the very negative impact of discrimination and to understand the historical as well as the psychosocial implications of exclusion, oppression, and discrimination. Thus, a major goal of this chapter is to examine intolerance and discrimination throughout history. A second goal is to explicate this information with an emphasis on the oral histories of people who have experienced discrimination, rather than totally relying on an “official” history that has tended to ignore the lived experiences of those who have been oppressed. Toward this end, I include interviews with a local professor, who is a historian, long acknowledged for his local research of discrimination-related history and the collection of related oral histories.

CULTURAL LANDSCAPE: ASSIMILATION Before beginning a systematic analysis of colonial oppression, it is essential to deconstruct a seemingly innocuous contribution to the unexamined acceptance of inherent qualities, which people supposedly possess, that lead to discrimination and separation.

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In the U.S. society, the conceptual contributor is the “melting pot theory.” The melting pot is simply a metaphoric extension of the cultural assimilation bias that exists in European countries, as well. The U.S. version of this cultural assimilation has been widely institutionalized in the American ethos. According to the melting pot theory, America is a giant cauldron filled with basic ingredients contributed by the various people who came to America. Regardless of their countries of origin, they are now “Americans.” All they had to do was give up speaking their native language, perhaps alter their family name so that it did not sound so “foreign,” and adapt a new way of behaving and dressing that made them indistinguishable from other Americans. In exchange, these people would gain total acceptance and access to the “American Dream.” (It is worth noting that the cultural “recipes” for the melting pot do not always include Native American, Asian, Latino, Hispanic, or African ingredients. The recipes are, almost exclusively, of European origins.) However, this proved to be a misguided fantasy. Many of the people who came here from other lands did not and would not give up their cultural identities. When they arrived in America, they were steered to areas where others “like them” lived. Thus, there was no need to learn English rapidly because many folks around them still spoke the native tongue. Many cultural practices still thrived in their adopted land. Although many immigrants encouraged their children to adapt to the new situations, not all of them elected to do so. These issues would not have been significant, were it not for the melting pot theory. One of the consequences of this teaching was that Americans adopted views that everyone who came here must be like them. This led to questions and perspectives such as “Why can’t they act like us? Why can’t they speak English without an accent? Why do they eat that strange food? Why can’t they dress like us?” As a result, people who did not fit into American culture were considered unfit to occupy our space. Adherence to the melting pot theory has created a climate that fosters an atmosphere of intolerance (Markus & Moya, 2010).

Ethnocentrism Ethnocentrism is the belief that one’s particular clan, tribe, or cultural group is superior to all others. The notion of race is not an essential or necessary condition for ethnocentrism to exist. The only necessity is that the “other group” is perceived as culturally different. This dynamic has been labeled as “othering” in popular parlance, evolving from philosophical and anthropological notions of “otherness.” Othering occurs when one individual or group constructs and reinforces a positive self-identity by projecting stigma and attributing negative qualities onto the other person or group. In such cases, groups and individuals elevate themselves by denigrating “others.” In some ethnocentric conflicts, the combatants appear to the casual observer to be identical. Often the differences between the groups are historical in nature, and the passage of time has actually brought them closer together in cultural context. However, the historical differences are treated as if they are vast cultural differences. Indeed, ethnocentrism can lead to the same kinds of extreme behavior exhibited in racist practices, but care must be taken to discern the differences in the root causes of each phenomenon (Markus & Moya, 2010).

Racism Colonial oppressors often have used racism as an excuse to murder, plunder, rape, assault and destroy groups of people from another so-called race. Racism, for the purpose of this chapter, is defined as any treatment by individuals or group of individuals

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that results in the unfair treatment of people based on the ill-defined concept of “race.” According to some experts, there were at one time as many as 64 so-called races. There is still disagreement, even among scholars, as to how many “races” there are (Markus & Moya, 2010). It is not the purpose of this chapter to settle the disagreement here. According to Dr. Ralph Proctor, whose doctoral degree is in history and who long has examined the history of ethnicity-based bigotry, the concept of “race is, strangely absent from the literature until after the beginning of the Atlantic slave trade.” In a series of interviews with Dr. Proctor, he offered the following explanation: I have been studying the conceptual framework of “race” for more than forty years. . . . I have concluded that the theory that divides human beings into distinct categories, is a “sociological construct” that someone created without the benefit of scientific evidence. It simply is a fantasy that is used for many purposes, most of which are nefarious. When Americans, for example, use the word “Black” to refer to an individual, or group of individuals they believe they have accurately identified certain people. What they do not know is that the use of the word has no scientific meaning and may be applicable only to the United States. It is highly likely that the individual or individuals, so described, would not be called “Black” in many other countries . . . (R. Proctor, personal communication, various dates in 2011)

Conditions of Racism Although the concept of “race” is a fallacy, one must still take a look at the systems of discrimination, murder, abuse, and subjugation brought about in the name of “race.” The late University of Pittsburgh Anthropology Professor Arthur Tuden lectured that there are three conditions necessary for racism to take hold and flourish. First, the two groups must be distinguishable from one another. A group cannot be persecuted, on racial bases, if the members of the group are not identifiable from the other people around them. This was a problem for Hitler; it was so difficult to distinguish Jews from Gentiles that Hitler and his followers had to resort to forcing German Jews to pin a paper Star of David on their outer garments. This, of course, could only be done after the Jewish person had already been identified by other means. The second necessary condition is that the two groups, at least initially, be culturally different. Cultural differences are then used to illustrate the attributions of inferiority of the soon-to-be oppressed group. Once the racist attitudes are constructed and socially imbedded, the need for articulated cultural differences vanishes. Although these cultural differences are initially used to define the inferiority of the other group based on socially constructed racism, the “other’s” culture becomes stigmatized. In many cases, through the process of cultural assimilation, the groups become culturally identical, but this no longer matters because the oppressor has already been successful in constructing and institutionalizing a racist ideology. The final condition is that one group must already be, for the most part, in a position of institutionalized inequity. The inequity may be in the form of educational and/or financial discrimination, or the group already may have been forced to live separately from the dominant group (McGlynn & Tuden, 1991).

Types of Racism For the purpose of this chapter, various types of racism essentially can be classified into four categories: individual, institutional, cultural, and liberal. Individual racism is easily seen; it is the act of an individual against other individuals or groups of

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individuals. Institutional racism is found closely woven into the fabric of an organization or institution. One need not be individually racist in order to practice institutional racism. The third type of racism is cultural. In this type of racism, those in control use cultural differences of “others” as proof of inferiority. Simply put, they claim that the cultural patterns, exhibited by people of color, are sufficient reason to discriminate against them (Marger, 2005). The last type is liberal racism, as formulated by Dr. Proctor: This form is extremely difficult to ferret out because the person exhibiting the racism is believed to be a friend; he or she is a so-called liberal, who has professed belief in the equality of all people. . . . The racism only comes to the surface when one examines the reason [behind] the Liberal Racist’s belief that Blacks should be able to integrate. I encountered this when I appeared on a panel. . . . One speaker, who was known as a liberal thinker, was making a presentation. At first I was pleased with his presentation because he was supporting the concept of total integration. Shortly, however, I found myself disturbed by his rationale for supporting integration. It soon became apparent that his belief that Blacks should be permitted to integrate into White American society was that this was the only way Blacks would ever become equal. In order to become equal, Blacks had to abandon all Black institutions, including schools, churches, colleges, business establishments and other Black cultural facilities and immerse themselves in White American culture. In other words, he was saying that Black life was so pathological that it had to be abandoned if Blacks ever wanted to be accepted as equal. I was stunned! I found myself confronting a friend who had been at our sides through much of the Civil Rights Movement. It was out of this meeting and my subsequent conversations, with other liberals, that I coined the phrase “Liberal Racism.” (R. Proctor, personal communication, various dates in 2011)

EXAMPLES OF COLONIAL OPPRESSION When Christopher Columbus set sail in 1492, most Europeans agreed that the world was flat and to venture too far would mean disappearing into the unknown void that existed at the end of the horizon. There is much controversy as to who reached America first. Some claim that the Swedish came before Columbus; some claim the first to reach America were Vikings from Norway. Others claim that the honor belongs to the Chinese (Levanthes, 1997; Manzies, 2008). Several scholars believe that Africans arrived long before 1492. Among them is Thor Heyerdahl (1971), who wrote about the ancient discovery of Hawaii and America. Ivan Van Sertima (2003) is another scholar who claims that Africans sailed to the Americas long before Columbus. The mystery cannot be solved within the confi nes of this chapter. It is interesting, however, to note that colonial oppression legacies may well explain why Americans tend to cling to the myth of Columbus’s “discovery” of America despite plentiful evidence to the contrary. When Columbus returned to Spain, he brought with him exotic-looking people who he said were inhabitants of India, and he referred to them as such. Word spread throughout Europe that Columbus had “found a new route to India”; yet, the land was not called “New India,” which would have been in keeping with patterns of European conquest. Instead, the place was called “the New World,” and all the sovereign European nations decided they had the right to own it.

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Estimates are that, prior to Columbus’s arrival, there were between 9 million and 25 million people already occupying the Americas. Colonizing European countries were responsible for the near annihilation of these people (Bennett, 1962).

Colonial Oppression of Native Americans Columbus’s return ushered in a headlong rush by Europeans to settle the so-called “New World.” Included in this rush to steal other peoples’ land were the English, the Spanish, the French, and the Portuguese. Even the Vatican became involved when it granted ownership of all the Western lands to Spain and Portugal. For the occupying Europeans, it was easy to construe the indigenous people of the Americas as “red savages.” Thus, began the propaganda that demonized the native population and justified taking their land, stealing their children, raping their women, and enslaving the population. The official fiction was that the “Indians” were pagans who did not believe in God and had no organized religion. They had to be conquered, converted to Christianity, and enslaved. The colonizers continued by saying that the indigenous people had no civilizations and were ignorant; thus, it was perfectly acceptable to God to take the land of the “Indians.” This process of propaganda led people to believe that “the only good Indian is a dead Indian.” After Columbus’s New World became the United States of America, in many cases Native Americans were forced to sign meaningless “peace treaties,” ceding land to the new White settlers and promising that the new locale, from which the native people were banned, was theirs “for as long as the grass grows and the water runs.” These words were spoken by President Andrew Jackson when he was addressing the Creek Nation in 1829 after the Creeks were forced to move from their land. However, each time more land was needed, the Native American people were packed up and force marched to yet another barren land. The native leaders were forced to sign more than 200 such treaties, written in a language they did not understand. In fact, these documents were signed by Native Americans by using an approximation of the letter “X” because they did not have written signatures. It is an unfortunate truth that the settlers and the U.S. government violated treaties whenever and for whatever reason (Trafzer, 2000). The official oppression continued with the establishment of new homes for the “Indians” on land that the U.S. government considered useless. There was nothing of value on the land, and the people were forced to live in poverty. The lands were overseen by the Bureau of Indian Affairs, which had no Native American members. The bureau was simply another tool of colonial oppression. This process of control and neglect continues to the present day. Another example of colonial oppression is shown in the use of missionary schools on or near the reservations. Indian children were taken from their parents, enrolled in these schools, forced to adopt Christianity, and had their hair cut short (like White men). The captives were forbidden to speak their own languages and sing their own songs. They were systematically robbed of their culture, and some were sent back among their families and told to convert them to the new ways. In many cases, the young children, after they were “converted,” were given to childless European couples, without the knowledge or permission of their parents. Let us consider the fable that we all learned in history class: how the Indians foolishly sold the island of Manhattan to the Europeans for 24 dollars’ worth of beads. Let us examine the fable a little closer. The Native population allowed the European settlers to occupy a portion of the land. As the European population grew, they sought to purchase land that would allow them to expand their colony. Let us remember that the “Indians” did not speak the language of the newcomers. They also could not read the

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documents the newcomers presented. Had they understood that the Europeans were trying to buy land, they would have told them that they could not sell the land because the land belonged to the Creator who had given the people the right to live there and the responsibility of caring for the land. Finally, they made the strange mark on the documents, even though they did not comprehend the significance of the deed. In return, the Europeans gave them a bunch of shiny glass beads. Of course, the Europeans were happy, they had just purchased a vast expanse of land for a mere pittance. Or so the story went. The truth is that the contract would have been declared invalid on the basis that the Indians could not read the document and therefore had no idea what the contents were. If the U.S. government repaid the Indians for the value of the land they lost, the U.S. treasury would be bankrupt. The same could be said if the U.S. government paid the overdue rent.

Colonial Oppression of Africans The experiment with “Indian” slavery failed for a variety of reasons and came to an official end when a Spanish Clergyman, Bartolomé de Las Casas, suggested that the Spanish substitute Africans for Indians in their quest to “settle” the New World (Vickery, 2006). In 1526, the Spanish established the first New World Spanish colony supported by African slaves. The importation of these 500 African slaves led to the rape of Africa and the importation of more than 40 million African slaves. Enslaving Africans was, at first, difficult because there were rules regarding slaves that were enforced by the Catholic Church. Their solution to this problem was simple; when the Church declared, “You cannot treat humans that way,” the slave traders and owners redefined Africans as nonhuman. This redefinition, they felt, excused their behavior because Blacks were then classified as “chattel” or property. This ushered in a period of official colonial oppression in the United States that lasted 339 years. Many believe that, in various forms, this colonial oppression still continues today (Adams & Sanders, 2004). Blacks were killed with impunity during slavery. In the rare cases when Whites were tried for killing slaves, nothing happened. Slave women were repeatedly raped by White men. At the same time, Southern White men were passing laws claiming they were protecting the White race from “mongrelization” and “miscegenation.” Such laws stayed on the books of Southern states until their repeal in 1965. Laws were passed preventing slaves from learning to read. Some locales provided education for Black youngsters but typically limited the education to the sixth grade. This was done because they believed that Blacks were incapable of learning beyond that level, and a sixth-grade education was all that was needed to perform menial labor. When the country passed universal, mandatory education laws, individual states were responsible for providing such education for their citizens. Blacks were initially excluded from the law. When states were forced to provide education for Blacks, they often did so in so-called “separate but equal” schools. The U.S. Supreme Court showed the fallacy of this practice when, in 1954, it declared such schools to be unconstitutional. In an attempt to get a unanimous decision, compromises were struck and the decision became nearly unenforceable. It called for public schools to be “desegregated, at all deliberate speed.” The term was immeasurable and, hence, unenforceable. The watereddown decision, Brown v. Board of Education (1954), is and was an example of the modern interpretation of colonial oppression. The lasting legacy of slavery in America leaves a horrible stain on our collective image. One has to realize that such an experience not only impacts the victims but also affects those who perpetuate the deeds. To justify the inhumane treatment to which

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Black slaves were subjected, some Whites claimed that Blacks allegedly were inferior and had to be kept “in their places” (Woodward, 1955). These justifications formed the basis for Jim Crow Laws, Black Codes, and other such legislation. Another legacy of colonial oppression was robbing Africans of knowledge of their past. By prohibiting Africans from speaking their own languages, the colonial powers deprived Africans of the ability to communicate about their past lives in Africa and pass on their heritage to their children. Furthermore, Africans were robbed of their last names. For the most part, Blacks did not have last names until the end of the civil war. Because the former slaves had no idea what their family names were, they adopted slave master names, names that belonged to Europeans and had no relationship to African history; names were simply made up, as well. Thus, most African Americans cannot trace their family histories beyond 1865. This process also robbed descendants of Africa of the ability to trace themselves back to their country or village of origin. Most White Americans have no trouble finding and visiting their country of origin (Bennett, 1962).

Colonial Oppression of Asians Colonial oppression was also used to exploit people from China. For the most part, early Chinese immigrants settled and worked in the Western half of the United States of America. They opened laundries, became gold prospectors, and worked as laborers. Many became cooks on Western ranches or cattle drives. Many also took very dangerous jobs, handling explosives used in building the transcontinental railroad system. Despite the dangerous and essential function they performed, the Chinese were considered to be inferior and expendable. There was a common saying, “the only good Chinaman is a dead Chinaman.” The colonial powers participated in and encouraged the erection of a wall of lies about Chinese people and condoned the ill treatment of Chinese, which included forcing them to create their own tent cities to provide the homes they were denied in White communities (Marger, 2005). This body of racism was not limited to the Chinese but extended to many other Asian races. During World War II, when our government incarcerated thousands of Japanese in response to the bombing of Pearl Harbor, immediate troubles surfaced in identifying who belonged in the prison camps. Anyone who looked Japanese was in danger of being rounded up as a potential enemy of the United States (Marger, 2005). Many of the Japanese who had their property confiscated, money taken, and livelihoods shattered were born in the United States and had never been to Japan. They identified themselves as Americans. Some young Japanese men were permitted to escape the camps if they agreed to join the U.S. Army and fight on the front lines against the Germans and the Italians (Dickerson, 2010). Some still argue today whether the decision to use the atomic bomb twice against Japan was, at least in part, based on racism. (It is interesting to note that our government did not engage in wholesale incarceration of Germans or Italians, even though we were also at war with Germany and Italy.)

Colonial Oppression of Poor Whites Oppressors do not always use physical force to control people. Rather, they may depend on psychological damage that convinces the oppressed people that they deserve to be in the state of inequality they occupy. This process is clearly illustrated by what happened to poor Whites at the end of slavery. When slavery was abolished, the plantation owners needed free or cheap labor to make their endeavors profitable. Thus, they turned to poor Whites, who were in nearly the same dire economic straits as Blacks. Both Blacks and Whites lived in conditions that

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were not much different from slave conditions. They lived in company-owned shacks that were freezing in the winter and sweltering in the summer. They were deeply in debt to the land owners and were, for the most part, uneducated. Often, they too were limited to a sixth-grade education because this was the level of education one needed to perform menial labor jobs. Poor Whites also took dangerous jobs in coal mines and steel mills. There were many cases of job-related illnesses and accidents. Most steel mill workers were forced to stay with the mills if they wanted to maintain their standard of living, because they could find no jobs outside the industry that paid as well. Many lived in barely adequate homes that were built by the owners of the mills. Most mills featured company-owned stores, which gave easy credit for overpriced goods. Many mill workers maintained high balances that had to be paid each payday. The owners of the mills made huge profits. Few complained because the relatively good wages paid to the mill workers obscured the vast fortunes being made on the backs of the laborers (Kester, 1997). The exploitation of coal mine workers was even worse. Coal miners often faced lasting, devastating health consequences, including black lung disease, emphysema, cancer, and other upper respiratory diseases. Both the steel mills and the mining systems are really just extensions of the old plantation system. In all three instances, owners became rich, although workers rarely shared in the profits.

Colonial Oppression of Australian Aborigines There is currently much disagreement about the origin of the native Australian population. The continent was largely isolated from the rest of the world and, consequently, had little genetic cross-fertilization with other species. The result was people, plants, and animals, unlike any found anywhere else in the world. Unfortunately, the land would not remain unspoiled. Early Dutch and French explorers found the land unsuited for colonization. By the 1700s, however, the English concluded that the land was indeed suitable for conquest. Early in the colonization process, England began to send prisoners to help “settle” it. In 1778, the English set up a penal colony in Australia as part of their military campaign. They, of course, claimed the land without negotiations with or payment to the native population. Records indicate that, from 1788 to 1869, the English sent 162,000 English prisoners to the land. The first prisoners sent were males who had been incarcerated for a wide variety of offences. They wreaked havoc and destruction on the Aboriginal population. They openly killed and raped the Aboriginal population, stealing their resources and capturing the children. In parliament, discussions followed as to what could be done to “gentle down” the men. There is little evidence to suggest that the English ever gave serious consideration to ceasing the practice of sending the prisoners to Australia. Instead, some suggested that the men needed women, and that England might consider sending female prisoners over. This they did; about 25,000 women, most who had been imprisoned for prostitution, were sent to Australia. As in America, the English introduced a variety of European diseases that wiped out the native population. The Aborigine had no historical immunity to diseases such as measles, mumps, common colds, and various fevers introduced by the British conquerors. Such diseases nearly wiped the Aboriginals out. The English also used the time-proven method of introducing conflict among the native population. Divide and conquer, once again, made some conquests possible without using military force. And, as in America, slowly but surely, Aborigines found themselves

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moved from their homelands and pushed to undesirable, isolated parts of the Australian landscape. Soon, the Whites were in control of all of Australia and relegated the original people to prisoners in their own land. During the conquest, the English created a body of propaganda that still stands today and “proves” the inferiority of the Australian Aborigine; they suggested that the Aborigines were childlike and had to be protected. As was done with Native Americans, the English turned their attention to the children of the Aborigine. They gathered many of the children, without the permission of their parents, and sent them to “Christian schools” that were nothing more than propaganda mills. These institutions were designed to convince the kidnapped children that their culture was unacceptable. Children often were punished for speaking their own language. They were forbidden to practice their own religion and were given “fine Christian” names. Their hair was shorn and they were given ill-fitting English clothing. Many were sent back and instructed to spread the “new” ways among their people. These children became known as the “stolen” children because they were removed from their homes, without the permission and often the knowledge of their parents. Some of them were given to childless English couples. Often, when children did not return home, the authorities lied and reported that the children had died. It is extremely interesting that this oppressive practice is still being debated today in Australia, with many Whites denying or excusing the practice and the government refusing to apologize for this terrible chapter in its history (Marger, 2010).

Colonial Oppression of Hawaiians The colonial oppression of Hawaii began when the Hawaiian royal family welcomed white-skinned Americans into their midst in 1778 with the landing, on the main island, by Captain James Cook. His men spread disease such as smallpox, measles, and gonorrhea among the native population. This had a genocidal impact, reducing the number of native people from 300,000 in 1778 to about 57,000 by 1872. Christian missionaries also arrived and promptly went about dismantling Hawaiian culture, including the banning of the traditional history dance, the Hula. (Missionaries considered the dance to be lewd with savage, sexual content. They made no attempt to understand that the dance was the carrier of the history of the people. Although they did not succeed in banning the dance, they did cause it to be driven underground. It did not resurface in a meaningful way until the Hawaiian cultural renaissance of the early 1970s.) These former missionaries ultimately led to the overthrow of the Hawaiian royalty and manipulated the vote that led to the annexation of Hawaii by the United States. Their descendants comprise a very large percentage of the people who now control the politics and wealth of Hawaii. The queen of Hawaii allowed American citizens to set up residence and establish sugar and fruit plantations. The owners of these establishments reaped huge profits and introduced a wave of foreign workers, largely Japanese, into the Hawaiian countryside. This move caused racial tension among the native-born individuals, who felt pushed off their lands and forced into poverty. Tensions grew as the American farmers began to buy more land, displacing more native Hawaiians. In about 1893, the Queen was about to enact a new constitution that the American farmers felt would be harmful to their interests. The Americans engineered a coup and convinced the U.S. government to enter Hawaii with the supposed intention of protecting the Americans. Hawaiians rightfully viewed this action by the United States as an invasion. The Americans took over the royal palace and detained the Queen while holding the citizens of Honolulu hostage. The United States set up a puppet government, the members of which were appointed by the U.S. president himself.

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Ultimately, a proposition that Hawaii become a state was placed on the ballot. The voting process was manipulated. Most of the folks permitted to vote were descendants of the land-stealing American plantation owners. Many native-born individuals were excluded from the voting process. The wording of the proposition itself was biased. It asked: Should Hawaii become a state or should it remain a protected territory? The question of the nation becoming independent of foreign control was never permitted. Thus, the American government took over Hawaii through a process of purposeful manipulation. In 1993, the 100th anniversary of the illegal overthrow of the Kingdom of Hawaii by the U.S. government, Congress passed a resolution, signed by then President William Clinton, offering an apology to Native Hawaiians on behalf of the United States. Many Native Hawaiians viewed the apology as “nice” but insignificant. They point out that the apology does not excuse colonial destruction of a sovereign nation, nor does it make restitution for lives lost, land stolen, lives ruined, or the fact that Hawaii is still controlled by foreigners.

Colonial Oppression of Indians in India England did not conquer India in some great war, but conquer and control India it did. The process began when the Indian Mughal Empire granted the British East India Company the right to control the spice trade in certain areas of India. The British expanded their control by establishing other British-controlled industries, such as salt and textiles. These businesses used cheap, exploited, and local labor to make fortunes for the British continent. Whenever the Mughal Empire faltered, the British set up a local government that they pretended was an extension of the legitimate Indian government. These local governments, in actuality, were puppet governments. The British controlled these puppet governments through the threat of attack by the merciless British-controlled sepoys, an army of ruthless soldiers. Gradually, the British took more and more control. They set up schools and public entertainment facilities, from which Indians were excluded. Railroad cars were segregated, with the “finer” cars being designated for British gentry. Beaches excluded nativeborn Indians. Anyone who challenged the segregation wound up beaten, jailed, or dead. They exercised considerable influence over the rest of India through the use of “divide and conquer” tactics. The largest religious group in India was Hindu, but there was a large minority population who were Muslim. The two groups did not trust one another, and the British mined this distrust in their efforts to control Indians. With these methods, the British, without using vulgar military power, were soon able to rule two thirds of India. They went as far as crowning Queen Victoria the “Empress of India.” In 1920, a man named Mohandas Karamchandi Gandhi decided to challenge British control. He used nonviolent challenges because he realized the Indian military forces were no match for the British. Later, the Indians would dub him “mahatma,” which means “great soul.” He convinced Indians to wear simple, homespun clothing that was made in India, thus damaging the British textile industry. His followers made salt out of sea water to show that India did not have to depend on England for their salt. His followers held demonstrations in front of facilities from which they had been banned. The lines could contain hundreds of people who stood peacefully in lines and demanded entry. British police would deny the demonstrators entry and would beat them with riot sticks; many demonstrators were beaten unconscious. Each time one person was beaten, another stepped forward to take his place. Gandhi also successfully employed

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the hunger strike as a means of getting international publicity. Thanks largely to his efforts, in 1947, India was free of its colonial oppressor. Gandhi was assassinated by a Muslim fanatic shortly after independence. The negative legacy still is present in India. Hundreds of children know that their ancestors died just so the British could exercise colonial control. Thousands of people were denied due process and jailed in support of colonialism. A legacy of mistrust and anger remains in the hearts of millions of people who have been told of or have witnessed man’s inhumanity to man (Featherstone, 1992).

Colonial Oppression of Africans in South Africa The colonial oppression of Africa dramatically changed the continent. In the 1800s, the colonial powers met in Berlin and reached “gentlemen’s agreements” as to the future of Africa. As a result, the entire African continent came under the military control of various European colonial powers. The usurpers divided Africa among themselves, so the countries would not combat each other over the vast resources of Africa (Mommsen & Robinson, 1988). As a result of these agreements, African rulers were killed, removed from office, or sold into slavery. Africa’s abundant natural resources came under the control of whiteskinned marauders who shipped vast quantities of gold and diamonds to their own countries. Europeans became rich while Africans lived in abject poverty, earning pennies slaving in dangerous mines. Countless millions of dollars were stolen, and millions of Africans were killed or sold into slavery. Experts estimate that somewhere between 20 and 150 million Africans either lost their lives or were lost because of colonial oppression (Bennett, 1962). All the European powers instituted their own form of racial segregation in Africa, but no system was more brutal than that set up in South Africa by the Dutch, called “apartheid.” Apartheid was a system of legal (at least as far as Europeans were concerned) racial segregation brutally enforced by the racist National Party government of South Africa between 1948 and 1993. Under this system, the people of South Africa were divided into distinct categories (Black, White, Colored, and Indian). Black people, who were the majority population, were brutally controlled by the minority White population. Shamefully, the rest of the world officially recognized the policy and did nothing about the horrors that were taking place. Black Africans were denied citizenship in a land that was taken from them, by force, by White people. They were forcibly moved from their homes and pushed into barbed-wire-enclosed areas called “homelands.” Opposition was banned, and people who protested were killed, beaten, and/or imprisoned. There were laws against interracial marriage and sex. The oppressors erected “White Only” signs much like those used by Jim Crow advocates in the United States. Even park benches were segregated. Blacks could not open businesses or practice professions in White areas without a license. Blacks had to carry identification passes wherever they traveled. Although the official apartheid system ended in 1994, the vestiges of the system still shape South African life today. Blacks have elected a Black African president, but the economy is still controlled by Whites. Most well-paying positions are held by Whites. Blacks can now attend schools from which they were once barred, but they cannot afford the tuition. Blacks cannot compete with Whites for jobs because institutional racism has replaced the apartheid system. Even more sadly, the racial divide may last forever. Many Whites are upset that they had to “give up” so much to Blacks. They ignore the fact that they built a society based on enforced White superiority and that superiority was generally enforced at the end of a rifle barrel. The legacy of the apartheid system is a society in which Blacks are still in

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a position of institutionalized inequity. Millions of Blacks are now forced and will continue to be forced to live their lives in quiet desperation in a land that was stolen from their ancestors (Marger, 2010).

CONTEMPORARY LANDSCAPE: WHITE PRIVILEGE During the urban riots of the 1960s when many American cities (primarily northern Black ghettos) exploded in violence, President Johnson wanted to know how to prevent these riots. He established the Kerner Commission to make recommendations. Many suspected that the commission was going to blame the riots on the pathology of the Black community and recommend the incarceration of many more Blacks. Instead, the Commission blamed the riots on the conditions found in Black ghettos; it said those conditions made riots inevitable. Indeed, as reported by Thernstrom, Siegel, and Woodson (1998), the Kerner Commission blamed civil unrest on persistent White racism. A companion to White racism is White privilege. Simply put, Whites enjoy privileges or accommodations in the world that people of color do not. It has been embedded in our socialization process. This system is so pervasive and so invisible that most Whites are unaware that it exists. Tim Wise (2008), a noted author and lecturer on the subject, asserts that White privilege is strongly denied by most and that the focus often is shifted to another group status, for example, poor or working-class Whites who view their own status as marginalized and therefore without privilege. For example, let us say that two people decide they are going to look for a new apartment. One of them is Black and the other is White. Both would have concerns, but the concerns would be quite different. The White person might be concerned about whether there were apartments available in the area in which they wished to live or the cost of such a unit, if available. The Black person might share those same concerns but might also be concerned if he or she will be lied to about the availability of such a unit, whether the price would be dramatically higher than the original quote, or whether the person might be turned away because of skin color. These different concerns are caused by White privilege. Wise (2008) speaks to this “birth right” as a daily psychological advantage for those who have benefited from the assumptive world of the dominant society. There are many everyday activities in America in which the evidence shows that Whites enjoy privileges that Blacks do not. Many Whites do not realize that America and other European societies routinely award these privileges without much thought as to the origin or existence of the process. How did they come about? All one need to do is examine who established this country. The answer is clear; America was established by White, Anglo-Saxon men who had rank, titles, money, and land. When this select group of American men established the country, they also established the nation’s institutions. By this, I mean formal systems with rules and regulations that were formed by like-minded people in order to control certain aspects of the society. These institutions grant or deny access to those things they control. Some examples of such institutions include the American Medical Society and all the medicalrelated training, education, and facilities it controls; law enforcement, the judicial system, including the Supreme Court; political institutions; the banking industry; and the religious institutions that determine who is God and who shall lead the flock. And let us not forget the educational institutions that determine who will be trained in or excluded from the vast knowledge base. It is easy to see how control of these and other institutions can have a positive or absolutely, devastatingly negative impact on human beings. In his discussion of how Whites deny the existence of White privilege, Wise (2008) speaks to the illogic of denying such privileges, noting that participation in and

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benefiting from the privileges acknowledges complicity and shows that one is implicated in a process of oppression. Wise asserts that if one has benefited from historical injustices, it becomes irrelevant who committed the original injustice.

Hate Crimes The term hate crime generally describes criminal activities such as physical violence, intimidation, and property defacement, which result from hatred directed toward a group or individual because of their membership in a particular group. Membership in the “hated” group is usually based on race, creed, color, national origin, sexual orientation, religion, or some other distinction. By processes hidden and open, people in the major cultural group instruct new-comers and newly born individuals that these “others” are undesirable. Messages may be subtle, such as television commercials and newspaper advertisements that exclude Blacks, Asians, and Latinos, thus giving the impression that “these people” are unworthy of inclusion in the American Dream. Or they may be more overt, such as in the hate literature passed out at Nazi and Ku Klux Klan rallies. Regardless of the venue, the messages are quite clear: “These people are different, horrible, evil creatures who should never have been born and have no acceptable role in ‘our’ pure society.” Many unstable hate-filled individuals use such propaganda to justify taking negative actions against members of these groups. Human rights commissions around the country are seeing an increase in the number of hate crimes committed each year.

COUNSELING IMPLICATIONS The implications of intolerance for counseling professionals are immense. Counselors are expected to develop treatment modalities that will help solve a myriad of personal and professional issues. It is expected that their training and education will enable them to come up with plans that will help, rather than harm, the clients. A multitude of problems can ensue if such interventions are based on a lack of knowledge of clients who come from multicultural backgrounds. One would hope, although it is not always true, that counselors have been provided with sufficient exposure to individuals who have been victimized by present and past colonial oppression. It is also hoped that such training/exposure will help practitioners take cultural backgrounds into consideration when designing intervention techniques. I can recall, vividly, speaking with a new counselor who had a Latino woman as a client. The woman was being physically beaten and psychologically traumatized by her husband. The counselor immediately grasped the idea that the behavior of the husband was illegal in the United States, and she began to counsel the client that she did not need to accept such treatment. She was vociferous in pressing the client to report the beatings to authorities. She could not understand why the client would not do so. In our next meeting, we discussed cultural implications relative to the South American country from which the man and woman came. I said the counselor should also try to determine what would happen to the woman if she reported her husband to U.S. authorities and returned to Argentina shortly. I suggested that the counselor learn concepts such as “machismo” and other cultural issues. Ultimately, the counselor came up with a treatment modality based on understanding culture and colonial oppression. Every university should make certain that cultural training is an integral part of the educational process for its counseling students. Furthermore, there should be mandatory education that speaks to the issues related to racism, intolerance, religious oppression, bullying, and the lasting impact of these practices on the psyche of oppressed people. A large portion of the educational process should be devoted to the lasting impact of

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colonial oppression, including how these issues play out based on the cultural, religious, race, and gender of the people who have been negatively impacted by such practices. Counselors also need to understand the histories of the people who came to this country, whether by choice or by chance. In addition, as counselors, we must learn more than how to place people in broad cultural categories. For example, it is good to consider that a client is Asian, but this is not enough. We must dig further and ask what is the country of origin of the individual client(s). Are they from Cambodia, Korea, Mainland China, Japan, Vietnam, Hong Kong, or Formosa? What are the cultural norms in their homeland? It is also important that counselors understand what version of “history” their clients understand. Americans often have difficulty accepting the idea that our government has done some terrible things and hid the truth from American citizens. It is important that counselors know the “truth” as non-Americans know it. Often, the truth lies somewhere between our version and their version. Counselors must also understand that clients of other cultures may initially distrust a White counselor. This has little to do with the counselor as an individual, but may have a great deal to do with the client’s culture, beliefs, and experiences with White Americans. Counselors must be cautious when reading cultural materials written by “experts” who are not members of the cultures about which they write. Mental health professionals should seek literature written by scholars who are from specific cultures or, at minimum, are people who have lived in a culture and been embraced by the people of the community. Also, mental health professionals need not be hesitant to explore the information derived from oral history. When possible, counselors should speak with people who are part of the particular cultural group, although many “insiders” tend to distrust “outsiders,” and it may take some time to build trust. Especially for those of us who conduct related research, we need to understand that the distrust is based on a history of dominant-culture information seeking at the expense of exploiting the people being researched. Counselors should seek opportunities to collaborate with members of “other” groups, being careful not to assume that one individual from a specific cultural group has the ability or permission to speak for all people of that group. Unfortunately, many well-meaning folks ask such thoughtless questions as: What do Latinos think about that? How do Blacks feel about the issue? No one individual can speak for all the members of the group. In all things cultural, counselors should proceed with due caution and be willing to learn from clients.

CONCLUSION In this chapter, I have presented a context for understanding racism and other variants of prejudicial behavior targeted at particular groups of people for no other reason than their “otherness.” I have detailed the histories of specific types of bigotry and the associated traumatizing events, which have been aimed at the identified “others,” in an effort to illuminate the connections between such bigotry and the effects of trauma, and to explicate the interplay between historical trauma and the remaining contemporary effects of racism and other forms of marginalization. Numerous implications arise for mental health professionals, and I have outlined some of the most salient of them. The various landscapes of current racial and ethnic intolerance continue to perpetuate a potent framework for violence and trauma; these landscapes will continue to dominate the horizon, and individuals will continue to experience associated trauma until we address the root causes of bigotry in our society.

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APPENDIX 17.1 “Experts” It becomes problematic that many of the cited “experts” are European people who have little experience with so-called minority individuals. These “experts” may know little about anyone other than people who are like him or her. In one of several oral interview sessions with Dr. Ralph Proctor, he addressed the issue of not always being able to trust the books written by experts. Proctor recounted the following experience: When I was on the faculty at Pitt [University of Pittsburgh], I was invited to sit in on an anthropology course taught by a visiting professor from Sweden. He had written what was considered to be a definitive book on a Black community in Washington, DC. He was giving his first lecture, as a visiting Mellon Professor. It just happens that I had spent a great deal of time in the neighborhood that was the subject of the book. Consequently, I knew it well. My aunt lived there and I had spent much time there. Keep in mind that the book was being treated as some sort of bible containing words of wisdom that could be used to address many of the issues in the community. As the lecture continued, I became puzzled by the information being dispensed. I did not wish to embarrass the guest so I held my tongue and waited until the Q&A session. It turned out that the gentleman had not really lived in the community that was the subject of the book. He did not live in the Black ghetto, at all. He lived in an adjacent community because he was afraid, as a White man, that he might not be welcome in the ghetto. He only visited the Black community. Furthermore, he left the community in which he lived at about 12:00 midnight. Consequently, he had no knowledge about what went on when the “night people” came out to play and do business. He had no information about Black women between the ages of 18 and 30 because he was afraid that the Black men would harm him if they saw him conversing with the Black, young women. He also had no info about Black men in the same age category because he did not talk to them out of fear of their perceived hostility. Fortunately, the book rather quickly fell from favor. Imagine the harm that might have been done had counselors used the erroneous and incomplete material in the acclaimed text! (R. Proctor, personal communication, various dates in 2011)

RESOURCES Websites Randall, V. R. (2006). Race, Racism and the Law. University of Dayton School of Law website (http:// academic.udayton.edu/race) Tim, W. (2008). On White privilege: Racism, White denial & the costs of inequality. Media Education Foundation. (http://www.mediaed.org/cgi-bin/commerce.cgi?preadd=action&key=137) Films and Videos Films Media Group. (2000). A conversation on race: Black, White or Other? (http://www.films.com) Films Media Group. (2003). A question of identity: What is race? (http://www.films.com) Films Media Group. (2001). Little things: When prejudice is unintentional. (http://www.films.com)

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Films Media Group. (1991). The mosaic: Managing the multicultural workplace. (http://www.films.com) Proctor, R. Voices from the firing line. Unpublished DVDs of major participants in the Pittsburgh Civil Rights Movement, conducted between 1991 and 2003.

REFERENCES Adams, F., & Sanders, B. (2004.). Alienable rights: The exclusion of African Americans in a White man’s land, 1619–2000. New York: HarperCollins. Bennett, L., Jr. (1962). Before the mayflower, a history of Black America. New York, NY: Penguin Books. Brown v. Board of Education of Topeka, 347 U.S. 483 (1954). Dickerson, J. L. (2010). Inside America’s concentration camps: Two centuries of internment and torture. Chicago, IL: Lawrence Hill Books. Featherstone, D. (1992). Victorian colonial warfare: India, from the conquest of Sind to the Indian mutiny. London, England: Casell Publishing. Forster, S., Mommsen, W. J., & Robinson, R. (Eds.). (1988). Bismarck, Europe and Africa: The Berlin Africa Conference, 1884-1885 and the onset of partition. Oxford, England: Oxford University Press. Heyerdahl, T. (1971). The Ra expeditions. Garden City, NY: Doubleday. Kester, H. (1997). Revolt among the sharecroppers. Knoxville: University of Tennessee Press. Levanthes, L. (1997). When China ruled the seas: The treasure fleet of the Dragon Throne, 1405–1433. New York: Oxford University Press. Manzies, G. (2008). 1434: The year a magnificent Chinese fleet sailed to Italy and ignited the renaissance. New York: William Morrow/ HarperCollins. Marger, M. N. (2005). Race and ethnic relations: American and global perspectives (7th ed.). Belmont, CA: Wadsworth Centage Learning. Marger, M. N. (2010). Social inequality: Patterns and processes (5th ed.). Columbus, OH: McGraw-Hill Humanities/Social Sciences/Languages. Markus, H. R., & Moya, P. M. L. (2010). Doing race, 21 essays for the 21st century. New York, NY: W.W. Norton. McGlynn, F., & Tuden, A. (Eds.). (1991). Anthropological approaches to political behavior. Pittsburgh, PA: University of Pittsburgh. Mommsen, W. J., & Robinson, R. (Eds.). (1988). Bismarck, Europe and Africa: The Berlin Africa Conference 18841885 and the onset of partition. Oxford, England: Oxford University Press. Proctor, R. (n.d.) Voices from the firing line. An oral history of The Pittsburgh Civil Rights Movement. Unpublished manuscript. Sertima, I. V. (2003). They came before Columbus: The African presence in Ancient America. New York, NY: Random House. Thernstrom, S., Siegel, R., & Woodson, R., Sr. (1998). The Kerner Commission Report and the failed legacy of liberal social. Heritage Foundation, Heritage Lectures. Retrieved from http://www.heartland.org/ sites/default/files/sites/all/modules/custom/heartland_migration/files/pdfs/4386.pdf Trafzer, C. E. (2000). As long as the grass shall grow and rivers flow: A history of Native Americans. Orlando, FL: Harcourt. Vickery, P. S. (2006). Bartolomé de Las Casas, great prophet of the Americas. Westminster, MD: Newman Press. Wise, T. (2008). The brain-rotting properties of White privilege. University of Dayton, School of Law. Retrieved from http://academic.udayton.edu/race/01race/whiteness07.htm Woodward, V. (1955). The Strange Career of Jim Crow. New York, NY: Oxford University Press.

BIBLIOGRAPHY Achebe, C. (1994). Things fall apart. New York, NY: Anchor Books. Akbar, N. (1984). Chains and images of psychological slavery. Jersey City, NJ: New Mind Productions. Allen, J., Als, H., & Litwack, L. (2004). Without sanctuary, lynching photography in America. Santa Fe, NM: Twin Palms.

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Axelson, J. A. (1999). Counseling and development in a multicultural society. Monterey, CA: Brooks/Cole Publishing. Bonvillain, N. (2001). Native nations, cultures and histories of Native America. Upper Saddle River, NJ: Prentice Hall. Boone, D. (2001). Toms, coons, mulattoes, mammies & bucks. An interpretive history of Blacks in American films (4th ed.). New York, NY: Continuum International Publishing Group. Browder, A. T. (1992). Nile valley contributions to civilization. Washington, DC: Institute of Karmic Guidance. Brown, C., & Mazza, G. (2005). Leading diverse communities. San Francisco, CA: Jossey-Bass. Brown, D. (1970). Bury my heart at wounded knee. New York, NY: Owl Books. Chamberlain, M. E. (1974). The scramble for Africa. Harlow, Essex, England: Longman Group. Clark, K. (2008). Defining “White privilege.” Dayton, OH: University of Dayton School of Law. Conrad, A. H., & Myer, J. R. (1964). The economics of slavery, and other studies in econometric history. Chicago, IL: Aldine Publishing. Diop, C. A. (1955). The African origin of civilization: Myth or reality (2nd ed.). Westport, CT: Lawrence Hill & Company. Englander, E. K. (2007). Understanding violence. New York, NY: Lawrence Erlbaum Associates. Ginsburg, R. (1962). 100 years of lynching. Baltimore, MD: Black Clinic Press. Hofstadter, R., & Wallace, M. (1970). American violence: A documentary history. New York, NY: Knopf. Jensen, R. (2008). White privilege shapes the United States. Dayton, OH: University of Dayton School of Law. Kitano, H. L. H., & Daniels, R. (1988). Asian Americans: Emerging minorities. Upper Saddle River, NJ: Prentice Hall. Kuykendall, R. (1967). The Hawaiian kingdom: Vol. 3. Honolulu: University of Hawaii Press. Lindsay, L. A. (2007). Captives as commodities. Chapel Hill, NC: Pearson Prentice Hall. McGrath, P., & Axelson, J. (1999). Assessing awareness and developing knowledge, foundations for skill in a multicultural society. Pacific Grove, CA: Brooks/Cole Publishing. McIntosh, M. (1988). White privilege: Unpacking the invisible knapsack. Wellesley, MA: Wellesley College Center for Research for Women. Miles, A. (1988). Devil’s island, colony of the damned. Berkeley, CA: Ten Speed Press. Mobasher, M. M., & Sadri, M. (2003). Migration, globalization, and ethnic relations. Upper Saddle River, NJ: Pearson Prentice Hall. Proctor, R. (1979). Racial discrimination against Black teachers and Black professionals in the Pittsburgh Public School System, 1834-197 (Unpublished doctoral dissertation). University of Pittsburgh: Pittsburgh, PA. Randall, V. R. (1997). Defining White privilege. Dayton, OH: University of Dayton School of Law. Ritchie, D. A. (2003). Doing oral history, a practical guide. New York, NY: Oxford University Press. Roediger, D. (2008). The liberal self-representation of HWCU. Dayton, OH: University of Dayton School of Law. Russ, W. A. (1992). The Hawaiian revolution (1893-94). Cranbury, NJ: Associated University Presses. Silberman, M. (2002). Violence and society, a reader. Upper Saddle River, NJ: Prentice Hall. Sue, D. W. (2003). Overcoming our racism: The journey to liberation. San Francisco, CA: Jossey-Bass. Sweet, F. W. (2005). The legal history of the color line: The rise and triumph of the one drop rule. Palm Coast, FL: Backintyme. Torres, G. (2008). Patriarchy as an expression of Whiteness. Dayton, OH: University of Dayton School of Law. Waldrep, C. (2011). Race and national power: A sourcebook of Black civil rights. New York, NY: Routledge, Taylor & Francis Group. Welsh, D., & Spence J. E. (2011). Ending apartheid. New York, NY: Pearson Longman. Wikipedia. (n.d.). Overthrow of the kingdom of Hawaii. Retrieved from http://en.wikipedia.org/ wiki/Overthrow_of_the_Kingdom_of_Hawaii Williams, E. E. (1966). Capitalism & slavery. New York, NY: Capricorn Books. Witzig, R. (1996). The medicalization of race: Scientific legitimization of a flawed social construct. Annals of International Medicine, 125(8), 675–679.

CHAPTER 18

Understanding and Responding to Sexual and Gender Prejudice and Victimization KATHLEEN M. FALLON AND SUSAN RACHAEL SEEM

INTRODUCTION Imagine being hated, victimized, violated, and even killed for characteristics with which you were born and over which you have no control. How might your sense of self be influenced by societal views of you? Despite changes in law and societal attitudes, sexual orientation and gender identity and expression continue to remain target points for emotional, verbal, physical, and sexual violence (National Coalition of Anti-Violence Programs [NCAVP], 2010; U.S. Department of Justice, Federal Bureau of Investigation, 2009). The purpose of this chapter is to help you understand the dynamic contextual influences that perpetuate prejudice and victimization of members of the lesbian, gay, bisexual, and transgender (LGBT) communities. Following an overview of relevant definitions, key questions are addressed that focus on context, the experience of hate and bias crimes, and ultimately, responses and implications for advocacy. To understand and respond to these issues comprehensively, the experiences and needs not only of the victim-survivors but also of the perpetrators of hate and bias crimes and the community affected by such events are addressed. Risk and protective factors are explored in social systems such as families, schools, communities, and governments. You are presented with narratives throughout the chapter as well as with a case study and reflection questions to help you consider the very personal face of what is captured, too often, only in statistics. Finally, the resources and references that are provided at the end of the chapter are intended to help inform and empower you to take next steps for responding meaningfully to crimes of sexual prejudice and hate in the LGBT community.

RELEVANT DEFINITIONS It is essential, in initiating this important discussion of trauma counseling relevant to the LGBT community, and even prior to exploring contextual issues, to establish a common ground for understanding pertinent terms. In this section, we review some of the relevant terms, which include sexual orientation, gender identity and expression, sexual and gender prejudice, and hate crime.

Sexual Orientation Definitions According to the American Psychological Association (APA, 2010), “Sexual orientation refers to an enduring pattern of attraction, behavior, emotion, identity, and social

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contacts” (p. 74). Biologically, sexual orientation refers to whether a person is aroused sexually primarily by members of the same or opposite sex (Jenkins, 2010). Physiological, psychosocial, and sociocultural hypotheses exist about the origins of sexual orientation development; however, there is no conclusive current evidence that resolves definitely the cause of sexual orientation (Jenkins). Lesbian women and gay men are terms describing a sexual and affectional orientation toward members of the same sex, whereas bisexual describes a person with a sexual and affectional orientation toward members of both sexes. Note that in these definitions, sexual arousal or emotional attraction are the defining criteria as opposed to sexual behavior. Thus, an individual may be attracted to a member of the same sex but not act on that attraction. Although used when referencing specific research or popular opinion, homosexual or homosexuality are terms used cautiously, given their outdated connotations of pathology and mental illness now inconsistent with current research findings (APA, 2010; Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force, 2000; Gay & Lesbian Alliance Against Defamation, 2010). Therefore, in this chapter, the terms lesbian, gay, and sexual orientation are used instead of homosexual and homosexuality.

Gender Identity and Expression Definitions Because of similar struggles with oppression and discrimination and with social, political, and cultural issues, persons with sexual orientations or gender identities outside the majority (e.g., heterosexual identity) often are aligned under a single communal identity (LGBT). Note that the following definitions focus on gender, not sexual orientation. Gender identity and expression are independent of sexual orientation. For example, a female-to-male transgender person in a relationship with a woman may consider himself to be heterosexual. Gender identity refers to a person’s self-identification as male or female, regardless of whether that identity corresponds to the person’s sex at birth (Human Rights Campaign, 2009). Gender expression refers to external mannerisms, behaviors, and customs socially and culturally defined as masculine and feminine (Human Rights Campaign, 2009). Note the distinctions between sex and gender. Sex is a biological term referring to genetically distinct characteristics, whereas gender is a sociocultural construct referring to customary expressions, attitudes, behaviors, and mores associated commonly with each sex. Transgender is a descriptor term for people whose gender identity or gender expression is different from their sex at birth (APA, 2010, p. 74). Transsexual identifies transgender persons who live or desire to live full time as members of the sex other than their sex at birth (APA, 2010). Transgender and transsexual distinctions might be less important for individuals who may refer to themselves as transgender, transsexual, or both. For example, Eddie grew up feeling different from other boys, believing he was born in the wrong body and should have been a girl. As Eddie grew up, he felt more disconnected as his body betrayed the gender he believed himself to be. With the support of his family, Eddie transitioned into Gwen, aligning her body and gender expression with the sex with which she felt most natural since early childhood (Prévost, 2007).

Sexual and Gender Prejudice Definitions Sexual orientation and gender identity and expression are emotionally charged concepts with social, political, economic, and cultural implications. Heterosexual orientation, gender identity consistent with the sex at birth, and gender expression consistent with culture and tradition are privileged in many cultures. Heterosexism is an ideological system that preferences heterosexual forms of behavior, identity, relationship, and

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community and stigmatizes nonheterosexual forms (Herek, 1992). Orientations, identities, and expressions that differ from heterosexual forms of behavior can be subject to sanction, violence, and even death. Sexual prejudice refers to negative attitudes toward a person because of his or her sexual orientation (Herek, 2000). Herek proposed replacing the widely used term homophobia. Critics of the term have argued that it assumes that antigay attitudes are based on an irrational fear, which can be understood by an individual psychopathology framework, rather than recognizing the socially reinforced nature of the attitudes and related behavior (Herek, 2000). Sexual prejudice characterizes negative attitudes toward homosexual behavior, people with actual or perceived homosexual or bisexual orientation, and communities of LGBT people. It has three key features: (a) it is an attitude; (b) it is directed at a social group and its members; and (c) it is negative, involving hostility or dislike (Herek, 2000). In keeping with framing phenomena without assumptions of underlying motivation, the term gender prejudice is used in this chapter to refer to negative attitudes toward a person because of his or her actual or perceived gender identity or expression.

Hate Crime Definitions Defining hate or bias crimes according to two primary reporting sources—the Federal Bureau of Investigation (Uniform Crime Reporting Program, 2004) and the NCAVP (2010)—illuminates the myriad of ways in which these behaviors can remain invisible and challenging to track accurately. Hate crime, also known as bias crime, is defined by the FBI as “a criminal offense committed against a person, property, or society that is motivated, in whole or in part, by the offender’s bias against a race, religion, disability, sexual orientation, or ethnicity/national origin” (FBI, as cited in Uniform Crime Reporting Program, 2004, p. 151). This definition omits bias-related crimes based on gender identity and expression, potentially eliminating accurate incident tracking for transgender and transsexual persons. Hate crime reporting by the FBI assumes that the crime was reported to law enforcement and assumes an illegal criminal offense, omitting bias-motivated acts that are not illegal (e.g., hate speech) and those not reported to law enforcement (NCAVP, 2010). Anti-LGBT hate violence is defined by the NCAVP as “any act that an offender commits against a person or a person’s property because of the offender’s bias toward or hatred for that person’s actual or perceived sexual orientation and/or gender identity and expression” (NCAVP, p. 11). Finally, hate speech describes the use of “speech attacks” and in this context is based on perceived or actual sexual orientation or gender identity and expression. The expression of hate is not a crime; rather it is symbolic, as opposed to hate crimes, which are behaviors or actions (Cowan, Heiple, Marquez, Khatchadourian, & McNevin, 2005). The previous definitions convey the potential difficulty in identifying, naming, and tracking hate crimes as well as the potential for individuals’ identities to be perceived incorrectly or to remain invisible. The next section explores the context in which LGBT hate crimes occur, how they are socially sanctioned, and how, through social awareness, they can be interrupted.

CONTEXT In the fall of 2010, five youths made national headlines for committing suicide (McKinley, 2010). They ranged in age from 13 to 18 years old. Each identified experiencing bullying during his or her life for his or her sexual orientation. In one case,

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a young man was “outed” to everyone with an Internet connection when, without his knowledge, his college roommate streamed live video footage of him kissing another man. Occurring around the same time as these suicides, three men, perceived to be gay, were abducted and tortured, sodomized, and robbed over a period of several hours (Dolnick & Moynihan, 2010). On the same day as eight suspects were arraigned in connection with this case, and in the same city, a political candidate in a prepared speech to a religious group raised concerns that children not be “brainwashed into thinking that homosexuality is an equally valid and successful option” and that “there is nothing to be proud of in being a dysfunctional homosexual” (Harris, 2010). The timing of these occurrences provides a framework in which to understand the context within which people are abused for their actual or perceived sexual orientation or gender identity and expression. Such understanding is critical to providing appropriate help and advocacy for LGBT persons. This section considers in what ways sociocultural context perpetuates heterosexism and how this context is linked to prejudice and hate crimes.

Culturally Supported Heterosexism Heterosexism is a phenomenon supported in many global contexts, including the United States (Amnesty International, 2008; Herek, 1992). It is expressed and experienced through religion, governmental legislation, the judicial system, popular culture and media, and through more personal methods such as attitudes, speech, and behavior (Amnesty International, 2008; Anti-Defamation League’s Washington Office, 2008; Burn, 2000; Cowen et al., 2005; Haider-Markel & Joslyn, 2008; Herek, 1986; Herek, 1992). Each of these fora can be mutually influential and dynamic, yet simultaneously perceived as fixed and rigid. Because practitioners are likely to work with clients from diverse backgrounds and because we are a global society due to technological advances, it is important to understand heterosexism in both its international and national contexts. Although numerous nations have enacted legislation inclusive of sexual orientation, in many countries, sexual orientation and gender identity and expression remain criminalized—supported by governmental legislation, laws, and religious culture (Amnesty International, 2008). Criminalization tends to be linked with privileging heterosexual relationships and traditional expressions of masculine and feminine genders, often languaged as human nature or God’s order. For example, in Iranian society influenced by Islamic teachings, homosexuality is outlawed and considered against human nature. “Humans are here to reproduce; homosexuals cannot reproduce” (Amnesty International, p. 27). In seven countries throughout the world, gay male sex is a capital offense, and in four countries, women can face the death penalty for engaging in lesbian sex (Amnesty International). In addition to prison sentences, discrimination can take forms such as being denied access to health and sexual information, being denied access to healthcare, being denied rights to organize and advocate, and being unable to marry and adopt children. Some political and business cultures support anti-gay attitudes and behaviors. The president of Zimbabwe was quoted labeling gays as “less than human” (Amnesty International, p. 29), and a Sri Lankan newspaper printed an editorial protesting a lesbian conference and suggesting to “. . . let loose convicted rapists among the jubilant but jaded jezebels . . . so that those who are misguided may get a taste of the real thing” (Amnesty International, p. 17). Such attitudes are supported by cultural institutions, a pattern mirrored in the United States. The United States is experiencing a complexly curious progression toward the inclusion into society of LGBT persons while maintaining a heterosexist preference. For example, the Supreme Court overruled all remaining same-gender and

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opposite-and-same-gender sodomy laws (Lawrence et al. v. Texas, 2003). At the time of this writing, 30 states have hate crime laws inclusive of sexual orientation, 26 states have laws inclusive of gender, and 12 have hate crime laws inclusive of transgender identity (Anti-Defamation League’s Washington Office, 2008). Five states have full marriage equality for same-sex partners, whereas six states have broad relationship recognition laws such as civil unions or domestic partnerships (National Gay and Lesbian Task Force, 2010). Despite changes in legal rights for LGBT persons, heterosexism continues to permeate the structures and institutions of the United States. The federal government maintains the Defense of Marriage Act (DOMA, 1996), and currently, there is no federal legislation prohibiting employment discrimination based on sexual orientation and gender identity. DOMA (1996) defines marriage as “a legal union between one man and one woman as husband and wife” (§7). It defines spouse as “a person of the opposite sex who is a husband or a wife (DOMA, §7).” Further, DOMA stipulates that no state is required to respect a relationship between individuals of the same sex that is considered a marriage by another state. For example, Texas is not required to recognize a lesbian couple’s legal marriage performed in Massachusetts. The Employment Non-Discrimination Acts (H.R. 1397, 2011; S. 811, 2011) were introduced to the House and the Senate of the 112th Congress. The bills would prohibit discrimination by employers with greater than 15 employees based on actual or perceived sexual orientation and gender identity. Religious organizations are exempt, and this bill is not applicable to members of the armed forces. Presently, it is legal in 29 states to discriminate based on sexual orientation and in 37 states to discriminate on the basis of gender identity (Human Rights Campaign, 2011a). As the text of these bills indicates, religious institutions are influential in maintaining a heterosexist and gender-normative culture. U.S. religious institutions articulate positions along a spectrum, from welcoming and inclusive acceptance to discrimination and condemnation (Herek, 1992; Human Rights Campaign, 2011b). Religious traditions opposing same-sex unions argue that marriages are heterosexual by definition, given the presumption that the union is one in which children can be conceived. Others use interpretation of scripture to condemn homosexuality. The Roman Catholic Church described homosexual feelings as those that are “ordered toward an intrinsic moral evil” (Herek, 1992, p. 91). Despite official separation of church and state, the United States was influenced heavily in its founding and evolution by a Judeo-Christian tradition, which continues to struggle to reconcile its understanding of sexual orientation and gender identity. In American culture, heterosexuality and traditional masculine and feminine gender expressions are the norm, supported by cultural, religious, and political institutions. This establishes a phenomenon of heterosexual privilege in which heterosexuals do not have to be aware of their sexual orientation; rather, they are identified by the roles they play in relationships and society (e.g., mother, father, wife, husband; Herek, 1992). It may appear confusing to define people based on what they do sexually, given that sexuality traditionally is relegated to the private sphere of one’s life (Herek, 1992). Yet, while private, a heterosexual sexual orientation is affirmed publicly through civil and religious marriages, tax and inheritance laws, employee benefits programs, and immigration and naturalization laws, as well as through customs surrounding parenthood, like tax deductions, religious rituals, and birth celebrations. Although advances have been made in many of these public affirmations of private sexual orientations, persons with minority sexual orientations and gender identities are vulnerable to invisibility or to defining themselves in opposition to or in attempting to mimic heterosexual norms (Herek, 1992). Heterosexual orientation is viewed as the norm, and thus, minority sexual orientations are seen as lacking, not normal, and sometimes deviant. Given this disempowered position, members of minority sexual orientations and gender expressions become vulnerable to prejudicial attitudes and hate crimes.

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Linking Heterosexism to Prejudice and Hate Crimes Heterosexism is a pejorative stance toward the “other,” that is, the “other than the norm,” and it can influence attitudes and behavior in a negative manner (Burn, 2000; Cowan et al., 2005; Palmer, 2004). Perhaps, most critical is the process called internalized homophobic, in which a LGBT person internalizes attitudes and systemic expressions of hate, rejection, condemnation, and prejudice and in which the person essentially punishes himself or herself for who he or she is. This is labeled internalized homophobia. For example, Stuart was a gay man whose sexual orientation was labeled as sinful by his faith system that persuaded him to change his sexual orientation. He wrote the following in response to growing up in that environment, and these words were a part of his suicide note: [My] church has no idea that as I type this letter, there are surely boys and girls on their callused knees imploring God to free them from this pain. They hate themselves. They retire to bed with their fingers pointed to their heads in the form of a gun. I am now free. I am no longer in pain and I no longer hate myself. As it turns out, God never intended for me to be straight. (Palmer, 2004, p. 40) Heterosexism also influences the use of hate speech and verbal harassment by those who consider themselves to represent the norm. For example, in a survey of college students, heterosexual males were found to use anti-gay words such as “fag,” and “queer” to refer to one another in derogatory fashions (Burn, 2000). Although this study did not find engaging in this behavior predictive of participants’ sexual prejudice, it appeared to be a part of fitting in with peers. We can infer from this study’s findings that LGBT students, witnessing these verbal insults, may internalize the messages self-critically, and the hate speech may contribute to a perception of an unsafe college campus. Sexual identity development may be experienced more acutely in school- and college-aged students, contributing to elevated stress, vulnerable self-esteem, shame and guilt, and higher suicide rates (Burn, 2000; D’Augelli, 1992; Friedman & Downey, 1995; Meyer, 1995). According to participants in a survey of gay and lesbian college students, 77% reported experiencing verbal insults, 27% experienced threats of physical violence, 22% reported being chased or followed, and 99% reporting hearing sexually prejudicial remarks (D’Augelli). Prejudicial comments based on sexual orientation and gender identity have a direct link to hate crime and violence. These comments, often heard on a daily basis, communicate the message that it is permissible to punish homosexuality and gender atypical behavior (Burn, 2000). Systemic institutions support inequality and lack of recognition of diverse sexual orientations and gender identities. This support and lack of recognition influence personal attitudes, which can then foster perpetration of hate crimes and violence. In the next section, we explore the impact of hate crimes on victim-survivors, perpetrators, and the broader community.

EXPERIENCING CRIMES OF HATE AND BIAS Within societal, familial, and community contexts, what are the experiences of those who perpetrate and are victimized by hate-based crimes? What information would help empower human service professionals to respond competently and professionally? In order to help and to advocate for LGBT persons, it is necessary to understand the context of both the perpetrators and the victims of hate-biased crimes. This section

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considers prevalence rates, describes the unique ways in which crimes against persons and property are perpetrated against LGBT persons, and proposes how these targeted offenses may foster distinctive wounds for victim-survivors.

Prevalence It has been challenging to interpret the prevalence of hate-bias crimes for several reasons, including the difficulty in determining motivation of a hate-bias crime and victims’ lack of reporting. According to incidents of violence reported between 2005 and 2009 to either law enforcement as tracked by the FBI or to the NCAVP, an average range of 1,194 to 1,688 incidents were reported each year (NCAVP, 2010; U.S. Department of Justice, Federal Bureau of Investigation, 2009). These prevalence rates for bias and hate crimes, based on actual or perceived sexual orientation or gender identity, represent conservative estimates. The FBI’s hate crime reporting program identified the subjective nature of motivation and the presence of bias alone as potential limitations in accurately determining whether a crime is a hate crime (U.S. Department of Justice, Federal Bureau of Investigation, 2009). In other words, it may be difficult to determine whether an offender’s motivation was based on bias and whether, therefore, the determination was based on the presence of sufficient evidence, thus suggesting that the offender’s actions could be considered to be motivated by bias. Examples of evidence included oral or written statements or gestures made during the offense, bias-related markings or graffiti, the proximity of the crime to known LGBT gathering areas, and the suspects’ own self-reports (Herek, Cogan, & Gillis, 2002; U.S. Department of Justice, Federal Bureau of Investigation, 1996). In addition to discerning the presence of sufficient evidence for bias-motivated crimes, prevalence rates are limited by agency resources and self-reporting. For example, the NCAVP comprises 38 antiviolence programs in 22 states in the United States with the mission of addressing violence against and within the LGBT community (NCAVP, 2010). Their annual report is based on a self-selected sample of people who reported to local antiviolence programs, in person or by phone, experiences of violence. The report includes data on victims-survivors, types of incidents, and offenders, and also details narratives of a representation of the sample. Although these data address some of the limitations of the FBI definition described in the hate crimes definitions section, they are based on self-reported information and may be limited by resources available in each state. Additionally, given the self-reported nature, the victim-survivors appeared responsible for determining the offenders’ bias motivations. Despite these potential limitations, the NCAVP annual report is a helpful tool for human service professionals as it identifies community-based resources and provides more contextualized information and personal narratives that help develop a richer understanding of this issue. In addition to these limitations in determining prevalence rates, individual survivors experienced reporting barriers such as fear of outing oneself, lack of trust in the law enforcement and judicial systems, and fear of further stigmatization or discrimination (Herek et al., 2002; NCAVP, 2010). Lack of reporting, therefore, has prevented an accurate understanding of the scope of the problem. The following statistics highlight incidents of verbal, physical, and sexual assaults that are only three of many forms of hate-motivated behavior. Multiple local and national surveys and interviews were conducted to assess recent and lifetime victimization based on sexual orientation and/or gender identity or expression (D’Augelli et al., 2006; Gross et al., 2000; Herek, 1989; Herek et al., 2002). In a survey of 528 LGBT and gender atypical youth in the New York City vicinity, 78% reported experiencing verbal sexual orientation victimization, beginning on average at age 13, with the earliest first report of verbal

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harassment at age 6. Eleven percent (11%) reported experiencing physical victimization, with first onset, on average, at age 13 and the earliest incident occurring at age 8. Nine percent (9%) of participants reported being sexually assaulted due to actual or perceived LGBT identity, with incidents beginning around age 13 (D’Augelli et al., 2006). Two surveys conducted in Philadelphia tracked exposure to violence and harassment due to sexual orientation within the 12 months prior to the survey and over the respondent’s lifetime (Gross et al., 2000; Herek, 1989). In the 1988 survey report, 92% of male respondents and 81% of females experienced verbal abuse; and in the 2000 report, 94% African American male, 88% White male, 70% African American female, and 75% White female respondents experienced verbal abuse (Gross et al., 2000; Herek, 1989). Twenty-four percent (24%) of male respondents and 7% of females in the 1988 survey reported being hit, kicked, or beaten; whereas 43% African American male, 32% White male, 13% African American female, and 8% White female respondents reported being punched, hit, or assaulted (Gross et al., 2000; Herek, 1989). Six percent (6%) of male respondents and 3% of females were sexually assaulted according to the 1988 survey, whereas 33% African American male, 7% White male, 18% African American female, and 5% White female respondents reported being sexually assaulted in their lifetimes (Gross et al., 2000; Herek, 1989). Two other statistics from the 1988 survey are relevant to human service professionals. Sixty-seven percent (67%) of male respondents and 33% of females experienced victimization in schools (Herek, 1989). Seventy-six percent (76%) of male respondents and 78% of females did not report the incidents (Herek, 1989). Although barriers to reporting limit accurate tracking of prevalence statistics, the previous survey results suggest a high lifetime exposure rate to verbal, physical, and sexual violence due to sexual orientation and gender identity and expression. AntiLGBT violence appears to begin early in life, is perpetrated in schools, and goes often unreported (Gross et al., 2000; Herek, 1989). Prevalence rates support a rationale for understanding the lived experience of LGBT persons, responding meaningfully to intervene when prejudice leads to violence, and fostering systemic change to prevent such hate crimes.

Forms, Settings, and Perpetrators of LGBT Hate Crimes Forms of violence are categorized by crimes against persons and property (U.S. Department of Justice, Federal Bureau of Investigation, 2009). Crimes against persons tend to be verbal, physical, and sexual. Crimes against property include theft, vandalism, burglary, and destruction of property (Herek et al., 2002). Youth and adults reported being called names (e.g., “fag,” “dyke,” “queer,” “homo,” as well as more sexually explicit terms; Burn, 2000). They report being spat on, shoved, urinated on, kicked, having items thrown at them, hit with rocks and bottles, and being attacked physically and sexually. Some are murdered (Herek & Berrill, 1992; NCAVP, 2010; Southern Poverty Law Center, 2010). Herek and Berrill (1992) described a typical incident. Kathleen began receiving threatening mail at work following her appearance as the spokesperson at a press conference for an LGBT-related organization. She brought the letters to local police who stated they could not do anything and suggested, “If I couldn’t stand the heat, I should get out of the kitchen!” The offender cornered her in her office alone one day and over a period of 3 hours, beat her with his gun and fists, sexually molested and raped her, eventually leaving her unconscious. According to her report, during the attack, the perpetrator “talked about how he was acting for God; that what he was doing to me was God’s revenge on me because I was a ‘queer’ and getting rid of me would save children . . .” (pp. 201–203).

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It is important to remember LGBT hate crimes also can be committed against those who are perceived to have an LGBT identity. For example, Joe, a straight male from Brooklyn, was beaten while riding the subway. He was attacked by two young men who boarded the train shouting, “There are faggots on this train and we hit faggots.” One of the men approached Joe, called him a faggot, and beat him in the face (NCAVP, 2010). LGBT persons have reported incidents in which their property, homes, and businesses were vandalized, burglarized, and destroyed (Herek et al., 2002; NCAVP, 2010). One lesbian couple had a gay slur written in lipstick on their car, which was covered in salsa and sour cream. A gay-friendly neighborhood in Lansing, Michigan, was vandalized with “Kill Gays” spray-painted throughout the neighborhood. Businesses lost customers who were afraid to enter the neighborhood (NCAVP, 2010). LGBT bias crimes tend to occur more in public spaces (e.g., outside a business), with bias property crimes occurring outside one’s home. However, bias crimes do occur in home and work spaces, school campuses, institutional settings, and rural locations. Gayidentified settings are recognized as common locations where hate crimes occur (Herek et al., 2002). Hate crimes against both people and property tend to be perpetrated by multiple offenders, with whom the majority of victims are not acquainted. The offenders tend to be White males, ranging from adolescents to young adults (Herek et al., 2002).

Consequences Relevant to LGBT Victims of Hate Crime Violence In addition to physical and psychological wounds that are consistent with violent victimization (see Herman, 1997), hate crimes communicate unique messages of fear for members of the LGBT community. For example, although gay-identified spaces are frequent targets for violence, people are victimized in places typically inhabited in daily life such as public parks and schools. Being targeted for one’s sexual orientation or gender identity in such familiar public places that commonly are accepted as “safe” spaces, the victim learns the message that no place in ordinary daily life is safe (Herek et al., 2002). The following are additional patterns of consequences expressed by survivors.

Intense Brutality Hate crimes against LGBT persons are perpetrated frequently with ferocious brutality. Through their actions, Willis (2008) suggests that offenders appear to be attempting to wipe out the existence of homosexuality and gender atypical behavior in addition to the life of their victims. Reflecting on her experience described in the previous section, Kathleen commented, “I also live with the knowledge that because of my orientation, because I chose to exercise what I believe are my constitutional rights, my life has no value to certain people” (Herek & Berrill, 1992, p. 203). Kathleen’s comments reflect the impact of her perpetrators’ actions. Another example of this type of perpetrators’ brutal expression of devaluing the lives of LGBT individuals is seen in the actions of a gang of nine men who kidnapped and tortured three men because of their perceived gay sexual orientation (Dolnick & Moynihan, 2010; McFadden & Dolnick, 2010). In this horrific crime, the following actions were perpetrated against the victims: they were stripped; they were burned with cigarettes; they were cut with box-cutter blades; they were raped multiple times with a bat, stick, and plunger handles; and they were beaten with bats (Dolnick & Moynihan, 2010; McFadden & Dolnick, 2010). In another example, a lone gunman, who only encountered them in passing, stalked and hunted Claudia and her partner, Rebecca, while they hiked on the Appalachian Trail. While stalking them, he watched them make love. He fired eight rounds from a single-shot rifle, killing Rebecca and hitting Claudia in the face and neck five times, leaving them to die alone in

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the woods (Brenner & Ashley, 1995; Herek & Berrill, 1992). Verbal, physical, and sexual assaults—including those that are fatal—are enacted with an intensity that terrorizes not only the victims but also LGBT community members.

Victim Blaming While committing violence, perpetrators and systems may blame the victim, such as stating “this is what faggots deserve” (Herek, 1989, p. 949). Remember Claudia from the previous paragraph? Claudia survived being shot five times in the face and neck and walked four miles for help. The shooter was arrested and convicted of first-degree murder, and sentenced to life without parole. During the trial, the defense attorney claimed Claudia and Rebecca’s sexual orientation and their engaging in sexual behavior provoked the defendant, leading Claudia through an extensive and specific line of questioning detailing her and Rebecca’s sexual activity prior to the shooting. Beyond allusions to the victims’ responsibility as a defense strategy, an Associated Press article that ran in Claudia’s hometown newspaper claimed the women teased and taunted the defendant repeatedly (Brenner & Ashley, 1995; Herek & Berrill, 1992). Victim blaming is supported by systems, as well. Some victims of school bullying have been told by school administrations that if students insist on being gay and acting in the manner they do, they should expect to be bullied (Southern Poverty Law Center, 2010). While not blaming individual victims but rather the gay rights movement, a Vatican statement claimed, “When civil legislation is introduced to protect behavior to which no one has any conceivable right, neither the Church nor society at large should be surprised when other distorted notions and practices gain ground, and irrational and violent reactions increase” (quoted in Herek, 1992, p. 90).

Barriers to Reporting Youth and adults may be reluctant to report their abuse for several reasons (Herek et al., 2002; NCAVP, 2010). Young students may perceive their school’s “no tolerance” bullying policy as useless and ineffective, given their daily experiences with violence and harassment. To report may mean outing oneself to school administrators, teachers, family, employers, church, friends, and community. Victims may fear the implications of outing, such as losing jobs, further bullying or harassment by individuals of groups with which they are associated, loss of family support, and possible legal ramifications. Victims also may fear harassment or discrimination within the medical, law enforcement, and judicial systems and not believe that reporting leads ultimately to the perpetrator being held responsible. One reason for the reluctance to report is that legal systems may not be responsive to hate crimes against LGBT persons (Herek & Berrill, 1992). For example, Bob experienced escalating harassment and physical attacks by a group of young men in his town. Name-calling led to chasing him in a vehicle, physically attacking him, and threatening to kill him. Despite contacting the young men’s families and filing 15 complaints with local law enforcement, the behavior continued without intervention. Law enforcement advised him to stay home or to move. Eventually, the young men broke into his home and began attacking him. In self-defense, he shot and killed one of the group. For his involvement in these crimes, the leader of the group accepted a plea bargain and was fined $35. The court told the victim that time for a trial could not be spared. In summary, LGBT persons experience varied and brutal attacks to their humanity, person, and property. They face additional obstacles to reporting experiences of hate crimes. Often, systems, such as legal and educational, do not respond to a victim’s

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reporting. Reporters often are ignored, blamed, and sometimes dismissed, resulting in the perpetuation of a cycle of silence and invisibility.

RESPONDING TO HATE AND BIAS Human service professionals have opportunities to respond to the wounds of hate and bias at intrapersonal, relational, community, and systemic levels. Meaningful goals include healing, preventing future violence, and advocating for systemic change regarding heterosexist attitudes and related policies. This section provides an overview of responses based on the lived experience of survivors and former perpetrators, findings from relevant research, and intervention and policy recommendations.

Attending to Survivors Attending to survivors’ experiences may require addressing psychological and physiological responses, access to resources and supports, attempts to make meaning from the experience, and the unique condition of being targeted based on one’s perceived or actual sexual orientation or gender identity (Herek, Gillis, & Cogan, 1999; Willis, 2008). Based on a qualitative study with gay male survivors of hate crimes, Willis (2008) discovered that the majority of participants’ physical injuries healed more quickly than the psychological and emotional scars. However, survivors can experience physical injuries that take years to heal or that cause permanent damage. Thus, although it may appear that the visible signs of wounding diminish over time, the hidden scars require significant healing. The hidden scars are often complex. For example, when compared with victims of nonbias crimes, survivors of bias-motivated hate crimes reported more significant symptoms of depression, anger, anxiety, and posttraumatic stress. Additionally, survivors have reported perceiving the world as more unsafe, viewing other people’s motivations as harmful, indicating a low rate of personal mastery, and attributing their personal problems to sexual prejudice (Herek et al., 1999). These results are consistent with Willis’s (2008) findings of gay male survivors reporting increased vulnerability, self-awareness of embodied distress, increased vigilance, and insecurity about interacting socially and in public. These consequences have resulted in diminished relationships with partners, decreased involvement with social networks, and increased isolation (Willis, 2008). Survivors of LGBT hate crime, as opposed to nonbias motivated crime, specifically were targeted and violated based on their perceived or actual sexual orientation or gender identity and expression. This can have negative consequences of self-perception for persons who are both open about sexual orientation or gender identity as well as persons who have internalized homophobia and gender prejudice (Herek et al., 1999). For example, upon experiencing a hate crime, a personal quality of self that once was associated with love, intimacy, pride, and community suddenly may be associated with violence, terror, fear, and shame. This may complicate the healing process, leaving the client feeling isolated and afraid to reach out to his or her usual support system. Based on their research, Herek et al. (1999) identified implications for counseling. Given the additional factor of bias motivation along with the experience of violence itself, healing may take longer than a nonbias motivated crime. Survivors may need help formulating a balanced world view, perceiving both the relative vulnerability and stability of daily living. Survivors reported the importance of making meaning of their experiences and participating in raising consciousness in the broader community of the

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reality of hate crimes and survivors’ needs (Brenner & Ashley, 1995; Willis, 2008). Finally, a broad resource assessment is indicated for LGBT survivors—including family of origin and family of choice, friends, and community members. Because some LGBT persons are ostracized by their birth families, service providers cannot assume that family of origin is a resource. This type of assessment can help both the counselor and the client determine who and what can comprise a support system rather than automatically assuming that traditional support systems such as family or church are available. Claudia Brenner’s story is consistent with many respondents from previously cited empirical research (Brenner & Ashley, 1995; Herek et al., 1999; Willis, 2008). Prior to her being shot and her partner being killed, she lived in pseudodenial that she was vulnerable to the violence in the world—“it can’t happen to me.” Once that denial was shattered, she was left to fend for herself on a journey of survival, one in which recovery was intuition oriented—“ . . . to feel safe, to remember and mourn, to make some sense of the shooting, to fit it into my view of myself and the world, and to restore social connection” (Brenner & Ashley, p. 154). Relevant for counselors, she identified the healing power and process of storytelling in this way: The more I told the story of the shooting, the less power it had over me, and the more my sense of safety grew. I told it and cried about it so many times that it eventually began to heal into a memory. As a memory, it could be integrated into my regular world. I began to make sense of the shooting as part of my life, my ‘selfstory.’ Integration did not mean that I was in less pain, but I did feel less split off from myself. The shooting was not compartmentalized in my thoughts, isolated from the rest of my life. It was becoming a memory that was interwoven with everything else in my world, and that world was being transformed into a place where it was not inconceivable that I could be shot. (Brenner & Ashley, 1995, p. 159) In summary, reports from survivors indicate that several conditions can help with the healing process: having a safe space to tell their stories as often as needed, experiencing acceptance for a survivor’s unique pacing, and processing through the dynamically linked emotional and cognitive shifts. Thus, counselors should not diminish the therapeutic healing power of being a witness to a survivor’s story, again and again, as well as all the feelings involved in the story. Given the incidence of psychological trauma experienced by survivors of hate crimes, might perpetrators of violence and hate crimes experience trauma also? Despite their responsibility for committing the violent acts, how might perpetrators’ experiences compare with survivors’ experiences? The next section illuminates current findings and areas for further research that could help in the goal of reducing hate bias and violent crimes.

Attending to Perpetrators of Hate and Bias Behaviors Two intervention and research directions show promise for working with people who perpetrate hate and bias crimes toward members of the LGBT community. The first approach considers the diverse functions that sexual and gender prejudice can play in a person’s life and recommends interventions specific to addressing each function (Herek, 1986). The second intervention considers the degree to which perpetrating violence has psychological and physiological responses consistent with posttraumatic stress disorder (PTSD; MacNair, 2002a, 2002b). Herek (1986) postulated a theory outlining homophobia’s varying functions in people’s lives. He argued that people experience secondary gains by holding onto and

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expressing homophobic attitudes. He identified two major attitudinal categories, each with specific functions describing the benefit to a person. First, individuals form their attitudes based on experiences. When people have positive experiences with someone they perceive as different, they may evaluate their prior assumptions. For example, Herek noted that in opinion polls, people who identified having one or more LGBT friend were less likely to have sexually prejudicial attitudes. He suggested the following relationship qualities in order to optimize the chances of experiences with someone of a different sexual orientation or gender expression being positive: (a) one should maintain an ongoing and genuine relationship rather than a brief or superficial one; (b) the relationship should be based on mutually shared beliefs, values, and interest not related to sexual orientation or gender expression; and (c) the relationship should occur in a mutually supportive rather than competitive context. Thus, people can move through fear of difference by getting to know someone on an authentic level. Herek (1986) identified expressive and defensive attitudes, and their corresponding functions, to help explain the secondary gains people experience from maintaining sexual and gender prejudice. Expressive attitudes may be related to values or social acceptance. For example, Mary’s identity is strongly attached to her religious values, and if these religious values define homosexuality as an abomination to God, she views a lesbian or gay person as a sinner and outside of her own value system in order to maintain consistency with her doctrine. Herek believed that the attachment to values was more influential to a person’s behavior than an outright hatred of lesbian or gay persons. In these instances, only having the types of experiences described previously may do little to change a person’s belief system. Instead, Herek recommended that respected authority figures, that is, those who share a person’s faith system but have an alternate view of sexual orientation, may be more influential in helping to expand a person’s belief structure. For example, members of religious traditions may influence attitudes when they speak out in support of LGBT persons and critique the church’s message as barriers rather than supports to a living faith. When these efforts are combined, sharing authentic experiences with an LGBT person may make more of a difference. Social-expressive attitudes stem from people’s need for approval and acceptance from a respected peer group. When this need is strong enough, they may choose behaviors in conflict with their own values. They may act out in sexually and gender prejudicial ways, attempting to fit in with social norms. In a similar way as valueexpressive attitudes, the attachment to being accepted may be more influential than any independent dislike for an LGBT person. In such cases, working with people’s selfconcepts and belief systems and expanding their peer group to include more accepting perspectives may assist in relieving the secondary gains. Finally, Herek (1986) adapted the construct of a psychoanalytic defense mechanism to conceptualize defensive attitudes. Existing at a more unconscious level, a person may avoid any homoerotic sensations within himself or herself by projecting that fear and anxiety onto an external object. For example, a person may assault a gay person in a rage of anger and rejection, lashing out against the “self” who he or she fears may be gay. Given its existence in the unconscious, this attitude may be more challenging to address, as it requires a person to become aware of and openly address fears about the self. In addition to addressing functions of homophobia, it may be relevant to assess the psychological and physiological responses to perpetrating violence. Thus, counselors can assess the functions that clients’ sexual or gender prejudice serves in their lives. Counselors can explore origins and contextual messages, which clients have learned, that may have supported prejudicial attitudes. When attitudes may be aligned closely with clients’ identities, such as strong religious or social values, counselors can identify key authority figures from similar religious or social circles but who advocate

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more inclusive positions. Also, counselors can work with clients demonstrating sexual or gender prejudice to explore clients’ sexual and gender identity and to assess for unconscious sexual or gender identity issues. Finally, when indicated by client readiness, counselors can work with local LGBT organizations and restorative justice agencies to help clients engage in dialogue with persons of different sexual orientations and genders to reduce fear of difference and enhance empathic connection. Traditionally, research on symptoms of PTSD has focused primarily on victims of sexual assault and domestic violence and on the experiences of military personnel (MacNair, 2002a, 2002b). Even when addressing combat service, research tends to address the responses of soldiers under fire rather than soldiers who have killed in combat (MacNair, 2002a, 2002b). Historical evidence suggests that committing violent acts has psychological consequences on perpetrators (MacNair, 2001). MacNair (2002b) coined the term “perpetration-induced traumatic stress” as a proposed subcategory of PTSD encompassing the psychological and physiological reactions by persons who perpetrate violence. Based on the author’s analysis of survey responses by combat veterans who identified killing soldiers or civilians, these veterans reported symptomatic responses such as “intrusive imagery . . . outbursts of irritability and rage . . . hypervigilance, alienation, and a sense of personal disintegration” (MacNair, 2002a, p. 69). This is a promising and new area representing a dearth of scholarship; however, implications for treatment interventions are significant. Exploring perpetrators’ purposes for maintaining sexual and gender prejudice, as well as their own experiences of trauma, may have implications for responding to LGBT hate crimes. Beyond the societal context that maintains a preference for heterosexuality and traditional masculine and feminine gender expressions, hate speech and actions are linked with deeply held personal wounds, attitudes, and value structures. Focusing on healing the trauma perpetrator’s experience may help interrupt the cycle of violence. Such responses are consistent with the NCAVPs’ (2010) recommendations: “. . . rather than viewing hate violence as a criminal justice problem with social implications, hate violence must be viewed as a social and public health issue with criminal justice implications” (p. 45). Based on this assumption, the NCAVP recommended a restorative justice-based rehabilitation focus for offenders rather than incarceration only. Frank Meeink’s story (Meeink & Roy, 2009) contained elements consistent with addressing functions of homophobia and the presence of traumatic symptoms following the perpetration of hate-motivated violence. Frank grew up in an environment of hate, drug abuse, and violence. Following his feelings of acceptance by a peer group of young skinheads, he channeled his pain and anger into blaming and hating people of diverse sexual orientations, races, cultures, and religions. He spent years viciously taking out his anger on victims, severely beating and almost killing many people. During his prison terms, he began engaging in the types of experiences that Herek (1986) recommended, that is, fostering ongoing relationships with groups of people whom he previously had considered as “the other.” With these experiences hinting at an expanding belief system, he had an intense awakening moment following the Oklahoma City bombing, an event in which he did not participate, but was perpetrated by a member of a similar hate group. Within a disconnected and fragmented self, the face of a dead child managed to pierce his heart. As Frank challenged his assumptions and changed his behavior, he used drugs and alcohol to cope with lingering intrusive thoughts and emotional pain from his violent past. He shared the following poignant reflections: I felt so . . . evil. For the first time ever, my victims haunted me. . . . The unarmed gay men I beat with an Orangina bottle. . . . How many of my victims had wished for death while I brutalized them? . . . I’d tried to escape by hating, by

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drinking, by drugging. . . . God has taken mercy I don’t deserve on me, mercy I never showed my victims. Their eyes still haunt me. I can’t remember their faces, but I cannot forget the desperation in their eyes. I pray to God every day to give them peace. And I pray to God never to erase their pain from my memory. I can’t make direct amends to most of the people I so brutally attacked. . . . But they are in my heart now when I speak out against hatred. They are the reason I will never stop speaking out against hatred. (Meeink & Roy, 2009, p. 21, 313) In ways that mirror this revelation, counselors can help perpetrators to heal from their violent acts by assessing for symptoms of PTSD, identifying the potential for selfmedicating coping behaviors that may be masking PTSD symptoms, acknowledging that perpetrators may experience remorseful emotions, and inviting them to share their stories. Also, in order to provide competent and ethical care, it is important for counselors to identify their own biases toward and assumptions about working with perpetrators and to seek supervision concerning prejudicial thoughts and feelings that the counselors may harbor. Perpetrators of violent crimes, particularly of the brutal nature as those directed against LGBT persons and described earlier, often are isolated and ostracized by society. The work counselors can do in addressing perpetrators’ prejudicial attitudes and trauma experiences can be a key component in reducing hate and violence in our communities. Having explored consequences and potential responses with the most intimate parties involved in LGBT hate crimes, what responses may be appropriate for community members who occupy the contexts in which this violence occurs? The next subsection considers the consequences of violence to survivor support systems, the LGBT community, and social and systemic implications.

Community and Systemic Implications Hate crimes occur within contexts in which crimes have an impact on families, friends, social networks, the LGBT, and broader communities. For example, during her initial hospitalization, Claudia Brenner had an inner circle of friends that stayed with her round-the-clock, witnessing her immediate physical consequences of being shot in the face and neck (Brenner & Ashley, 1995). On a broader scale, the Laramie Wyoming community experienced shock when college student Matthew Shepard was brutally murdered for being gay (Loffreda, 2000). This section provides a brief overview to raise awareness of the needs of survivors’ significant others, the unique impact of hate crimes on the LGBT community, and integrative recommendations for community response. Research has shown that significant others can be vulnerable to indirect secondary traumatic stress (Arm, Horne, & Levitt, 2009; Bride, 2007; Phelps, Lloyd, Creamer, & Forbes, 2009; Salston & Figley, 2003). Secondary traumatic stress is defined as “the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person” (Figley, 1999, p. 10). Cognitive, emotional, physical, and behavioral symptoms can include a negative self-concept, alterations in perceptions of safety and justice, emotional and physical exhaustion, interpersonal relationship difficulties, nightmares, feelings of helplessness and powerlessness, intrusive thoughts, and irritability (Salston & Figley, 2003). These symptoms can be exacerbated by any previous traumatic experiences that caregivers may have suffered, such as abuse or assault (Salston & Figley). Response strategies can include individual and group counseling that acknowledges and conveys the following: accepting support persons’ thoughts, feelings, and behaviors; sharing their experiences of witnessing significant

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others’ trauma and recovery; and restoring healing balance to their lives (Salston & Figley). Targeting LGBT persons with hate-motivated violence communicates messages to the LGBT communities (Herek, 1989). Given the tendency for crimes to be committed in public spaces—particularly spaces identified with the LGBT community—and given the brutality often present in attacks, LGBT hate crimes can create a climate of fear. “[B]ias-motivated attacks function as a form of terrorism, sending a message to all lesbians, gay men, and bisexuals that they are not safe if they are visible” (Herek et al., 2002, p. 336). Therefore, when hate crimes occur, service providers could link with local LGBT community agencies, business, and community centers to provide opportunities for community members to express their thoughts and feelings and identify intervention strategies to respond to systemic fears. Finally, service providers have opportunities to advocate for reduced violence on a societal level. Service providers can critique policies and legislation to determine the influence of biased gender expression or heterosexist norms. They can identify and advocate for systemic change on local, state, and federal levels when hate crime definitions and response policies exclude LGBT persons. Service providers also can create opportunities for dialogue among LGBT community members, spiritual and religious organizations, law enforcement, school, and medical groups. This can assist in identifying methods to recognize accurately and to track incidents of LGBT hate crimes, survivor and support needs, and factors that may influence the maintenance of disrespect, hate, and violence. For example, a local LGBT advocacy organization facilitated restorative dialogues with the community and family members of Fred Martinez, a 16-year-old Native American transgender youth bludgeoned to death (Coates, Umbreit, & Vos, 2006). The purpose was to encourage dialogue among community groups that had not connected previously. The outcome of the single community conference was the beginning of an ongoing dialogue. Such restorative dialogue approaches are consistent with policies that are recommended by the NCAVP (2010). Although understood and studied in distinct victim and perpetrator categories, research suggests that some degree of trauma is experienced by survivors, perpetrators, and the community when LGBT hate crimes are committed (MacNair, 2002a, 2002b; Meeink & Roy, 2009; Salston & Figley, 2003). With interconnected goals of healing and reducing the prevalence of sexual and gender prejudice and violence, service providers have opportunities to investigate more integrative responses to those who have been wounded.

CONCLUSION Despite evolving understanding of and acceptance for diverse sexual orientations and gender identities and expressions, LGBT persons continue to experience wounding to their bodies, minds, spirits, and souls. Their core selves are denigrated and defiled, and at times, their very existence is deemed unworthy and extinguished. This wounding cycle can occur within families, communities, work settings, and places of worship; at times, it can be perpetuated by systems of culture, government, religion, and tradition. As helping professionals, our challenge is to recognize and interrupt cycles of hate and bias, to foster individual and community healing, and to advocate for humane and dignified relationships with people of all sexual orientations and gender identities and expressions. We hope that this chapter has served to have an impact upon, inform, and empower the reader to respond with competence and compassion.

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APPENDIX 18.1 Case Study Franco is a 15-year-old biracial son of a Jamaican father and a Latina mother, raised in an inner city setting. Daily, he walks to his high school, where he is a sophomore. His parents struggle economically, both having high school educations and dealing with unpredictable job security. Franco has a younger sister Gabriella, and his immediate and extended family members are active in a neighborhood Catholic church. Growing up, Franco did not embody the masculine role embraced by his father and male cousins and uncles. They teased him, calling him “sissy” and “momma’s boy.” They would taunt and beat him in an effort to “toughen him up.” Franco doubted that they liked him, let alone loved him. Franco is quiet and often withdrawn, preferring to remain invisible in group situations. He feels confused and insecure, recognizing that he has feelings different from his family and people he sees at home, school, and church. Since he was a young boy, Franco felt curiously drawn to and developed crushes on other boys. This was unlike anything he saw in his extended family. Thinking he might be gay, he would secretly search for books at the library that could answer his questions. He paid attention to Internet and media stories and to church sermons to find answers to his growing questions. Often, the information confused Franco; sermons advised loving the sinner but hating the sin, and there were stories of both successful attempts to pass marriage equality acts and groups protesting the “abomination” of homosexuality. From his family, he was pressured to join in with cousins who were flirting with neighborhood girls and taunted when he did not appear interested. The more his feelings of attraction intensified, the more withdrawn and ashamed he felt for being so unlike his family and friends. From his family, Franco hid the verbal mocking of “spic fag,” “queer,” and “homo nigger” that regularly seemed to announce his walk down the street and his entrance onto school grounds. Each school day brought more abuse such as being tripped, punched, and spat on by other students. When no teacher was present, some students would mock sexual acts while calling out his name. While in the boys’ room, a group of kids held him down while the ringleader urinated on his head, bending over him afterward and threatening to kill him if he told anyone. Cynically, Franco considered the school’s “zero tolerance” policy for bullying to be a joke, because no one seemed ever to do anything aimed at stopping the violence; and he was too scared to report it. “Who could I tell?” wondered Franco, as he feared that his family likely would blame him for not defending himself like a man and disown him for a lifestyle they believed would send him to hell. His minister warned of the sins of homosexuality, a wasted and meaningless life plagued with sickness, drugs, and sex. He felt like an unwanted outcast at school and knew of no one with whom he could talk. In his world, he had no role models for the person he held locked inside of himself; he only knew to fear and loathe this inner self. He coped by withdrawing, as he sat alone behind an abandoned building, numbing his pain with the alcohol that he stole from his family’s liquor cabinet. Growing increasingly isolated and desperate, one day Franco walks into your office. Through his tears, he begs for help: “I can’t live like this anymore!”

Reflection Questions 1. What are your own feelings, thoughts, and assumptions as you hear Franco’s story? How might these guide your intentions in working with him? In what ways do you believe you could be effective, and what barriers might you experience? (continued)

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APPENDIX 18.1 (continued) 2. Identify the complex layers involved in Franco’s current situation. How are these influencing his current state? 3. What do you think Franco needs? In your professional role, how might you address these needs? 4. Identify the ways in which bullying and hate crimes wound Franco. How would you begin to conceptualize a treatment plan? How do you imagine his healing process might unfold? 5. Based on your own community, identify supportive resources for Franco and his family. How might you assume an advocate role with Franco, in his multiple community spaces: school, neighborhood, church, and family? 6. What language frames your local and state government and school’s nondiscrimination policies? How might this language be a support or a barrier to assisting Franco?

RESOURCES Websites Gay, Lesbian and Straight Education Network (http://www.glsen.org/cgibin/iowa/all/home/index.html) Human Rights Campaign. (2010). Hate Crimes. (http://www.hrc.org/issues/hate_crimes.asp) National Coalition of Anti-Violence Programs. (2010). (http://www.avp.org/ncavp.htm) National Gay and Lesbian Task Force (http://thetaskforce.org/) Savage, D. (2010). It gets better project. (http://www.itgetsbetter.org) Springkle, S. V. (2010, November 1). Unfinished lives: Remembering LGBT hate crime victims. (http:// unfinishedlivesblog.com/) The Trevor Project. (n.d.). Home. A national organization addressing crisis and suicide prevention among LGBT youth. (http://www.thetrevorproject.org/) Films and Videos Martin, R. (Producer), & Nibley, L. (Writer). (2009). Two spirits [DVD]. United States: Say Yes Quickly Productions, Riding the Tiger Productions, & Just Media. (http://twospirits.org) Prévost, M. (Director). (2007). Trained in the ways of men [DVD]. United States: Reel Freedom Films. (http://reelfreedom.com/ReelFreedomMainIndexPage.htm) Southern Poverty Law Center. (Producer). (2010). Bullied: A student, a school and a case that made history [DVD]. (http://www.tolerance.org/bullied) Takesian, G., & Esposito, R. (Writers). (2010). Teach your children well: A film about homophobia and school violence [Film]. United States: Left Coast Flix. (http://www.imdb.com/video/wab/vi3597638169/) Vachon, C., & Kolodner, E. (Producers), & Peirce, K. (Director). (1999). Boys don’t cry [Film/DVD]. United States: IFC Films. Publications Brenner, C., & Ashley, H. (1995). Eight bullets: One woman’s story of surviving anti-gayviolence. Ithaca, NY: Firebrand Books. Herek, G. M., & Berrill, K. T. (Eds.). (1992). Hate crimes: Confronting violence against lesbian and gay men. Newbury Park, CA: Sage Publications. Loffreda, B. (2000). Losing Matt Shepard: Life and politics in the aftermath of anti-gay murder. New York, NY: Columbia University Press. Meeink, F., & Roy, J. M. (2009). Autobiography of a recovering skinhead. Portland, OR: Hawthorne Books & Literary Arts.

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REFERENCES American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author. Amnesty International. (2008). Love, hate and the law: Decriminalizing homosexuality. London, England: Author. Anti-Defamation League’s Washington Office. (2008). Anti-defamation league state hate crime statutory provisions. Washington, DC: Author. Arm, J., Horne, S., & Levitt, H. (2009). Negotiating Connection to GLBT Experience: Family Members’ Experience of Anti-GLBT Movements and Policies. Journal of Counseling Psychology, 56(1), 82–96. Brenner, C., & Ashley, H. (1995). Eight bullets: One woman’s story of surviving anti-gay violence. Ithaca, NY: Firebrand Books. Bride, B. E. (2007). Prevalence of secondary traumatic stress among social workers. Social Work, 52(1), 63–70. Burn, S. M. (2000). Heterosexuals’ use of “fag” and “queer” to deride one another: A contributor to heterosexism and stigma. Journal of Homosexuality, 40 (2), 1–11. doi:10.1300/J082v40.02_01 Coates, R. B., Umbreit, M. S., & Vos, B. (2006). Responding to hate crimes through restorative justice dialogue. Contemporary Justice Review, 9 (1), 7–21. Cowan, G., Heiple, B., Marquez, C., Khatchadourian, D., & McNevin, M. (2005). Heterosexuals’ attitudes toward hate crimes and hate speech against gays and lesbians: Old-fashioned and modern heterosexism. Journal of Homosexuality, 49 (2), 67–82. doi:10.1300/J08v49n02_04 D’Augelli, A. R. (1992). Lesbian and gay male undergraduates’ experiences of harassment and fear on campus. Journal of Interpersonal Violence, 7, 383–395. D’Augelli, A. R., Grossman, A. H., & Starks, M. T. (2006). Childhood gender atypicality, victimization, and PTSD among lesbian, gay, and bisexual youth. Journal of Interpersonal Violence, 21(11), 1462–1482. doi:10.1177/0886260506293482 Defense of Marriage Act, 28 U.S.C.§1738C (1996). Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force. (2000). Guidelines for psychotherapy with lesbian, gay, and bisexual clients. Washington, DC: American Psychological Association. Dolnick, S., & Moynihan, C. (2010, October 11). Bronx attacker’s ultimatum: Be hit with a bat, or a pipe. New York Times. Retrieved from http://www.nytimes.com/2010/10/11/nyregion/11bias.html Employment Non-Discrimination Act of 2011, H.R. 1397, 112h Cong. (2011). Employment Non-Discrimination Act of 2011, S. 811, 112h Cong. (2011). Figley, C. R. (1999). Compassion fatigue: Toward a new understanding of the cost of caring. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers and educators (2nd ed., pp. 3–28). Lutherville, MD: Sidran Press. Friedman, R. C., & Downey, J. (1995). Internalized homophobia and the negative therapeutic reaction. Journal of the American Academy of Psychoanalysis, 23, 99–113. Gay & Lesbian Alliance Against Defamation. (2010). Media Reference Guide: A Resource for Journalists (8th ed.). New York, NY: Author. Gross, L., Aurand, S. K., & Addessa, R. (2000). The 1999–2000 study of discrimination and violence against lesbian women and gay men in Philadephia and the Commonwealth of Pennsylvania. Philadephia, PA: The Philadelphia Lesbian and Gay Task Force. Haider-Markel, D. P., & Joslyn, M. R. (2008). Beliefs about the origins of homosexuality and support for gay rights: An empirical test of attribution theory. Public Opinion Quarterly, 72(2), 291–310. Harris, E. (2010, October 11). Paladino laces speech with antigay remarks. New York Times, p. A17. Retrieved from http://www.nytimes.com/2010/10/11/nyregion/11paladino.html Herek, G. M. (1986). The social psychology of homophobia: Toward a practical theory. Review of Law and Social Change, 14 (4), 923–934. Herek, G. M. (1989). Hate crimes against lesbians and gay men: Issues for research and policy. American Psychologist, 44 (6), 948–955. Herek, G. M. (1992). The social context of hate crimes: Notes on cultural heterosexism. In G. M. Herek & K. T. Berrill (Eds.), Hate crimes: Confronting violence against lesbians and gay men (pp. 89–104). Newbury Park, CA: Sage Publications.

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Herek, G. M. (2000). The psychology of sexual prejudice. Current Directions in Psychological Science, 9(1), 19–22. Herek, G. M., & Berrill, K. T. (Eds.). (1992). Hate crimes: Confronting violence against lesbians and gay men. Newbury Park, CA: Sage Publications. Herek, G. M., Cogan, J. C., & Gillis, J. R. (2002). Victim experiences in hate crimes based on sexual orientation. Journal of Social Issues, 58 (2), 319–339. Herek, G. M., Gillis, J. R., & Cogan, J. C. (1999). Psychological sequelae of hate-crime victimization among lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology, 67(6), 945–951. Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York, NY: Basic Books. Human Rights Campaign. (2009). Sexual orientation and gender identity: Terms and definitions. Retrieved from http://www.hrc.org/issues/workplace/equal_opportunity/gender_identity_terms_definitions.asp Human Rights Campaign (2011a). Employment non-discrimination act. Retrieved from http://www.hrc. org/laws_and_elections/enda.asp Human Rights Campaign. (2011b). Faith positions. Retrieved from http://www.hrc.org/issues/religion/ 4955.htm Jenkins, W. J. (2010). Can anyone tell me why I’m gay? What research suggests regarding the origins of sexual orientation. North American Journal of Psychology, 12(2), 279–296. Lawrence et al. v. Texas, 539 C.F.R. § 558 (2003). Loffreda, B. (2000). Losing Matt Shepard: Life and politics in the aftermath of gay murder. New York, NY: Columbia University Press. MacNair, R. M. (2001). Psychological reverberations for the killers: Preliminary historical evidence for perpetration-induced traumatic stress. Journal of Genocide Studies, 3 (2), 273–282. MacNair, R. M. (2002a). The effects of violence on perpetrators. Peace Review, 14 (1), 67–72. MacNair, R. M. (2002b). Perpetration-induced traumatic stress: The psychological consequences of killing. Westport, CT: Greenwood Press. McFadden, R. D., & Dolnick, S. (2010, October 10). Two worlds collide in a gritty Bronx neighborhood. New York Times, p. A1. Retrieved from http://www.nytimes.com/2010/10/10/nyregion/10bias. html?pagewanted=all McKinley, J. (2010). Suicides put light on pressures of gay teenagers. New York Times. Retrieved from http://www.nytimes.com/2010/10/04/us/04suicide.html?ref= tyler_clementi Meeink, F., & Roy, J. M. (2009). Autobiography of a recovering skinhead: The Frank Meeink story as told to Jody M. Roy. Portland, OR: Hawthorne Books & Literary Arts. Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56. National Coalition of Anti-Violence Programs. (2010). Hate violence against the lesbian, gay, bisexual, transgender, and queer communities in the United States in 2009. New York: National Coalition of Anti-Violence Programs. National Gay and Lesbian Task Force. (2010). Relationship recognition for same-sex couples in the U.S. Washington, DC: Author. Palmer, P. (2004). A hidden wholeness: The journey toward an undivided life. San Francisco, CA: Jossey-Bass. Phelps, A., Lloyd, D., Creamer, M., & Forbes, D. (2009). Caring for carers in the aftermath of trauma. Journal of Aggression, Maltreatment and Trauma, 18 (3), 313–330. Prévost, M. (Writer). (2007). Trained in the ways of men. United States: Reel Freedom Films. Salston, M., & Figley, C. R. (2003). Secondary traumatic stress effects of working with survivors of criminal victimization. Journal of Traumatic Stress, 16(2), 167–174. Southern Poverty Law Center (Producer). (2010). Bullied: A student, a school and a case that made history [DVD]. In Southern Poverty Law Center (Producer). United States: Author. Uniform Crime Reporting Program. (2004). Uniform crime reporting handbook. Clarksburg, WV: U.S. Department of Justice-Federal Bureau of Investigation. U.S. Department of Justice, Federal Bureau of Investigation. (1996). Training guide for hate crime data collection. Retrieved from http://www.fbi.gov/about-us/cjis/ucr U.S. Department of Justice, Federal Bureau of Investigation. (2009). Hate crime statistics, 2008. Washington, DC: Author. Willis, D. (2008). Meanings in adult male victims’ experiences of hate crime and its aftermath. Issues in Mental Health Nursing, 29, 567–584. doi:10.1080/01612840802048733

Section IV: Community Violence, Crisis Intervention, and Large-Scale Disaster CHAPTER 19

Contextual Issues of Community-Based Violence, Violence-Specific Crisis and Disaster, and Institutional Response LISA LOPEZ LEVERS AND ROGER P. BUCK

INTRODUCTION The nefarious impact of violence in communities, in its various forms, cannot be overstated. Although in one sense, all acts of violence occur in a “community” setting, we make a distinction here between interpersonal or one-on-one violence and violence that affects a number of people or an entire community. In previous sections of this book, authors have identified and discussed various types of traumatic events, which largely involve interpersonal violence, such as rape and intimate partner violence. The chapters in this section of the book deal with instances of violence or disaster that are perpetrated against or affect numbers of people, multiple groups, or whole communities. These events or situations include the following: chronic community violence; violence that occurs in schools, on college campuses, and at the workplace; natural disasters; massive ethnic and political violence and genocide; the impact of war on civilians and on military veterans; and terrorism and other civil crises. The goals of this chapter are to identify some of the contextual factors that underlie such events or ongoing situations and to examine some of the crisis responses and other best practices. We aim to highlight practices that are most likely to mitigate the effects of trauma, thereby preventing the development of more serious conditions, as well as those that are most amenable to continued interventions, thereby setting the stage for ongoing therapy as needed. To meet these intentions, we offer the following discussions: an Introduction to Community Crises, Predictable Responses to Community Crisis- and Trauma-evoking Events, Models of Crisis Response, and Counseling Implications. These sections are followed by a summary of the chapter and helpful resources for students, clinicians, and instructors.

COMMUNITY CRISES The literature indicates that the rate of co-occurrence of one type of violence with other types of violence exposure is high (Margolin & Gordis, 2000), as is the co-occurrence of violence with serious life adversity (Felitti, 2002; Felitti et al., 1998). Violence seems to beget violence. Many types of events qualify as community crises. Some are due to natural causes, like floods and tornadoes; these are considered to be natural disasters and are covered in another chapter. Some are caused by criminal activity or other unfortunate circumstances, like school shootings, workplace violence, or accidents; these are

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considered to be man-made disasters or crises, and many types of man-made or crimeinvolved disasters or crises are covered in other chapters. One issue that is not covered in other chapters in this book is the issue of chronic community violence, which plagues urban areas around the world. We discuss this issue in the succeeding section, followed by sections regarding related theories of crisis intervention.

Chronic Community Violence The deleterious effects of exposure to chronic community violence, as well as the impact of attendant levels of poverty, are well documented (e.g., Jones, 2007; Morrison, 2001; Overstreet & Mazza, 2003; Ronzio, Mitchell, & Wang, 2011; Wolfer, 2000). Chronic community violence, especially in U.S. urban areas, affects the health and mental health of children and families at an alarming rate and with tragic consequences (Garbarino, Dubrow, Kostelny, & Pardo, 1992; Jones, 2007; Lynch & Cicchetti, 1998; Margolin & Gordis, 2000; Morrison, 2001; Overstreet & Mazza, 2003; Wolfer, 2000). Chronic community violence is a cumulative environmental risk factor that includes ongoing exposure to gunshots, murders, sexual and physical assaults, armed robberies, home invasions, threats, and other crimes or acts of interpersonal violence; people living in impoverished areas are more likely to be exposed to chronic community violence. The Centers for Disease Control and Prevention (CDC) has identified youth violence, and by extension, exposure to violence, as a public health issue (Reiss, 1993). Witnessing violence also may have a profoundly negative impact (Lynch & Cicchetti, 1998; Ronzio et al., 2011), and a constellation of symptoms may result from exposure to violence (Jones, 2007). Horowitz, Weine, and Jekel (1995) have proposed the concept of “compounded community trauma” in their study of urban female adolescents, finding that the young women experienced a mean of 28 violent events. Of these young women, 90% experienced hyperarousal, 89% had symptoms of reexperiencing, 80% used avoidance as a coping mechanism, and 67% met criteria for posttraumatic stress disorder (PTSD). An increased number of types of violent events was positively correlated with meeting PTSD criteria and with greater symptom severity. The young women endured prolonged and repeated exposure to multiple types of community as well as domestic violence events via multiple modalities of contact over time. The overall relevance here is that the effects of violence are cumulative and may be traumatic. Overstreet and Mazza (2003) suggest that an ecological-transactional model of understanding community violence can assist in guiding future research in this area. Family-based and community-based interventions have been proposed for reducing the impact of violence exposures in urban youth (Devoe, Dean, Traube, & McKay, 2005; Garbarino, 1995, 1998, 1999, 2009; Garbarino & Bedard, 2001; Garbarino et al., 1992) along with a focus on prevention (Cohen, Chavez, & Chehimi, 2007).

Basic Crisis Intervention and Management Theories of crisis intervention have evolved from the earliest understandings of how to respond to grief and loss (e.g., Lindemann, 1944, 1956), as well as to developmental crises (e.g., Caplan, 1961, 1964), and have expanded to include applications in multiple psychosocial theories (e.g., psychoanalytic, interpersonal, and systems). More recent applications of crisis theory and intervention have evolved into what Gilliland and James (1997) refer to as an ecosystem theory (p. 19). The latter is based on an ecological and macrosystemic view of the individual as being in constant interaction with environmental, human, and systemic factors in multiple arenas and at multiple levels. Gilliland and James suggest that all individuals may face any of the following

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types of crises: (a) developmental crises, as they relate to the “normal flow of human growth”; (b) situational crises that arise from “uncommon and extraordinary events”; and (c) existential crises that comprise the “inner conflicts and anxieties” associated with “important human issues of purpose, responsibility, independence, freedom, and commitment” (p. 19). Basic models of crisis intervention that frequently are identified in the literature include the equilibrium model, the cognitive model, and the psychosocial transition model (e.g., Gilliland & James, 1997; James, 2008; Roberts, 2005). Although all of the abovementioned theories and models are conceptually useful, we believe that crisis intervention with people who experience trauma requires an integrative and eclectic approach that is grounded in developmental and ecosystemic theory (e.g., Bronfenbrenner, 1979; Bronfenbrenner & Ceci, 1994; Cicchetti & Lynch, 1993, 1995; Cicchetti & Toth, 1995; Lynch & Cicchetti, 1998; Vygotsky, 1978, 1986, 1997). The specific construction of such an approach also is dependent upon the philosophy of the particular agency and the population that it serves, as well as upon the nature of the traumatic crisis being experienced by individuals. Gilliland and James (1997) define a crisis as the “perception of an event or situation as an intolerable difficulty that exceeds the person’s resources and coping mechanisms” (p. 3). They further assert that “Unless the person obtains relief, the crisis has the potential to cause severe affective, cognitive, and behavioral malfunctioning” (Gilliland & James, p. 3). Roberts (2005, p. 13) notes that most definitions of a crisis “emphasize that it can be a turning point in a person’s life.” Although an individual may feel overwhelmed by the results, the personal pain and anxiety evoked by the crisis may cause the person to seek help. If the person can take advantage of this help-seeking opportunity, the intervention may serve as the beginning of increased self-awareness, personal growth, and healthy change. The nature of a crisis situation often is complex. The personal problems of people in crisis may be difficult to understand at surface, and these problems usually are intertwined throughout all dimensions of the person’s life. Because crises sometimes represent a culmination of longer-term problems, the crisis worker must be able to assess the differences between the immediate crisis situation and larger problems that perhaps led or contributed to the dilemma. Although crisis response calls for immediate solutions to the crisis situation, there are no quick fixes for long-term problems. Living sometimes is a process of interrelated crises and challenges. The experience of crisis situations is a universal phenomenon for all human beings; however, the availability of effective crisis intervention or crisis management services depends upon the local community. Mental health professionals working with clients in crisis, along with the institutions that serve them, need to understand crisis intervention or crisis management strategies. Purvis (1994) offers the following definition: Crisis management is the careful and tactful management of a situation in which there is trouble or danger that has the possibility of serious and negative consequences. The possible serious and negative consequences might include litigation, injury to individuals and/or property, death of an individual, disruption of the normal routine, and loss of confidence and trust in an individual or an institution. It is important to note that serious and/or negative consequences associated with a crisis situation can be valid or imagined, depending on the mind-set of the individual directly involved in the crisis or a person totally removed from the event. In either situation, it is extremely important for those assisting in a crisis to be fully aware of this very important aspect and respond in a professional, legal, humane, and ethical manner. (p. 23)

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Two useful models for understanding crisis intervention theories and strategies are expounded in Gilliland and James’ (1997) six-step model of crisis intervention and Roberts’ (2002) three-stage integrated intervention model. These are described briefly in the following texts.

Six-Step Model of Crisis Intervention In response to an assortment of problems that may be experienced as various types of crises, the six-step crisis intervention model suggested by Gilliland and James (1997, pp. 28–32) incorporates an ecosystemic approach, as well as offering the flexibility for adaptations across cultural settings. Their model includes the following steps: (a) defining the problem, (b) ensuring client safety, (c) providing support, (d) examining alternatives, (e) making plans, and (f) obtaining commitment. These six steps provide a beginning framework by which crisis workers can assist clients and their families. Gilliland and James describe effective crisis workers as those who demonstrate competency in their professional skills, maintain poise, are creative and flexible in dealing with problems, possess energy and know how to organize and direct that energy, think and react quickly, and are generally positive in outlook (pp. 10–11).

Three-Stage Integrative Intervention Model Roberts’ (2002) Integrative Assessment, Crisis Intervention, and Trauma Treatment (ACT) Intervention model offers a three-stage framework for providing acute crisis services and employs his seven-step crisis intervention model. The ACT model engages assessment, crisis intervention, and trauma treatment services that arise from an integration of bioecological presumptions about the importance of treating the whole person, inclusive of cultural sensitivity, along with tried-and-true crisis intervention (Mitchell & Everly, 1993) and trauma treatment (Lerner & Shelton, 2001, 2008) strategies. Roberts’ seven-step crisis intervention model moves from initial engagement to crisis resolution using the following steps: (a) assess lethality, (b) establish rapport, (c) identify problems, (d) deal with feelings, (e) explore alternatives, (f) develop an action plan, and (g) follow up (Roberts, 2002, p. 10). Yeager and Roberts (2003) advocate strongly for crisis workers being able to differentiate among the sequelae and symptoms associated with stress and crisis, on the one hand, and the diagnostic considerations of acute stress disorder, trauma, and PTSD, on the other.

Crisis Training We concur with Roberts (2002, p. 9) that “Although counselors, psychologists, and social workers have been trained in a variety of theoretical models, very little graduate coursework has prepared them with a crisis intervention protocol and guidelines to follow in dealing with crises.” One training model that has been used successfully in a variety of community-university collaborative crisis-response settings combines microcounseling skills (Ivey & Authier, 1985), Interpersonal Process Recall (IPR; Kagan & Kagan, 1995), and basic crisis intervention strategies (e.g., Gilliland & James, 1997; Hoff, 1995). Strabakhina and Levers (2008) used such a training model for an IREX-funded (International Research Exchange Board) project that enabled the purchase of IPR training tapes and related training manuals and textbooks. Pilot training groups were conducted at universities in Moscow, Novgorod, and St. Petersburg to evaluate the cultural appropriateness and adaptability of the model in Russia. The pilots were highly successful, and the students confirmed the cultural applicability of the model. The training formats for these pilots were expanded to meet the needs of crisis intervention training

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aimed at addressing the problems of social orphans in Russia (Strabakhina & Levers, 2008). Such integrative or theory-blending strategies easily could be incorporated into graduate social services curricula for the purpose of ensuring the basic competencies of program graduates in the areas of crisis, trauma, and disaster response. It also is essential that human-service graduate programs assist students in developing adequate self-reflection skills to cope with and manage their “cost of caring” responses to crisis, trauma, and disaster events and situations.

Implementing Crisis Services Community Wide Commitment from the leadership of governmental institutions and nongovernmental organizations is essential for the successful implementation of community-wide crisis intervention services. In addition to commitment, according to Purvis (1994), the following components of a crisis management plan need to be in place at the community level: (a) determining goals, (b) conducting a needs assessment, (c) examining other crisis management plans, (d) selecting members of the crisis management team, (e) developing and implementing a training program, (f) preparing and maintaining a list of resources and support services, (g) establishing a communication network, (h) designating a base of operation, (i) planning and conducting team meetings, (j) documenting, (k) implementing and evaluating the plan, and (l) revising the plan as needed. Communities that implement crisis intervention services in a systematic way are building a solid foundation for dealing more effectively with the problems of the citizenry.

PREDICTABLE RESPONSES TO CRISIS- AND TRAUMA-EVOKING EVENTS Human responses to danger and violence are understood more effectively through the lens of a complex and integrated system of normal reactions to abnormal events. The entire person is affected by extreme crisis and traumatic events. Biological, emotional, social, existential, and spiritual reactions occur, and these are based on the complex anatomy of a normal human response system. Understanding this complex anatomy of variables, which determine an individual’s reactions, helps in the identification of appropriate services, supports, and interventions to aid in recovery (Herman, 1992; Webb, 1991). In this section, we first explore pertinent conclusions based on a review of the relevant literature. This is followed by discussions of the importance of a bioecological perspective, potential symptom development, and the implications of individual treatment and institutional intervention.

Review of the Relevant Trauma Literature Five major topical areas appear in the research literature regarding human trauma response and PTSD. These five topic areas include psychophysiological, individual or personal aspects, trauma-specific characteristics, treatment modalities/outcomes, and social factor studies (Buck, 1998). To investigate adequately and to understand fully the human responses that individuals experience following crisis and traumatic events, each of the following five categories are considered: ■ Psychophysiological studies provide insight into the alteration of the brain’s struc-

ture and chemical make-up, as well as other physical reactions within the body, in response to traumatic events. The neuroscience of traumatic events focuses on brain structure, neurochemistry, and plasticity.

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■ Individual/personal aspects of the person include characteristics such as age,

moral development, gender, fears, physical health, self-esteem, pre-crisis adjustment, preexisting issues/conditions (e.g., alcohol addiction or mental illness), cultural background, personality type, spiritual perspective, and cognitive level of function. ■ Trauma-specific characteristics include variables such as intensity, duration, type of traumatic experience, whether the crisis is experienced alone or as a shared experience, the nature of the event (i.e., natural disaster, human-made accident, terrorist act), criminal events, nature and intensity of loss, separation from family members, death of family members or peers, level of direct exposure to the event, physical injury/pain, loss of body function, and personal responsibility for the crisis event. ■ Social factors entail the support of others, nonsupportive others, peers, family, school, local community, extended family, friends, availability of treatment and social services, and other types of supports. ■ Treatment research focuses on various treatment modalities and outcomes and is essential in the process of understanding recovery from crisis, extreme danger, violence, or traumatic experiences.

Importance of a Bioecological Perspective As the professional clinician embarks on providing mental health treatment services for the individual who has experienced crisis, extreme danger, violence, or other traumatizing events, it is imperative that a holistic approach be considered. The root cause of the symptoms that individual trauma victims develop is the trauma event(s) itself. Being “trauma informed,” as encouraged by the National Center for Trauma Informed Care (NCTIC), means that clinicians recognize that there is a precipitating event that has caused the development of the symptoms and that appropriate interventions actually address the event(s) in treatment along with symptom reduction techniques. The emotional pain of the events may cause the person to lose a sense of self-control, resulting in behaviors that others may see as deviant or diagnosable. When treating only the deviant behavior, and not the source of the symptoms, the mental health system potentially becomes another source of abuse and can re-traumatize the individual. Recovery from trauma is a process of individuals reclaiming or recovering a sense of self by taking control over their lives. The changes that need to occur for the recovery process to be effective include both internal and external variables (Buck, 1998). Treating individual symptoms exhibited by a trauma victim, such as mood disorder or sleeping disorder, with medication, while ignoring the underlying causes of symptom development, is ineffective and inefficient. Therefore, it is essential that professionals take a multifaceted approach, to the treatment of individuals who have experienced traumatic events, in the following ways: ■ Focusing on psychophysiological changes that have occurred as a result of the

trauma; ■ Assessing the individual characteristics, possessed by the person, which may

influence the development of various symptoms; ■ Identifying the specific characteristics of the trauma event itself, which can help

the clinician to understand more fully any of the underlying reasons for the particular trauma symptoms that manifest; ■ Addressing the social needs of the individual crisis/trauma victim by accurately assessing the current social support system; and

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■ Using current knowledge about evidence-based best-practice models that need

to be employed to intervene with the most appropriate, thorough, and efficient interventions possible.

Potential Symptom Development Human responses to traumatic events often are manifested through symptom development. These predictable symptoms may be experienced by each individual victim on a continuum of intensity and severity based on many of the factors listed earlier. There are predictable responses during and immediately following a traumatic event, and there are potentially long-lasting effects or symptoms that may linger for months and even years. The trauma victim’s short- and long-term responses and symptom development are determined by the specifics of the trauma event, the individual’s characteristics, and available supports (Buck, 1998; Herman, 1992). Because of a variety of unique conditions or situations, delayed responses, and symptom development, the long-term effects or symptoms of traumatic experiences may not manifest immediately. An example of this delay in symptom development is the college coed who experiences date rape and is afraid to report it because of her belief that nobody will believe that she was raped. Several months later, she is walking down a hallway in a college administration building and she sees that the individual who raped her is approaching, which triggers a response of extreme anxiety and panic. Another example is the student military veteran who is in a darkened classroom in which the professor is using a laser pointer to highlight material on a slide being shown; the laser is a visual stimulus that alerts the combat veteran’s autonomic nervous system to respond with a fight-or-flight response and to seek cover because of his training with laser-guided weaponry. The fight-or-flight response might be to drop to the floor and hide under a desk, which is parallel to the response of hitting the dirt while in a combat zone. Both of these anxiety-producing events are triggered by a visual occurrence in the environment that creates a normal and appropriate physiological response to a historically dangerous situation. Aspects of symptom formation are explored briefly in the following sections.

Five Categories of Individual Symptoms Five general categories of responses to traumatic experiences appear as symptom development in trauma victims. These categories include physical, cognitive, emotional, behavioral, and spiritual or existential (PCEBS) responses. These categories of responses to crisis, trauma, and disaster events are a part of the complex anatomy of an instinctual human survival process; these are normal stress reactions to abnormal or crisis events and should not be considered pathological in nature.

Cycle of Adjustment and Symptom Formation Individuals, as well as institutions, tend to follow a normal cycle of adjustment to stressful experiences during single crisis or traumatic events. The ensuing symptoms often subside over time as the individual or the institution adjusts to the particular event. Trauma survivors often experience repetitive positive and negative emotional, cognitive, and spiritual or existential symptoms as they attempt to adjust to or make sense out of the traumatic event. Following a traumatic event, individuals initially often conduct a sort of internal cognitive review and processing that includes a disbelief that the event occurred, followed by shock, denial, and disorientation. Survivors often feel numb, which may develop into feelings of anger and even rage. Victims may blame

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others for the event and its outcome, and this might include the desire for revenge and retribution. As time passes, many victims may sink into a period of sadness and despair and even blame themselves for not being able to have prevented the crisis or traumatic event from having happened. This sense of guilt may result in behaviors such as avoidance or isolation from others, substance abuse, or other self-defeating behaviors. Over time, survivors may develop a hypervigilance or anxiousness, including an inability to stop intrusive thoughts about the event from entering into their daily life. As affected persons struggle to make sense of the event or to assign meaning to it, they often feel isolated or alone and potentially may become more and more depressed. However, when survivors develop some understanding of the event, they can begin to recover a sense of self-control, and through their own resiliency they are able to adjust effectively (U.S. Department of Health and Human Services [USDHHS], 2004). Some of the predictable, normal symptoms following a severe crisis or traumatic event are listed here: ■ Physical: Rapid heartbeat, fatigue, tension, insomnia, nausea, gastrointestinal

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■ ■

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distress, hypervigilance, increased startle response and body aches, appetite changes, worsening of chronic illness, sensory limitations (e.g., sight, hearing). Cognitive: Indecisiveness, worry, memory loss, difficulty concentrating, selfblame, disorientation, confusion, preoccupation, intrusive thoughts, intrusive memories, increased attention deficit, recurring dreams/nightmares. Emotional: Anger, guilt, fear, shock, feeling numb, hopelessness, diminished capacity to feel pleasure or love, anxiety, despair. Behavioral: Interpersonal relationship problems may develop caused by distrust, irritability, social isolation, or withdrawal. Reduced relational intimacy may lead to relationship breakup and divorce. Other behavioral symptoms include school problems, work problems, overcontrolling others, substance abuse, resisting authority, excessive expectations of self and others through a strong moral or ethical code, avoidance of memories by limiting exposure to the environment, sleep problems. Spiritual/Existential: Survivors begin to question good and evil and are unable to develop an existential understanding of why bad things happen to good people or to make sense out of the senselessness of the traumatic event. This inability to understand often can cause anger toward God (or a higher power), or anything representing God such as clergy or places of worship.

More Severe or Complex Symptoms The National Center for Posttraumatic Stress Disorder (NCPTSD) reports that chronic trauma, which continues for months or years, may result in more complex symptoms. The diagnosis of PTSD may not capture fully the severe psychological harm that occurs with prolonged and repeated trauma. People who experience chronic trauma can experience potentially permanent changes to their self-concept or sense of self-understanding. Examples of long-term trauma include concentration camps, prisoner of war camps, prostitution brothels, long-term domestic violence, long-term severe physical abuse, childhood sexual abuse, repeated tours of duty in a combat/war zone, chronic physical illness, long-term police work with extensive violence, long-term work as a first responder (e.g., firemen, EMTs), work in a very active emergency room or trauma center, long-term workplace harassment, bullying, and other types of victimization. The following subsections detail additional problematic symptoms at individual and institutional levels, which may be observed in those with chronic trauma experiences (United States Department of Veterans Affairs [USDVA], 2011).

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Individual Level. Dissociation (including depersonalization, derealization, amnesia), emotional numbing (unable to feel any form of emotion), avoidance of memories (substance abuse, drop out or isolation behaviors such as remaining homeless or jobless or rejecting society), intrusive re-experiences (flashbacks, night terrors), hypervigilance and hyperarousal (panic attacks, irritability, intense rage), excessive anxiety (compulsions/ obsessions, debilitating worry), severe mood disturbance (depression, hopelessness, lack of any pleasure or interest), crisis of faith (meaninglessness, self as permanently damaged, questioning God or life purpose/meaning; USDVA, 2011). These more severe symptoms of PTSD often occur due to certain aspects of the trauma event and may include the following: ■ ■ ■ ■ ■ ■

Life-threatening danger and physical injury, especially if children are involved; Loss of home, neighborhood, or community integrity; Extreme destruction of the environment or human violence; Sensory reality of death and bodily injury (sights, sounds, smells, tastes, touch); Extended exposure to dangerous environment or violence; Extreme emotions related to caregiving (first responders’ interaction with the dying, or survivors who have lost family members); and ■ Exposure to the unknown, such as toxic life-threatening contaminants (e.g., radioactivity, chemical or biological agents). Chronic and severe long-term trauma experiences potentially cause more long-term psychological damage than single-event traumas. Long-term damage is characterized by individual behaviors such as self-mutilation, other forms of self-harm, alcohol and drug abuse, isolation (psychological as well as physical), and suicide. Additionally, there may be stigma associated with some trauma experiences and resulting symptoms (i.e., the domestic violence victim who does not leave the abuser). It is important that clinicians recognize that some trauma survivors may be faulted for the symptoms they experience as a result of victimization and are therefore unjustly blamed as well as inappropriately labeled with a mental/emotional disorder. Individuals at higher risk for PTSD symptom development include those who have been exposed to multiple traumas (i.e., exposure to earthquake followed by tidal wave and nuclear power plant explosion with radiation exposure). Individuals with chronic psychological or psychiatric disorders or those with debilitating medical conditions are potential candidates for a PTSD diagnosis. Other situations may include having continuous life stressors or other recent major emotional strain such as financial devastation, divorce, or job loss. Other high-risk individuals are those who are experiencing discrimination, bullying, sexual harassment, poverty, and homelessness. Multiple exposures to various violent or traumatic situations potentially may exacerbate the condition and delay adjustment to previous traumatic experiences. A new traumatic experience may trigger old memories of previous traumatic events, resulting in the intensification of previous economic, spiritual, psychological, psychiatric, medical, or social problems. Institutional Level. Reactions by institutions to traumatic events such as college campus or workplace violence are determined primarily by the nature of the event. Whenever there is violence in a community, it is generally sudden, intentional, and happens without warning. The result of this type of traumatic event is shock and disbelief among the individuals involved. The entire community suffers from increased fear, and any previously held beliefs that the world is a safe place are shattered. Violence within a specific community such as a neighborhood can destroy the sense of safety in that environment while creating a permanent sense of distrust of others.

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The NCPTSD suggests that survivors of traumatic community violence may experience the following struggles: (a) How to protect themselves, their loved ones, and their specific community from further dangerous situations; and (b) How to build trust within their respective community, which includes considerations of power and control, victimization, and personal empowerment. Another challenge for survivors relates to making sense out of the event or finding some positive meaning in the experience, and teasing this apart from feelings of anger and resentment and the desire for revenge.

MODELS OF CRISIS RESPONSE Several models of crisis intervention and management are used commonly in response to community violence and to community-wide traumatic or disaster events. Whereas these models may be used to assist large groups of people, their mechanisms are likely to play out differently for individuals and institutions. In this section, we discuss best practices in relationship to the recommended interventions for individuals, the recommended interventions for institutions, and referrals and level-of-care considerations for trauma survivors.

Recommended Interventions for Individuals According to a Rand Corporation publication (Wilson, Chermak, & McGarrell, 2010), more than 6 million people in the United States were victims of crime in 2006. Although violent crime has decreased statistically since a high point in the 1990s, levels of interpersonal violence remain high. Widespread media reporting on violence in communities, the workplace, and educational and other institutions has sparked simultaneous increases in research on the topic. Antiviolence campaigns along with terror management and threat assessment are all part of the new language for community and institutional safety and security as well as Homeland Security at the national level. When traumatic events occur, there are both primary victims and secondary or indirect victims. Behavioral health professionals may be working with primary victims or secondary/indirect victims, depending on the environment in which the crisis occurs. A myriad of possible physical, cognitive, emotional, behavioral, and spiritual or existential (PCEBS) responses and potential symptoms may occur among all categories of victims, so there is not one specific intervention that can be touted as the single best practice model of intervention. The USDHHS publication (2004) identifies the following ten key principles to guide mental health providers, first responders, and other human service support workers in recommended interventions following major crisis events. 1. No one who witnesses the consequences of mass criminal violence is unaffected by it: Groups such as emergency first responders, disaster workers, mental health providers, and government officials all may be affected emotionally by traumatic events. This makes the use of educational interventions and other psychological supports appropriate. 2. Mass crimes, involving trauma and loss, affect both the individual and the community: Community services and structures may be damaged, thus causing multiple stressors and prolonging recovery of trauma victims. 3. Most people pull together and function following a mass tragedy, but their effectiveness is diminished and they may have brief periods of being overwhelmed: Even though human resiliency and support are present in a disaster, the severity of PCEBS responses still mitigate personal well-being.

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4. Although most traumatic stress and grief reactions are normal responses to extraordinary circumstances, a significant minority of survivors experience serious long-term psychological difficulties: There are groups at greater risk for severe and long-term psychological damage, such as those who lose a loved one through death, prior trauma experiences, psychiatric problems, and substance abuse histories. 5. Mental health, crime victim assistance, and other human services must be tailored to the communities they serve: Cultural competence is essential in knowing how different cultural backgrounds determine an individual’s responses to disaster and crisis. 6. Most survivors respond to active, genuine interest and concern. However, some will reject services of all kinds: Being kind and supporting to an individual’s right to choose the level or extent of help he or she is willing to consider is an essential component to any response. 7. Mental health assistance is practical, flexible, and empowering. It reflects survivors’ need to pace their exposure to harsh realities resulting from the event. First and foremost, providers must do no harm when intervening: Determining each individual victim’s coping style and personal needs is an important predetermining factor to any support or intervention with a trauma victim. 8. Law enforcement procedures, medical examiner’s protocols, disaster relief requirements, and criminal justice proceedings often confuse and distress survivors: Coordinating with crisis response officials is essential to the delivery of appropriate services to trauma victims. 9. Provision of mental health services is an element of a multidisciplinary emergency response and supports the efforts of the primary responding agencies: Mental health services include support for the roles and mission of the first responders as well as support for the individual victims. 10. Support from family, friends, and the community helps survivors to cope with the trauma and their losses: Family and other normal support persons are an essential part of the recovery process for trauma victims. Rapidly connecting with these normal supports helps to reduce the sense of alienation and isolation that often occurs during traumatic events. (USDHHS, 2004, pp. 31–33) Each individual is unique, and this fact alone needs to drive any decisions related to appropriate interventions in times of large-scale crisis events. Behavioral health professionals, paraprofessionals, and other first responders have an opportunity to help victims of traumatic events in reducing their symptoms and keeping these symptoms from becoming debilitating. Each of the following models considers the 10 guiding principles listed earlier and provides step-by-step recommendations for intervention with trauma victims of community or mass violence and crisis or disaster events. The primary goal of these models is to help stabilize individuals in the immediate aftermath of a traumatic event; such responses are not considered to be professional therapy or counseling, but rather, more of a step-by-step process of empowerment and regaining emotional control of self. (Internet sites associated with the following models are listed in the Resources section at the end of this chapter.)

American Red Cross Model Of the several behavioral health intervention models used during and immediately following a disaster, perhaps the most familiar is the American Red Cross behavioral response model. The American Red Cross responds primarily to natural disaster sites such as hurricanes, tornadoes, ice storms, floods, and other natural disasters. The Red Cross offers a specific step-by-step model of intervention for individuals who experience

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these events. To become a behavioral health first responder, licensed mental health professionals must go through the specific training offered by the American Red Cross.

National Organization for Victims Assistance (NOVA) Model The primary purpose of NOVA is to promote the rights of and services for victims of crime and crisis everywhere. Their multistep model of interaction with individuals is designed to connect with victims of crime and to help empower them in making appropriate, effective, and efficient behavioral choices. NOVA also strives to reduce the emotionality and negative interpretations that the victims of crime often make, which, in turn, potentially sabotages their recovery from the trauma event. The NOVA model has four primary purposes and accomplishments: (a) national advocacy, (b) direct services to victims, (c) assistance to professional colleagues, and (d) membership activities and services.

Critical Incident Stress Management (CISM) Often referred to as the Mitchell model, CISM was developed to help emergency responders, who experience repeated exposure to violence, danger, death, and destruction, to debrief those experiences more effectively in order to remain on the job. Many first responders would reach a saturation point of exposure to these traumatizing experiences, basically burning out and leaving the profession. Several different curriculum topics are available through the international organization that created this model (International Critical Incident Stress Foundation, Inc.).

Ohio Model “Helping People Find Strength Following Disaster” is a curriculum developed by the University Linkages Committee, with support from the Ohio Department of Mental Health, Ohio Department of Alcohol and Drug Addiction Services, Ohio Department of Health, Ohio Association of County Behavioral Health Authorities, and through funding by the Health Resources and Services Administration. This six-step model was developed in 2005 to train mental health professionals about the practical interventions and strategies that should be used primarily with civilian victims of traumatic events associated with various natural disasters. More experienced clinicians might find this model helpful and applicable in the initial aid to and support of victims of violence.

Psychological First Aid The NCPTSD developed the Psychological First Aid curriculum in 2005 to identify practical intervention strategies that should be used to help trauma victims in times of disaster. This model of intervention does not assume that the person providing support to victims is necessarily a licensed clinician, but rather, it instructs individuals who desire to be a Good Samaritan on knowing what to do in times of crisis. The goals of the model are as follows: ■ Protect: Preserve survivors’ and workers’ safety, privacy, health, and self-esteem. ■ Direct: Get people to where they belong; help them to organize, prioritize,

and plan. ■ Connect: Help people communicate supportively with family, peers, and service

providers. ■ Detect: Screen, triage, and provide crisis support and care to those who are at

risk for more severe symptoms.

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■ Select: Refer those people in need to mental health, social, spiritual, health, and

financial services. ■ Validate: Use educational opportunities to inform and normalize the emotional

and psychological responses that people are having and to validate the appropriateness of their concerns, reactions, and ways of coping with the situation.

Psychological First Aid on College Campuses In 2008–2009, the University Linkages Committee of Ohio, with permission from the NCPTSD, developed a college campus version of the NCPTSD Psychological First Aid Manual. This version of the Psychological First Aid model gives specific recommendations for college campuses following violence or other on-campus crisis events. This manual is available in its current DRAFT form through the Ohio Department of Mental Health website.

Recommended Interventions for Institutions In the event that there has been an incident in the workplace or at an institutional setting, such as a school or college campus, recommended organizational activities should occur to help the organization and its employees recover more effectively and efficiently. Law enforcement and other first responders are likely to be involved in the incident, and the resulting Incident Command System (ICS) is in charge of the initial responses. The psychological issue or fear of most concern is the experience of helplessness (Buck, 1998); therefore, the task for any organization that has experienced a traumatic event is to help the people of the organization to regain a personal sense of power and control over their lives. Each person has various resiliency factors such as positive, caring relationships; social problem-solving skills; a sense of direction or mission; empathy; humor; adaptive distancing; and realistic expectations for self and others. These assets are important in the postevent recovery process and in keeping the organization stable and effective in completing its function (Bishop, McCullough, Thompson, & Nakiya, 2006). Responses to violence in communities, the workplace, or other institutional settings must be swift and appropriate for the event. Interventions occur with the full knowledge that many of the residents or employees may experience significant traumatic responses to the event and also recognizing that the response to the event has just begun. Potential exists for long-lasting and negative effects on the community or organization as well as individual residents or employees unless the situation is handled appropriately. In the case of workplace or campus violence, action designed to instill a sense of personal autonomy, power, and control among stressed employees includes immediately pulling employees together to enhance their sense of group connection. This may be done by creating a buddy system of support by sharing personal contact information such as personal cell phone numbers. Another strategy is using any internal support structure that already exists, such as an employee assistance program (EAP) with management, to establish a phase or level of response to the needs of employees or faculty members. It is essential that senior management and leadership be an integral part of physical responses by being on site. The visibility of senior officials of the organization at the crisis event instills a sense of safety through effective leadership. This is true of elected and appointed officials in the case of community violence as well. The belief that leaders care about employees and residents, as well as how they are doing, provides significant reassurances. Positive attributes should be praised by senior administrators or civic leaders regarding the bravery, courage, and dedication shown by employees and residents during the crisis event.

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Following a crisis event, it is important to show continued support by holding social events, memorials, and other postcrisis activities, preferably within a few weeks, to maintain the solidarity that was formed during and immediately following the event (Bishop et al., 2006). The U.S. Department of Agriculture (2001) suggests other activities that include a reviewing of what took place, establishing a threat assessment team, providing critical incident stress debriefing, and ensuring that all questions from news media personnel are directed to the proper authority. Perhaps the most effective organizational behavior related to mass violence and trauma response is that of prevention. Several strategies can help an organization avoid becoming a victim of violence in the workplace or an institutional setting; these include maintaining lower rates of violence, having effective grievance policies and procedures, developing antiharassment policies, and offering security programs and support policies that help develop higher levels of employee job satisfaction (Mannita, 2008).

Referrals and Level-of-Care Considerations for Trauma Survivors In crisis situations, mental health professionals engage in a triage process to evaluate which individuals may need more intense levels of care, beyond psychological first aid. The individuals and groups that respond to various crisis events include mental health professionals who are trained in the various models listed earlier and who are charged with making appropriate referrals to other level-of-care treatment professionals on an as-needed and case-by-case basis. Disaster mental health professionals are an integral part of this process. Several faith-based groups also respond in times of disaster and employ the services of mental health professionals who use a faith-based perspective of recovery from traumatic events. It is essential that any behavioral health disaster group that responds to a crisis event also takes into consideration the population it is helping. Such cultural sensitivity includes recognizing the beliefs, cultural perspectives, and spiritual understandings held by the group in need. This assists with constructing a disaster response that is appropriate, effective, and efficient.

COUNSELING IMPLICATIONS The nature of the crisis, trauma, or disaster most often is the primary determining factor or indicator of interventions needed for both the individual victim as well as the institution that is affected by traumatic events. The implications, at both individual and institutional levels, are discussed briefly in the following sections.

Individual Level The effects that traumatic experiences have on an individual, which are manifested through symptom development, are subjective responses to the objective experiences in an individual’s environment. It is important that victims of dangerous situations learn active coping processes to limit the intensity of symptom development. Basically, active coping means that the individual behaviorally initiates an active approach of taking power and control over his or her own recovery. The person recognizes the effects that the crisis, disaster, or traumatic event has had, and he or she accepts the impact, while simultaneously taking personal action; in other words, the individual is using personal agency as a resource. By actively coping, the individual develops the habits and behaviors of adjustment to strengthen a personal sense of power and control over symptoms that may have developed as a result of the traumatic event.

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The process of recovery involves survivors in developing the awareness that they are having normal responses to abnormal events and that over time the intensity, duration, and amount of symptoms can subside. It is important for individuals to recognize that, while they may be changed permanently as a result of their traumatic experiences, they do not have to be damaged permanently by these events. Those who struggle with adjustment may develop more severe symptoms that require referral for further psychological support and professional care. Individuals experiencing the more severe chronic symptoms listed earlier require triage and referral for a higher level of care.

Institutional Level It is extremely difficult to identify or isolate institutional responses to traumatic events without first identifying and including the individual victim’s responses. It is the specific responses and unique needs of individuals that determine an institution’s desired behavioral reactions to events. The characteristics of the trauma event and of the individuals in leadership positions ultimately determine the institutional response to crisis. The classification of disasters are based on their effects as minimal, moderate, severe, or very severe; depending on the category, human and institutional responses need to coincide with the type and intensity of the disaster (Norris et al., 2002). Norris et al. (2002) suggest that when the trauma, crisis, or disaster event is more severe, the incidence of PTSD tends to be higher among survivors. Many other issues evolve, as a particular instance of community violence or disaster is assessed. The more severe the traumatic incident, the more appropriate it is to provide psychosocial support. The type of supports and who and how these supports are provided is part of an ongoing debate in the research. Psychosocial support, in times of crisis, must be offered cautiously and judiciously; this is because of the unique issues that arise as the result of individual characteristics, trauma-specific problems, and contextual concerns. The research literature is conflicting regarding what constitutes appropriate and evidence-based interventions, and the need remains for more rigorous research concerning trauma, crisis, and disaster response.

CONCLUSION Chronic community violence has had deleterious effects on children, youth, adults, families, and neighborhoods, especially in urban areas. Mental health professionals working with chronic community violence, violence-specific crises and disasters, and related institutional responses need to understand crisis intervention theories and to employ relevant strategies for helping victims to manage the effects of their experiences. Understanding contextual factors of the violence can help in the matter of managing crises, mitigating further harm, and assessing the need for additional counseling. In this chapter, we have introduced the prevalence and impact of chronic community violence. We have discussed crisis intervention theories and strategies associated with community violence, crisis, and disaster, along with institutional responses. We have explored some of the most predictable responses to crisis- and trauma-evoking events, identifying and describing the most widely employed models of crisis and disaster response. We have elaborated the implications for counselors who work with crisis, trauma, and disaster. We have concluded by offering a list of helpful resources.

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RESOURCES The following list of resources related to community violence, crisis, disaster, and institutional response include websites, electronic training manuals, and films. Websites American Academy of Experts in Traumatic Stress (http://www.aaets.org/index.html) American Red Cross Disaster Services (http://www.redcross.org/services/disaster) International Critical Incident Stress Foundation, Inc. (http://www.icisf.org/) National Center for Crisis Management (http://www.nc-cm.org/biogeorgeeverly.htm) National Center for Posttraumatic Stress Disorder (http://www.ncptsd.va.gov) National Organization for Victims Assistance (NOVA) (http://www.trynova.org) Ohio Department of Mental Health (http://www.MH.state.oh.us) Electronic Training Manuals Lerner, M. D., & Shelton, R. D. (2008). Comprehensive acute traumatic stress management: CATSM: Addressing the emergent psychological needs of individuals, groups and organizations before, during and after a traumatic event. Melville, NY: The Institute for Traumatic Stress. Retrieved from http:// www.marklerner.com/Site/ebooks_fi les/ITS%20CATSM%20EBOOK%20LR.pdf U.S. Department of Health and Human Services. (2004). Mental health response to mass violence and terrorism: A training manual. DHHS Pub. No. SMA 3959. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Retrieved from http:// store.samhsa.gov/shin/content/SMA04-3959/SMA04-3959.pdf Films Fudakowski, P. (Producer), & Hood, G. (Director). (2006). Tsotsi [Motion picture]. UK: Momentum Pictures. Nickolaides, S. (Producer), & Singleton, J. (Director). (1991). Boyz N the Hood [Motion picture]. USA: Columbia Pictures.

REFERENCES Bishop, S., McCullough, B., Thompson, C., & Nakiya, V. (2006). Resiliency in the aftermath of repetitious violence in the workplace. Available online at http://jwbh.haworthpress.com Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press. Bronfenbrenner, U., & Ceci, S. J. (1994). Nature-nurture reconceptualized in developmental perspective: A bioecological model. Psychological Review, 101(4), 568–586. Buck, R. P. (1998). The meaning six Vietnam veterans attach to war trauma. Unpublished doctoral dissertation, Kent State University, Kent, OH. Cicchetti, D., & Lynch, M. (1993). Toward an ecological/transactional model of community violence and child maltreatment: Consequences for children’s development. Psychiatry, 56(1), 96–118. Cicchetti, D., & Lynch, M. (1995). Failures in the expectable environment and their impact on individual development: The case of child maltreatment. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology (Vol. 2, pp. 32–71). New York, NY: Wiley. Cicchetti, D., & Toth, S. L. (1995). A developmental psychopathology perspective on child abuse and neglect. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (5), 541–565. Cohen, L., Chavez, V., & Chehimi, S. (Eds.). (2007). In Prevention is primary: Strategies for community wellbeing. San Francisco, CA: Jossey-Bass. Devoe, E. R., Dean, K., Traube, D., & McKay, M. M. (2005). The SURVIVE community project: A familybased intervention to reduce the impact of violence exposures in urban youth. Journal of Aggression, Maltreatment & Trauma, 11(4), 95–116. doi:10.1300/J146v11n04_05

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Felitti, V. J. (2002). The relationship of adverse childhood experiences to adult health: Turning gold into lead. Retrieved from http://www.acestudy.org/files/Gold_into_Lead-_Germany1-02_c_Graphs.pdf Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14 (4), 245–258. Garbarino, J. (1995). Raising children in a socially toxic environment. San Francisco, CA: Jossey-Bass. Garbarino, J. (1998). Children in danger: Coping with the consequences of community violence. San Francisco, CA: Jossey-Bass. Garbarino, J. (1999). Lost boys: Why our sons turn violent and how we can save them. New York, NY: Free Press. Garbarino, J. (2009). Children and the dark side of human experience: Confronting global realities and rethinking child development. New York, NY: Springer Publishing. Garbarino, J., & Bedard, C. (2001). Parents under siege: Why you are the solution, not the problem, in your child’s life. New York, NY: Free Press. Garbarino, J., Dubrow, N., Kostelny, K., & Pardo, C. (1992). Children in danger: Coping with the consequences of community violence. San Francisco, CA: Jossey-Bass. Gilliland, B. E., & James, R. K. (1997). Crisis intervention strategies. Pacific Grove, CA: Brooks/Cole Publishing. Herman, J. L. (1992). Trauma and recovery. New York, NY: Basic Books. Hoff, L. A. (1995). People in crisis: Understanding and helping (4th ed.). San Francisco, CA: Jossey-Bass. Ivey, A. E., & Authier, J. (1985). Microcounseling: Innovations in interviewing, counseling, psychotherapy, and psychoeducation (2nd ed.). Springfield, IL: Charles C. Thomas. James, R. K. (2008). Crisis intervention strategies. Florence, KY: Cengage Learning. Jones, J. M. (2007). Exposure to chronic community violence: Resilience in African American children. Journal of Black Psychology, 33 (2), 125–149. doi:10.1177/0095798407299511 Kagan, N., & Kagan, H. (1995). Interpersonal process recall manual and tapes. North Amherst, MA: Microtraining Associates. Lerner, M. D., & Shelton, R. D. (2001). Acute traumatic stress management: Addressing emergent psychological needs during traumatic events. Commack, NY: The American Academy of Experts in Traumatic Stress. Lerner, M. D., & Shelton, R. D. (2005). Comprehensive acute traumatic stress management (CATSM): Addressing the emergent psychological needs of individuals, groups and organizations before, during and after a traumatic event. Melville, NY: The Institute for Traumatic Stress. Retrieved from http:// www.marklerner.com/Site/ebooks_files/ITS%20CATSM%20EBOOK%20LR.pdf Lynch, M., & Cicchetti, D. (1998). An ecological-transactional analysis of children and contexts: The longitudinal interplay among child maltreatment, community violence, and children’s symptomatology. Development and Psychopathology, 10 (2), 235–257. Mannita, C. (2008). How to avoid becoming a workplace violence statistic; ensure a safer workplace by speaking up and staying alert. T&D, July 2008. Available from American Society for Training and Development (ASTD). http://www.astd.org. Margolin, G., & Gordis, E. B. (2000). The effects of family and community violence on children. Annual Review of Psychology, 51, 445–479. doi: 10.1146/annurev.psych.51.1.445 Mitchell, J., & Everly, G. (1993). Critical incident stress debriefing: An operations manual for the prevention of traumatic stress among emergency services and disaster workers. Ellicott City, MD: Chevron. Morrison, J. A. (2001). Protective factors associated with children’s emotional responses to chronic community violence exposure. Trauma Violence Abuse, 1(4), 299–320. doi: 10.1177/1524838000001004001 Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002). 60,000 disaster victims speak, Part I: An empirical review of the empirical literature, 1981–2001. Psychiatry, 65(3), 207–239. Overstreet, S., & Mazza, J. (2003). An ecological-transactional understanding of community violence: Theoretical perspectives. School Psychology Quarterly, 18 (1), 66–87. Purvis, J. R. (1994). Crisis management. Encyclopedia of human behavior: Volume 2. New York, NY: Academic Press. Reiss, D. (1993). Children and violence. New York, NY: Guilford Press. Roberts, A. R. (2002). Assessment, crisis intervention, and trauma treatment: The integrative ACT intervention model. Brief Treatment and Crisis Intervention, 2(1), 1–21.

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Roberts, A. R. (Ed.). (2005). Bridging the past and present to the future of crisis intervention and crisis management. In Crisis intervention handbook: Assessment, treatment, and research (3rd ed., pp. 3–34). New York, NY: Oxford University Press. Ronzio, C. R., Mitchell, S. J., & Wang, J. (2011). The structure of witnessed community violence amongst urban African American mothers: Latent class analysis of a community sample. Urban Studies Research, 2011. doi:10.1155/2011/867129. Retrieved from http://www.hindawi.com/journals/ usr/2011/867129/ Strabakhina, T., & Levers, L. L. (2008).Children and families in crisis: A Russian perspective. In T. Maundeni, L. L. Levers, & G. Jacques (Eds.), Changing family systems: A global perspective (pp. 165–182). Gaborone, Botswana: Bay Publishing. U.S. Department of Agriculture. (2001, October). The USDA handbook on workplace violence prevention and response. Retrieved from http://www.ars.usda.gov/SP2UserFiles/Place/54360000/3-CivilRightsWorkplace_Violence.pdf U.S. Department of Health and Human Services. (2004). Mental health response to mass violence and terrorism: A training manual. DHHS Pub. No. SMA 3959. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Retrieved from http://store.samhsa.gov/shin/content/SMA04-3959/SMA04-3959.pdf U.S. Department of Veterans Affairs. (2011). National Center for PTSD. Retrieved from http://www .ptsd.va.gov/ Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press. Vygotsky, L. S. (1986). Thought and language. (A. Kozulin, ed. & trans.). Cambridge, MA: MIT Press. Vygotsky, L. S. (1997). Educational psychology. Boca Raton, FL: St. Lucy Press. Webb, N. (1991). Play therapy with children in crisis: A case book for practitioners. New York, NY: Guilford Press. Wilson, J. M., Chermak, S., & McGarrell, E. F. (2010). Community-based violence prevention: An assessment of Pittsburgh’s one vision one life program. Pittsburgh, PA: The Rand Corporation. Retrieved from https://www.ncjrs.gov/pdffiles1/nij/grants/230758.pdf Wolfer, T. A. (2000). Coping with chronic community violence: The variety and implications of women’s efforts. Violence and Victims, 15(3), 283–301. Yeager, K. R., & Roberts, A. R. (2003, Spring). Differentiating among stress, acute stress disorder, crisis episodes, trauma, and PTSD: Paradigm and treatment goals. Brief Treatment and Crisis Intervention, 3(1), 3–25.

CHAPTER 20

School Violence and Trauma JEFFREY A. DANIELS AND JENNI HAIST

INTRODUCTION Several issues emerge that are relevant to understanding school violence. These issues are elaborated hereafter by defining school violence, focusing on the school environment, discussing the reality of weapons, and emphasizing the importance of having a disaster plan.

School Violence Defined As we begin our discussion of school violence, it is important that an operational definition be set forth because a simple, straight forward definition is not evident. The problem is twofold: first, do events occurring “at school” include only those that occur in the building, or do we also consider violence that takes place on school grounds, during school hours, at school-sponsored after-hours events, and on the school bus? Second, what is meant by violence? Does it only include physical violence, or does it extend to property crimes, verbal harassment, social aggression, and other forms of bullying? A study of school shooters conducted by the U.S. Department of Education and the U.S. Secret Service defined the parameters of school violence as that which occurs in the school building or on school property, at after-hours school-sponsored activities, or to a student or faculty member as he or she commutes to or from school (Vossekuil, Fein, Reddy, Borum, & Modzeleski, 2002). We concur with these parameters. We define school violence as consisting of two sorts: lethal and nonlethal. Nonlethal school violence includes all forms of bullying (physical, relational, cyber), threats, intimidation, harassment, assault, sexual assault, and property crimes. This is by no means intended to be an exhaustive list of possible nonlethal acts of aggression, because there are continually evolving forms of violence and aggression. Daniels and Bradley (2011) defined lethal school violence as: [T]hat which . . . results in the death of one or more individuals. Lethal school violence may therefore include suicide, domestic murder/suicide, gang-related deaths, fights that result in death, barricaded captive situations that end in one or more fatalities, and rampage school shootings. (p. 7) For the purposes of this chapter, then, we define school violence as lethal and nonlethal acts of aggression that take place in the school building or on school property,

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at after-hours school-sponsored activities, or to a student or faculty member coming to or going from school.

The School Environment Much has been written about the relationship between the school environment and violence. There are two components to the school environment: the first is the physical layout and condition of the building and the second is the social–emotional climate. We now examine each of these in turn.

Physical Building The physical condition of the school plays a role in the overall safety of that school (Goldstein, 2004). Buildings that are clean and well cared for generally have lower levels of violence than those that are dirty and cluttered. In addition, hidden or poorly lit sections of the building may become hot spots for aggressive behavior. For example, some older buildings have alcoves and nooks that are shielded from view, and in these locations, students are more likely to engage in harassing and other negative behaviors. Newer schools are being designed to limit these spaces. A final point is that schools with multiple entry points that cannot be easily monitored are more likely to attract intruders. A single entry point that can be monitored by office personnel can enhance school safety by limiting who comes into the building. Ideally, this entry point is locked from the inside, and access is gained only by being “buzzed” in.

Climate In addition to the physical environment is the social–emotional climate of the school. Cohen, McCabe, Michelli, and Pickeral (2009) defined the school climate as “the quality and character of school life . . . and reflect[ing] norms, goals, values, interpersonal relationships, teaching and learning practices, and organizational structures” (p. 182). Reviewing the research on school safety, Daniels and Bradley (2011) described characteristics of the social–emotional climate that are related to school safety. They suggested that a safe school community is characterized by the following five factors, which are discussed subsequently: ■ ■ ■ ■ ■

Skills instruction Expected student behaviors Engagement with the community Student self/other awareness Positive adult interactions

Skills instruction cuts across both students and faculty/staff. Students benefit from instruction in communication, decision making, problem solving, conflict resolution, how to cooperate with others, self-control, and friendship-making skills. Faculty and staff may benefit from instruction in crisis response, quality teaching, and other forms of professional development (Daniels & Bradley, 2011). Expected student behaviors are those behaviors students are expected to exhibit while at school, often with the help of faculty/staff. These include limits on unacceptable behavior, consistent and fair consequences, clear guidelines and rules that must be followed, enhanced monitoring and supervision, intolerance of disrespectful behavior, establishment and enforcement of clear rules and boundaries, taking all rumors seriously and then acting on them, physical safety, and effective leadership.

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The third factor related to safe schools is engagement with the community (Daniels & Bradley, 2011). This entails efforts by the school to engage, interact, and integrate with the surrounding community, and the importance of extracurricular activities to bring the community together. The fourth factor is student self/other awareness and includes understanding one’s own and others’ emotions and social, emotional, and ethical learning. Finally, the fifth factor is positive adult interactions. This factor includes adults displaying warmth and interest, behaving as positive role models of authority figures, engaging in equitable treatment for all students, establishing trusting relationships, breaking the code of silence (including reframing snitching to helping), and treating all people with dignity and respect. Moreover, this factor includes forming connections and relationships with all students, providing emotional and social safety, and respecting diversity. Although there are conditions that can be established to decrease the likelihood of a traumatic incident of school violence, we cannot completely prevent trauma from entering our schools. Weapons play a role in the level of violence that is inflicted on others. In the next section of this chapter, we turn our attention to weapons in schools.

Weapons Weapons are used to commit acts of violence at schools throughout the world. For example, we have seen multiple school attacks in China recently, in which knives and meat cleavers have been used to slash children and teachers. In Egypt, lethal school violence has included beheadings with swords. And in Canada, Finland, Germany, the United Kingdom, and the United States, to name a few, guns and knives have been the most common weapons in lethal attacks (United Nations Educational, Science and Cultural Organization [UNESCO], Ohsako, 1997). The conclusion is that while violence may occur at schools, the addition of weapons increases the lethality of these attacks. Surveys suggest that a large percentage of students carry a weapon to school at least occasionally. A widely cited number is that 135,000 guns are brought into schools daily (e.g., Cornell, 2006). However, as Cornell (2006) clearly argued, there is no discernible indication of where this number came from or how it was derived. The problem with assessing the number of guns brought to school is that we must rely on self-report. Cornell showed that on self-report surveys, many who indicated they brought a gun to school also reported consuming alcohol from 19 to more than 40 times in the previous 30 days. Are we to believe, at face value and without further probing, that some youth bring guns to school and also drink more than once per day? Cornell also examined other “extreme answer” surveys and showed that it is very likely that some students exaggerate their engagement in risky behaviors, including bringing firearms to school. Thus, although accurate numbers of weapons in schools may not be as high as often cited, we know that some students bring weapons and, on occasion, use them to harm others at school. When this happens, it is imperative that schools have a well-developed and rehearsed crisis plan.

The Disaster Plan Schools are mandated to have a disaster plan. This plan must include contingencies for natural and human-made disasters, such as earthquakes, tornadoes, floods, fires, chemical spills, and a host of other potential crises (Dorn, Thomas, Wong, & Shepherd, 2004). Contingencies for acts of violence, including intruders and active shooters, must also be included. The Office of Safe and Drug-Free Schools (OSDFS) of the U.S. Department of Education (2007), released a comprehensive crisis planning guide, which is available online and listed in the Resource section of this chapter. The guide describes critical information about mitigation and prevention, preparedness, response, and recovery for

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all types of school disasters. The OSDFS publication details 10 key principles for effective crisis planning, which are described briefly hereafter.

Leadership First, “effective crisis planning begins with leadership at the top” (U.S. Department of Education, OSDFS, 2007, pp. 1–9). Thus, along with the vertical leadership from the governor down to school principals, teachers, school nurses, and school resource officers need to be involved in creating safe schools.

Collaboration Second, “crisis plans should not be developed in a vacuum” (U.S. Department of Education, OSDFS, 2007, pp. 1–9). Local plans need to come from ongoing school and community collaborations to construct safe learning communities.

Communication Third, “schools and districts should open the channels of communication well before a crisis” (U.S. Department of Education, OSDFS, 2007, pp. 1–10). These relationships must extend to emergency responders, law enforcement, and mental health professionals.

Partnership A fourth principle is that “crisis plans should be developed in partnership with other community groups, including law enforcement, fire safety officials, emergency medical services, as well as health and mental health professionals” (U.S. Department of Education, OSDFS, 2007, pp. 1–10).

Common Vocabulary Fifth, “a common vocabulary is needed” (U.S. Department of Education, OSDFS, 2007, pp. 1–10). Educators and emergency responders may not always use the same terms, so it is important that a common vocabulary be established prior to an emergency. This can limit confusion and miscommunications.

Local Needs Sixth, “schools should tailor district crisis plans to meet individual school needs” (U.S. Department of Education, OSDFS, 2007, pp. 1–10). So-called “canned” crisis response plans do not always adequately address local concerns (Dorn & Dorn, 2005).

Diversity Seventh, “plan for the diverse needs of children and staff” (U.S. Department of Education, OSDFS, 2007, pp. 1–10). For example, the plan must address the needs of individuals with special needs and individuals with limited English language proficiency.

Systemic Inclusion Eighth, “include all types of schools where appropriate” (U.S. Department of Education, OSDFS, 2007, pp. 1–11). These include public, private, alternative, and charter schools.

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Preparedness Ninth, “provide teachers and staff with ready access to the plan so they can understand its components and act on them” (U.S. Department of Education, OSDFS, 2007, pp. 1–11). School personnel all need to be educated about the plan and practice different scenarios before a disaster strikes.

Implementation Finally, the 10th key principle is that “training and practice are essential for the successful implantation of crisis plans” (U.S. Department of Education, OSDFS, 2007, pp. 1–11). The OSDFS (2007) guide offers a high degree of flexibility, so that planning easily can be adapted to local needs. The reader is encouraged to consult this resource when developing or refining the school crisis plan. Moreover, the plan should be reviewed yearly to accommodate any changes in the school and surrounding community.

TREATING STUDENTS EXPOSED TO VIOLENCE In this discussion of school violence, it is important to consider the effects of violence on children. An understanding of the degree to which children’s developmental stages, past experiences, and living conditions are affected by violence exposure, and the manner in which children display their distress, will help practitioners to identify those children who are most in need of assistance. In this section, we discuss the following treatment-related issues: effects of violence on children, internal and external factors having an impact on students, and school-based interventions.

Effects of Violence on Children Many young children and adolescents are exposed to violence, but not all of them develop pathological responses as a result of this exposure. Most of the literature emphasizes the importance of knowing the difference between responses that are considered normal from those that are extreme deviations. The National Institute of Mental Health (NIMH, 2001) provided a delineation of common reactions to trauma based on developmental stages. Children 5 years and younger may exhibit behaviors indicative of anxiety, usually in the form of separation anxiety, as well as fear. For example, a traumatized 5-year-old girl is likely to cry and cling to her parents when they have to leave her. She may show regressive behaviors, such as fear of the dark, wetting her bed at night, and sucking her thumb. She may cry and whimper, and possibly scream more frequently. Her fear could be expressed through frightened facial expressions, trembling, or even immobility or aimless motion. Although older children experience similar emotions to their younger counterparts, their symptoms may not be as evident to adults. Adults may interpret older children’s behaviors as defiant rather than distressed. Elementary school-aged children (6–11 years old) who have experienced trauma are likely to get into trouble at school more often and may even be seen more frequently by the school nurse. It is common for children to refuse to attend school. School reprimands can result due to lack of attendance or problematic behavior. Likewise, persistent somatic symptoms can result in frequent visits to the school nurse or absences from school. Children may withdraw completely, seem inattentive, and become disruptive in class. These children may show signs of irritability and may even become easily angered. Typically, school-aged children develop irrational fears, which, when traumatized, may be exhibited in frequent nightmares and sleep problems. According to

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the NIMH (2001), these students are likely to develop depression, anxiety, guilt, and a general sense of emotional numbness. Emotional numbing and nightmares also are observed in adolescents (12 to 17 years old). However, unlike younger children, adolescents may experience flashbacks of the traumatic event. In general, given that children lack the cognitive capacities to process traumatic events, their emotional responses either are manifested as physical symptoms or are displayed through divergent behaviors. As one can imagine, normal responses to trauma may appear extreme to those who are uninformed. Therefore, it is important for school faculties to be knowledgeable of normal responses to crises. By doing so, they can be better equipped to normalize students’ reactions and to identify students who should be referred for counseling so that determinations regarding pathological behaviors can be made by professionals who are well-versed in trauma counseling. In order to distinguish between normal and aberrant responses to trauma in children, counselors often refer to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR). A diagnosis is made if an individual portrays an explicit number of behavioral and psychological symptoms for a specified time. Depending on the student’s age and the type of symptoms displayed, the time period can vary from 2 days to 6 months to ensure that the student is accurately diagnosed. The most common disorders that develop in response to exposure to violence delineate anxiety-based symptoms, such as posttraumatic stress disorder (PTSD), panic disorder, and acute stress disorder (ASD). Children and adolescents also may develop adjustment, mood, sleep, and substance-related disorders. With this said, there is a range of factors that contribute to whether children will develop pathological responses after exposure to school violence.

Internal and External Factors Affecting Students The effects of violence exposure vary depending on the student’s unique background and the conditions of the crisis. Just as every individual reacts differently in times of crisis, not every student develops psychological problems. Those students who develop adverse symptoms in response to violence exposure differ in the type of symptoms they develop and in the degree to which they develop these problems (Kamphuis & Emmelkamp, 2005). This difference depends on the type of violence exposure, the degree of exposure to the violence, the perceived life threat, the loss of loved ones, the person’s developmental stage, the level of resiliency, the social support, and the previous exposure to trauma (Clark & Miller, 1998). In fact, students who are exposed directly to a violent event show different symptoms than those who witness it (Ward, Martin, Theron, & Distiller, 2007). The level of acquaintance a student has with the victim further affects his or her psychological well-being (Gelinas, 2003). A student who has a close relationship with the victim is likely to be more distressed than a student who has had only brief interactions with the victim. However, this is not to say that the student who has a lower level of acquaintance with the victim is not affected. The level of impact depends on how that particular student’s maturity level or age, home life, and past experiences shape his or her ability to cope with the after effects of the violent incident. These factors have strong implications for treatment of students exposed to school violence.

School-Based Interventions Children exposed to violence in schools need to be evaluated to determine the severity of the trauma and the extent to which further intervention is needed. Immediate

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responses to violence exposure are designed to prevent pathological reactions and to alleviate the initial distress. Debriefing is used as an intervention strategy of this sort. Therapy, on the other hand, is designed to treat students who develop pathological responses despite debriefing or other initial preventative measures. In the subsections hereafter, we discuss the importance of debriefing and longer-term counseling.

Debriefing Therapy for children exposed to violence has focused primarily on trauma resulting from multiple exposures, specifically community violence, terrorism, natural disasters, war, and domestic violence (Aisenberg & Mennen, 2000; Miller, 2002; Miller, 2004; Saunders, 2003; Williams, 2007). A great deal of research addresses immediate responses to crises in schools or treatments for pathological responses to bullying, suicide, and natural disasters in school settings. Even though reports of school shootings and hostage takings (Daniels, Royster, Vecchi, & Pshenishny, 2010; Vossekuil et al., 2002) are becoming more frequent, there is little literature available regarding treatment for students exposed to this specific type of violence. School shootings and hostage takings are typically one-time events; however, the majority of the literature on therapy for single-incident exposures is associated with child physical and sexual abuse (Mabanglo, 2002). Nonetheless, children who develop pathological responses to trauma do so regardless of the type of violence exposure. As mentioned earlier, there are several mental disorders commonly resulting from traumatic incidences. Although the exposure to violence contributes greatly to the onset of such disorders, it is also dependent on the psychological makeup, developmental level, and psychosocial factors of the child (Williams, 2007). It could be argued that counseling for children diagnosed with mental disorders that are preceded by traumatic events also can be effective for students exposed to one-time incidents such as school hostage takings or school shootings who, as a result, develop pathological responses. A great deal of the literature on school violence addresses the use of mental health services immediately after a crisis occurs. Psychological debriefi ng (PD) is the most recognized method in schools. This approach, applied in both individual and group formats, is designed to prevent negative psychological responses to the traumatic event. The Critical Incident Stress Debriefing (CISD) model is one type of group psychological debriefing commonly applied in schools (Everly, Flannery, & Eyler, 2002). Both interventions (PD and CISD) are designed to provide accurate information regarding the crisis, to normalize the children’s responses, and to encourage positive coping skills (Pynoos & Nader, 1988). Given that school violence affects multiple people, all of whom may serve as support systems for students, a group-based intervention such as the CISD model seems to be a necessary condition for lessening the impact of trauma on students. Miller (2010) illuminated how school crises can influence multiple individuals through the following example: A suicide by a teacher will particularly affect students, teachers, and other school personnel, but many parents may experience secondary trauma either through their children or because of their own contact with the teacher. Likewise, a student suicide, homicide or assault will affect all members of the school community, albeit differentially. (pp. 264–265) The CISD model was derived from the Critical Incident Debriefing (CID) model. The latter originally was used by emergency responders to assist groups of people in crisis situations (Wei, Szumilas, & Kutcher, 2010). The CISD is based on a progression

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of topics that are discussed throughout the sessions (Morrison, 2007). In order to be effectively applied to all members, the service providers, who are also referred to as responders, must be able to adjust the group format to the developmental abilities of the students. To enable applicability of the model to varying developmental stages, a range of adaptations for the group process have been extended to this model (Everly & Mitchell, 2000; Miller, 2010). Nevertheless, the general structure of the group process remains the same. In the initial phases of the group process, the counselors help students achieve a sense of unity while also reducing their distress by addressing misconceptions regarding the crisis. The counselors begin the group process by reviewing the events of the crisis with the students. This normalizes the students’ responses to the trauma. Recalling the traumatic details allows the group as a whole to process their cognitive, emotional, and physical reactions to the event. The students are then informed of universal experiences students have had during the aftermath of the crisis. This ranges from the common psychological reactions associated with trauma to the responses of parents, teachers, and the community as a whole. Similar to psychoeducation, students are informed of techniques that may help them to cope with the after effects. The final phase of the group process emphasizes the continuation of self-care practices and addresses the importance of maintaining a support system. Ideally, this process should reduce the overall level of stress and help students to make meaning of the crisis, thereby preventing future occurrences of PTSD (Miller, 2003). At this phase, counselors identify any students in need of referrals for further treatment. The school is conceptualized as a community in and of itself. Therefore, it can be used as a major form of support for the students, which is, in essence, the ultimate goal of the debriefing model: to encourage the school community to foster a sense of unity and cohesion. It is important to note that these debriefing models are not therapy models. Students who do not benefit from these services may be better suited for longer term counseling.

Longer-Term Counseling Various therapeutic models have been applied to violence-exposed students, including, but not limited to, eye-movement desensitization and reprocessing therapy, play therapy, solution-focused therapy, cognitive therapy, rational emotive behavior therapy, cognitive-behavioral therapy (CBT), and family therapy (Chemtob, Nakashima, & Carlson, 2002; Cohen, Mannarino, Murray, & Igelman, 2006; Tinker & Wilson, 1999). To date, most of the literature demonstrates more positive outcomes when therapies based on cognitive-behavioral and solution-focused theories are used to treat victims of violence. Although several theoretical orientations may contribute to treatment of traumatized individuals, a CBT approach to trauma has been shown to be “superior to other treatments in improving PTSD and depressive symptoms in all comparative trials to date” (Cohen et al., 2006, p. 739). Thus, given the available research on current therapeutic models, victims or witnesses of school violence seem likely to benefit more from CBT than from other therapies. The reason for the positive outcomes of CBT might be that it takes a more individualized approach to treatment than the debriefing models discussed earlier. Therapy is tailored to address “specific symptom clusters, developmental level, and/or level of severity/chronicity more than specific types of trauma experiences” (Cohen et al., 2006, p. 739). Specific models of CBT are implemented with traumatized children who have been exposed to violence, namely Cognitive Behavioral Interventions for Trauma in Schools (CBITS) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2006; Stein et al., 2003). Both therapies integrate psychoeducation, relaxation and affect-modulation skills,

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cognitive processing, gradual exposure to a feared event, stress reduction techniques, problem solving (safety planning), and relapse prevention (Cohen et al.). Each therapy aims to reduce symptoms of PTSD, anxiety, depression, trauma-related shame, and trauma-related cognitions, all of which are emotional, cognitive, and behavioral responses to violence exposure. There are, however, slight differences between the two treatments. One difference between CBITS and TF-CBT is that the two treatments ultimately change the social support system each emphasizes and builds on in therapy while using different modalities. Counseling based in TF-CBT entails individual therapy and includes the parent in the child’s healing process. On the other hand, CBITS takes place in the school setting and is a group therapy model comprised of same-aged students; the teacher is included in the psychoeducational phase of therapy. Cohen et al. (2006) indicated that a lack of parental participation in school-based therapy leads to the inclusion of teachers and peers as an alternate support system for students. Another distinction pertains to the manner in which children learn to examine thoughts that they had during the traumatic event. A key component of TF-CBT, the trauma narrative, encourages the child to describe his or her experiences in a storylike format. Depending on the developmental level and preference of the child, the student either may write the story or dictate it to the counselor while the student draws pictures. The design of the trauma narrative is not as important as the child’s descriptions of his or her experiences. Once the child has finished the creation of the narrative, the counselor and the child reread the story, first to identify additional details, such as what the child could see, hear, smell, or feel. Such sensory information helps to elicit additional thoughts and emotions. Afterward, the counselor helps the child to identify and process cognitive distortions about his or her experiences (Cohen et al., 2006). Once the child feels comfortable with the narrative, he or she shares the story with a parent. This final component helps to ensure that the parent and child are able to communicate openly about the traumatic event (Cohen et al.). Similar to the debriefing models discussed earlier, psychoeducation is provided to the child in the initial stages of therapy in order to alleviate anxiety through a sharing of knowledge regarding past survivors’ experiences and addressing possible misconceptions about the traumatic incident. In the case of a school hostage taking or school shooting, for example, the counselor must be knowledgeable of the behavioral, cognitive, and psychological impact that this violence has on the child. Although there is a vast amount of literature on the course of PTSD and on intervention models for children in crisis, this particular treatment component requires a basic understanding of what it is like for students, teachers, school staff members, and families to survive a school shooting or hostage taking. To date, there is only one model available to enhance our understanding of the psychological effects and needs that arise from school shootings. Jordan (2003) developed a trauma and recovery model for victims and their families based on his experiences with victims of a school shooting. It should be noted, however, that the author cautioned mental health professionals on widespread applications of the model due to the fact that he based this model “primarily on a middle-class white population after a catastrophic suburban school shooting” (Jordan, p. 408). In this model, Jordan broke down the experiences of both primary and secondary victims into stages. The stages reflect periods of time, beginning with the actual school shooting (first stage). The second stage represents the experiences of victims when the primary victim is brought to safety but not yet reunited with loved ones (also referred to as displacement and separation). The third and fourth stages are broken down into two possible outcomes of the school shooting: (a) the death of the primary victim and the recovery process thereafter or (b) the reunification of the primary victim with his or her loved ones and dealing with the traumatic

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effects of the school shooting. This model also addresses the behavioral, cognitive, and psychological responses and identifies the psychological needs of victims at each stage. The trauma and recovery model makes it possible to educate students, parents, and teachers alike about the psychological effects of school shootings (Jordan, 2003). For example, a 13-year-old girl who develops PTSD after witnessing a hostage-taking incident may benefit from hearing that it is normal for people to freeze and be unable to decide what to do when faced with a life-threatening situation. Furthermore, the counselor could inform her of common emotional responses after the incident, such as survivor’s guilt, irritability, anxiety, helplessness, and feelings of estrangement from others (Jordan). Educating students about the emotions that arise from the time they are taken hostage, or realize a friend or family member has been taken hostage, to the recovery period helps to validate the students’ experiences and to normalize their feelings (Cohen et al., 2006). Trauma-focused cognitive behavioral therapy and CBITS both integrate interpersonal therapy components, and, as mentioned, TF-CBT incorporates elements of family therapy into the sessions through parenting skills and conjoint child–parent sessions. In these sessions, the therapist can strengthen the students’ support systems by offering insight into the impact of trauma on students, family, and friends. Educating the family that it is normal for all members to be affected and possibly traumatized by an act of school violence will help to lower any defenses and to create a warm, trusting environment. Also, it is important to inform members that every involved person’s reactions may be completely different. Multiple protective and risk factors may play a part in the development of pathological symptoms after exposure to violence. Therefore, there seems to be value in sharing such information with victims of extreme violence, such as school shootings. It is important to acquire a basic understanding of the complex interaction among past experiences, coping methods, support systems, preexisting mental health, cognitive resources, physical health, and spiritual beliefs; this can have an impact on one’s ability to cope with a traumatic event and thereby increases the likelihood that members may be more accepting of one another. Consider, for example, an honor roll student who was held hostage. Suppose this student has never been exposed to violence, has supportive parents, and is generally described as a healthy, happy teenager. Based on the fact that this student was a primary victim, one might expect him to experience severe psychological responses to the traumatic incident. However, he may not develop pathological reactions given that he has many other positive factors mitigating the psychological impact of the incident. Now, suppose this student was compared to a secondary victim, a female whose friend was taken hostage. One might wrongly believe that she should not be as severely traumatized as the first student, given that he was able to successfully cope with the trauma. However, this particular student may have little-to-no parental involvement and may have struggled to maintain a “C” average in school. Additionally, she previously may have been exposed to violence, either in her home or in her neighborhood. Although the honor student’s proximity was closest to the hostage taker, the young woman had many factors that compromised her ability to cope with the traumatic experience. We are postulating that she had a close relationship with her friend (a hostage), she lacked the cognitive resources to process the event, she had no one she could depend on to support her, and she already had been traumatized prior to the incident. This comparison suggests that once members of the support system, whether family, friends, or school staff, are knowledgeable of the many variables that may affect reactions, they are better able to empathize with traumatic experiences; this, in turn, can work to create a more accepting environment. By considering the reactions and needs of both primary and secondary victims, the counselor becomes better equipped to lower any defenses

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and create a trusting environment, where all members feel understood and validated. Furthermore, addressing the needs of the support system as a whole can help members to learn how to help one another in the healing process.

COUNSELING IMPLICATIONS A number of implications related to school violence arise for professional practitioners. The dearth of information regarding treatment of students exposed to school violence speaks to the need for more research in this area. However, the research that is available does address specific components found to be effective in attending to the mental health needs of these students. This research provides a foundation on which counselors can build. For instance, it is important for counselors to familiarize themselves with factors that are likely to increase students’ vulnerability to traumatic events. These include factors contributing to the psychological makeup of children prior to the event as well as specific conditions of particular crises. Such knowledge can provide valuable insight into why students react differently to crises and better equips counselors to identify students who are likely to develop adverse psychological symptoms. The point in time when counselors intervene determines what approach should be taken. For instance, psychological debriefing has been found to be effective when intervention occurs immediately after a crisis. According to this model, it is important to address misconceptions of the crisis, provide psychoeducation regarding both the violent incident and the psychological responses that are common to violence, and teach coping skills to all students who have been (directly or indirectly) exposed to the crisis. Counselors who intervene after a prolonged time will take on students as clients, whose symptoms persist regardless of any initial intervention. Presumably, these students need a more intense treatment. One such treatment that has proven to be effective in reducing trauma-related symptoms is TF-CBT. Although TF-CBT uses some interventions that are similar to psychological debriefing, it differs inasmuch as it can be tailored to meet the individual needs of clients. This focus on individual needs allows students to process traumatic memories within the confinement of a safe and accepting environment. In addition to treating symptoms resulting from violence and, in particular, resulting from school violence, a final implication for practitioners is the importance of integrating the students’ support systems. Support systems are an essential component for children who still depend on others to fulfill their emotional and physical needs. Research on school violence reveals that because not all students have a strong support system at home, practitioners will need to improvise by including those who are invested in the children’s welfare, such as teachers and school staff. In general, it is important for practitioners to know that the factors that affect students’ reactions to violence are complex. The treatment modalities found to be effective in treating pathological symptoms arising from exposure to school violence are to minimize them as much as possible through debriefing and strengthening support systems and developing long-range therapies when needed, such as TF-CBT.

CONCLUSION School violence has a profound effect on the school community as a whole. In response to the rising violence rates in schools, there has been an increase in the number of prevention and crisis intervention programs. While these programs are necessary to

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ensure the safety of students, it is also important to provide appropriate treatment to the victims of such school violence. Additionally, several psychotherapies are designed to treat children suffering from PTSD, anxiety, and depression related to violence. Among these treatment models, TF-CBT and CBITS seem to be the most promising therapies for children exposed to violence. Their individualized approaches make it possible to tailor the counseling specifically to the child’s unique experience. Moreover, these approaches take into consideration the systemic influences on children’s lives. These treatment models seem to serve as a framework for victims of extreme violence, such as school shootings. However, because these victims have unique experiences, it is important for mental health professionals to educate themselves on the effects of other forms of school violence. In addition to Jordan’s (2003) trauma and recovery model for victims of school shootings, there is a great deal of literature revealing the personal experiences of these victims. An understanding of how victims’ past experiences and levels of functioning affect their ability to process and cope with the event can provide further insight into the victim’s world. Therefore, treatment for victims of school violence requires knowledge of factors contributing to or mitigating the effects of trauma, in addition to an understanding of experiences specific to the various types of school violence.

RESOURCES Websites Ohsako, T. (1997). Violence at school: Global issues and interventions. Laussane, Switzerland: UNESCO. (http://www.ibe.unesco.org/fi leadmin/user_upload/archive/publications/SalesPublications/ salespdf/Oshako.pdf) Safe Havens International (http://www.safehavensinternational.org/) U.S. Department of Education, Office of Safe and Drug-Free Schools. (2007, January). Practical information on crisis planning: A guide for schools and communities. (http://www2.ed.gov/admins/lead/ safety/emergencyplan/crisisplanning.pdf) Virginia Youth Violence Project (http://youthviolence.edschool.virginia.edu/) Films and Videos Insight Media. (Producer). (2003). School violence. [DVD]. Insight Media. (Producer). (2008). Boys will be boys, but what about girls? Childhood aggression and gender. [DVD]. Insight Media. (Producer). (2010). Bullying in schools: Six methods of intervention. [DVD]. Omni Publishing. (Producer). (2007a). Essentials of threat assessment. [DVD]. Omni Publishing. (Producer). (2007b). Preventing lethal school violence: Lessons from successful outcomes. [DVD].

REFERENCES Aisenberg, E., & Mennen, F. E. (2000). Children exposed to community violence: Issues for assessment and treatment. Child and Adolescent Social Work Journal, 17, 341–360. Chemtob, C., Nakashima, J., & Carlson, J. (2002). Brief treatment for elementary school children with disaster-related posttraumatic stress disorder: A field study. Journal of Clinical Psychology, 58, 99–112. doi:10.1002/jclp.1131 Cohen, J. A., Mannarino, A. P., Murray, L. K., & Igelman, R. (2006). Psychosocial interventions for maltreated and violence-exposed children. Journal of Social Issues, 62, 737–766. Cohen, J., McCabe, E. M., Michelli, N. M., & Pickeral, T. (2009). School climate: Research, policy, practice, and teacher education. Teachers College Record, 111, 180–213.

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Cornell, D. G. (2006). School violence: Fears versus facts. Mahwah, NJ: Lawrence Erlbaum Associates. Clark, D., & Miller, T. (1998). Stress response and adaptation in children: Theoretical models. In T. W. Miller (Ed.), Children of trauma: Stressful life events and their effects on children and adolescents (pp. 3–27). Madison, CT: International Universities Press. Daniels, J. A., & Bradley, M. C. (2011). Preventing lethal school violence. New York, NY: Springer Publishing. Daniels, J. A., Royster, T. E., Vecchi, G. M., & Pshenishny, E. E. (2010). Barricaded captive situations in schools: Mitigation and response. Journal of Family Violence, 25, 597–594. doi:10.1007/s10896010-9318-4 Dorn, M., & Dorn, C. (2005). Innocent targets: When terrorism comes to school. Macon, GA: Safe Havens International. Dorn, M., Thomas, G., Wong, M., & Shepherd, S. (2004). Jane’s safe schools planning guide for all hazards. Surrey, UK: Jane’s Information Group. Everly, G. S., Jr., Flannery, R. B., Jr., & Eyler, V. A. (2002). Critical incident stress management (CISM): A statistical review of the literature. Psychiatry Quarterly, 73, 171–182. Everly, G. S., & Mitchell, J. T. (2000). Critical incident stress management: Advanced group crisis interventions: A workbook (2nd ed.). Ellicott City, MD: International Critical Incident Stress Foundation. Gelinas, D. J. (2003). Witnessing violence: The effects on children and adolescents. In J. Miller, I. R. Martin, & G. Schamess (Eds.), School violence and children in crisis: Community and school interventions for social workers and counselors (pp. 37–49). Denver, CO: Love Publishing Company. Goldstein, A. P. (2004). Controlling vandalism: The person-environment duet. In J. C. Conoley & A. P. Goldstein (Eds.), School violence intervention: A practical handbook (2nd ed., pp. 324–356). New York, NY: Guilford Press. Jordan, K. (2003). A trauma and recovery model for victims and their families after a catastrophic school shooting: Focusing on behavioral, cognitive, and psychological effects and needs. Brief Treatment and Crisis Intervention, 3 (4), 397–411. doi:10.1093/brief-treatment/mhg031 Kamphuis, J. H., & Emmelkamp, P. M. (2005). 20 years of research into violence and trauma: Past and future developments. Journal of Interpersonal Violence, 20, 167–174. doi:10.1177/0886260504268764 Mabanglo, M. A. (2002). Trauma and the effects of violence exposure and abuse on children: A review of the literature. Smith Studies in Social Work, 72, 231–251. doi:10.1080/00377310209517657 Miller, J. (2003). Critical incident debriefing and social work: Expanding the frame. Journal of Social Service Research, 30, 7–25. doi:10.1300/J079v30n02_02 Miller, J. (2010). The use of debriefing in schools. Smith College Studies in Social Work, 71, 259–270. doi:10.1080/00377310109517627 Miller, L. (2002). Psychological interventions for terroristic trauma: Symptoms, syndromes, and treatment strategies. Psychotherapy: Theory/Research/Practice/Training, 39, 283–296. doi: 10.1037/00333204.39.4.283 Miller, L. (2004). Psychotherapeutic interventions for survivors of terrorism. American Journal of Psychotherapy, 58, 1–16. Morrison, J. Q. (2007). Social validity of the critical incident stress management model for school-based crisis intervention. Psychology in the Schools, 44, 765–777.doi:10.1002/pits.20264 National Institute of Mental Health (2001). Helping children and adolescents cope with violence and disasters (NIH Publication No. 01-33518). Retrieved from www.nimh.nih.gov Ohsako, T. (1997). Violence at school: Global issues and interventions. Laussane, Switzerland: UNESCO. Pynoos, R., & Nader, K. (1988). Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress, 1, 445–473. Saunders, B. (2003). Understanding children exposed to violence: Toward an integration of overlapping fields. Journal of Interpersonal Violence, 18, 356–376. doi:10.1177/0886260502250840 Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., & Fink, A. (2003). A mental health intervention for schoolchildren exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290, 603–611. doi:10.1001/jama.290.5.603 Tinker, R., & Wilson, S. (1999). Through the eyes of a child: EMDR with children. New York, NY: W. W. Norton. U.S. Department of Education, Office of Safe and Drug Free Schools (2007). Practical information on crisis planning: A guide for schools and communities. Retrieved from http://www2.ed.gov/admins/ lead/safety/emergencyplan/crisisplanning.pdf

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Vossekuil, B., Fein, R., Reddy, M., Borum, R., & Modzeleski, W. (2002). The final report and findings of the safe school initiative: Implications for the prevention of school attacks in the United States. Washington, DC: U.S. Secret Service, National Threat Assessment Center. Ward, C. L., Martin, E., Theron, C., & Distiller, G. B. (2007). Factors affecting resilience in children exposed to violence. South African Journal of Psychology, 37, 165–187. Wei, Y., Szumilas, M., & Kutcher, S. (2010). Effectiveness on mental health of psychological debriefing for crisis intervention in schools. Educational Psychological Review, 22, 339–347. doi:10.1007/s10648010-9139-2 Williams, R. (2007). The psychosocial consequences for children of mass violence, terrorism and disasters. International Review of Psychiatry, 19, 263–277. doi:10.1080/09540260701349480

CHAPTER 21

Workplace and Campus Violence ERIC W. OWENS

INTRODUCTION The terrorist attacks of September 11, 2001 shook a nation. In the wake of color-coded threat levels, anthrax-filled letters, and growing fear of the unknown, Americans were understandably scared. College campuses were no exception, especially those with large numbers of international students. The fear of terrorism and potential future attacks created a sense of xenophobia in some corners. So it came as no surprise that students were concerned when a suspicious package was found on the steps of a University of Massachusetts residence hall (Bellis, 2002). The concern was compounded by the fact that the building housed students from countries around the world. The package exploded. On a Saturday night in September, 2006, five student-athletes at Duquesne University attended a dance held in the campus student union. Later that night, all five were shot and seriously injured on “academic walk,” directly outside the union building. On the morning of April 16, 2007, Seung-Hui Cho entered a residence hall on the campus of Virginia Polytechnic University, where he shot and killed two students. Several hours later, Cho chained the doors of a classroom building and opened fire on students and faculty attending classes. By the end of the morning, 33 people were dead and another 17 were injured (Virginia Tech Review Panel, 2007). Of course, these are the extremes; these are the crises that make the front pages of newspapers and lead the evening news. Other stories do not receive such media attention, probably because they occur all too frequently. It was a weeknight and a young woman was on our floor visiting one of my residents. Later that same night that same young lady was found naked in my floor lounge. Right from the start it appeared that she had been raped. It took a few days to sort out all of the information but eventually it was confirmed— we were dealing with a gang rape situation. The reports ran that anywhere from 5 to 10 people were involved—all of who [sic] lived on the floor. Those who weren’t involved were scared out of their minds. (D’Angelo, Connolly, & Oltersdorf, 2000, p. 37) Violence occurs all too frequently on college campuses; but perhaps the violence we find on campus is simply an extension of the violence found in our society. For example,

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media reports of violence in the workplace are quite common. In 2002, authorities in California searched the home and storage locker of a veteran mechanic at a nuclear power facility. The search revealed a rocket launcher, tear gas, hand grenades, assault rifles, more than 250 weapons, and thousands of rounds of ammunition (Krolicki, 2002). According to law enforcement, the suspect was angry over the loss of his job. He told a colleague, “They have taken my job. They have taken my life. I don’t have anything to lose. I’m going to take my guns, go to San Onofre (Nuclear Generating Station) and whack a bunch of people” (Martell & Leonard, 2002, para. 5). This chapter reviews issues related to violence in the workplace and on college campuses. These topics are treated together, as there are many commonalities between them; aggression is aggression regardless of the locale. Additionally, the college campus is a workplace for the faculty who teach, the staff who provide services, and the students who learn. This chapter examines general issues related to campus and workplace violence. These include definitions of violence and general characterizations of aggressive activity. Workplace aggression is then described in greater detail, including the prevalence of violence and aggression in the workplace, various types of aggression, the etiology of violence, and precipitating factors that can lead to workers committing violent and aggressive acts. Similar issues related to campus violence are also examined and implications for professional counselors are discussed.

WORKPLACE VIOLENCE Workplace violence has become increasingly prevalent in American society, research indicates slight differences in degrees, but the literature is consistent on one fact; workplace violence is a serious concern. The National Institute for Occupational Safety and Health (NIOSH) estimated that more than 2 million acts of violence occur in the workplace each year (NIOSH, 1996). A study by a national insurance company estimated 16 million acts of verbal aggression occur in the workplace annually (VandenBos & Bulatao, 1996).

Definitions Defining the operational constructs related to this topic provides a better understanding of the notion of workplace violence. Most scholars suggest there is a difference between workplace violence and workplace aggression. To define workplace aggression and violence, we will begin with general definitions of human aggression and violence. Human aggression has been defined as “any behavior directed toward another individual that is carried out with the proximate (immediate) intent to cause harm” (Anderson & Bushman, 2002, p. 28). The perpetrator must believe that the action will cause harm to the target of the aggression, and that the target wants to avoid the aggressive act (Anderson & Bushman, 2002). Using this definition, accidental harm is not an aggressive act because there is no intent or malice involved. Violence, on the other hand, is a form of aggression where extreme harm is the goal of the perpetrator (Anderson & Bushman, 2002); physical injury or homicide would be examples of violence. Aggression may be overt or covert, and may or may not involve physical force, whereas violence is typically the result of a physical act. All acts of violence are acts of aggression, but the converse is not true. For example, a physical assault would meet the definition of violence; however, making a verbal threat against someone would not. An important distinction must be made between acts of human aggression and violence and those that occur specifically in the workplace. Human aggression occurs when people harm other people; in the case of workplace violence, the organization or

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institution (i.e., the workplace) may also be the target of the aggressive act (Neuman & Baron, 1998; Robinson & Bennett, 1995). For example, workplace aggression may occur when an individual verbally harasses another employee; it may also occur when an employee steals from the employer or intentionally sabotages the work product. On the other hand, workplace violence most certainly occurs when one employee physically assaults another; it would also occur if an employee were to commit an act of arson in the workplace. Examples such as theft, sabotage, or arson are not acts directed toward individuals, but instead toward the organization where the individual is, or was, employed. Regardless of where the violent or aggressive act is committed, behavior of this sort is typically characterized in one of three categories: physical, verbal, or psychological (Pezza, 1995). Acts of physical violence include physical assault, sexual assault, battery, and so forth. Examples of verbal aggression are name calling; threats of violence; racial, ethnic, homophobic, or gender-related slurs; or other acts where words are used to intimidate or injure. Psychological aggression may include intimidation or acts of obstructionism or undermining another person socially. An important distinction regarding workplace violence is the context in which the violent act occurs. The California Occupational Safety and Health Administration (CAL/OSHA) described three distinct contexts in which workplace violence occurs, which can be characterized by the “three c’s”: criminal, client, and co-workers (CAL/ OSHA, 1995). In the case of criminal violence, perpetrators have no formal affiliation with the place of employment; they commit aggression or violence in the context of a criminal act. For example, robbery is an example of a criminal act that meets the definition of workplace aggression. Individuals who work in service industries (e.g., taxicab drivers, convenience store employees) are often victims of this type of violence. In the case of a client act of violence, the perpetrator is the recipient of a service provided by the employee and employer. In these cases, the employee is attempting to provide a service to a client when that employee becomes the victim of an act of aggression; frequently, client violence involves physical assault. Health care providers and social service workers (e.g., nurses, doctors, counselors, social workers) are often the victims of this type of violence. The third category of workplace violence—co-worker violence, occurs when an employee of the organization targets other employees, supervisors, or the workplace itself. This type of violence typically occurs when one employee feels as if he or she has been treated unfairly by other employees, supervisors, or the organizational culture. Although co-worker violence receives significant media attention, it is relatively rare; for example, Braverman (1999) determined that only 4%–7% of workplace homicides were co-worker related. As discussed previously, workplace violence is a growing concern for employers, employees, and those who work to stem these violent and aggressive acts. With 2 million workers subjected to acts of workplace violence, and 16 million more victims of verbal aggression, there are sure to be consequences, both short and long term. For example, in 2009 the Bureau of Labor Statistics (BLS) reported 521 homicides and 237 suicides that occurred in the workplace; homicides accounted for 12% of all workplace deaths, and suicides 5% of fatal workplace injuries (BLS, 2010). Assaults and other violent acts were the second leading cause of death for American workers, behind only transportation-related accidents (BLS, 2010). In 2009, homicide was the leading cause of death for women in the workplace (BLS, 2010).

Descriptions of Workplace Aggression There are various manifestations of workplace aggression and violence, both against individuals and organizations; there are as many forms of workplace aggression as

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there are perpetrators. Workplace violence against individuals may include physical assault, sexual assault, homicide, suicide, or any other overt, physically damaging act. Workplace violence against organizations includes acts such as vandalism and arson. Workplace aggression against organizations may be more subtle, such as corporate espionage, excessive absenteeism, tardiness, or theft, especially if the act of stealing is meant to cause suffering to the employer. However, there are specific descriptions of interpersonal workplace aggression that are worthy of discussion. What follows are definitions of the more commonly discussed forms of interpersonal workplace aggression: 1. Workplace harassment: “Repeated activities, with the aim of bringing mental (but sometimes physical) pain, and directed toward one or more individuals who, for one reason or another, are not able to defend themselves” (Björkvist, Öesterman, & Hjelt-Back, 1994, pp. 173–174). 2. Bullying: “A situation where a worker or a supervisor is systematically mistreated and victimized by fellow workers or supervisors through repeated negative acts . . . one must feel inferiority in defending oneself in the actual situation” (Einarsen & Skogstad, 1996, p. 185). 3. Mobbing: A “severe form of harassing people in organizations” (Zapf, Knorz, Kulla, 1996, p. 215). 4. Emotional abuse: The acts may include verbal or nonverbal behaviors that are repeated or part of a pattern. They are unwelcome, unsolicited, and violate appropriate standards of conduct. The perpetrator intends to harm the target of the abuse (Keashly, 1998). 5. Workplace incivility: “Low intensity deviant behavior with ambiguous intent to harm the target, in violation of workplace norms for mutual respect. Uncivil behaviors are characteristically rude and discourteous, displaying a lack of regard for others” (Anderson & Pearson, 1999, p. 457). 6. Victimization: “An individual’s perception of having been exposed, either momentarily or repeatedly, to the aggressive acts of one or more persons” (Aquino, Grover, Bradfield, & Allen 1999, p. 260). 7. Social undermining or obstructionism: “Behavior intended to hinder, over time, the ability to establish and maintain positive relationships, work-related success, and favorable reputation” (Duffy, Ganster, & Pagon, 2002, p. 332). 8. Identity threat: “Overt action by another party that challenges, calls into question, or diminishes a person’s sense of competence, dignity, or self-worth” (Aquino & Douglas, 2003, p. 196). 9. Abusive supervision: “Subordinates’ perceptions of the extent to which supervisors engage in the sustained display of hostile verbal and nonverbal behaviors, excluding social contact” (Tepper, 2000, p. 178). 10. Petty tyrant: “Someone who uses their power and authority oppressively, capriciously, and perhaps vindictively . . . in short, someone who lords their power over others” (Ashforth, 1997, p. 126). It should be noted that with the exception of the last two forms of interpersonal workplace aggression, there need not be a power differential between the parties (i.e., the victim and perpetrator may be peers, or the perpetrator may even be a subordinate of the victim). However, the last two forms are exclusive to supervisor–supervisee relationships. Additionally, workplace aggression occurs on a continuum in terms of severity and the negative consequences that are inflicted upon the intended victim. For example, Mantell (1994) proposed a workplace violence spectrum that evaluates the

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likelihood that an individual will engage in various forms of workplace violence, ranging from covert acts of aggression to physical violence and attempted homicide. In addition to these traditional acts of aggression and violence in the workplace, the growth and ubiquity of technology has allowed perpetrators to incorporate information and communication technologies into their repertoires. The use of technology in the perpetration of aggression is known as cyberaggression, defined as “the commission of aggressive or hostile workplace behaviors committed either through or with information and communication technologies” (Weatherbee & Kelloway, 2006, p. 450). As with other forms of workplace aggression, cyberaggression can be directed at organizations, such as through software piracy (Markis, 2004; Sundararajan, 2004); the use of spyware to compromise computer networks (Stafford & Urbaczewski, 2004); or the theft and dissemination of information related to payroll and other financial records (McBride, 2004). Cyberaggression may also be directed at an individual or individuals, through acts such as cyberstalking (Brandt, 2003; Rosenwald & Allen, 2004).

Etiology of Workplace Aggression These data beg the question, what is the etiology of workplace aggression and violence? In examining the origins of workplace aggression, it is important to again differentiate between criminal aggression, client aggression, and co-worker aggression. In the case of criminal aggression, the causes are typically different than for other types of aggression. For example, in the case of armed robbery, the goal of the perpetrator is to cause fear, and possibly physical harm, to successfully carry out the criminal act. However, in the cases of client and co-worker violence and aggression, the causes are not as straightforward. Most research on the topic categorizes the etiology of workplace violence in one of two ways: individual or situational; each of these categories will be examined separately. Individual causes of workplace aggression are the personality traits that are unique to the individual and may indicate a propensity toward aggression and violence against co-workers, service providers, or places of employment. Studies have shown that individuals typically have stable predispositions to behave in certain ways (Shoda & Mischel, 1993), and that those predispositions can cause an individual to interpret environmental stimuli differently (Skarlicki, Folger, & Tesluk, 1999). How one is predisposed to react to his or her environment is critical to understanding aggression and violence, as is how one interprets the behaviors and interactions of others and of organizational systems. What follows is an examination of the individual factors that have been the focus of research on workplace aggression and violence. Individual factors include the characteristics that the person brings to the situation such as personality traits, attitudes, and genetics (Anderson & Bushman, 2002). Individual factors that influence workplace violence and aggression include: ■ Trait factors: Certain personality traits predispose individuals to high levels of

aggression (Anderson & Bushman, 2002). For example, trait anger, defined as the predisposition to respond to situations with hostility (Spielberger, 1991), has been linked to workplace aggression (Douglas & Martinko, 2001). Additionally, individuals with inflated or unstable self-esteem may react aggressively when that self-image is challenged (Bushman & Baumeister, 1998). ■ Gender: Numerous studies have been conducted examining the relationships between gender and aggression, both in and out of the workplace. Some studies have shown that men are more aggressive than women (Geen, 1990; McFarlin,

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Community Violence, Crisis Intervention, and Large-Scale Disaster Fals-Stewart, Major, & Justice, 2001), whereas others have found women to be more aggressive than men (Namie & Namie, 2000). Öesterman et al. (1998) found that women tend to prefer indirect forms of aggression, whereas men prefer more overt forms. Although the research has yielded mixed results, there is significant empirical evidence to suggest different affective reactions from men and women in response to workplace aggression. Negative affectivity: Negative affectivity refers to the extent that an individual experiences negative emotions (Watson & Clark, 1984). People who are high in negative affectivity tend to be more emotionally sensitive and reactive to difficult or challenging events (Douglas & Martinko, 2001). Individuals with a static negative disposition are prone to aggression in the face of negative events (Hershcovis et al., 2007). Type A behavioral pattern: Individuals classified as type A tend to be impatient and irritable (Glass, 1977). Type A behavior is characterized by a propensity toward anger and demonstration of higher degrees of aggression than type B behavior (Holmes & Will, 1985). Neuman and Baron (1997) found a significant relationship between type A behavior pattern and various forms of workplace aggression. Self-monitoring behavior: Some individuals are more adept at social sensitivity and monitoring their behaviors in the face of challenging events. People with low self-monitoring ability are less aware and less concerned with others’ reactions to them (Snyder & Gangestad, 1986). Individuals who struggle with self-monitoring tend to behave in a manner that is congruent with long-held attitudes and beliefs, and are less adept to change with shifting social conditions (Snyder, 1987). People with high self-monitoring behavior are more apt to be conciliatory and less likely to provoke others in conflict situations (Baron, 1989). Neuman and Baron (1997) found a significant relationship between low self-monitoring and obstructionism. Hostile attributional bias: When people interpret another individual’s behavior as hostile, they are likely to feel defensive and consider retaliation (Newman and Baron, 1998). Some research suggests that individuals may incorrectly interpret hostile intent on the part of others (Dodge & Coie, 1987). When this occurs, individuals who believe they are the victims of hostility or aggression begin to expect hostility from others, even before any interpersonal interaction occurs. People who exhibit these characteristics are more likely to behave aggressively, even in response to minor frustrations (Dodge & Coie, 1987).

In addition to individual factors, social or situational factors may also influence the development of aggressive or violent behavior in the workplace. Examples include: ■ Injustice or unfair treatment: The literature is rich with research suggesting

relationships between the perception of being treated unjustly or unfairly and acts of aggression toward individuals or organizations (Baron & Neuman, 1998; Brockner et al., 1994; Greenberg, 1990, 1993; Hoad, 1993; Neuman & Baron, 1994). Neuman and Baron (1997) found that employees who believed they were being treated unfairly by a supervisor were significantly more likely to report aggressive behavior toward that superior. The literature suggests two distinct forms of injustice, distributive injustice and procedural injustice. Distributive injustice “reflects the unfairness of outcomes,” such as salary or work products, which likely leads to aggression targeting the supervisor or organization (Hershcovis et al., 2007). Procedural injustice occurs when an individual

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believes the processes used to determine work outcomes are unfair (Thibaut & Walker, 1975). Interpersonal conflict: Interpersonal conflict describes different viewpoints or incompatibility between individuals (Boulding, 1963). Workplaces are becoming increasingly diverse (Neuman & Baron, 1998), which may lead to greater degrees of interpersonal conflict. When employees believe they have been the targets of aggression, they are likely to respond in kind; that is, they will respond to aggression with aggression. Anderson and Pearson (1999) suggest workplace incivility becomes cyclical, with an aggressive act (whether real or perceived) being met with aggression, which leads to increased aggression, and so forth. Frustration: Frustration is considered a key situational element that may lead to aggression (Anderson & Bushman, 2002). Defined as “the blockage of goal attainment”(Anderson & Bushman, 2002, p. 37), frustration comes in various forms and has been linked with increased aggression toward the perceived source of the frustration (Dill & Anderson, 1995), or even against those who were not responsible for causing the frustration (Geen, 1968). Frustration may be caused by situational constraints, such as the availability of resources or other workplace stressors that interfere with an individual’s performance or goals (Fox & Spector, 1999). Job dissatisfaction: Job satisfaction is the degree to which an employee likes his or her job (Spector, 1997). Individuals who experience job dissatisfaction are likely to exert less effort or actively work to prevent workplace goals from being attained. Judge, Scott, and Ilies (2006) suggested that job dissatisfaction may lead to organizational aggression in an effort to regain a sense of control. Losing one’s job: Layoffs, downsizing, or being terminated may affect workplace aggression. Both victims and survivors of downsizing may experience depression, resentment, or hostility (Catalano, Novaco, & McConnell, 1997). Those who survive layoffs experience increased workloads (Tomasko, 1990), declining morale, and a distrust of supervisors and the organization (Cascio, 1993). Following major restructuring, downsizing, and layoffs, employees who remain in the organization are more likely to become hostile or obstructionist (Baron & Neuman, 1998). Environmental conditions: Berkowitz (1993) found that exposure to conditions such as hot temperatures, loud noises, and unpleasant odors was linked to increased degrees of aggression. Conditions such as these may be found in many workplaces, as are: overcrowding, high humidity, extreme cold, poor lighting, or poor air quality. These conditions have all been linked to increases in workplace aggression (Anderson, Anderson, & Deuser, 1996; Baron, 1994; Cohn & Rotton, 1997). Drug and alcohol use: Many drugs can increase the likelihood of aggressive behavior (Bushman, 1993). Bushman (1997) found that drug use exasperates aggressive behavior that stems from factors such as frustration.

CAMPUS VIOLENCE Issues of violence and aggression on college campuses are growing concerns for university administrators, public safety officials, campus planners, college counselors, and counselor educators. The definitions of aggression and violence that were previously described will be used for this discussion of campus violence, and aggressive acts will be categorized as physical, verbal, or psychological in nature. Whereas acts of aggression and violence on campus can be directed at individuals or at the organization

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(i.e., the campus or educational institution), much of the research has focused primarily on acts perpetrated against individuals. In 2009, there were more than 23 million students enrolled in more than 4500 colleges and universities across the United States (Knapp, Kelly-Reid, & Ginder, 2011). Between 1995 and 2002, college students aged 18–24 were the victims of approximately 479,000 violent crimes, nationally (Baum & Klaus, 2005). The following statistics provide an overview of the problem. ■ Approximately 15% to 20% of female college students have been raped in their

lifetime (Douglas et al., 1997; Koss, Gidycz, & Wisniewski, 1987). ■ Approximately 20% to 25% of college women are projected to survive a rape or

attempted rape during college (Fisher, Cullen, & Turner, 2000). ■ Approximately 5% to 15% of college males have admitted to committing an act

of rape (Koss et al., 1987; Rapaport & Burkhart, 1984). ■ Simple assault accounted for approximately two-thirds of all violent campus

crimes, whereas rape and sexual assault accounted for 6% (Baum & Klaus, 2005). ■ Only 5% of rapes and attempted rapes are reported to police (Fisher et al., 2000). ■ The use of alcohol or other drugs was involved in 50% to 75% of campus sexual

assaults (Lisak & Roth, 1990; Muehlenhard & Linton, 1987). ■ In 41% of violent crimes committed against college students, the perpetrator was

believed to be under the influence of drugs or alcohol (Baum & Klaus, 2005). ■ Men were twice as likely as women to be the victims of campus crime (Baum &

Klaus, 2005). ■ Only 35% of all violent crimes were reported to police (Baum & Klaus, 2005). ■ A reported 36% of students who identify as lesbian, gay, bisexual, or transgen-

der (LGBT) have experienced some form of harassment in the past 12 months (Rankin, 2003). It should be noted that campus crime statistics are typically flawed because of the underreporting of these crimes. Sloan, Fisher, and Cullen (1997) conducted a study of 3,400 students at 12 different colleges and universities across the United States. The researchers found that only one-quarter of all campus crimes were reported to any institutional authority (i.e., police, public safety, residence hall staff, judicial affairs, etc.). These incidents were underreported because: (a) they were considered minor, (b) the victim wanted to maintain privacy or anonymity, or (c) the victim was unaware or unsure that the event met the criteria for a criminal act. Of the crimes experienced by these respondents, 8% included acts of violence, and 37% were thefts. Property crimes accounted for 30% of the incidents, and threats and harassment accounted for 25% of these criminal acts. Federal legislation has been passed to make campus crime statistics more accessible and available for students and families. In 1990, the United States Congress passed the Crime Awareness and Campus Security Act, which required all colleges and universities that participate in federal financial aid programs to disclose crime statistics (U.S. Department of Education, 2005). The law was amended in 1992, 1998, and 2000; the 1998 amendments were known as the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act (commonly referred to as the Clery Act). Jeanne Clery was a student who was killed in her residence hall room in 1986 (U.S. Department of Education, 2005). The law and subsequent amendments were meant to make campus crime information more widely available and transparent. When considering the various forms of individual aggression and violence on college campuses, there are a number of specific examples of aggressive behavior described in the literature.

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Sexual/Relationship Violence Acts of sexual and relationship violence can be perpetrated in a number of different forms, including sexual harassment, sexual assault, rape, stalking, and domestic or dating violence. Carr (2005) defines sexual harassment as “unwelcome sexual contact which is related to employment or evaluation of student performance” (p. 307). It may include sexually related comments, sexually explicit images, unwanted physical contact, and so forth (Carr, 2005). Offensive jokes, language, rumors, or the dissemination of graphic images all fall under the definition of sexual harassment. Sexual harassment causes the victim to feel humiliated or uncomfortable, and continues after the victim has expressed his or her desire that the offensive behavior cease (Sandler & Shoop, 1997). Sexual assaults occur far more often than are reported to campus or law enforcement authorities, and the majority of perpetrators of rape and sexual assault are never apprehended or prosecuted (Carr &Van Deusen, 2004). The American College Health Association (ACHA) found that almost 6% of female students were survivors of rape or an attempted rape in the previous year (ACHA, 2004). Another 12% reported acts of unwanted sexual touching (ACHA, 2004). Regarding stalking, Melton (2000) defines the term as “the willful, repeated, and malicious following, harassing, or threatening of another person” (p. 248). Research suggests that female college students may experience greater rates of stalking than do women in society at-large. Various studies have suggested that 25% to 30% of women and 11% to 17% of men have been stalked on college campuses (Bjerregaard, 2000; Fremouw, Westrup, & Pennypacker, 1997). Fisher et al. (2000) reported that 10% of stalking led to forced or attempted unwanted sexual contact. Dating violence continues to be a serious concern on campuses across the United States. In a 2004 study by the ACHA, 15% of women and 9% of men reported being in an emotionally abusive relationship within the previous academic year. During this same period, 2.4% of women and 1.3% of men had been in physically abusive relationships, and 1.7% of women and 1% of men reported being in sexually abusive relationships (ACHA). Specific to the LGBT population, the National Center for Victims of Crime (2004) reported a 25% increase in acts of intimate partner violence over the course of 1 year.

Hate Crimes Hate crimes have been defined as crimes “motivated, in whole or in part, by hatred against a victim based on his or her race, religion, sexual orientation, ethnicity, national origin, or disability” (Wessler & Moss, 2001, p. 17). Gender was included in the legal definition with passage of the Hate Crimes Sentencing Enhancement Act (1995), and the Violence Against Women Act also addressed gender issues (1994). Hate crimes involve threats or acts of aggression against people, property, or organizations, and may include harassment, threats, physical assault, or damage to property; acts that do not meet the criteria for criminal behavior may include harassing or demeaning language. It is believed that hate crimes and acts of biased-based aggression are underreported because of fear of reprisals or lack of awareness about the criminal statutes protecting people from such aggression (Center for Preventing Hate, 2010).

Suicide and Murder A 2004 study from the ACHA estimated that 11% of female college students and 9% of male students had seriously considered taking their own lives during the academic year, and 1.3% of students reported at least one suicide attempt within the academic

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year (ACHA, 2004). Statistics from Gallagher’s (2009) survey of college counseling center directors indicated that almost 25% of the respondents reported at least one completed suicide on their campuses in the previous year, and 90% of those centers had hospitalized a student for a psychological crisis. Concerning campus murders, statistics from the U.S. Department of Education (2010) indicate that 202 students were killed between 2005 and 2009.

Hazing Although media reports of hazing activities on college campuses are quite frequent, it is important to understand what hazing is and how it affects students. Hazing “refers to any activity expected of someone joining a group (or to maintain full status in a group) that humiliates, degrades, or risks emotional and/or physical harm, regardless of the person’s willingness to participate” (StopHazing.org, 2010, para. 1). Hazing can take various forms such as subtle hazing, which is the process of emphasizing the power imbalance between old and new members of a group. This form of hazing serves to embarrass or humiliate the new member (StopHazing.org, 2010). Subtle hazing includes behaviors such as deception, requiring new members to perform tasks not asked of other members, or name calling (StopHazing.org, 2010). Harassment hazing involves more blatant acts such as verbal abuse, threats, sleep deprivation, or forcing new members to perform humiliating acts (StopHazing.org, 2010). Harassment hazing causes emotional and physical discomfort for new members and can cause stress or frustration. Finally, violent hazing involves physical acts intended to cause harm; violent hazing may also lead to emotional or psychological distress on the part of the new member (StopHazing.org, 2010). Acts of violent hazing include forced consumption of drugs, alcohol, or other items, burning, sexual assault, kidnapping, or physical assault.

Other Types of Campus Violence Although it would be difficult to develop an exhaustive list of the many individual and organizational acts of violence that occur on college campuses, a few specific forms are worthy of discussion. According to the data compiled by the U.S. Department of Education (2010) through disclosures under the Clery Act, 26,436 cases of aggravated assault occurred between 2005 and 2009, an average of 5,287 cases per year. Aggravated assault is “a completed or attempted attack with a weapon and an attack without a weapon in which the victim is seriously injured” (Carr, 2005, p. 311). In addition, there were 4,781 reported cases of arson during the same period, an average of 956 cases per year (U.S. Department of Education, 2010). Finally, many college campuses have experienced the challenge of celebratory violence. These incidents typically involve riots or serious campus disturbances that occur after sporting events, damaging sports venues (e.g., tearing down goalposts), or destruction of other campus or local property. Following a victory over the University of Notre Dame in 1999, University of Pittsburgh students rushed the field, tearing down both goalposts and removing them from the stadium, as well as removing large portions of the artificial turf from the playing surface. Students at the same university participated in this type of violence following the Pittsburgh Steelers victories in 2006 and 2009, overturning cars, setting fires, destroying bus shelters, and spilling into city streets, bringing traffic to a halt. Although these acts of violence are typically not directed at individuals, they often cause serious disruptions to the learning environment, strained relationships with the local community, and severe property damage.

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Although it is difficult to thoroughly explain why people act violently or aggressively toward others, it is helpful to examine the factors that are linked or associated with violence and aggression, as well as predictive features of perpetrators and victims of aggression. It should be noted that an association between variables does not imply causality; that is, we cannot say with certainty that any of the factors discussed here cause aggressive behavior. However, research does suggest that there are three categories of factors that may be associated with violent and aggressive behavior: predisposing, enabling, and reinforcing factors. Additionally, environmental factors (e.g., family of origin and personal history) and developmental issues may also be correlated to aggressive behavior.

Predisposing Factors “Predisposing factors are the beliefs, attitudes, values, and perceptions of college students that may cause an individual to be more prone to violent or aggressive actions, or more likely to become a victim of aggression” (Pezza & Bellotti, 1995, p. 106). For example, the belief that engaging in minor acts of aggression or violence relieves tension is flawed, but may cause an individual to be more prone to act violently (Pezza & Bellotti, 1995). Prejudices about others and the concept of invincibility may also lead to aggression (Roark, 1987). Conversely, some beliefs may make one more prone to become a victim of aggression. Sugarman and Hotaling (1989) found that 25% to 33% of participants in a research study interpreted violence as evidence of a partner’s love. This attitude could easily result in an individual becoming a victim of dating violence.

Enabling Factors Enabling factors describe the various skills, resources, or barriers that may encourage or discourage the realization of the predispositions previously discussed (Pezza & Bellotti, 1995). For example, college students are often experiencing their first taste of freedom and independence. College is perceived as a period of experimentation and boundary testing, and the boundaries that are challenged may include those related to aggressive behavior (Hollingsworth, Dunkle, & Douce, 2009). First-year students may not have the experience necessary for effective limit setting and self-protection (Carr, 2005). Additionally, college students, especially first-year students, have often recently left the safety of their psychological and emotional support networks and have not yet established new networks. In the absence of emotional support and parental control, some students may turn to aggressive behavior as a means of coping with the stresses of higher education (Carr, 2005).

Reinforcing Factors Reinforcing factors are the beliefs, behaviors, and attitudes that can encourage aggressive behavior and the victimization of others (Pezza & Bellotti, 1995). For example, popular culture encourages violence in such venues as sports, television, and film. It can be argued that some acts of aggression and violence on campus are symptomatic of the racism, sexism, homophobia, and xenophobia found throughout society (Carr, 2005). The culture related to sports found on many college campuses can also reinforce aggressive behavior. “Sports culture can promote competition, aggression, and male privilege” (Carr, p. 312). Although it is unfair to blame athletics for campus violence and aggression, the culture created on many campuses encourages aggressiveness both inside and outside the stadium or field house.

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Environmental Factors There are numerous studies suggesting significant increases in the frequency and severity of mental health issues presenting in college counseling centers (Benton, Robertson, Tseng, Newton, & Benton, 2003; Cornish, Kominars, Riva, McIntosh, & Henderson, 2000; Gallagher, 2009; Pledge, Lapan, Heppner, Kivlighan, & Roehlke, 1998). The 2009 National Survey of [College] Counseling Center Directors provides data to support the notion that college students are presenting with greater mental health concerns, including severe psychological distress (Gallagher, 2009). Of the directors surveyed, 91% reported an increase in the number of students who are arriving on campus having already been prescribed medications for mental illness. Almost 90% of these directors reported an increase in the number of students who present with severe psychological problems, with less than 1% reporting a decrease in these presentations. Almost 25% reported increases in the number of clients presenting after a sexual assault and 23% reported increases in students who are survivors of childhood sexual abuse. Of the directors surveyed, 90% had hospitalized a student for psychological reasons, and almost 25% reported a completed suicide of at least one student. These data suggest that students are experiencing psychological distress prior to their arrival on campus, and that these concerns are often exacerbated after arriving on campus. The most recent generation of college students, sometimes referred to as the millennial generation, have much greater access to information than did previous generations. This unfettered access to national and global news, at any time, any day, has exposed this generation to greater degrees of violence and personal trauma than ever before (Hollingsworth et al., 2009). Often, this exposure comes before the individual is developmentally able to process the difficult images and anecdotes available to them (Hollingsworth et al., 2009). This generation of students has also been exposed to greater degrees of violence in sociocultural settings, such as the home and community environments (Hollingsworth et al., 2009). Exposure to violence in the community or family of origin may lead to an increased tendency toward violence and aggression in other social milieu (Gannon, 1989).

Developmental Issues For traditional-aged students (i.e., 18 to 22 years old), the collegiate experience is a time for personal, social, moral, and intellectual development. For example, Perry (1968, 1981) discusses the development of critical thinking in college students, describing the shift from a sense of dualism and response to authority to an understanding of ambiguity and relativism. Kohlberg (1981) and Gilligan (1982) describe the anticipated shifts in moral development among young adults. Kohlberg describes a pattern of moral development which begins with responses to reward and punishment and ends with congruence between moral judgments and ethical principles. Gilligan (1982) argues that men and women follow different developmental trajectories, with men being more concerned with what is “right,” whereas women focus more on an “ethic of care in moral evaluations” (Gilligan, p. 63). Certainly, in terms of the intellectual and moral development of college students, it is possible to see how aggressive and violent behavior may result when traditional developmental trajectories are not followed. For example, a student who is at a stage of moral development where self-interest is the only driving factor may not consider the consequences of aggressive or violent behaviors toward others. Chickering and Reisser (1993) describe the psychosocial development of college students. Specific to this discussion, Chickering and Reisser discuss the development of certain skills, such as emotional management, the development of autonomy, developing purpose, and increasing tolerance of others. Again, students who are struggling

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with these developmental tasks may find themselves more prone to violent or aggressive behavior. A student who struggles with emotional management may be more likely to lash out at others; a student who has yet to develop tolerance toward others may become one of the statistics related to hate crimes mentioned earlier in this chapter. Finally, no discussion of developmental issues and college students would be complete without discussion of alcohol and other drugs. As described previously, the statistics regarding the use of drugs and acts of campus aggression are significant. According to Wechsler and Nelson (2008), “the drinking style of many college students is one of excess and intoxication” (p. 3). Wechsler et al. (2002) surveyed more than 50,000 students at 120 colleges and universities across the United States between 1993 and 2001. This study found that 44% of college students binge drink; that is, males consume five or more drinks in a row, and women consume four or more drinks in a row. Among students who do drink, 48% reported that drinking for the purpose of intoxication was an important reason for drinking, 23% drink alcohol 10 or more times each month, and 29% report being intoxicated three or more times each month (Wechsler et al., 2002). Gallagher’s (2009) study of counseling center directors suggests that more students than ever before are seeking counseling for concerns related to alcohol and drug use. Almost 50% of respondents reported an increase in the number of students presenting for alcohol-related concerns, whereas not a single respondent reported a decrease in alcohol-related presentations. Of these respondents, 49% reported an increase in the number of students seeking counseling for illicit drug use, whereas only one respondent reported no change regarding drug use. The relationship between alcohol and aggressive behavior has been discussed previously, but is worth further discussion here. Presley, Meilman, and Cashin (1997) reported that alcohol or other drug use was involved in 13% of incidents of ethnic or racial harassment, 46% of cases of theft when force or the threat of force was involved, 64% of physical assaults, 71% of forced sexual contact, and 79% of rapes. These data are congruent with previous studies that suggest alcohol and drug use is directly related to perpetrating campus crimes, as well as being the victim of a crime (Bausel, Bausel, & Siegal, 1991). Finally, research indicates that alcohol use ranked second as the cause of dating violence (Sugarman & Hotaling, 1989).

COUNSELING IMPLICATIONS Although there is considerable information about workplace and campus aggression, these data beg the question, how does this affect the professional counselor? Obviously, those who work on college campuses need to be aware of research on campus violence, and the effects violence can have on students. Those who have been victimized by perpetrators of campus violence and aggression may seek the services of college counselors in the aftermath of such incidents. However, it is also critical that counselors proactively identify the factors that have been linked to aggression and work with those students to stem the propensity toward violence. Conversely, counselors also must be ready to be reactive, providing therapeutic interventions to perpetrators of campus violence. Just as those who work in the college counseling center should be prepared to address issues of aggression, so should individuals who work in the field of college student affairs. Student affairs professionals are often the first to address issues of campus aggression; for example, residence life professionals may be the first to discuss behaviors with students who commit acts of aggression toward others (e.g., assault), or toward the institution (e.g., vandalism). These professionals, who often are trained as helping professionals, should be aware of the data regarding campus aggression, as well as methods of effective intervention.

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Similarly, counselors who work in employee assistance programs (EAPs) must be prepared to identify individuals who are likely to act aggressively in the workplace and provide effective mental health counseling that could prevent these aggressive acts. They also should be prepared to work with individuals who are the victims of workplace aggression. Critical to this discussion is the understanding that workplace aggression comes in many forms, from covert bullying and obstructionism, to overt acts such as assault, arson, theft, and so forth. Counselors who work in other fields also should be aware of the proliferation of violence and aggression on campus and in society at large. For example, counselors in mental health agencies may work with individuals who seek therapy for aggressive cognitions or behaviors; they also may be called upon to work with criminal offenders who have been convicted of violent acts. Family therapists are not immune to the issues described in this chapter. Acts of campus and workplace violence not only affect the victim, but also can affect the family systems of both the victim and the perpetrator. Systems theories may help to explain some aggressive and violent behavior as described previously in this chapter. Counselor educators should be preparing counselors in training for the many effects of campus and workplace aggression. Those studying mental health counseling, school counseling, college counseling and student affairs, and marriage and family therapy may all feel the impact of the issues addressed in this chapter. In short, violence and aggression are part of our society and have influenced the systems in which people work and learn. Professional counselors must be prepared to address the various effects of violence and aggression for the victim, the perpetrator, and the many others who feel the consequences.

CONCLUSION This chapter examined various issues related to violence and aggression that occur in both workplaces and on college campuses. Similarities and differences between aggression and violence were discussed, as were issues specific to workplace violence. Distinctions were made between organizational and individual acts of aggression as well as between different types of aggression. This chapter examined where workplace violence occurs, why it occurs, and the forms in which it may manifest. Specific individual and situational factors that have been tied to workplace violence were described, as was a growing form of workplace aggression, cyberaggression. Violence and aggression on college campuses were also discussed, as there are a number of similarities between campus and workplace aggression. The scope of the problem was described, as were various manifestations of campus aggression, including hazing, suicide, homicide, hate crimes, and other forms of campus violence. This chapter also described the various factors that are linked with perpetrating or becoming a victim of campus crime, including predisposing, enabling, reinforcing, environmental, and developmental factors. Finally, this chapter described the various implications for professional counselors, supervisors, and counselor educators regarding workplace and campus violence. The topics discussed can affect counselors working across disciplines, from campus counseling centers and EAPs, to community agencies, family therapy, and schools. Violence and aggression are issues that have an impact on every corner of our society, and our campuses and workplaces are no exception. As a profession, counselors must be ready and able to address these issues, proactively and reactively, and with a host of clientele.

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RESOURCES The following resources are helpful in learning more about workplace and campus violence: Websites Centers for Disease Control and Prevention (http://www.cdc.gov/niosh/topics/violence/) National Institute for Occupation Safety and Health (NIOSH; a subsidiary of the Centers for Disease Control and Prevention) information on workplace violence and prevention. Provides readings, statistics, and videos regarding workplace violence and prevention. StopHazing.org (www.stophazing.org) A website providing information and resources regarding hazing. ED.gov (http://www2.ed.gov/admins/lead/safety/campus.html) U.S. Department of Education resource for campus crime reporting and statistics. Office of Postsecondary Education (http://ope.ed.gov/security/) U.S. Department of Education website that provides campus crime statistics. Bureau of Justice Statistics (http://www.bjs.gov/index.cfm?ty=pbse&sid=56) Bureau of Justice Statistics (U.S. Department of Justice) website that provides statistics on workplace violence. Bureau of Justice Statistics (http://www.bjs.gov/content/pub/pdf/vvcs00.pdf) Bureau of Justice Statistics report on campus crime statistics. National Center for Victims of Crime (http://www.ncvc.org/ncvc/Main.aspx) Publications Carr, J. L. (2005). American College Health Association campus violence white paper. Baltimore, MD: American College Health Association. Drysdale, D. A., Modzeleski, W., & Simons, A. B. (2010). Campus attacks: Targeted violence affecting institutions of higher education. Washington, DC: U.S. Secret Service, U.S. Department of Homeland Security, Office of Safe and Drug-Free Schools, U.S. Department of Education, and Federal Bureau of Investigation, U.S. Department of Justice. Gallagher, R. P. (2009). National survey of counseling center directors. Alexandria, VA: International Association of Counseling Services. Namie, G., & Namie, R. (2000). The bully at work: What you can do to stop the hurt and reclaim your dignity on the job. Naperville, IL: Sourcebooks. VandenBos, G. R., & Bulatao, E. Q. (Eds.). (1996). Violence on the job. Washington, DC: American Psychological Association. Virginia Tech Review Panel. (2007). Mass shootings at Virginia Tech: Report of the review panel.

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CHAPTER 22

Natural Disasters and First Responder Mental Health SCOTT TRACY

INTRODUCTION Natural disasters can strike anywhere and at any time. Individuals, over their lifetimes, can expect to be affected by some sort of catastrophic event of nature. In fact, over the last few years, massive hurricanes, paralyzing blizzards, killer tornado outbreaks, and earthquakes have wreaked havoc on every continent. There is general consensus among earth scientists that the effects of global warming may be responsible for the intensity of severe weather outbreaks that Earth has recently experienced. Natural disasters seem to be on the rise, and no one is immune. Often times, professional counselors are called to duty to help survivors deal with the emotional consequences of nature’s fury. In addition to providing service to the civilian population, counselors also are enlisted to help the emergency service providers who are on the front line of disaster response. These emergency providers (e.g., paramedics, fire fighters, and police officers) experience a deeply deleterious psychological toll as a result of their rescue efforts. The purpose of this chapter is to identify the nature of natural disasters and their impact on both civilian populations and emergency service providers. More importantly, this chapter aims to review the considerations of, actions by, and interventions for mental health professionals who are called to service during disaster events. These goals are realized through the discussions in the following sections: Types of Natural Disasters, Disaster Response System, and Counseling Implications. These main sections are followed by a summary of the chapter and a list of relevant resources for students, clinicians, and instructors.

TYPES OF NATURAL DISASTERS A natural disaster is defined as a catastrophic event of nature that creates a significant and often long-lasting change to the environment. Natural disasters can be categorized into several classes and are named by the etiological event (Table 22.1). These categories include weather- and climate-related, earth movement-related, and biological/ ecological related disasters. It is important to note that this chapter does not directly discuss man-made disasters such as war, environmental pollution, and economic collapse, which also induce similar psychological sequelae, but warrant independent discussion separate from events of nature; the consequences of these man-made disasters are discussed in various chapters of this book.

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Table 22.1 Disaster Events by Cause Weather related

Hurricane, flood, tornadoes, severe thunderstorms, drought

Earth movement related

Earthquakes, tsunamis, volcanic eruptions

Biological/ecological related

Pandemic/disease, global warming, ecosystem destruction

It is important for counselors to understand the category types and likely events of natural disasters so they can better debrief both civilian and emergency service populations as they recover from horrific events. Disasters tend to have a regional probability of occurrence. For instance, towns located near a tectonic plate boundary may experience earthquakes, the American plains is known as “tornado alley” because of the preponderance of those storms in that region, and any ocean coast region may at some time see the effects of a tropical cyclone. Counselors need to become better informed about the regional disaster probability patterns of their practice area so they are better able to respond in times of crisis. The three categories of natural disaster are discussed in the remaining parts of this section: Weather-Related Disasters, Earth Movement-Related Disasters, and Biological/Ecological Disasters.

Weather-Related Disasters Weather-related disasters are the most common types of catastrophic events. Hardly a week passes without breaking news of a hurricane, flood, blizzard, or tornado outbreak somewhere in America. Weather-related events are the product of a perpetual battle between warm air masses originating in the tropics, cold air masses stubbornly in place at the Earth’s poles, and the collision between the two as a result of the planet’s upperlevel wind pattern, known as the jet stream. The bumping of these air masses at their boundaries creates instability in the atmosphere and becomes the breeding ground for storm systems. Atmospheric storms can occur in various types. The most common type of atmospheric storm, and the leading cause of death from weather-related phenomena, is a thunderstorm. Thunderstorms originate from cells, or columns of rising warm air and sinking cold air. Lightning, hail, and heavy rain become the by-products of the storm’s energy release. Cells that rise high into the atmosphere are termed super cell thunderstorms and can spawn tornadoes. The single leading cause of weather-related deaths is from lightning strikes. However, flash flooding and wind damage can take human life and create significant structural damage to a region. Tornadoes have been the scourge of the American Plains and the deep South throughout recorded history. These regions are prone to tornadoes because of their close proximity to the warm and cold air battle zones. Tornadoes develop most often in the spring and fall and often occur in outbreaks that can terrorize several states. Thanks to advanced atmospheric imagery, such as Doppler radar, severe thunderstorm and tornado warning systems have improved dramatically over the last two decades. As early as the 1960s, communities often received no warning of an incoming storm, and loss of life was enormous. However, with innovations in weather radar imagery and climate diagnostics, communities now can get warnings of severe storms as they form and then

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track the direction and intensity of their courses. The average person can expect to receive about a 12-minute window of warning before the arrival of a storm; however, outbreak regions can be identified days ahead of time. The problem is that people in the watch area need to monitor the weather forecast. Smart phones, for example, provide a great warning system mechanism; however, many folks in tornado alley cannot afford this type of technology. An overriding theme in natural disasters is that impoverished populations suffer the greatest impact. The poorest socioeconomic groups do not have the money to purchase warning technology, nor can they afford reinforced housing that is more resistant to damage from natural disasters. In essence, lives can be saved provided that people can afford it. Despite better warning systems, since 2000, the National Weather Service has reported nearly 1,300 deaths from tornadoes in United States of America, with 400 communities destroyed. In the spring of 2011, 505 people died in three states during two outbreaks. These atmospheric storms strike quickly and with devastating consequences. A family can lose its home and life possessions in minutes. Children and the elderly present the highest risk for loss of life. Individuals who live in impoverished areas face the greatest economic impact, often because they live in unreinforced housing such as mobile trailer parks that offer little protection from storms. Twisters have a selective nature to their destruction. One home may be destroyed, whereas others on the same street are left untouched. Loss of life and injury reports have been reduced dramatically over the last 20 years, but the emotional effects of losing valuable possessions and the anxiety of starting life over after the devastation remain potent. The largest type of atmospheric storm is a tropical cyclone, or a hurricane. Many American folktales surround these enormous storms. The National Oceanic and Atmospheric Administration ranks hurricanes as first among the disaster categories that can affect an entire region. Hurricane Katrina in 2005 is listed as the single greatest natural disaster to ever affect the United States. Many other great hurricanes have made landfall on America’s shore: Camille, Andrew, and the monster unnamed storm that destroyed Galveston, Texas in 1900 are among these historic cyclones. Hurricanes not only cause loss of life, but the massive flooding from a storm surge can submerge large areas of coastal land for months. A storm surge is the sudden rise of the ocean level that accompanies the approaching eye wall or center of the storm. The storm surge causes the greatest loss of life in hurricanes. Torrential rains and devastating winds can destroy the infrastructure of a region, shutting down power plants, water treatment facilities, and hospitals and making roads impassable. Once emergency personnel evacuate a region before the arrival of a hurricane, they often are unable to get back into the damaged area because of these infrastructure disruptions. This was the case in Hurricane Katrina and caused a several-day delay in the arrival of water, food, and medical supplies into the Gulf Coast region after landfall. Not only can the infrastructure of a region be affected, but the entire ecological environment can be altered after a great storm. The disappearance of marshes, beaches, and wildlife often occur and can disrupt the tropical ecosystem for decades. In many cases, the ecosystem is related to the economy. Beach towns are dependent upon the tourism industry. If the beach disappears, so do the tourists, thus further depleting the region’s recovery resources. Not only could storm survivors lose their home to the disaster, but they may lose their jobs as well. No part of America is free from the threat of flooding. Even the desert regions of the Southwest have seen devastation and loss of life from flash flooding. Flooding can occur from three sources. The first type occurs from prolonged rainfall over a region. The ground becomes saturated, and rainfall runoff fills lakes, streams, and rivers, which then rise over their banks. Along rivers, the area near the banks is called the flood plain.

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The second origination of flooding occurs from snowpack melting and ice jamming. As the winter snowpack melts in the northern latitudes, mountain downslope movement of water can overtake a region’s watershed, which acts as a natural drainage system. Damming can occur from debris and ice in the runoff streams and cause rapid water rises along these streams and their tributaries. The heavy runoff can affect areas hundreds of miles from the actual melting ice and snow. Finally, flash flooding can develop quickly in an area that experiences heavy rainfall in a short time. Many factors predict flash flooding such as the ground saturation, runoff stream condition, terrain, and the amount of rainfall. Generally, rainfall amounts greater than 4 inches per hour can cause a flash flooding event. This type of torrential rain can occur in the late stages of a thunderstorm. Some regions may experience all three types of flooding. The city of Johnstown, Pennsylvania was destroyed twice in the span of a century by a prolonged rainfall that caused a dam to break and a flash flood event from slow-moving thunderstorms. Winter storms also constitute large scale disasters because of their ability to disable a region’s infrastructure. Storms that produce heavy snowfall and ice may shut down roadways and snap trees and power lines, interrupting transit and turning off electrical supply for days at a time. The loss of power forces many citizens to endure cold, unheated homes. Again, the greatest impact typically is felt among impoverished populations and the elderly. Under winter storm conditions, people often attempt to heat their homes using portable heaters that can create fires and cause dangerous levels of carbon monoxide gas to build in their homes. Initially, primary roadways such as interstate highways close. Secondary roads may remain snow-covered for days, preventing an entire population to have access to primary roads. Winter storms also slow rescue workers in their ability to respond to emergency situations. Winter storms are typically a national event. During winter weather outbreaks in 2010 and 2011, one third of the nation was affected by four separate blizzard occurrences. The bitter cold that typically follows a winter storm may have a further blistering impact on a region’s ability to cope with snow removal and rescue those trapped by the storm.

Earth Movement-Related Disasters The Earth’s interior is a dynamic system. Earthquakes, tsunamis, and volcanoes are the products of this dynamic system. The surface of our planet sits on top of a layer known in geology as the crust. The Earth’s crust is divided into two types, identified as either oceanic or continental. These layers are named because of the rocks that compose them. The oceanic rock, which contains the Earth’s oceans, is lighter than the continental rock and tends to dive, or subduct, under the continents and near shorelines. The movement of these large plates of rock against one another is fueled by large convection currents of magma and heat originating from the Earth’s interior. The battle between these large plates is mostly a stalemate, but breaks or cracks can occur near the fringe areas of continental and oceanic plates. This entire process, known as plate tectonics, produces earth movements. Earthquakes, tsunamis, and volcanic eruptions occur because of these movements and have produced some of the greatest catastrophes in Earth’s history. An earthquake occurs when a shift or break occurs along a boundary or fault line. The San Andreas Fault in Southern California is one of the most famous of these fault lines. Large metropolitan centers have been built on or near many of the Earth’s fault lines and subduction zones. The recipe for disaster has been made. Structural collapse and fires from broken gas lines represent the greatest land threat during an earthquake.

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This decade alone has seen massive death tolls in the hundreds of thousands from quakes in Haiti, Chile, China, and Japan. When earthquakes occur in the ocean basin, large sea waves known as tsunami can be formed. Twice in a 10-year span, the world watched in horror as these giant waves devastated the Indian Ocean basin (2004) and the Japanese coast (2011). These waves inundate coastal regions with giant, fast-moving walls of water. The height and speed of these waves act as a battering ram, destroying everything in their path. The water itself can be propelled miles inland, causing rapid flooding. There is no prewarning of an earthquake; however, because tsunamis occur after an earthquake, some advanced notice is possible, provided that people have access to the warning system. This lack of warning-system accessibility explained the massive loss of life in the Indian Ocean occurrence. The intensity, or magnitude, of an earthquake is measured on a scale known as the Richter scale. The scale measures from 1–10. Earthquakes over a rating of 7 are major, and those of 9 or greater are catastrophic. There is a direct correlation between the magnitude of a quake and the damage it creates. It is important to note that a quake measured at 5 or 6 on the Richter scale can be devastating if it is centered in a populated area that lacks reinforced structures. Poorer sections of a region experience the greatest impact and loss of life because of this. As with weather-related disasters, impoverished populations suffer the greatest in an earth movement catastrophe. As the rocks shift and return to a stalemate after an earthquake, smaller tremor activity, known as aftershocks, can occur. Many people initially have survived an earthquake, only to be trapped in a damaged building that finally collapses during one of these aftershocks. Aftershocks pose a significant threat to emergency responders during disaster rescue operations. These smaller quakes also provide a great mechanism for secondary traumatization among the survivors of a disaster. Volcanoes are areas on the Earth where magma rises from deep under the crust and emerges onto the surface. Volcanoes can be contained in large mountains, such as Mt. St. Helens in Washington, or as flatter, more dome-shaped structures, such as the Hawaiian Islands. The large mountain volcanoes present a great risk for becoming a natural disaster. The city of Pompeii, Italy was destroyed by the eruption of Mt. Vesuvius in 79 ad and has become one of the most famous volcanic eruptions in history. There was, however, another volcanic eruption that occurred in 1833 that caused a disaster of global proportion. The explosive eruption of Krakatoa sent a large ash cloud high into the earth’s atmosphere that was absorbed into global wind patterns. This large debris cloud reflected warming sunlight back into space, sending the entire planet into a mini ice age. Disease, severe weather outbreaks, and extreme cold weather wreaked havoc on our planet for several years. The eruption of this volcano was so large that the explosion was heard hundreds of miles away. The scale of an earth movement disaster can occur over very large areas. Travel into the region would be difficult at best. Roads, bridges, and highway systems would be destroyed. Multiple triage and crisis counseling centers would need to be established and maintained for extended time, while rescue and recovery operation continue and aftershocks subside.

Biological/Ecological Disasters Every year our planet is threatened with a potential natural disaster of biblical proportion. This event is one of the largest health threats to any individual. It is influenza, or the flu. The flu, over recorded history, has taken more lives than all of Earth’s wars combined. Prior to the advent of flu vaccines, major outbreaks became common and

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would shut down schools, businesses, and entire communities. Although the flu strain itself is generally not fatal, the secondary effects of dehydration, respiratory failure, and secondary infection can be lethal. Young children, the elderly, and individuals with chronic illness are the most vulnerable. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia monitors influenza patterns and issues flu forecasts, much in the way that the National Weather Service predicts weather. The CDC maintains a stockpile of vaccines for the known strains of influenza and other contagious diseases and has an extensive infectious disease research unit that continuously develops new vaccines. Epidemics occur when a viral strain affects a region. Most of us only need to think back a year or so to remember when the H1N1 virus was running rampant around work or school. Lost wages and productivity are among the systemic impacts resulting from an epidemic. Pandemics are much more serious and involve outbreaks that are global in nature. The great Bubonic Plague, also known as “Black Plague,” of the Middle Ages (c.1300 ad) caused an estimated 100 million deaths. This Black Plague may have reduced the planet’s population by 50%. Humanity was on the verge of extinction. The H1N1 is a more recent example of a pandemic. It is important to receive an annual flu vaccination, especially for counselors, because they work in close contact with others. Frequent hand washing and the use of antibacterial and antiviral soap are important in helping to prevent the spread of disease. The types of weather and earth movement disasters mentioned previously can lead to a secondary biological disaster. Broken sewage lines in earthquakes and stagnant water in flooded areas become the breeding ground for germs. Poor hygiene among displaced survivors can cause various diseases. Emergency medical personnel may require universal or other special precautions for counselors interacting in a disaster area. These precautions almost always are enforced in the morgue and medical treatment areas and include gowns, masks, and medical gloves. Counselors usually are briefed by health care providers on the greatest disease risk and the ways to minimize contact prior to going into these areas. Ecological disasters can involve the food or lifecycles of a region. The functions of ecosystems are based upon a natural balance of animals that prey upon one another and plant life that supports the animals and environment in which they live. Oil spills, such as the one that affected the Gulf Coast in 2011, destroy both animal and plant life by making the ecosystem uninhabitable for both. Humans may not notice the immediate effects of an ecosystem disaster; however, mental health professionals should be aware of the delayed emergence of ecosystem disasters and expect to engage in long-term counseling services in an affected region. Changes in the lifecycle may take years to become permanent. As an example, previously rich fishing waters may become spoiled as the plant and animal life adapts to the ecosystem disaster. In human terms, an ecosystem disaster can knock a wealthy tourist town into a poverty-ridden ghost town. In most cases, ecosystem disasters are anything but natural and are created by man’s need to conduct industrial manufacturing and pillage the natural resources of Earth’s land and waters. Our water is particularly vulnerable to an ecosystem disaster. Most people would think of an ocean oil spill as the most vivid type of ecosystem disaster, but we need only consider that 99% of Earth’s water is unusable for human consumption. Most of our water is either filled with salt, as in the oceans, buried deep underground, or frozen in the polar ice caps. Humans exist on only 1% of the total water composition of Earth. Our fresh water supply is depleting, and if the trend is not reversed, this could have a serious impact on the time that humans have on this planet.

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DISASTER RESPONSE SYSTEM The disaster response system originated during post World War II America as a way to prepare the American public for a response to nuclear attack. The war proved to be particularly devastating to large, under-resourced civilian population centers in Europe and Asia. Known initially as civil defense, this government agency planned responses to large-scale disaster. The focus of civil defense surrounded what to do after a disaster strike and not on ways to mitigate or prevent a major emergency event. As the cold war ended, civil defense expanded its role and became a much broader government agency, now known as the Federal Emergency Management Agency, or FEMA. FEMA coordinates local, state, and federal responses to disasters of all types. Training, research, and prevention are core tenets of FEMA’s role in the American government. A major focus of disaster response involves managing the psyche of the affected population and coordinating the needs of emergency providers called to duty in rescue and recovery operations. Current literature in counseling describes phases of behavior and symptom patterns that affect individuals exposed to a natural disaster. Counseling interventions can be intimated to help individuals recover from devastating events. The study of the psychological effects of disaster and intervention strategies is known as disaster mental health (DMD) and is recognized by FEMA as a core response to any horrific event. This section elaborates upon the disaster response system by discussing the following relevant issues: the psychological effects of disaster, interventions, and working with emergency providers.

The Psychological Effects of Disaster Traumatic experiences from horrific disasters go beyond the human boundaries of age, culture, gender, or religion. The question is not “can it happen?” but rather, “when will it happen?” Entire populations affected by a disaster can experience an intense release of emotions as a result of sudden sad and catastrophic events. Release of these emotions can cause various stress reactions. Medical literature has described these stress reactions as having an impact on both the physical and emotional well-being of an individual. Additional evidence also points toward the negative effects of frequent ongoing stressors called “cumulative stress” in the weeks and months that follow a disaster. Traumatic experiences from natural disasters can be defined as occurring in two distinct phases, known as primary and secondary (or ongoing) traumatization. This section reviews relevant aspects of primary and secondary traumatization along with identifying the phases of disaster in psychological terms.

Primary Traumatization Posttraumatic stress disorder (PTSD) is the most studied of the stress reactions. PTSD, as defined in the Diagnostic and Statistical Manual of Mental Disorders IV, is a serious condition that involves somatic illness, personality changes, and self-destructive behavior (American Psychiatric Association [APA], 2000). PTSD can interfere with every aspect of an individual’s life, including relationships, work, educational activities, sleep, rest, and, most importantly, physical health. Detailed discussion of PTSD has been offered in previous chapters of this book, but it is worthy of revisiting specific details, because of the prevalence of PTSD among disaster victims. In 1920, Sigmund Freud published his book Beyond the Pleasure Principle, in which he addressed the topic of trauma (1920/1956). In a timeless metaphor, he described a “protective shield of the ego” as a defense mechanism for traumatic experiences. Freud

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described traumatic events as those instances which are powerful enough to break through the protective shield of the ego. He also wrote that: . . . such an event as an external trauma is bound to provoke a disturbance on a large scale in the functioning of the organism’s energy and to set in motion every possible defense measure. At the same time, the pleasure principle is, for the moment, put out of action. There is no longer any possibility of preventing the mental apparatus from being flooded with large amounts of stimulus, and another problem arises instead—the problem of mastering the amounts of stimulus which become broken in and of themselves binding them, in the psychical sense, so they can be disposed of. (Freud, 1920/1956, pp. 29–30) After understanding the framework for traumatic response as described by Freud, we are better able to discuss the development of the diagnostic criteria for PTSD. In 1952, the APA published its first DSM. The initial DSM described a diagnostic category known as transient situational personality disorder (TSPD). TSPD contained a subcategory disorder termed gross stress reaction (GSR). GSR was used to address psychological symptoms exhibited by combat or civilian populations after exposure to a catastrophe (APA, 1952). In 1968, the APA published its second edition of the DSM and renamed GSR as an adjustment reaction of adult life. In this edition, APA listed many events as possible triggers to the disorder such as car, boat, and airplane accidents and natural disasters such as tornadoes, hurricanes, and floods. From 1968 through 1980, numerous syndromes emerged such as rape trauma syndrome, battered woman syndrome, and Vietnam veteran syndrome, to name a few. According to van der Kolk and McFarlane (1996), “these syndromes were merged into a new diagnostic label called posttraumatic stress disorder (PTSD)” (p. 16). In 1980, the DSM-III finally incorporated the new official diagnosis of PTSD and listed it among the anxiety disorders (APA). In its description of PTSD, the DSM III described affective reactions (i.e., anxiety, emotional distress, and somatic complaints) that occur from exposure to an extreme traumatic event (Rapport & Ismond, 1996). A revision to the DSM-III occurred in 1987 (APA). The clinical research that was gained from victims of traumatic events was included in the DSM-III-R. Three major symptom clusters were identified (Table 22.2). These clusters included reexperiencing the traumatic event, avoidance of stimuli associated with the traumatic event, and increased physiological arousal. Wilson (1995) reported that the revisions attempted to

Table 22.2 Posttraumatic Stress Disorder Symptom Clusters Reexperiencing traumatic event

Nightmares, physical reactions triggered by cues that resemble the event, vivid recall, hallucinations

Avoidance behaviors

Sense of foreshortened future, inability to recall an important aspect of the traumatic event, diminished pleasure in daily living, efforts to avoid thoughts, feelings or conversations about the trauma

Increased psychological arousal

Sleep disturbances that include difficulty falling asleep or staying awake, hypervigilance, difficulty concentrating, irritability or anger outbursts, exaggerated startle response

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provide clarity, meaning, specific vocabulary, and specificity of the reactions to horrific events. These horrific reactions were defined as “any external event outside the usual range of daily hassles that would be distressing to almost anyone” (Wilson, p. 22). In 1994, the APA published the DSM-IV, with only minor changes to PTSD diagnostic information. An APA subcommittee added acute stress disorder (ASD) along with PTSD. ASD was defined as “those immediate reactions such as overwhelming anxiety, dissociation and physical illness that occurred acutely within 1 month of exposure to an extreme traumatic event” (Rapport & Ismond, 1996, p. 122). The DSM-IV revision published in 2000 had little change in its discussion of PTSD and ASD (APA, 2000). Since the first mental health classifications that were published in 1952, stress reactions have emerged into a clinical subspecialty (Everly, 1995). Theoretical writings and empirical studies have bombarded psychiatric, psychological, and counseling journals. Everly defined psychotraumatology “as a broad based knowledge on the processes, factors, consequences, and treatments associated with psychological trauma” (Everly, p. 284). The lived experience of a natural disaster can cause immediate psychological distress, but the psychological consequences generally are transient (McFarlane, 1987). According to McFarlane, “In the early months, somatic complaints, PTSD and travel anxiety are frequently described. In the long term, however, depressive symptoms emerge. Many individuals with early difficulties rapidly improve while a few develop substantial long term psychiatric problems” (p. 365). McFarlane suggested that early intervention and education on both the social and psychological impact of disaster may help to predict those who are at high risk for long-term problems. Numerous studies (Dyregrov, 1989; Mitchell & Bray, 1990; Hodgkinson & Stewart, 1991; Schnyder, 1997) concluded that prevention programs may also help to limit the high-risk group. Many surveys and studies that ask recipients about their opinions surrounding the effectiveness of mental health services during disaster response report favorable findings (Robinson & Mitchell, 1993). For example, a 1997 study in Australia found that police and fire brigade workers rated professional mental health services as 95% effective, peer support services as 93% effective, and debriefing/defusing as 91% effective in helping them to cope with disaster response (Robinson, 1997). In that same study, 95% of respondents (n ⫽ 755, at a 60% response rate) supported the perceived importance of continuing counseling services for an extended period of time after a disaster. Knowledge about recovery from psychological trauma is growing. One aspect of recovery involves the importance of talking about one’s experiences (van der Kolk & McFarlane, 1996). This belief infers that humans need to express their thoughts in some way. However, it has been suggested that people resist acknowledging, validating, and deliberating on those aspects of our existence that are emotionally difficult to comprehend. The horrific images of a natural disaster would serve as an example of such an event (Herman, 1992). Herman has asserted that, over time, an individual experiences waves of acknowledgment, followed by periods of denial of his or her experienced event. Herman has argued that the episodic nature of trauma requires continuous support for those exposed to it. Long-term outcomes after trauma are influenced by the nature of the posttrauma environment (Rapheal & Wilson, 1993). Repeated traumatization, such as aftershocks following an earthquake, adds an enduring traumatic stress response that is thought to synergize subsequent traumatic events. This means that lesser traumatic events can cause greater stress responses. As the individual experiences more and more traumatic events, as often occurs in the post-disaster recovery phase, the ability to cope becomes compromised. Rapheal and Wilson also recommend long-term support for those who experience disaster first hand. Populations need continued system-based support services in helping them to deal with the emotions and cognitive distortions provoked by exposure to stressful events. Some observers see the role of mental health professionals

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as providers of vocabulary (Gist & Lubin, 1999). Counselors are able to offer labels for what individuals think and feel; in this way, mental health workers also can help survivors to normalize their emotional reactions. Other factors that have an impact on the psychological response to disaster include the degree to which an individual perceives that events are uncontrollable versus preventable. Gist and Lubin (1999) suggest that individuals experience a faster return to normalcy when uncontrollable natural events such as a flash flood or hurricane strike occur. When horrible events occur that are man-made and perceived as preventable, psychological responses linger (Gist & Lubin). Baum (1987) argued that victims of technological disasters are at greater risk for developing stress reactions because technology systems are assumed to be controllable; recent examples of this would be the nuclear radiation leaks in Russia and Japan and the Gulf of Mexico BP Oil Spill. Likewise, incompetence and failure of sociopolitical systems in a disaster can increase the risk for stress reactions and psychological disorder.

Secondary Traumatization Jankoski (2002) conducted research that focused on the cost of caring; she stated that the “individuals who care for others often undergo a pain as a consequence of their exposure to others traumatic material” (p.11). Many other studies also have supported this claim of secondary or vicarious traumatization on emergency workers like emergency medical technicians, fire fighters, and law enforcement (McCann & Pearlman, 1990; Dyregrov & Mitchell, 1992; Raphael, Singh, Bradbury, & Lambert 1983). This vicarious traumatization has occurred in emergency personnel after working with individuals who had undergone traumatic events. Likewise, relatives of survivors coming into a region to help loved ones cleanup, utility workers, insurance adjusters, and members of the news media all can be victims of secondary traumatization. Figley (1998) described a process called compassion fatigue in which traumatic symptoms can develop in individuals who are “empathetically engaged” with others who have experienced traumatic events. Figley listed two factors that have a causal relationship to compassion fatigue: “First, is that an exposure to another’s traumatic experiences must occur; and second is an empathetic engagement with that individual must take place” (Figley, 1998, p. 7). The construct of compassion fatigue contends that trauma stress reactions are contagious and create effects in those individuals who work with psychological trauma victims. Dyregrov and Mitchell (1992) said that “the same traumatic stress symptoms that affect victims of psychological trauma also impact the professionals who work with them. These symptoms include sleep disturbances, flashbacks, nightmares, irritability, anxiety, and depression” (p.51). Vicarious traumatization continues to be a concern for professionals during the recovery phase of a disaster.

Phases of Disaster in Psychological Terms The sociological and psychological patterns of recovery occur in five specific stages (Farberow & Gordon, 1981). These patterns of behavior should dictate the types of interventions counselors use in helping individuals and communities to recover from a disaster. These five stages include: ■ Initial impact phase. Patterns in the first phase include shock, fear, and extreme

anxiety. ■ Heroic phase. This phase can last up to 1 week after the event and may occur in

some cases before the initial impact phase. Disaster survivors reach out to one

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Table 22.3 Phases of Disaster Recovery Initial

Impact to 1 day

Shock and pervasive fear

Heroic

Impact to 1 week

Acts of heroism and risk taking to save life and property

Honeymoon

1 week to 2 months

Mood of optimism and energy

Disillusionment

2 months to 1 year

Feelings of isolation and abandonment, depression

Reconstruction

Several years

Return to normalcy but with sadness episodes

another in an attempt to save life and property and often involve extreme risktaking or heroism involving altruistic actions. ■ Honeymoon phase. This phase may last from 2 weeks to 2 months. Survivors, and the community as a whole, develop a synergy from the outpouring of support and services that stream into a disaster area. A mood of optimism is prevalent and fueled by promises of relief from the government and service agencies. ■ Disillusionment phase. Lasting from 2 months to a year or more, this phase is characterized by resentment, a sense of loss, and the development of an existential vacuum as government and relief agencies leave the region. The survivors often feel alone and abandoned, which may reactivate previous psychological trauma. This phase is often termed the second disaster. Counselors need to be aware of the development of disillusionment and begin interventions that address traumatization and take care to provide reassurance. ■ Reconstruction Phase. Communities and individuals may remain in this phase for several years post disaster. A pattern of rebuilding and moving forward is prevalent as survivors achieve control of their reactions and personal problems related to the disaster. These phases (Table 22.3) are labile and meant to identify general behavior patterns. It is important to note that individual responses vary and are based on many factors such as the health of the person’s coping mechanisms, the presence of a support system, physical health, and other comorbid factors. It is useful to understand the behavioral patterns in order to establish an appropriate intervention strategy.

Interventions Current interventions in disaster mental health (DMH) are based on a developmental three-stage model. Each stage in the model represents a different counseling intervention that matches victim behaviors along a temporal continuum of recovery. The model also uses a triage scheme, which helps to sort out individuals who are at high risk and at the same time provide support to those who appear to be adequately recovering. The three stages of this model (Table 22.4) include acute support, intermediate support, and ongoing treatment. Although specific timelines are given for each stage, it is important to understand the many variables that occur with each type of disaster and to know that no two disasters are ever alike. These variables are called temporal issues and must be considered by practitioners as they plan interventions. The three-stage model should be used as a guide rather than a dogmatic protocol. Hurricane Katrina is an example of

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Table 22.4 Support Stages of Disaster Mental Health Acute stage

1 week

Provide psychological first aid to survivors and perform triage

Intermediate support

1 week to 1 month

Promote anxiety management and reduce stress. Perform triage and referral for ongoing support

Ongoing support

1 month to 1 year or more

Provide diagnostic and long term behavioral health services

the developmental nature of disasters. Many Gulf Coast residents were relieved as the outer edge of the hurricane passed, leaving their homes unharmed, only to be traumatized as the man-made levees failed, flooding their homes. Individuals who were recovering adequately, and perhaps were euphoric initially, were suddenly acute victims of a natural disaster. As a general procedural rule, behavior health specialists need to be aware of the setting they are entering and knowledgeable about the specific leadership, organizations, and polices already in place by the emergency management agencies. Many hazards are present near disaster areas, and hazards such as downed power lines, disease, flooding, threat of structure collapse, and fire may linger for weeks post impact. Behavioral health providers always should follow the directions of the emergency management system that are in place. Depending on the scale of the disaster, the general command chain, known as the incident command system, follows a linear local, state, and FEMA structure. Large-scale and terrorist threats also may fall under the jurisdiction of military personal. Order from chaos is the primary goal of emergency response organizations, as they begin the rescue operation phase of a disaster. Counselors need to understand that behavioral health issues may not be at the forefront of FEMA goals. It is important for counselors to support the incident command system as well as the leaders, who are experiencing a tremendous amount of rescue-work stress.

Stage 1: Acute Support Acute support is the first stage and takes place immediately after the mass disaster. This treatment phase may last for up to 1 week. The counselor’s goals in this initial stage are to establish contact with survivors, provide direct care, identify individuals who are at high risk for future psychological problems, and arrange for behavioral health followup. Many term this type of intervention plan as psychological first aid (PFA; Brymer et al., 2006). PFA focuses on managing the initial needs of survivors by providing support and resources to begin the recovery process and diminish posttraumatic stress. PFA often occurs within the disaster area at shelters established in churches, schools, or community centers. PFA promotes calm, connectedness, and hope through eight core counselor actions (Table 22.5). The actions of PFA include: 1. Make contact with and engage survivors in a compassionate and nonintrusive way. 2. Provide safety in both a physical and emotional domain. In others words, provide a safe place to cry and express emotions in a nonjudgmental and trusting place. 3. Stabilize emotionally overwhelmed survivors.

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Table 22.5 8 Steps of Psychological First Aid Step 1

Make contact with survivors

Step 2

Provide physical and emotional safety

Step 3

Stabilize survivors emotions through active listening, validation, and supportive statements

Step 4

Gather information about survivors immediate needs

Step 5

Offer practical help to meet needs

Step 6

Connect survivors with family, friends, and support systems such as the ARC

Step 7

Provide psycho-educational information about stress reactions and reduction

Step 8

Link survivors to collaborative services such as FEMA or a CMHA

4. Gather information about the immediate needs and concerns of the victims. This may include basic needs such as food, shelter, and water. 5. Offer practical help to address the needs and concerns identified. 6. Connect survivors with social supports such as family, friends, churches, the Red Cross, and other response agencies. 7. Provide individuals with psycho-educational information about ways to cope and reduce stress. 8. Link survivors with collaborative services that may be needed in the future. PFA is a beginning tool that counselors can employ for use in a mass disaster. The primary result of PFA is establishing the linkages with other support systems that aid in the recovery process.

Stage 2: Intermediate Support Intermediate support is the second stage and takes place from 1 week to 1 month post impact. The primary focus of treatment during this stage is to promote anxiety management and reduce stress, which may preclude an acute stress disorder. This is accomplished by the development of a therapeutic relationship using traditional clientcentered theory and integrating cognitive-behavioral techniques to train survivors in anxiety management. Specific triage for ASD should occur and referrals made to behavioral health providers for intensive care when derealization, depersonalization, or flashbacks are present. There are five core treatment principles in the intermediate stage, and these are identified as follows: 1. 2. 3. 4. 5.

Develop a strong working alliance with the survivor Collaborate with the client in the development of goals Provide empathy, friendship, and support Provide positive regard and acceptance Relate an attitude of authenticity and genuineness

Attention to the sociocultural dynamics of the survivors is critical during this stage and is best supported by the five steps listed previously. Issues of privilege and dominance often emerge in survivors during this stage. The healer must be aware of his or her own personal beliefs and biases in order to support a trusting, collaborative therapeutic relationship.

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Stage 3: Ongoing Treatment The final stage typically occurs between 1 and 3 months, but can last for years after the disaster impact. This stage focuses on individuals identified in stage 2 and provides more specific diagnostic and long-term behavioral health services. Specific goals in this stage are to offer a differential diagnosis and modify treatment based upon the clinical presentation. These diagnoses often involve anxiety, mood, and substance abuse disorders. Treatment often is carried out in a traditional mental health environment. It is important to note that most individuals exposed to a natural disaster recover on their own and do not experience lasting psychological effects. Counselors always should focus on helping the survivors achieve safety and meet basic needs before providing other services. Professionals should make an effort to identify themselves as helpers and what their roles are in the disaster. It is important to help survivors gain accurate information about what is going on around them; this can be accomplished by providing practical and useful psycho-education. Finally, helpers need to take care of themselves and know their limits. A wounded healer is of little use in disaster mental health operations.

Working With Emergency Providers It has been recognized for many years that emergency medical service (EMS) workers encounter psychologically stressful situations in the course of their jobs, especially those involving disaster and major emergency responses (Mitchell, 1981; Rapheal, 1977). In his groundbreaking work on stress reactions among EMS personnel, Mitchell (1981) listed events that are likely to cause stress reactions in EMS responders. These events include emergencies involving the death of a coworker in the line of duty, death of a child, gruesome accidents, exposure to domestic violence, and natural disasters with widespread damage, injury, and death. Other scenarios, such as exposure to suicide and homicide crime scenes, terrorist attacks, and failed procedures by rescuers also have been attributed to causing stress reactions in emergency medical providers (Mitchell & Everly, 1996). Medical literature has described these stress reactions as having an impact on both the physical and emotional well-being of rescue workers. In a 2002 study, conducted by McSwain (2003), nearly one third of all EMS workers left their jobs within 3 years of hire for other occupations. The study also discovered that their workman’s compensation insurance claims were three times higher than the average health care professional and that job dissatisfaction among emergency workers remained high. Some empirical evidence suggested that the negative effects of frequent ongoing stressors, also referred to as “cumulative stress,” are possible reasons for attrition, illness, injury, and job dissatisfaction among EMS personnel (Mitchell & Bray, 1990). On average, natural disasters such as earthquakes, hurricanes, or tornadoes happen somewhere on the earth each day. What these horrific natural events have in common is the ability to affect many people at the same time but in different ways. Disaster workers can be both directly and indirectly affected by their work in these events. Lundin and Bodegard (1993) reported that the impact of the disaster on emergency workers is dependent upon several factors. First, the impact involves the harshness of the environment of the rescue operation. The harshness can be defined as the weather conditions, travel distance of the rescue teams, and the number of victims. Another aspect is the demography of the victims whom the disaster workers are trying to aid. Lundin and Bodegard suggest additional examples of this, including whether the victims have the same language and ethnic, religious, or cultural backgrounds; have the same interests; or, are members of a shared occasional group, such as plant or office workers. Finally, McFarlane (1987) notes

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that “personal factors of the rescue workers such as maturity, level of education, amount of emergency service training, and earlier experiences in disaster response strongly influence the reactions of disaster workers” (p. 367). EMS personnel deal with the sociocultural consequences of disaster at interpersonal levels. Not only do they experience the loss of life and physical disability of disaster victims, but the financial, interpersonal, and spiritual losses within the survivors (Raphael, Singh, Bradbury, & Lambert, 1983). As such, vicarious traumatization continues to be a concern for the rescue worker.

Previous Counseling Interventions for Emergency Personnel A process to treat and prevent stress reactions, called critical incident stress debriefing (CISD), was introduced to emergency personnel by Mitchell in 1983. CISD became a widely accepted protocol for use by emergency service agencies such as law enforcement, fire department, paramedical and rescue teams, and emergency room staff (Wilson, 1995). CISD evolved over time into a more comprehensive process involving a multicomponent work-based systems approach to helping EMS workers deal effectively with the traumatic and highly stressful components of their work. This evolved process was titled critical incident stress management (CISM; Mitchell & Everly, 1997). CISM was adopted in 2000 by the National Transportation and Highway Safety Administration (NTHSA, 2002) as the part of the national curriculum for Emergency Medical Technicians and Paramedics, which deals with the stress reactions and the well-being of the EMS provider. NTHSA, the federal agency that regulates EMS training in America, has made attempts at addressing PTSD and burnout among emergency health workers. This process of CISM involves a team approach based upon a partnership of mental health professionals and a peer support group. The team helps the affected individual express his or her feelings toward a particular event or situation that had a strong emotional effect for the individual (Mitchell & Bray, 1990). CISM engages in an open discussion that relies on group support for helping participants overcome the stress brought about by a particular event (Mitchell & Everly, 1997). The five core components of CISM include the following: 1. 2. 3. 4. 5.

Early intervention treatments for EMS providers exposed to critical incidents Provision of psychosocial support to rescuers in need An opportunity for expression of thoughts and feelings Crisis education Assistance in the development of coping mechanisms

Mitchell dictates “that of all these components should be administered with cultural understanding and sensitivity” (p.116). Furthermore, he describes that a disruption in one of these components can exacerbate stress reactions. Also, PTSD can create negative effects on the way care givers perform their duty. CISM programs consistently yield very positive comments in surveys and studies (Everly, Flannery, & Mitchell, 2000). Even studies that cited evidence of the lack of efficacy of CISM still reported high perceived helpfulness of the debriefing process by participants (Hytten & Hasle, 1989; Kennedy, et al., 1996; Rogers, 1996). American College of Emergency Physicians (ACEP [2000]) indicates that “CISM involves a partnership between mental health professionals and a peer support group of emergency workers. This partnership allows participants to express their feelings toward a particular situation that had a strong emotional effect and should be used as the mainstay for EMS provider wellness” (p. 62).

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Although CISM has been identified as a process for the management of critical incident stress, little is known about cumulative stress and its effects on EMS workers. In fact, I found no studies on cumulative stress reactions among emergency providers. CISM commonly is used in day-to-day high-impact incidents, but not for day-to-day low-impact incidents. Cumulative stress continues to be a significant problem for emergency workers, and it typically goes unaddressed. Better ways to support emergency workers from the long-term psychological effects of their job and a clearer understanding of the subculture of rescue work is needed.

The Culture of the Rescue Worker and Current Counseling Approaches Paramedics, police officers, fire fighters, and other emergency workers know that they are the first to respond to horrific events on a daily basis. The reality of encountering extremely physically and emotionally traumatic situations, especially those involving disasters and major emergency responses, is an accepted part of the profession (Mitchell, 1981; Rapheal, 1977). As a result, the first responders to medical emergencies and traumatic injury experience an intense, yet controlled release of emotions because of these catastrophic events. This unique experience helps to define the subculture of the emergency worker. Mitchell and Bray (1990) outlined personality characteristics common to emergency service providers. Labeled as rescue personality traits, EMS personnel tend to be detailoriented, set high performance standards, and be very dedicated. Additionally, rescuers are quick decision-makers and are action-oriented (See Table 22.6). Understanding the rescue personality is an important part of gaining entry into the subculture of emergency service providers. Working in emergency service professions exposes an individual to significant suffering and pain. Counseling interventions should focus on helping rescuers to understand their emotions and use that insight to help the victims who have called for their care (Tracy, 2006). EMS personnel need counseling models, which help them frame and control their emotions, rather than compiling a symptom inventory checklist of their physical and emotional reactions. Existential rather than cognitive and behavioral approaches may be advantageous for this specialized counseling population. Existential theory (ET) orientations provide a viable therapeutic system because they help the emergency worker to verbalize, converse, question, and debate the horrific and stressful experiences they encounter. There are four key therapeutic issues in existential psychology. They include the search for meaning from life experiences, exploring feelings of isolation, developing an understanding of freedom, and the acceptance of death. EMS providers are faced with many of these issues at once. Focused listening and Socratic

Table 22.6 General Personality Traits of Emergency Service Providers Thinking patterns:

Behavioral patterns:

Detail oriented

Action oriented

Obsessive

Quick decision makers

Easily bored

Risk takers

Highly dedicated

Need to be in control

Need to be needed

High need for stimulation

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dialogue are the main techniques as the counselor listens for themes in the client’s talk that reflects struggles with meaning and identity (Day, 2007). The main objective is to help the emergency workers restructure attitudes about themselves and their chaotic environment. This self and environmental awareness can lead to positive new attitudes about the work. The ultimate outcome would be to help rescuers not become trapped by past decisions, events, or patterns of behavior. Using the ET approaches would focus emergency workers on the importance of life-saving work and help the rescuer define the meaning of his or her existence. Mental health professionals need to work with families of emergency workers as well. Counseling and psycho-educational services should focus on assisting family members to gain insight into the stresses of emergency work and on helping their loved ones to employ effective coping strategies for the management of job-related stress. Most importantly, frequent referral and follow-up of EMS workers exposed to cumulative stress must occur. Working with EMS personnel in essence is a counseling specialty. Training on cumulative stress and stress management, in general, must be an ongoing process during therapy sessions with rescue workers. Professional counselors should be aware of the specific stressors unique to rescue work and tailor counseling interventions to meet the needs of this special population. Finally, counseling theory grounded in ET can be a useful approach in helping EMS and their families make meaning out of human suffering.

COUNSELING IMPLICATIONS Disaster mental health has many implications for counselors and really should be viewed as a counseling subspecialty. Mental health professionals are likely to be called to duty to help populations affected by disaster. It is important for them to understand the nature of the disaster and how to work with emergency service providers. Prior knowledge of the disaster response is important. Preservice education on disaster mental health is needed. Such preservice training should include the skills of triage and assessment that are commonly used in disaster areas. The work environment of a counselor changes during disasters. The tranquil office is moved to a school, church, or nosey community center. The office may become mobile and move from street to street as the rescue and recovery efforts progress. In a disaster, counselors must be able to adapt their intervention approaches to meet the needs of the population as well as the demands of the environment, as dictated by the catastrophe. A thorough knowledge of the psychological effects of disaster is needed by all counselors. Counselors routinely should practice the skills of PFA. Professional counselors also should be aware of their changing role as the phases of disaster recovery progress. Oftentimes, counselors themselves are victims—a tornado does not skip over a home because there is a healer inside. Therefore, it is important to recognize that healers may be experiencing the same psychological effects as the population of a region. Counselor self-awareness is extremely important as the chaos of a disaster encompasses the counselor’s environment. Response protocols usually dictate that counselors from other communities be used for psychological response efforts, but, as stated earlier in this chapter, infrastructure damage may delay the arrival of out-of-town helpers. In the event of regional disasters, many towns are affected, and the arrival of counselors is dependent upon their ability to gain entrance into the area from other parts of the country. This process may take many days to organize. These factors place counselors at high risk for secondary traumatization and other stress reactions. Counselor awareness

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and supervision are essential for practitioners functioning in a disaster area. Whenever possible, one experienced clinical supervisor should be identified to provide only supervision services. This supervisor should not participate in any other duties in the disaster response and should concentrate all of his or her efforts on helping the healers.

CONCLUSION No one is immune to a natural disaster. Counselors can expect to be called to service several times during their career to help populations cope with the psychological consequences of a disaster. Counselors themselves often become a survivor of these events. It is important for healers to review disaster scenarios with emergency management agencies ahead of time. Counselors need to learn and practice their roles in a disaster and work as part of the emergency services team. All professional counselors should be aware of the stages of disaster response and be competent practitioners of PFA and triage. Counselors need to be aware of the cultural nature of disasters. The poor, elderly, and young children are at greatest risk for the development of psychological trauma from a disaster. Rescue personnel need immediate and long-term attention to help them deal with the psychological cost of caring. Specialized training and continuing education on disaster mental health is a mandate for our profession and continues to emerge as our dynamic planet changes as a result of global warming. The question is not will you be called to service, but when?

RESOURCES American Counseling Association (http://www.counseling.org/sub/dmh/resources.aspx) 5999 Stevenson Avenue, Alexandria, VA 22304 800-347-6647 American Psychiatric Association (http://www.psyh.org/Resources?DisasterPsychiatry.aspx) 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209 703-907-7300 American Psychological Association Disaster Response Network (http://www.apa.org/practice/ drindex.html) 750 First St. NE, Washington DC, 20002 800-374-2721 American Red Cross (http://www.red cross.org) 2025 E Street NW, Washington, DC 20006 202-303-5000 Centers for Disease Control and Prevention (http://emergency.cdc.gov) 1600 Clifton Road, Atlanta, GA 30333 800-232-4636 Federal Emergency Management Agency (http//www.fema.gov/hazards/index.shtm) 500 C Street, Washington, DC, 20472 U.S. Department of Education (http://www.ed.gov/admins/lead/safety/training/responding/crisis) Crisis Response: Creating Safe Schools 400 Maryland Avenue, Washington, DC, 20024 1-800-USA-LEARN

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U.S. Department of Health and Human Services, Office of Minority Affairs. (n.d.). Cultural competency curriculum for disaster preparedness and crisis response. Retrieved from https://cccdpcr. thinkculturalhealth.hhs.gov/ U.S. National Response Team (http://www.nrt.org) 800-424-8802

REFERENCES American College of Emergency Physicians. (2000). Emergency medical technician basic field care (2nd ed.). New York, NY: Mosby. American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders. Washington, DC: Author. American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders. (2nd ed.). Washington, DC: Author. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., text rev.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Baum, A. (1987). Toxins, technology, & natural disasters. In G. R. VandenBos & B. K. Bryant (Eds.). Cataclysms. Crises and catastrophes: Vol. 6 Psychology in Action (pp. 5–33). Washington, DC: American Psychological Association. Day, S. X. (2007). Theory and design in counseling and psychotherapy (2nd ed.). New York, NY: Houghton Mifflin. Dyregrov, A. (1989). Caring for helpers in disaster situations: Psychological debriefing. Disaster Management, 2(1), 25–30. Dyregrov, A., & Mitchell, J. T. (1992). Work with traumatized children: Psychological Effects and coping strategies. Journal of Traumatic Stress, 5(1), 5–17. Everly, G. S., Jr. (1995). The role of critical incident stress debriefing (CISD) process in disaster counseling. Journal of Mental Health Counseling, 17(3), 278–290. Everly, G. S., Jr., Flannery, R. B., Jr., & Mitchell, J. T. (2000). Critical incident stress management: A review of the literature. Aggression and Violent Behavior, 5, 23–40. Farberow, N. L., & Gordon, N. S. (1981). Manual for child health workers in major disasters (DHHS Publication No. ADM. 81-1070). Rockville, MD: National Institute of Mental Health. Figley, C. R. (1998). Introduction. In C. R. Figley (Ed.), Burnout in families: The systemic costs of caring. Boca Raton, FL: CRC Press. Freud, S. (1920/1956). Beyond the pleasure principal. New York, NY: Liveright. Gist, R., & Lubin, B. (1999). Responseto disaster: Psychosocial, community and ecological approaches. Philadelphia, PA: Taylor & Francis. Herman, J. L. (1992). Trauma and recovery. New York, NY: Basic Books. Hodgkinson, P. E., & Stewart, M. (1991). Coping with catastrophe: A handbook of disaster management. London, United Kingdom: Routledge. Jankoski, J. A. (2002). Vicarious traumatization and its impact on the child welfare system (Doctoral dissertation). Ann Arbor, MI: UMI Dissertation Services. Kenardy, J. A., Webster, R. A., Lewin, T. J., Carr, V. J., Hazell, P. L., & Carter, G. L. (1996). Stress debriefi ng and patterns of recovery following a natural disaster. Journal of Traumatic Stress, 9 (1), 37–49. Lundin, T., & Bodegard, M. (1993). The psychological impact of an earthquake on rescue workers: A follow-up study of the Swedish group of rescue workers in Armenia, 1988. Journal of Traumatic Stress, 6(1), 129–139.

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McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3 (1), 131–149. McFarlane, A. C. (1987). Life events and psychiatric disorder: The role of a natural disaster. The British Journal of Psychiatry, 151, 362–367. McSwain, N. (2003). Basic Emergency Medical Technician. Inglewood, CA: Mosby. Mitchell, J. T. (1981, November). Acute stress reactions and burnout in pre-hospital emergency medical services personnel. Paper presented at the First National Conference on Burnout, Philidelphia, PA. Mitchell, J. T. (1983). When disaster strikes . . . the critical incident stress debriefing process. Journal of Emergency Medical Services, 8 (1), 36–39. Mitchell, J., & Bray, G. (1990). Emergency services stress: Guidelines for preserving the health and careers of emergency service personnel. Englewood Cliffs, NJ: Prentice Hall. Mitchell, J., & Everly, G. (1996). Critical incident stress debriefing: An operations manual for the prevention of traumatic stress among emergency service and disaster workers. Ellicott City, MD: Chevron Publishing. Mitchell, J. T., & Everly, G. S., Jr. (1997). The scientific evidence for critical incident stress management. Journal of Emergency Medical Services, 22(1), 86–93. National Transportation and Highway Safety Administration. (2002). National curriculum for emergency first responders. Retrieved from http:www.nhtsa.dot.gov/people/injury/ems/pub/frnsc/.pdf Rapheal, B. (1977). The Granville train disaster: Psychological needs and their management. Medical Journal of Australia, 1(9), 303–305. Raphael, B., Singh, B., Bradbury, L., & Lambert, F. (1983). Who helps the helpers? The effects of a disaster on rescue workers. Omega, 14 (1), 9–20. Rapheal, B., & Wilson, J. P. (1993). Theoretical and interventional considerations in working with victims of disaster. New York, NY: Plenum Press. Rapport, J. L., & Ismond, D. R. (1996). DSM IV training guide for diagnosis of childhood disorders. Levitttown, PA: Brunner Printing. Rogers, O. W. (1996). An examination of critical incident stress debriefing for emergency services providers: A quasi-experimental filed study (Doctoral dissertation). Ann Arbor, MI: UMI Dissertation Services. Robinson, R. (1997). Evaluation of the Victorian ambulance crisis counseling. Melbourne, Australia: Victorian Ambulance Crisis Counseling Unit. Robinson, R. C., & Mitchell, J. T. (1993). Evaluation of psychological debriefing. Journal of Traumatic Stress, 6(3), 367–382. Schnyder, U. (1997). Crisis intervention in psychiatric outpatients. International Medical Journal, 4(1), 11–17. Tracy, S. (2006). How cumulative stress affected the lived experience of emergency medical service workers after a horrific natural disaster: Implications for professional counselors. Unpublished doctoral dissertation. Duquesne University. van der Kolk, B. A., & McFarlane, A. C. (1996). The black hole of trauma. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and soul. New York, NY: Guilford Press. Wilson, J. P. (1995). The historical evolution of PTSD diagnostic criteria: From Freud to DSM-IV. In G. S. Everly & J. M. Lating (Eds.), Psychotraumatology: Key papers and core concepts in post-traumatic stress (pp. 9–26). New York, NY: Plenum Press.

CHAPTER 23

Genocide, Ethnic Conflict, and Political Violence KIRRILY PELLS AND KAREN TREISMAN

INTRODUCTION The evolution of trauma as a psychological concept is intimately connected with the shifting nature of warfare during the twentieth century. The term shell shock was introduced to explain the trauma exhibited by soldiers following the First World War. It was understood as being due to soldiers’ inner vulnerabilities being brought to the surface. This was challenged by research emanating from later conflicts, specifically Vietnam and the pioneering work of psychiatrist Robert Lifton (1973), which formed the basis for the diagnosis of posttraumatic stress disorder (PTSD). In more recent years, conflicts and specifically genocide and ethnic cleansing such as in Rwanda (1994), Bosnia (1992–1995), and Darfur (2003–2009) once again have challenged conventional understandings of trauma and PTSD. Psychologists and psychiatrists engaging with individuals and societies affected by interethnic violence have become increasingly critical of the universal applicability of a narrowly biomedical model based on Northern notions of trauma (Bracken, 2002; Boothby, Strang, & Wessells, 2006; Jones, 2004; Summerfield, 1999, 2001, 2002).1 This is not to deny that trauma can be conceived in biological and psychological terms, but an overemphasis on symptomology and intrapsychic functioning results in the divorce of the mind from the body, the individual from the community, and the community from the war-torn environment. The purpose of this chapter is to review the preceding critiques and to advocate for the need to incorporate a sociological and anthropological approach, one that is underpinned by a firm commitment to human rights and that can inform work with survivors of genocide, ethnic conflict, and political violence. A major aim of this discussion is to identify the challenges for practitioners, both of working within the societies in which the violence was perpetrated and those arising when working with refugee and asylum-seeking populations in exile, with particular reference to understanding sociocultural processes of meaning-making, multiple identities, losses, disempowerments, resiliency, agency, and calls for justice. The goals of this chapter are accomplished by 1 This chapter uses the terms North/South (rather than developed/developing, First/Third, West/ Third, majority/minority) to refer to structural inequalities in global, political, and economic relations, including those between donor countries and agencies and recipient countries and organizations. While each set of terms is problematic, the North/South polarity is perhaps the least confusing and so used here.

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the discussion of relevant issues in the following sections: definitions, trauma and meaningfulness, multiple loss and disempowerment, helping refugees and asylum seekers access a range of services, bearing witness, engaging with the political and counselling implications. These major sections are following by a summary conclusion of the chapter and helpful resources for instructors, students, and practitioners.

DEFINITIONS Given the enormity of this topic, it is necessary to define carefully the most relevant terms. These are discussed briefly in the following subsections and include genocide, ethnic cleansing, political violence, and “unfathomable trauma.”

Genocide Genocide is not a new phenomenon. From the campaign of Athens against Melos, through the crusades of the Knights Templar and Mongol conquests, to the decimation of the indigenous peoples of the Americas and Australia, the deliberate destruction of groups of people because of who they are is a constant refrain of human history (Chalk & Jonassohn, 1990; Levene, 2000). However, genocide as a concept came into being in the wake of the Holocaust, defined legally within the United Nations (UN) Convention on the Prevention and Punishment of the Crime of Genocide (1948, Article 2). The Convention defines genocide in the following way: . . . as any of a number of acts committed with the intent to destroy, in whole or in part, a national, ethnic, racial or religious group, as such: a) Killing members of the group; b) Causing serious bodily or mental harm to members of the group; c) Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part; d) Imposing measures intended to prevent births within the group; e) Forcibly transferring children of the group to another group. The Convention has been criticized for privileging certain “groups” of people over others (Hinton, 2002) and needing to evolve to address more recent crises such as Darfur, Sudan (Shaw, 2007). It has however led to the prosecution of some of the architects of genocide in Rwanda and Bosnia and less successfully established the obligation on the international community to intervene in preventing genocide.

Ethnic Cleansing Ethnic cleansing is a more contested term, defined by the UN (1994) as “a purposeful policy designed by one ethnic or religious group to remove by violent and terrorinspiring means the civilian population of another ethnic or religious group from certain geographic areas” (para. 130). Critics have argued that it is an attempt to water down the Genocide Convention, which carries the obligation on the international community to intervene in order to prevent its occurrence (Shaw, 2007). For example, there is considerable disagreement about the 1992–1995 “Bosnian War.” Legally, the only part of the conflict deemed to be genocide is the 1995 Srebrenica massacre, where more than 8,000 Bosnian Muslim (Bosniak) men and boys were killed by Bosnian Serb forces in a designated UN safe area (Bosnia and Herzegovina v. Serbia and Montenegro, 2007; Prosecutor v. Radislav Krstic´ , 2001). Other cases before the UN established International

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Criminal Tribunal for Yugoslavia have been ruled to be ethnic cleansing, war crimes, and crimes against humanity rather than genocide, arguing that it was not possible to demonstrate the “intention to destroy” (Liberman, 2010). This is despite the following: massacres in Prijedor, Focˇa, and Višegrad; the systematic rape of women and girls; the establishment of concentration and rape camps; the forcible expulsion of large numbers of the population; and the destruction of cultural heritage and ways of life through the demolition of places of worship, cemeteries, and historical buildings associated with a particular ethnic group.

Political Violence Political violence is a much broader concept still and without an exact legal definition in international law. The closest definition, perhaps, is the concept of “crimes against humanity,” as propounded by the Rome Statute of the International Criminal Court (United Nations, 1998), which was set up to try cases of genocide, crimes against humanity, and war crimes. According to the Statute, crimes against humanity include any of the following acts when committed as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack: (a) Murder; (b) Extermination (including the deliberate deprivation of access to food and medicine); (c) Enslavement (including trafficking in particular of women and children); (d) Deportation or forcible transfer of population; (e) Imprisonment or other severe deprivation of physical liberty in violation of fundamental rules of international law; (f) Torture; (g) Rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization, or any other form of sexual violence of comparable gravity; (h) Persecution against any identifiable group or collectivity on political, racial, national, ethnic, cultural, religious, gender grounds; (i) Enforced disappearance of persons; (j) The crime of apartheid; (k) Other inhumane acts of a similar character intentionally causing great suffering, or serious injury to body or to mental or physical health. (Rome Statute of the International Criminal Court, 1998, Article 7) Crimes against humanity may take place during genocide or ethnic cleansing, as illustrated by the case of Bosnia. The United Nations ruled in 1976 that apartheid in South Africa constituted such crimes against humanity, and the International Criminal Court has charged Sudanese President Al Bashir with genocide, war crimes, and crimes against humanity in relation to the targeting of civilians in Darfur.

Unfathomable Trauma The psychological construct of “trauma” has been defined in other chapters in this book. However, as profound as the experience of trauma is on an individual basis, in the face of genocide, the lived experience of trauma becomes an unfathomable concept to grasp. In order to try to understand the enormousness of the traumatic aspect of genocide, we need to operate within a broader paradigmatic framework. Thus, moving from a psychological and legal level to a more sociological and political perspective, four key themes emerge. First, mass ethnic and political violence is a collective experience, with individuals targeted because of their identity as a member of a group or

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collectivity. Their social fabric is ripped apart, and the bonds between individual and community are severed, with the result that the entire “social universe itself becomes the victim” (Nordstrom, 1997, p. 169). Second, mass ethnic and political violence results in the destruction of the physical, social, psychological, and spiritual world through attempts to eradicate entire groups or collectivities and their ways of life. Hinton outlines the “incalculable” nature of the consequences of genocide as encompassing material devastation (e.g., the destruction of homes, property and infrastructure; poverty, malnutrition, and starvation; economic collapse), human suffering (e.g., bodily injury; bereavement and intense grief; trauma; chronic fear; mental health problems; living with perpetrators; continued discrimination and structural violence), and social turmoil (e.g., dislocated populations; the loss or disappearance of family, friends, and relatives; the destruction of social institutions and networks; lingering hatreds). (Hinton, 2002, p. 12) “Trauma” is therefore very much ongoing, not just as a psychological construct, but it is also firmly embedded in daily lives, relationships, and environments. Third, to facilitate these processes of destruction, one “group” constructs itself as superior and subjugates “the other” as inferior, the outsider, dangerous, and impure. For example, Nazi propaganda blamed the Jews for the economic depression in Germany and construed them as subhuman, in contrast to the pure Aryan race; the Nazis viewed the Jews as threatening to overrun the country. Likewise, in Rwanda, the Hutu Ten Commandments, disseminated by the extremist regime during the early 1990s, portrayed Tutsis as dishonest and as threatening the country and the supremacy of Hutus, and they depicted them as cockroaches that needed to be exterminated. As emerges in the following sections, this repeated discrimination, dehumanization, and disempowerment can be compounded in the present, through engagement with the asylum system and nonreflexive health services. Finally, genocide and ethnic violence are inherently political acts. Engaging with questions of politics, justice, and agency are therefore inescapable. These four themes pose specific challenges for practitioners and ways of working with trauma survivors of genocide and ethnic violence, not the least of which is the reality that interventions usually are developed in the North or for working with northern clients. The implications of these challenges are discussed in more depth in the following three sections before turning to some specific considerations for practice.

“THE MAGIC CIRCLE OF EVERYDAY LIFE”: TRAUMA AND MEANINGFULNESS Patrick Bracken (2002) uses the metaphor of the “magic circle of everyday life” to convey how our sense of meaning is constructed from the world around us, at once both “wonderful and mysterious” as well as one which “connotes a feeling of fragility and precariousness” (p. 3). Bracken poses the question of what happens if we step outside the magic circle of everyday life. However, we would argue that instead of the individual “blundering outside” the circle, in the case of conflict, violence comes inside this circle, attempting to destroy the structures and processes of daily life. Numerous studies have argued that PTSD is a universal response to traumatic incidents (Dyregrov, Gupta, Gjestad, & Raundalen, 2002; Marsella, Freidman, Gerrity, & Scurfield, 1996). Although the physiological and neurological components of trauma symptoms may well exist universally (Marsella & White, 1982; Perrin, Smith, & Yule, 2000, p. 278), the meanings given to the symptoms are shaped by a host of other factors, including history, culture, religion, politics, and personal life experiences (Bracken,

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2002; Jones, 2004; Patel, 2003; Summerfield, 1999, 2004). This creates what Kleinman (1977) terms the category fallacy. For example, nightmares are designated as a symptom of PTSD, yet it depends whether a given society regards nightmares as significant or problematic as to whether they may be reported (Bracken, 2002, p. 75). Moreover, the ways in which the symptoms are interpreted may vary according to local ways of understanding and meaning-making. While in the North, “medicalized ways of seeing have displaced religion as the source of everyday explanations for the vicissitudes of life and the vocabulary of distress,” in other societies, religious or cultural beliefs still shape understandings (Summerfield, 2004, p. 233). So nightmares “may convey messages from ancestors. Survivor guilt may be seen as an essential preliminary to ritual reparations for the dead” (Jones, 1998, p. 243). Thus, there exists a discrepancy between PTSD symptoms that are argued to exist universally and how they are understood locally. Instead, any successful intervention requires an understanding of local knowledge and processes of meaning-making. As Summerfield states, Human responses to war are not analogous to physical trauma: people do not passively register the impact of external forces (unlike, say, a leg hit by a bullet) but engage with them in an active and problem-solving way. Suffering arises from, and is resolved in, a social context, shaped by the meanings and understandings applied to events. [ . . . ] Helping agencies have a duty to recognise distress, but also to attend to what the people carrying the distress want to signal by it. (Summerfield, 1999, p. 1454) Wessells and Monteiro (2000) document a case of an Angolan orphanage where the children exhibited typical clinical symptoms of trauma including nightmares, bedwetting, and concentration problems. The children believed a spirit was haunting the building, and so the Christian Children’s Fund (CCF), now named ChildFund International, called on a local healer to perform a ritual for spiritual purification. Subsequently, the trauma symptoms diminished and the relationship between the children and adults improved. The CCF modified their projects as a consequence of this experience to work more closely with local healers, including holding seminars where traditional beliefs and practices could be understood by Non-Governmental Organization (NGO) staff, and discussions took place on the integration of “Western-based, expressive methods with the local, ritual-focused methods” (Wessells & Monteiro, 2000, p. 180–181). Consequently, Wessells and Monteiro (2000) argue that by developing a hybrid program combing perspectives from both cultural systems, a more holistic and context-specific understanding of healthy child development was gained and was thus reflected in the success of the projects. The lack of official, formal structures for dealing with the consequences of violence, especially in rural areas, increases the importance of “the creative members of the culture such as healers, visionaries and performers” (Nordstrom, 1997, p. 191). Within communities, these individuals are vital for “not only their abilities to imagine, but to convey these images to others so that they too may share in the reconstruction of their symbolic and social universes” (Nordstrom, 1997, p. 191). In processes of rebuilding, social relations can be strengthened through rituals reaffirming the place of an individual in his or her family and community, thus restoring a sense of belonging and acceptance on both sides. At the same time, care must be taken not to “romanticiz[e] local traditions in ways that obscure important questions about efficacy and ethics” (Wessells & Monteiro, 2000, p. 184). Therefore, society must be wary, as Cleaver (2001) warns, against the “danger of swinging from one vulnerable position (we know best) to an equally untenable and damaging one (they know best)” (p. 47).

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Accompanying understandings of local processes of meaning-making is the need to understand the priorities of survivors who often “are largely directing their attention not inwards, to their mental processes, but outwards to their devastated social world” (Summerfield, 1999, p. 1454). This is particularly the case in non-northern societies, which are not as individualistic and see the mind/body/spirit and world around as interconnected (Jones, 1998; Summerfield, 1999). Psychiatrist Lynne Jones concluded from her research in Goradže, which is located in Bosnia-Herzegovina, that the lasting well-being of the children did not correlate solely with the amount or length of violence to which the children had been exposed to or with the ratings on PTSD scales. Instead, what mattered was “how personally disruptive the event had been: What had happened to their family and friends and the landscape in which they lived?” (Jones, 2004, p. 245). Consequently, she argues throughout her work that “the main psychic injury of war is the disruption of those ties, the destruction of identity through the destruction of our social world” (Jones, 1995, p. 510). This suggests that continuity of the activities of daily life, such as going to school, can be influential (Shalhoub-Kevorkian, 2006). Therefore, interpreting the responses of survivors solely through the symptomology of the Diagnostic Statistical Manual of Mental Disorder (DSM) criteria for PTSD can fail to capture what is prioritized by survivors as problematic in their lives and thus which factors adversely affect their well-being. For those who remain in the countries where the atrocities were perpetrated, challenges are presented not only with the destruction of the physical and social landscape but also with having to live alongside those who perpetrated such atrocities (Pells, 2011). Everyday encounters and objects can serve as a constant reminder of the past, particularly in contexts such as Rwanda, where neighbors killed neighbors using everyday implements, such as machetes. Veena Das (2000) develops the notion of “poisonous knowledge” to describe this interaction between past and present. Das argues that if it were “one’s way of being-with-others” that “was brutally injured, then the past enters the present not necessarily as traumatic memory but as poisonous knowledge” (p. 208). Past events are not “present to consciousness as past events” but instead have come “to be incorporated through an individual’s thoughts and actions into the temporal structure of relationships” (Das, p. 220). The knowledge of past events thus can cause the destruction of social relations within families and the community, highlighting the interconnection between the experience of the individual and the community. This is reflected in the following Rwandan’s description of life, postgenocide: People are living peacefully, but actually they are avoiding one another. The atmosphere is chill. Danger is watching from both camps. We can be humble and nice, we’ll share, we’ll co-operate as we should. But believing them is unthinkable. (Hatzfeld, 2009, p. 212) It is not necessarily just the memories of the events themselves that are problematic, but the ways in which the knowledge of these events are used in the present. Although mental health practitioners cannot be expected to address all of the consequences of genocide and ethnic and political violence, this does suggest the need for a more expansive understanding of “recovery.” This is one which encompasses all areas of everyday life, the importance of external factors as sources of distress, and the recognition of local ways of interpreting experiences and restoring sense of normality. In a similar manner, Levers, Kamanzi, Mukamana, Pells, and Bhusumane (2006) have emphasized the importance of considering the whole community in addressing emergent mental health needs after genocide or political violence.

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“THIS IS WORSE THAN THE TORTURE I SUFFERED BEFORE”: MULTIPLE LOSS AND DISEMPOWERMENT The totality of the destruction wrought by genocide and ethnic oppression can result in a sense of multiple losses among survivors. Patel (2003) describes the intersection of multiple losses common among those living in exile: . . . the loss of home, of homeland; the loss of health, of role, language and culture; the loss and separation from family, friends, compatriots; the loss of identity, dignity, purpose and opportunity in life. The loss of hope . . .: the hope of justice, the hope of recognition, the hope of safety and protection, and the hope of a life without fear (p. 18). Past traumas are compounded by ongoing struggles and feelings of discrimination and disempowerment in the present and can be compounded by encounters with health systems not equipped to meet the complex needs of refugees and asylum seekers (Patel, 2003). Patel (2003) describes how a combination of a harsh (legal) asylum system, racism, detention, poverty, homelessness or very poor housing, difficulties in accessing health services, isolation and continued uncertainty in exile is often subjectively described by refugee people thus: “this is worse that the torture I suffered before” or “this is torture in an open prison, there are no four walls, but we are imprisoned and treated like criminals, not even like humans” (p. 18). Whereas violence hinders the ability of individuals and societies to carry out the actions of daily life, recovery and healing are dependent on regaining agency. The meaning of agency here is important and follows that ascribed by Robson, Bell, and Klocker (2007), being “an individual’s own capacities, competencies, and activities through which they navigate the contexts and positions of their lifeworlds fulfilling many economic, social and cultural expectations, while simultaneously charting individual/collective choices and possibilities for their daily and future lives” (p. 135). This underscores again the importance of health services adopting a holistic approach, which builds on individual and communal capacities and resilience. The vulnerability versus resilience debate has the tendency to become black and white, with individuals depicted as either vulnerable or resilient (Shalhoub-Kevorkian, 2006). To overcome this polarity, Jareg proposes viewing resilience as a “mobile capacity” rather than a “fixed quality” (Jareg, cited in Wessells, 2007, p. 6). Instead, health services are based frequently solely on a biomedical model, which pathologizes rather than builds on strengths and sources of resilience. The interpretation of experience lies in the hands of professionals (usually from the North or trained in the North and reflecting northern values). This can be disempowering, potentially and fundamentally, for survivors, as other ways of understanding or interpreting a situation are discredited by the authority invested in medical science (Breslau, 2004; Kostelny, 2006; Patel, 2003). The experiences of individuals and communities can be seized, interpreted, or reframed in another alien language: psychological discourse. Traumatic incidents usually take the form of individuals being placed in situations over which they have limited or no control. Often, survivors speak of having their identities erased and of no longer having a sense of who they are (Herman, 1992). In spite of this, however, people still possess their own voice, even if they do not have

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the capacity or the wish to use it, as well as their narrative of what happened. These are potentially powerful tools to restore a sense of meaning to the self and to life. To have this taken away or silenced through being told how to think or feel and being rewritten and interpreted in an alien discourse is a further violation of the self and is fundamentally disempowering. In such instances, individuals are once again in positions over which they have limited influence with their fate lying largely in the hands of another. Moreover, the trauma discourse, if inappropriately applied, can pathologize normal coping responses and can generate passivity through designating people as “victims” (Baker & Shalhoub-Kevorkian, 1999; Jones, 2004; Wessells, 2006). For example, numbness can protect an individual from feeling the full intensity of emotion and from becoming unable to cope with life. Likewise, the desire for revenge toward killers is reinterpreted as a sign of poor mental health (Hughes & Pupavac, 2005; Summerfield, 2002). It might not be a “good” or even a “healthy” emotion, but it is hard to dispute its normality for people who have lost family members. While giving a name to a group of symptoms can be useful in affirming that an individual is suffering from an illness and is thus blameless, it also can have serious repercussions, particularly because of the stigma associated with mental illness in many societies (Dowdney, 2007; Summerfield, 2002; Wessells, 2006). Distress does not necessarily equate with clinical disturbance (Wessells, 2006). Although the majority of any war-torn society grieves for lost loved ones and becomes distressed by the impact of conflict on their daily lives, this does not mean that they are mentally ill. Grieving is a natural and normal human response to loss. Wessells uses the image of a pyramid to depict the range of responses to conflict. The bottom layer of the pyramid represents the 50% of the population who “have experienced shock, grief, economic losses and other stressors but are relatively resilient and function normally as defined in the social context” (Wessells, 2007, p. 3). The middle segment consists of the 40% of the population “who remain relatively functional but who have been affected; are at risk of becoming worse if they do not receive support” (Wessells, 2007, p. 3). It is only the remaining 10% in the top tier who “exhibit crippling trauma, depression, or anxiety; are dysfunctional; and need intensive care and psychosocial interventions” (Wessells, 2007, pp. 2–3). Outsiders who intervene in the aftermath of genocide or political violence need to take care not to exacerbate existing inequalities. The dangers of failing to consider the balance of power within societies are exhibited in Argenti-Pillen’s (2003) study of the “Cinnamon Garden culture.” The “Cinnamon Garden culture” refers to the central Colombo location of many of the Sri Lankan mental health NGOs. The Sri Lankan workers have translated “the humanitarian discourse on trauma into Sinhalese, using parallel concepts such as fear, terror and violence” (Argenti-Pillen, 2003, p. 202). However, this process has been conducted by those in authority who are part of the Colombo elite resulting in a “discursive distance” between the “knowledge brokers” and the communities with whom they work. This has enabled the manipulation of knowledge to support concepts according to Orthodox Buddhism, over and against “the heterodox, synergetic religious practices of Sinhalese Buddhist villagers” (Argenti-Pillen, p. 204). Consequently, Argenti-Pillen argues that the introduction of foreign concepts has exacerbated preexisting inequalities in Sri Lankan society and served “to sponsor the nationwide spread of religious extremism and intolerance” (Argenti-Pillen, p. 204). Therefore, any intervention needs to take the utmost care in fi rst understanding local power dynamics and socially inscribed roles, according to gender, ethnicity, social class, and other identities such as sexual orientation.

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BEARING WITNESS: ENGAGING WITH THE POLITICAL Genocide and ethnic conflict and political violence are all political acts, and so working with survivors necessitates engaging with political questions, both within one’s own work, as well as within a broader context. As Jones (1998) states, it is important to be clear that this is not “party politics but politics with a small ‘p’; that is, our beliefs and practices about the exercise of power and government in organized society, most of which express underlying moral values” (p. 239). This means not only addressing issues of power and inequalities in one’s own therapeutic work but addressing the root causes of trauma “in the structures, political and social processes and conditions which enable social injustices and torture to continue, with impunity” (Jones, 1998, p. 243).

Addressing Injustice “We are not mad, we are betrayed” was the response of a Bosnian refugee to researchers from a mental health project pilot (Summerfield, 2002, p. 1106). The refugee resented the “problem” being presented as a matter of individual illness rather than a collective, moral, and political issue. Although psychological interventions can assist survivors in coping with traumatic experiences, they rarely address the root of human rights violations and injustice. While this may not be the remit of therapists per se, it raises important questions of power, politics, and justice, which surface in work with survivors of genocide, ethnic conflict, and political violence. There are two principal ways in which this can happen. First, supporting survivors in addressing questions of truth and justice and, second, being aware of how trauma-orientated interventions can be used as a bandage rather than addressing the root causes of suffering.

Supporting Survivors in Addressing Truth and Justice The drive for supporting survivors is illustrated by the (re)claiming of political space and demands for truth and justice, following the 1994 exhumations at Plan de Sànchez, Guatemala. Issues of truth, memory, and justice took tangible forms through community support groups, which involved truth-telling processes, in addition to the initiation of prosecutions of local military commissioners by NGOs (Sanford, 2003). Victoria Sanford (2003) argues that through combining “community recovery, the reintegration of agency, and a political project for seeking redress through the accretion of truth” it was possible to break “the binary that counterpoises justice and healing” (p. 242). Although Sanford places great emphasis on the cathartic nature of testimony, more crucial is her claim that in adapting the testimonial model from the individual to the community dimension, it can be possible for communities to challenge “structures of violence and lateral impunity” through the interaction between the local and national level (Sanford, pp. 240–242). Sanford’s (2003) claim underscores the importance of addressing structural violence and its interconnection with issues of power. At the same time, testimony or public expression of past pain is not culturally acceptable in all societies. Again, care should be taken to understand sociocultural dynamics. Shaw (2005) writes of the antipathy toward the Sierra Leonean Truth and Reconciliation Commission as “speaking of the violence—especially in public—was (and is) still viewed as encouraging its return, calling it forth when it is still very close and might at any moment erupt again . . . social forgetting is a refusal to reproduce the violence by talking about it publicly” (p. 9). Coulter (2009) stresses that, although individuals did not forget what had happened to them and their families, “healing was conceived in terms of being able to procure a livelihood—to go to school, to trade, to get a job, to make a living—so that life could

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go on” (p. 180). I (Kirrily) had similar responses from research participants in Rwanda. Whereas for young people talking publicly about their experiences was an important part of bearing witness and keeping the memory of loved ones alive, for others, the challenges of everyday life were presented as more pressing (Pells, 2011). Similarly, for asylum-seeking and refugee people, the search for justice can be an important part of recovering a sense of agency and identity. As with the examples given previously, this is a very individual choice. Whereas for some, speaking out is an important part of challenging injustices past and present, for others, addressing immediate needs such as housing and food, as well as concerns for personal security, may be paramount. Therapists can play an important role in helping clients connect with solidarity groups and in acting as an advocate for clients to access other services, such as housing, legal representation, education, and other health services (Patel, 2008).

Trauma as a Smokescreen According to Summerfield (2002), it is essential for those working with survivors not to let trauma interventions become a smokescreen for lack of political engagement. Psychosocial assistance can become a way to avoid dealing with the real root causes of suffering, such as poverty and conflict, through the guise of neutrality. Yet through selecting an apparently “neutral” course of action, a political stance, in fact, is taken. Jones (1998), for instance, argues that ignoring the political and social context may appear to be taking a neutral stance, but that it can have adverse psychological and political consequences. This refers both to the individual therapist working on the ground as well as to organizations, donor agencies, and governmental departments in which the psychosocial approach is the selected mode of intervention. Jones (2004) comments that during the siege of Sarajevo, in 1994, seven NGOs were running counselling programs, yet, “You know 80 percent of our psychological problems would disappear tomorrow a weary social worker told me one day, if you could persuade your government to lift the siege of the city” (pp. 200–201). Thus, psychosocial programming can become a substitute for political action. This neglect may add to political injustices and harmful environments (Jones, 1998). Practitioners need to be reflexive of their own work and interventions in order not to sustain injustice and power inequalities in such situations. Jones (1998) argues the following: There is no such thing as political neutrality and that to ignore one’s own biases and commitments can on occasion be equally dangerous, allowing tacit collaboration with political ills. We are all influenced by our personal histories and our best course of action is to acknowledge our subjectivities. [ . . . ] Thus, we have a responsibility to be politically literate and open to new information. We should neither impose our views on our patients nor avoid discussion of them, and we should be prepared to work with them, both individually and collectively, to understand, engage with and confront those political and social problems that impact on mental health. (Jones, 1998, p. 246)

CLINICAL CONSIDERATIONS Beyond the therapeutic skills typically taught in preservice academic programs, when working with survivors of genocide, ethnic conflict, and political violence, there are some additional considerations on which to reflect. These are presented in the following

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two subsections. First, possible common themes that may emerge or may be areas for exploration during therapy are explored. Second, additional practical issues that warrant further attention are identified, along with some therapeutic ideas of working with these clients. Noteworthy is that these lists are not exhaustive, as each individual has his or her own context and story, and therefore, a prescriptive list would be reductive of the clinical complexity. Moreover, it is important to stress that specialist training and supervision should be sought before working with individuals who have experienced trauma. Well-meaning but ill-informed interventions can cause serious damage.

Common Themes In identifying and discussing common themes that can occur when working with this population, it is important to begin by emphasizing that they all may be connected and interlinked, as well as vary hugely depending on the individual, the systems and organizations around that individual, his or her social context, and his or her local knowledge. Furthermore, these experiences also must be explored and understood within a holistic and ecological framework, incorporating the person’s physical, sexual, and cognitive health; his or her spiritual, religious, cultural, and political frameworks; his or her social and economic circumstances; his or her age and gender; his or her family and cultural scripts; and his or her ideas around help-seeking behavior. So as not to disconnect one’s experience from their life story, therapists must attend to possible effects of clients’ intergenerational transmission of trauma, multigenerational legacies of trauma, attachment histories, and previous significant experiences. Some of the themes worth considering include self-blame, guilt, rage, humiliation, shame, powerlessness, hopelessness, persecution, stigma, injustice, unfairness, anger, uncertainty, unpredictability, loss, grief, isolation, betrayal, depersonalization, fear, helplessness, separation, secrecy, survivor mission, and resiliency. In the remaining parts of this subsection, the following practical considerations are discussed: working with interpreters, power dynamics and reflexivity, the impact of the work, the therapist’s position, and the safe place.

Working With Interpreters Clinicians working with interpreters would be advised to read further around this complex area, as well as to think carefully about the different dynamics and issues that may be encountered (Farooq & Fear, 2003; Haenal, 1997; Hoffman, 1989; Raval, 1996; Tribe & Raval, 2003). Having someone interpret is qualitatively different from having someone translate, and therefore having an interpreter in the room can be seen as an additional relationship with which to work. Working with interpreters can be a rich and beneficial experience. However, some key issues are worth considering: (a) allowing additional session time, including the time to meet and build rapport with the interpreter; (b) examining roles and expectations; (c) discussing any observed nuances such as body language, gestures, and tone of voice (sometimes in the context of their cultural/local knowledge); and (d) offering time to provide a debriefing experience for the interpreter. Furthermore, the actual session may require more time, as the inclusion of an additional person slows down the pace and time. The selection of an interpreter is a critical decision, and the clinician should be mindful of this. Some people feel uncomfortable speaking with someone from their own community because of fears of confidentiality and/or of being judged, and this can be a barrier for openness. Other people may have specific preferences for interpreters

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with whom they would feel more comfortable with, and these should be discussed and reflected on. For example, I (Karen) saw a client who reported having had a traumatic experience when confronted with an interpreter who was from the same tribal grouping as the man who had raped her. For her, being confronted by this man felt retraumatizing; it was reminiscent of being in a powerless position. Unfortunately, many services are limited by a lack of resources, and therefore, this choice is not always an option. However, if an interpreter is needed, and in order to build rapport, encourage engagement, and create a safe space, it is important to acknowledge and be curious about some of the issues that arise around interpreters and their characteristics.

Power Dynamics and Reflexivity The previously discussed issues of needing more time and confidentiality extends to all areas of work with this client group, particularly in the context of people who have experienced numerous breaches of trust and human rights, often from people in positions of power. This highlights the need for clinicians to be reflective and reflexive about their position and its impact on the client; this may relate to attributes of whiteness, gender, authority, and so forth. The therapy itself may be reminiscent of aspects of the torture experience, for example, being alone in a closed room with a person positioned as powerful/authoritative asking personal questions. Moreover, as clinicians, we could be perceived as representing various roles, including that of being a rescuer or savior to that of being an oppressor or persecutor. One must question if the therapist is positioned as rescuer that might place the client in a position of victim or passive recipient. These issues around power, as well as other relevant issues, are important to discuss in clinical supervision, as this type of work can provoke powerful transference and countertransference reactions.

Impact of the Work Health care professionals report profound psychological effects of the therapeutic work with refugee and asylum-seeking people (Rees, Blackburn, Lab, & Herlihy, 2007). Workers may experience changes in the way they perceive the world with it becoming unsafe or unjust (Butler, 2008). They also may experience feelings of anger, anxiety, depression, low self-esteem, and intrusive memories of events described by clients. The therapist may identify with the client’s helplessness and vulnerability, which can change the way the listener perceives the world (Sabin-Farell & Turpin, 2003). Therapists may feel an overwhelming sense of responsibility to help their clients, and thus, their rescue valence may go into overdrive. The therapist may feel as if he or she is never doing enough or may feel guilty, as a person or representative of a particular group, for the mistreatment experienced by the client. Therapists may experience survivor guilt or regret having not taken a more active role in the prevention of torture. In the literature, exploring the impact of trauma work and of self-care, these experiences often are termed vicarious trauma (McCann & Pearlman, 1990), secondary traumatic stress (Figley, 1995), compassion fatigue (Figley, 1995), and burnout. Self-awareness and self-care are crucial, even more so when working in a postconflict area with restricted resources and limited support networks. Conversely, working with trauma can be incredibly rewarding, as one can experience an enhanced sense of self, meaning, and spirituality (Steed & Downing, 1998). Furthermore, working with this client group can enhance one’s appreciation for one’s own situation, and can foster feelings of resilience, faith, and acknowledgment of humans’ capacity for survivorship and strength.

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Therapist’s Position It has been argued that remaining “neutral” when working with refugee and asylumseeking people is impossible given the sociopolitical context (Tribe & Raval, 2003). In taking a non-neutral stance, the therapist clearly is making his or her opposition to the atrocities experienced by the client known. The client’s experiences should be actively listened to and validated, and care needs to be taken to address the person as a whole individual and not to define the person by his or her traumatic experience and/ or his or her immigration status. Providing a space in which the client can be held emotionally, is crucial, one where the person is recognized, and his or her experiences are acknowledged. Additionally, it is essential to foster an environment of containment, in which the person can be supported in finding words or alternative ways to express (verbal and nonverbal) or name some of the unbearable experiences, and where these expressions can be tolerated. This can support the client in meaning-making and serve to break the “conspiracy of silence” (Danieli, 1998) that often is experienced by survivors of torture. This will not be discussed further in this chapter; however, it is also worth considering the therapist’s position and/or influence in other torture/trauma-related areas, including in arenas of media, journalism, and research.

Safe Place It is widely acknowledged that supporting trauma survivors practically and emotionally, to feel safe and secure, is of utmost importance. However, after personal safety and security have been achieved practically and before commencing therapeutic work, the client should be encouraged to find a “safe place” that they can visit when dynamics in or out of therapy feel unsafe or overwhelming. This place can be a real or imagined place or space. The feelings, sounds, smells, and sensations associated with it need to be connected with and linked to a trigger word so that the person can self-soothe by going to this safe place; alternatively, the therapist can support or facilitate the client’s connection with the safe place. Other grounding and self-soothing techniques should be in place, as well as buffering and building on the client’s coping strategies and resources. This is particularly important with clients who cope with their experiences through dissociating.

Psychological Approaches and Tools A plethora of literature is available regarding well-researched psychological approaches in working with people who have experienced trauma such as trauma-focused cognitive behavioral therapy and eye movement desensitization reprocessing therapy (EMDR; Shapiro, 2001). This section will therefore focus on less-represented approaches. This is by no means an inclusive summary; however, it is hoped that some of the breadth of options demonstrates the wide range of approaches available, to be creatively used and interwoven into existing multimodal therapies. Many of the described approaches take into account people’s wider contexts, and this is because the authors take the position that “political violence causes social trauma which is an imprint on the collective identity of a people” (Sales & Beristain, 2008, p. 15). It is not possible within the scope of one chapter to provide the full details of traumarelated therapeutic approaches; however, the interested reader can see the reference section for further reading. Selected therapies are discussed briefly in the following subsections: narrative therapy, tree of life technique, cultural genograms and life storybooks, testimonial psychotherapy, creative therapies, and bereavement work. A careful

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assessment and formulation is needed to ascertain the appropriateness of the type and time of the interventions hereafter in order to ensure that the therapist is being clientcentered and not adhering to a one-size-fits-all approach.

Narrative Therapy Narrative therapy is rooted in social constructionism, and its stance can be helpful when working with survivors of torture and mass violence. This approach involves helping clients to deconstruct and challenge their dominant stories and to create more empowering life narratives (White, 2000). Clients’ lives may seem full of problem-saturated stories and negative dominant discourses, such as of being “bad, damaged, and hopeless,” which they then may internalize and thus self-stigmatize. Therefore, externalizing the problem, that is, seeing the problem as separate from the person, might support clients to see that they are not the problem; the problem is the problem (White, 2004). Additionally, clients can be supported in identifying unique outcomes or exceptions, which thicken the clients’ less told stories and may assist them in reconnecting with their strengths, skills, and values, as well as providing an opportunity for them to reauthor their stories (Beaudoin, 2005). Narrative therapy acknowledges the connectedness of peoples’ lives and builds on people’s skills and sense of agency. Narrative therapy takes the stance that people always respond to trauma, and that these responses say something about what the person values or was preserving and protecting. For example, this can be supported through questions such as the following: What is this pain you feel a testimony to? What is it you hold precious that has been violated? What kind of life have you been fighting and struggling for? Other tools include using outsider witness groups, and remembering conversations have been used successfully with survivors of torture.

Tree of Life Technique This is a narrative therapy tool that originally was developed by Ncazelo Ncube, a Zimbabwean psychologist for children who had been orphaned by HIV/AIDS. Since its origin, the tool has been extended to working with numerous age groups and in wide-reaching areas, including with those who have experienced trauma and loss. The Tree of Life enables people to strengthen their relationships with their own history, their culture, and significant people in their lives. In this technique, people use a tree as a metaphor to discuss and document their lives. The metaphor promotes clients’ discussion about the following: ■ Their roots (these represent family life, origin of family name, country of birth,

stories and songs from their past, and ancestry) Their ground (this represents everyday activities and the situation at present) The trunk (this represents people’s strengths, resiliencies, and skills) The branches (these represent people’s hopes, wishes, goals, and dreams) The leaves (these represent people—real, imagined, or pets—who have been important to the person) ■ The fruits (these represent the gifts people have been given and can include material or essential gifts of life such as love and kindness) ■ ■ ■ ■

Often, these representations are in pictorial form, and people can express their ideas in which ever way they choose, including using objects, pictures, paints, and so forth. When the Tree of Life is done as a group, people can display all their trees together, and in doing so, they can create a forest of trees, a community. This can support people in feeling part of something and listened to; then the group may choose to reflect and

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comment on what they have been struck by when reading other people’s trees. The group then discusses the storms and dangers faced by trees; they can use this as a metaphor for thinking of ways of weathering through the storm and remembering the roots, leaves, and so forth. This process is usually completed with a certificate and ceremony. The Tree of Life has been extended to match the background of different clients. For example, the principles of the tool were applied to the metaphor of a football pitch and were used with former child soldiers (See Denborough, 2008). This technique has encouraged people to draw on their strengths, resiliencies, and narratives of the past, as well as to be part of a wider community. More examples of the Tree of Life can be found at http://www.dulwichcentre.com.au/tree-of-life.html. Extensions of the tool and imaginative adaptations have been documented on the website, including the Kite of Life, which focuses on moving participants from intergenerational conflict to intergenerational alliance (Denborough, 2010).

Cultural Genograms and Life Storybooks Cultural genograms have similar aims as those of the tree of life technique. A genogram is a pictorial representation of a family tree that goes beyond the factual detail by attending to themes, relational dynamics, and psychological factors (Hardy & Laszloffy, 1995; McGoldrick, Gerson, & Shellenberger, 1999; Rigazio-DiGilio, Ivey, Kunkler-Peck, & Grady, 2005; Thomas, 1998). A cultural genogram is an extension of this, facilitating the clinician in an exploration of various themes with the client while attending to cultural considerations. The clinician uses a position of curiosity to discover more about the client and to support the client in retelling his or her story. This enables a way to support the client in reconnecting with the personal past and in thickening the life story. For example, when talking about overcoming hardship, the clinician may look at the genogram and inquire what hardships the person’s grandmother or cousin may have experienced or what the person thinks an aunt or husband might have thought of the hardship the client faced. This can be a sensitive way to explore other areas of difference such as spirituality, religion, cultural rituals, and race. This is an opportunity to explore further people’s illness representations, cultural conceptualizations, and explanations of their experiences, while attending to differences and similarities. Furthermore, this is a powerful exercise for therapists to use to enhance their understanding of their own cultural influences and multigenerational legacies. For many clients who have a disjointed or fragmented sense of self, these approaches aim to provide a coherent reconnection and continuity with one’s identity. These can be complemented by other tools such as ecomaps, life storybooks, or timelines. These documents are a construction or reconstruction of an individual’s life and involve the integration of internal processes and the relationships and values within the family, community, and culture (Cook-Cottone & Beck, 2007).

Testimonial Psychotherapy It is important to support clients in having their voices heard and encouraging them to feel that their voices are worth hearing; this ultimately can assist in moving clients toward a position of social action and change (Holland, 1988). One way that incorporates this stance, as well as embracing the storytelling culture of some communities, is through testimonial psychotherapy (Akinyela, 2005; Schwartz & Melzak, 2005). This therapy places justice as the therapeutic entry point (Agger, Raghuvanshi, Shabana, Polatin, & Laursen, 2009). Testimonials allow the retelling of events to a therapist, who documents the narrative, and through an interactive process of reviewing it with the client, produces a written testimony that acknowledges the experiences and provides

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vital documentation for political or personal purposes, transforming private pain into political or spiritual dignity (Agger & Jensen, 1990). The testimonial process enables the victim to gain some distance from the event and to focus on different aspects of the story, such as the courage or intelligence that led to their survival (Lustig, Weine, Saxe, & Beardslee, 2004; Weine, Kulenovic, Pavkovic, & Gibbons, 1998). This can lead to essential and powerful meaning-making discoveries. Lustig et al., (2004) states the following: Testimonial therapy emphasizes an individual’s personal resources by creating a written document for socio-political purposes, thereby engendering a sense of agency, and counteracting innate feelings of powerlessness and inferiority. Moreover, participants’ control over the creation of the document, as well as their right to disseminate it, or keep it to themselves, contrasts sharply with the lack of influence over original events described in the testimony (p. 34). Testimonial psychotherapy has since been extended to consider incorporating ending ceremonies/rituals which may include local customs and leaders (e.g., monks) to provide a form of social recognition and re-connection with the community (Agger et al., 2009).

Creative Therapies Traumatic memories are stored in the right hemisphere of the brain, making verbal declarative memory of trauma more challenging (Glaser, 2000; Schiffer, 2000). Therefore, other means of expression and communication can be beneficial when working with people who have experienced trauma, such as through using art, music, narradrama (Dunne, 2000), sociodrama (Kellerman, 2007), and dance/movement therapy (Callaghan, 1996; Gray, 2001; Harris, 2007). These are especially relevant as trauma can also impair nonverbal domains of the body (van der Kolk, 1994). Using different media may be helpful in expressing the traumatic experiences while attending to multiple sensory processes. Additionally, using creative means can provide a contrary experience to that associated with trauma, thus facilitating distance, desensitization, processing of trauma memories (Kozlowska & Hanney, 2001), and enhancing one’s sense of control and authorship. Creative therapies encourage clients to be active participants in the therapeutic process. Furthermore, different ways of expressing oneself may resonate more with those from backgrounds where dance and music are culturally important means of storytelling. Using creative means to connect with the client can be fruitful. For example, in addition to verbally creating a safe place, the clinician and client may create a safe box, whereby the outside of the box can signify comforting and safe images, and the inside of the box can be used for objects and pictures that represent the client’s difficult feelings. Additionally, people can be encouraged to act, write a song or poem, dance, make a movement, or draw their life as a journey; others may find using dolls, puppets, and masks as powerful symbols for unexpressed feelings, and others may find writing a book about their experiences to be cathartic (Malchiodi, 2008).

Bereavement Work Many clients who have experienced mass violence and torture also have experienced multiple losses and bereavements. Furthermore, some people may be uncertain of their family’s whereabouts, the burial site, or the situation surrounding the deaths or murders. Therefore, work around grief may be important in these cases. Using a medium that seems relevant to the client is crucial, bearing in mind that ideas about death, afterlife,

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and “goodbye” rituals differ, including beliefs about spirits, ghosts of the past, and cleansing rituals (Honwana, 1999). Useful techniques may include any of the following: ■ ■ ■ ■ ■

To write a letter to lost one/ones To create a memory box To form a remembrance mural To try to find ways of carrying out cultural rituals and ceremonies To discuss the stories, legacies, values, memories and lessons that the person living can carry with him or her throughout his or her life

Several stories written about bereavement may be particularly helpful for children, as seen in the use of bibliotherapy (Best Children’s Books, 2011). Experiences of multiple losses must be taken into account throughout the therapy, as the ending of therapy might be representative of these earlier losses and/or abandonment. These factors must be taken into consideration when working with grief and loss.

IMPLICATIONS FOR COUNSELING Based on the discussions in this chapter, it is clear that in working with people who have experienced and/or witnessed genocide, ethnic cleansing, or political violence, it is important to be intentional in all practices and to proceed with extreme caution. At all times, one must be sensitive to contextual factors, as well as to the individual’s unique experience, background, and possible different cultural beliefs and values when developing the therapeutic approach. This may mean adopting new methods of working, including nonverbal tools such as using art, music, and movement. Equally, due to the extreme and horrific nature of the atrocities being explored, therapists must be acutely aware of the impact the work may have on them. Good supervision is essential to explore transference and countertransference issues and to anticipate and prevent experiences of vicarious trauma and compassionate fatigue.

CONCLUSION The existential horror of genocide, ethnic cleansing, and political violence, and its enduring legacies for survivors, has been explored throughout this chapter. The extreme nature of the violence experienced presents several challenges for practitioners above and beyond the usual therapeutic considerations. In addressing these challenges, we have advocated the adoption of a broader framework than the purely psychological, illustrating how insights from sociology and anthropology can strengthen therapeutic work. This includes understanding sociocultural processes of meaning-making, multiple identities, losses, disempowerments, resiliency, agency, and calls for justice. In practice, this requires a holistic framework, which addresses the needs of the individual in his or her sociocultural, political, and environmental context while also addressing the challenges of past, present, and future. These approaches should also focus on building on individuals’ strengths, resources, and values rather than pathologizing and medicalizing his or her unique experiences. The extreme nature of genocide, ethnic cleansing, and political violence also accentuates the need for consideration of power dynamics, self-care, and transference within the therapeutic relationship. Above all, it calls us to bear witness to gross human rights violations, to stand with those who have been abused, and work with them to restore or create anew the “magic circle of everyday life.”

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APPENDIX 23.1 Child Soldiers The image of a small child bearing an AK-47, almost as big as himself, beneath headlines proclaiming “innocence lost” have become emblematic of “modern” conflict. Estimates suggest 300,000 children less than 18 years old are involved as fighters, cooks, porters, informants, and sex slaves and in other laboring roles with government armies, paramilitaries, and rebel groups in countries as diverse as Colombia, Israel, Myanmar, Sri Lanka, and Uganda (Machel, 2001). Some of the most brutal acts of violence of “modern” warfare have been carried out against and by children, and these include murder, amputations, rape, looting, and destruction. Given the highly emotive nature of the subject, the pathways into and out of soldiering by children are frequently misrepresented or misunderstood. While some children are forcibly recruited, often having to kill family members in the process, others join voluntarily due to the lack of other viable livelihood options or belief in the cause for which forces are fighting (Peters & Richards, 1998; Wessells, 2006). Former child soldiers have rejected narratives that position them as purely victims, describing the reality as much more complex (Beah, 2007). A wide range of factors influence the ways in which child soldiers cope with their experiences, including “age and developmental level at the time of recruitment; the manner of their recruitment; their length of time in the armed group and the role they played in the group” as well as “gender, religious belief and ethnic and cultural factors” (Dowdney, 2007, pp. 5–6). Consequently, in terms of interventions, “one-size doesn’t fit all” (Dowdney, 2007, p. 8). Moreover, having a supportive social environment with educational or economic opportunities is essential in enabling children and youth to move forward from traumatic experiences. Yet interventions have tended either to focus on a clinical approach to trauma or to address broader psychosocial needs, such as livelihoods, family separation, stigmatization, and education (Wessells, 2007). Instead, interventions would be strengthened by adopting a holistic approach that brings together clinical understandings of trauma with local understandings and practices and seeks to restore the socioeconomic fabric of societies. Activities may include “not only counselling but also traditional healing, structured group activities, trust-building exercises, nonviolent conflict resolution, livelihood support, reconciliation, substance abuse rehabilitation, and education” (Wessells, 2007, p. 190). Conducting research with war-affected children and ex-combatants in Angola and Mozambique, Honwana (1999) illustrates how rituals have been used to cleanse the individual and the community from the angry spirits of those killed during the conflict. Undermining a Western Cartesian dichotomy between the mind and body, she describes a holistic response to healing that combines the mind and body, the individual and the community, and is “tied to specific social, cultural and cosmological understandings” (pp. 32–33). These rites may consist of a symbolic washing of an individual’s body, a sacrifice of a chicken, and burning of old clothes indicative of the break being made with the past. These latter rituals contain an acknowledgment of the horrific acts that have been committed and require the participation of a traditional healer (Honwana, 1999). At the same time, it is vital not to romanticize traditional practices, which do not exist in all places and which also may serve to re-assert power inequalities, especially against girls (Coulter, 2009). (continued)

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APPENDIX 23.1 (continued) Re-recruitment into fighting forces can remain a real challenge as long as the socioeconomic problems predating the outbreak of violence remain. In postconfl ict Mozambique and Angola, Honwana (1999) notes that children and their families and communities worked to restore some kind of normality, but the persistence of poverty predating the confl ict hindered reintegration. A similar problem has emerged in West Africa, where the cyclical nature of confl icts has created “regional warriors,” many of whom are children. For example, children demobilized in Liberia were re-recruited into the militia in Côte d’Ivoire and were attracted back into the militia by the promise of economic incentives. Most of the recruits were sending money back to support their extended family in buying food and paying rent, school fees, or health care costs (Human Rights Watch, 2005). Having education and livelihood opportunities are therefore essential for successful demobilization and reintegration. In the aftermath of genocidal and ethnic violence, where neighbors have fought against neighbors, and children have killed family and community members, reintegration can be highly problematic. Community resentment of former child soldiers is due not only to past atrocities committed, but can stem also from the tendency in externally led rehabilitation programs to privilege the needs of ex-combatants over noncombatants, in areas where large numbers of children were associated with the fighting forces. Focusing on former combatants can only serve to reinforce the stigma faced. This underscores the importance both of working with children involved in multiple roles with fighting forces, as well as “war affected children” more broadly (Wessells & Monteiro, 2000, p. 185). For example, the Christian Children’s Fund (CCF) pioneered a community-based project called Support for Skills Training and Employment Generation (STEG), which sought to build the skills of former child soldiers in Angola through cooperation with civilians (Wessells, 2006). Through rebuilding the physical infrastructure and focal buildings of the community, more abstract concepts of peace and reconciliation were made concrete and civilian identities strengthened.

RESOURCES Websites Tree of Life: An Approach to Working With Vulnerable Children. (http://www.dulwichcentre.com.au/ tree-of-life.html) Films and Videos Aghion, A. (Director). (2005). In Rwanda we say . . . The family that does not speak dies. [DVD]. Aghion, A. (Director). (2009). My neighbor, my killer. [DVD]. Films for the Humanities & Sciences. (Producer). (2000). Worse than war: Genocide, eliminationism, and the ongoing assault on humanity. [DVD]. Films for the Humanities & Sciences. (Producer). (2008). Zimbardo speaks: The Lucifer effect and the psychology of evil. [DVD]. Samura, S. (Director). (2000). Cry freetown [DVD]. Žbanic´, J. (Director). (2006). Grbavica: Land of my dreams. [DVD].

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CHAPTER 24

The Impact of War on Civilians ELAINE HANSON AND GWEN VOGEL

INTRODUCTION The 20th century represents the most war-ridden century in recorded history and the most lethal for civilian deaths from war. Beginning with World War II, civilians increasingly were targeted as a strategy of warfare and political struggle (e.g., the civilian casualty rates for WWI, WWII, and current armed conflicts are 5%, 50%, and more than 90%, respectively; Kolb-Angelbeck, 2000). This same source estimates that since WWII, there have been 127 wars and 21.8 million war-related deaths. The Red Cross (1999) estimates a total that is twice as high, or about 40 million people killed in war and conflicts since WWII. Wars in developing countries in the last decade of the 20th century resulted in massive civilian casualties. In terms of geographical distribution, all but two of the 127 20th century wars have taken place in developing countries (Kolb-Angelbeck, 2000). Hynes (2004) estimates that, since the 1990s, nine out of 10 who died in war were civilians. Genocide Intervention Network (2010) reports that between 1.7 and 2 million people died in the Khmer Rouge killing fields in the 1970s, that the conflict in the Democratic Republic of the Congo resulted in an estimated 5.4 million civilian deaths since 1996, that between 96,000 and 200,000 Bosnians were killed in the civil war in the Balkans, and that 800,000 to 1 million died in the Rwandan genocide. Although the number of civilian casualties is great, the numbers do not begin to capture the masses of civilians who suffer the psychological, and often invisible, scars of war. The effect of war on civilians involves multiple traumas over time. Before fleeing the war zone, civilians are victims of extreme violence and witness extreme acts of violence directed toward self and others. Psychological and emotional injuries may be the most enduring effects of war, yet historically, they may be the least addressed in terms of rebuilding a society and preventing future violence (Olweean, 2003). According to the World Health Organization (WHO), mental illness comprised 12% of the global burden of disease in 2000—a figure that is expected to rise to 15% by the year 2020 (WHO, 2001). Although communicable diseases continue to represent the leading cause of disease burden in resource-poor areas, noncommunicable diseases are becoming increasingly more significant as causes of disability and premature death. In particular, unipolar depression is the third leading cause of disease burden worldwide—representing 4.3% of total disability-adjusted life years. It is predicted to become the second leading cause of disease burden by the year 2020 (Michaud et al., 2001; Ustun et al., 2004). Perhaps there is a relationship between war and global mental health statistics. To date,

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Figure 24.1 11-year-old boy portrays how his father and older brother were killed in a regional conflict in northern Nigeria. All illustrations published with permission of Gwen Vogel.

large-scale recovery efforts commonly have focused on more visible needs such as food, shelter, clothing, and physical health, as well as economic aid. Psychological trauma and disease have been overlooked or minimized, leading these issues to become part of the psyche of a society that extends into future generations. The second and equally devastating trauma comes during the process of fleeing the war zone and subsequent resettlement in uncertain conditions. Prior to WWII, immigrants often were driven from their countries by economic forces such as unemployment, famine, and poverty, often combined with various forms of prejudice and oppression (Kolb-Angelbeck, 2000). War and ethnopolitical conflict were not primary causes for emigration. Studies to assess the rates of posttraumatic stress disorder (PTSD) among community samples of refugees worldwide consistently have found high rates of this disorder (usually between 30% and 60%, depending on the population and measurement methods; Van der Veer, 1998). In addition to having an impact on civilians in combat zones, wars also have a direct impact on civilians living in nearby countries that are forced to create and maintain refugee camps and in countries that accept individuals and families for resettlement. According to the United Nations High Commissioner for Refugees (UNHCR), there are almost

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Figure 24.2 13-year-old boy portrays how his community was attacked and a football match ended in chaos during a regional conflict in northern Nigeria.

22 million refugees located throughout the world, and approximately half of them are children (UNHCR, 2002; Westermeyer, 1991). Recent arrivals to first world countries have known social oppression, including inadequate education, lack of job opportunities, inability to practice their faith or marry whom they wished, and inability to live where they wanted. However, unlike most previous immigrants, many of them also have experienced or witnessed government-sponsored torture and terror (Amnesty International, 1999).

THE LIVED EXPERIENCE OF WAR—SOCIAL TRAUMA War is unique from personal trauma because of the massive devastation rendered by large-scale violence. The effects of war are felt on the individual, the family, and the

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community in which the individual lives. Entire political systems and governments are destroyed or devastated in its wake. Communities and cultures lose their historical and spiritual meaning systems (collective stories). The physical environment that sustains life is ravaged, often leaving food sources and other necessities for life unavailable to those caught in and fleeing from the violence. The concept of intrapsychic trauma, as delineated by the diagnosis of PTSD, does not capture either the devastation of war or the context in which war exists. MartínBaró (1989) used the concept of “social trauma” to capture the effects of prolonged conflict and political persecution. He stated, “There is no person without family, no learning without culture, no madness without social order; and therefore neither can there be an I without a We, a knowing without symbolic knowing, a disorder that does not have reference to moral and social norms” (p. 41). Hernández (2002) urges that in order truly to understand and treat trauma resulting from war and political violence, we must expand our way of labeling trauma disorders and our treatment interventions to address contextual issues. He states, “[I]f we acknowledge that individuals are not the only ones who experience traumatic events and their sequel but that meaning about trauma is developed with families and communities, then shall we label whole families and communities?” (Hernández, 2002, p. 21). The following section addresses the effects of shared trauma or social trauma of war and political persecution on the individual and the family (with an emphasis on children and returning child soldiers), as well as on communities.

Effects of War on the Individual Much has been stated throughout this text about the widespread effects of witnessing and experiencing violence either against oneself or one’s family, one’s friends, or one’s fellow community members. The symptoms and specific diagnostic facets of PTSD will not be reviewed at this time, as they are well documented throughout the research and in other chapters of this book. The research to date regarding PTSD has been conducted primarily on accident or crime victims or soldiers. Less has been studied about the intrapsychic trauma of war, as the pragmatic obstacles of systematically studying the impact of war on individual civilians are epic and often prevent systematic scientific investigation. The study of the psychological impact of war on soldiers did not begin in earnest until the second half of the 20th century, whereas the systematic psychological investigation of effects of war on civilians did not begin until much later. The impacts are usually assessed after the war and trauma, often with refugees living in camps or other safe zones. One of the first groups of civilian survivors to be systematically researched was survivors of the Holocaust after WWII. These civilians survived WWII in the horrific conditions of German concentration camps. Krell (1993) studied the postwar experiences of Holocaust survivors and found that they adequately adapted to life after trauma. He found that survivors were able to live and raise families. Danieli (1981), however, studied the marital relations of Holocaust survivors, which she characterized as “despair marriages.” Long-term effects were found to include chronic anxiety and depression (Niederland, 1968) and personality disorders (Dor-Shav, 1978). Fifty years after the Holocaust, Sagi, van IJzendoorn, Joels, and Scharf (2002) found that victims still showed disorganized thinking patterns about their losses and traumas, which they concluded was indicative of unresolved mourning. Although the available research shows that PTSD, depression, and anxiety, as well as other indicia of emotional distress, are prevalent in civilians subjected to war, some debate the use of the diagnostic category of PTSD as unhelpful and inappropriate in

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different cultural settings and detrimental to civilian populations (Hernández, 2002). In particular, they oppose the use of the diagnosis as it does not capture a victim’s psychological experience of war and violence (Janoff-Bulman, 1992). They object that the PTSD diagnosis, derived from the study of veterans after the American war in Vietnam, was subsequently expanded to others, especially to civilians. The diagnosis is seen as both too much and too little. It implies pathology and yet fails to capture the full experience of civilians. It is too much because the label of “disorder” often leads to undesirable consequences. Those who live through wars may be seen as sick, damaged, and pathological, rather than resilient and resourceful. The diagnosis of pathology is detrimental to the individuals and the society and hinders the process of post-conflict healing. They need hope and reinforcement of resilience rather than a diagnosis to move forward and embrace a rebuilding process. Alternatively, some view the diagnosis of PTSD as too little or simplistic. They argue that it fails to capture the systemic aspect of the war experience. It does not address all of the complex trauma experiences of both the individual and the society, such as dramatically altered sense of self and changes in social structure. The categorical diagnosis seems to minimize the profound and multidimensional experience of individuals and societies. Becker (1995) objects to the word “post” in PTSD, as it relates to a specific period in time and does not pertain to civilians, who often live and work in the war zone over an extended period of time, and whose traumas have no distinct beginning or end. Argentina and Liberia are just two countries whose civilians endured decades of exposure to the trauma of civil war and political violence. As Hernández states, “uncertainty remains about how to conceptualize trauma and long-term effects after exposure of whole generations to mass atrocity and the destruction of their social and cultural norms” (p. 20). The sequelae of war on the individual include effects on self-esteem and affect regulation, changes in personality and beliefs, and interpersonal functioning. Some have suggested a diagnosis that extends beyond the diagnosis of PTSD to those described in the Disorder of Extreme Stress Not Otherwise Specified (DESNOS; de Jong, Komproe, Spinazzola, van der Kolk, & Ommeren, 2005; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). DESNOS was first suggested by the work of Judith Lewis Herman (1992). The diagnosis includes the traditional symptoms of PTSD but expands the symptom constellation to include the following: (a) dysregulation of affect and impulses (unmodulated states of emotion distinct from mania); (b) dysregulation of attention and consciousness (dissociation); (c) impaired self-perception (viewing oneself as damaged); (d) maladaptive interpersonal relationships (impaired relationships); (e) somatization; and (f) spiritual alienation or ineffective sustaining belief systems. Research has confirmed the presence of the construct among military veterans (Ford, 1999). It has been hypothesized that the diagnosis may be applicable to civilians, as well as military war victims who have experienced extreme violence, and research has focused on the applicability of the diagnosis. A study of 24 victims of Bosnian ethnic cleansing was conducted by Weine et al. (1998), after the conflict and genocide in the Balkans. The study found that although the civilians reported symptoms consistent with DESNOS, few met the full criteria. Morina and Ford (2008) studied civilian victims of war in Kosovo. They found that DESNOS rarely occurred among civilian victims of war in Kosovo (2% prevalence). However, symptoms of DESNOS, including somatization, altered relationships, and altered systems of meaning were reported by between 24% and 42% of the civilians assessed. The presence of DESNOS symptoms was associated with poorer overall psychological functioning and satisfaction with life. DESNOS severity was associated with both PTSD and major depression. Rather than talking about a “disorder,” some prefer a discussion of the concept of resilience, with focus on the type of factors that make a person more adaptable in the

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face of disaster or war. Landau and Saul (2004) have taken such an approach. They investigated resilience in order to design postwar interventions that foster a return to everyday life following disaster. Resilience is the ability to recover from adversity, to learn from difficult experiences, and to move forward following hardship. Resilience is present at the individual, family, and community level. Individual resilience is dependent upon the ability to access and use adequate coping strategies to face the trauma, biological, psychological, spiritual, and social, in order to promote long-term recovery and healing (Landau, 1982). Resilience is premised on the assumption that people are by nature competent, and that the majority will return to healthy life following setback and war. Resiliency is generally related to secure attachments (Besser & Neria, 2010), as well as a sense of connection to one’s family, community, and traditions. Adolescents in Angola, for example, fared better after war trauma if they were connected to their parents, embraced traditional tribal values, and had not been relocated from their communities (McIntyre & Ventura, 2003). In addition to the above-mentioned psychosocial factors, the potential for neurobiological impacts of war must be appreciated in any discussion of the human condition after war. Most of the neurobiological responses to trauma have been investigated with either war veterans or victims of childhood physical or sexual abuse. Research has shown that prolonged trauma and exposure to severe or prolonged stress results in a variety of brain and neurophysiologic responses. These responses are designed to prepare one to respond to a potentially dangerous situation by the mechanism of “Fight or Flight.” These resources include such changes as glucocortoid release, increased cardiovascular activity, and slowing of unnecessary physiological processes such as reproduction and digestion (Bremner, Krystal, Charney, & Southwick, 1996; Bremner et al., 1995; Stein, Koverola, Hanna, Torchia, & McClarty, 1997). The research has found that adults with PTSD display reduced hippocampal volume, resulting in memory problems. In a study pairing samples of Vietnam PTSD veterans and veterans not suffering from combatrelated PTSD, combat veterans displayed significantly decreased hippocampal volume, greater on the right side than on the left. Similar decreases in hippocampal volume also were found among survivors of childhood abuse (Bremner et al., 1996). There is indication that early childhood trauma may interfere with brain development and may subsequently lead to fragmentation of memory and to deficits in concentration. Stein et al. (1997) studied women who had been sexually abused as children and found that, as compared with subjects without abuse histories, they had decreased hippocampal volume. These studies have yet to be duplicated with civilian victims of war, but it is likely that similar findings may surface.

Effect of War on Families War is profoundly devastating for families and touches every aspect of family functioning. Families often are forcibly separated or relocated, and family members may become lost to the conflict. The effect is found in the disruption of basic structures of family functioning, including power distribution, traditional gender and age roles, and patterns of communication. During war, families experience profound loss and upheaval. Key family members, often sons and husbands, may be lost when they fight in the conflict or may return to their families altered by the experience of war. They often return home with significant psychological distress and are unable to fulfill their traditional roles or to provide for their families. As a result, levels of alcohol and substance abuse increase. Addictive behavior may be an attempt to adapt to disruption of the family unit (Landau & Saul, 2004). The loss of traditions and rituals also contribute to an increase in domestic violence and child abuse in families after mass trauma (Bentovim, 1995;

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Sheinberg & Frankel, 2000). Roles change within families. Children lose parents or become caregivers for parents who are either physically or psychologically disabled following the conflict. Transitional conflict results as the balance of power within the family structure is shifted. Family communication patterns change as a result of being exposed to mass trauma. Parents may engage in a “conspiracy of silence” and avoid speaking about their trauma to their children or other family members. Danieli (1985) documented this phenomenon among families of Holocaust survivors. She found that family members avoided speaking with other members of their families and their children about their experiences during the war. These gaps in communication have led to an incomplete experience of the world and a loss of a sense of personal history. They also have contributed to a sense of disconnection between families and their communities. The same tendency not to communicate with children about war-related trauma was observed among Japanese Americans who were traumatized by their internment by the American government during WWII. Nagata and Cheng (2003) found that those interned after the attack on Pearl Harbor communicated only minimal details about that trauma to their children. The desire not to communicate might be a result of PTSD-related avoidance or of a generational desire to protect the next generation from retraumatization; however, it ultimately may result in an impaired sense of racial, ethnic, or community identity.

Effects of War on Children Children are affected profoundly by war. They often lose their parents, their homes, and their schools. In addition, they often witness acts of extreme violence that are inherent in any armed conflict, as well as being exposed to conduct among adults in their environment that would not be tolerated during times of peace. These acts might include lying, stealing, acts of revenge, and other crimes. Children are most vulnerable as wars are fought in urban arenas where children often cannot escape the arena of the war and get out of harm’s way. Since the 1990s, reports indicate that 2 million children have been killed as a result of wars, and another 6 million have been disabled; 20 million have been left homeless, and over 1 million have become separated from their parents (Stichick & Bruderstein, 2001). Research on the impact of war on children has tended to focus on the immediate effects of the war and also on the more long-term effects of political violence on children’s development. Relatively little systematic longitudinal research is available. Some researchers have focused on the concept of resilience, factors that insulate or protect children from psychological harm and distress during crisis. Others have researched the effect of the recent rise in the use of children in the conflict itself. Children are no longer just victims or witnesses, but are being recruited into the forces perpetuating the conflict either to fight as warriors or to support, in some manner, others who are fighting. Of concern is the developmental effect on these children as well as their ability to be reintegrated into their families and communities after the conflict. The following sections discuss these issues.

Children’s Exposure to Armed Conflict Findings of psychological distress are common among children and adolescents exposed to armed conflict. Children are found to suffer from symptoms of PTSD, anxiety, depression, and somatic stress disorders. The psychological effects of the war in Afghanistan on young Afghan refugees were reported by Mghir and Raskin (1999). They studied two different ethnic groups and found varying levels of depression. The

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degree of trauma and receiving a diagnosis of PTSD was related to being located in rural areas and witnessing heavy combat between warring forces. McIntyre and Ventura (2003) studied the psychological effects of war trauma among Angolan adolescents. They studied three groups of adolescents between the ages of 13 and 16 for the prevalence of PTSD symptoms as well as for other issues pertaining to cognitive, affective, and social development. The three groups were divided on the basis of their exposure to the war in Angola and the severity and length of exposure. The researchers found that the frequency of a PTSD diagnosis increased with more exposure to war. Adolescents with greater war exposure were more likely to exhibit symptoms of reexperiencing traumatic events. Higher rates of PTSD were found among the Angolan adolescents as opposed to similar studies on Croatian and Irish adolescents. These higher rates were attributed to the younger age of the Angolan children, the fact that the Angolan children were assessed at a time when war was still a part of their lives, and the greater length of the Angolan war as opposed to the less extended situations in Croatia and Northern Ireland. Scores on intelligence assessment, specifically the Wechsler Intelligence Scale for Children-Revised (WISC-R), showed a decrease in performance with an increase in war exposure. Adolescents exposed to more war trauma with PTSD symptoms did worse on measures of cognitive and behavioral adjustment.

Child Diagnosis The use of the PTSD diagnosis with children exposed to war is controversial, as it tends to stigmatize and lead to a conclusion that the children are suffering from a disorder. Other research has focused on factors that protect children from the effects of extreme violence. Mghir and Raskin (1999) studied the influence of factors that might mitigate the development of PTSD among the Angolan adolescents. They found that greater importance attributed by the adolescents to religious beliefs tended to increase the incidence of PTSD, whereas those attributing less importance to religious beliefs were more prone to depression. Tribal or traditional values tended to be a positive factor for insulation to PTSD; those who endorsed tribal values were less prone to PTSD. In summary, they found that those adolescents most at risk for a PTSD diagnosis were female, separated from their parents, relocated because of war, and disconnected from their tribal values. Socioeconomic factors, such as accessibility to food and the necessities of life, were found to insulate the young Afghanis from the effects of war (McIntyre & Ventura, 2003). Others have questioned whether growing up in a war zone affects children’s moral development (e.g., Garbarino, Kostelny, & Dubrow, 1991; Punamaki, 1987). Punamaki (1987) offers the following: “In such societies, children cannot be successfully socialized . . . in a period when the behavior of their whole society is based on . . . the denial of basic human values” (p. 33).

Children’s Capacity for Reconciliation One investigation, Bayer, Klasen, & Adam, 2007, examined former Ugandan and Congolese child soldiers with symptoms of PTSD, who had been exposed to traumatic events, on average 11.1 traumatic events during the course of their child soldiering. These youth were found to be less open to the aspect of reconciliation with an enemy and more likely to have feelings of revenge directed toward the enemy. The 11- to 18-year-old-children were living in reconciliation centers at the time of the Bayer et al. (2007) study. It is unclear whether the children’s feelings of revenge and lack of openness to reconciliation would mitigate over time; however, it was clear that those with the symptoms felt less open to the prospect of reconciliation and harbored more feelings of revenge (Bayer et al., 2007). Similarly, in another inquiry, Colombian children living

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in war zones understood that stealing from and hurting others was wrong, but they also said that it was acceptable to steal from and to hurt others for revenge (Posada & Wainryb, 2008). According to Posada, these propensities were more pronounced among teenagers.

Child Soldiers The most striking and alarming development is the use of children as child soldiers. A recent trend has emerged as the pervasive use of child soldiers in conflict. The 2008 Child Soldiers Global Report describes the abduction and forced recruitment of child soldiers into government and armed groups in at least 86 countries (Coalition to Stop the Use of Child Soldiers, 2008). According to the United Nations Children’s Fund, child soldiers are defined in the following way: . . .any person below the age of 18 years who is or who was recruited or used by any armed force or armed group in any capacity, including but not limited to children, boys and girls, used as fighters, cooks, porters, messengers, spies, or for sexual purposes. It does not refer only to a child who is taking or has taken a direct part in the hostilities. (UNICEF, 2007, p. 7) Child soldiers are found in all areas of the world but are most prevalent in Africa and Southeast Asia. The psychological impact of child soldiering is devastating on many fronts. Kohrt and Harper (2008) found that 55.3% of Nepalese child soldiers suffered from symptoms of PTSD. Findings in northern Uganda found rates of PTSD to be approximately 97% in a sample of 71 former child soldiers (Derluyn, Broekaert, Schuyten, & De Temmerman, 2004). Another study of former Ugandan and Congolese child soldiers found that 34.9% met the diagnostic criteria for PTSD (Bayer et al., 2007).

Returning Home The children may suffer intense harm after they return to their homes and families. They may suffer significant stigma, and often they are rejected by their families and communities. At times they commit postwar acts of violence in their communities. Upon reintegration into their communities, these children face obstacles when attempting to return to a normal life. The response to their return often is marked by fear and distrust among other community members (Betancourt et al., 2008). Young girls recruited for sexual purposes during wartime are seen as promiscuous and unclean. Males are viewed with apprehension and seen as potentially dangerous (Burman & McKay, 2007). Disarmament, demobilization, and reintegration (DDR) is the process by which child soldiers are returned to their communities. Such programs have been established in several countries, but Betancourt, Borisova et al. (2010) report on the program in Sierra Leone. In that country, the National Center for Disarmament, Demobilization and Reintegration Mission in Sierra Leone works to facilitate the reintegration. The process is begun by having child soldiers surrender their weapons, which are then destroyed. The next phase is demobilization, or the disbanding of armed groups, and the release of child soldiers back to civilian life. Attempts are made to reconnect the soldiers with their families or alternative caregivers. During the third phase, reintegration, children are reintroduced into their families and communities. Reintegration is a long process, and complex psychosocial issues often arise. Community awareness campaigns attempt to raise awareness of reintegration issues (Betancourt, Borisova, et al., 2010).

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Betancourt, Brennan, and their colleagues (2010) studied the longitudinal reintegration of child soldiers in Sierra Leone. They found that child soldiers who had wounded or killed others during armed conflicts demonstrated increased hostility toward others during reintegration. Youth who had survived rape displayed higher levels of anxiety and hostility but were more confident and displayed more prosocial attitudes. Community acceptance of the returning child soldiers enhanced their adjustment, and this included less depression, more confidence, and prosocial attitudes at the time of a 2-year follow-up. Retention in school also served as a protective resource for former child soldiers and was associated with more prosocial attitudes. Betancourt, Brennan, et al. (2010) concluded that reintegration must encompass the reduction of stigma and the building of social and educational resources to aid in the reintegration process.

Effects of War on Communities After a country is destroyed by war, all of its systems are destroyed, and individuals no longer have a structure in which to work, raise their families, or seek help. They lose their meaning, their history, and their culture. This was seen in postwar Bosnia and Herzegovina after the civil war that devastated the former Yugoslavia in the 1990s. People living in the major city of Sarajevo lost not only their homes and their schools but also their treasured national library that housed many of their national treasures. Priceless books, national treasures, and pieces of art were destroyed. The loss of these cultural symbols contributed to trauma on an individual and societal level. The loss of family, friends, and community leaders results in the formation of a firm sense of an in-group and an out-group among survivors. The in-group consists of those who can be trusted and who share traumatic experiences. The out-group consists of outsiders, those that do not share the trauma and cannot be trusted. Ethnic and racial discrimination is likely to become more pronounced during and after war, as people rely upon members of the “in” and “out” groups to formulate the criteria that defines who can or cannot be trusted. Refugees seeking to return to the homeland that they left at the time of war often experience this phenomenon of resulting discrimination. They find that they are sometimes not accepted by a society composed of those who either did not or could not leave their homeland during the conflict. Chemtob and Taylor (2002) describe a two-system response to mass trauma, which may explain this phenomenon. People become highly sensitive to any perceived threat in their environment, and they also are prone to social bonding and group cohesion. Although these reactions are adaptive during the period of the threat, they may become maladaptive after the threat has passed, and survival mode reactions are no longer needed. Those working with postwar communities can focus on factors that lead to community resilience and postwar growth. Community resilience is premised upon building a community and upon social connectedness as a foundation for recovery. This entails strengthening support systems, coalition building, and sharing resources and information (Saul, 2004). Community recovery also is premised on other psychosocial interventions such as: 1. Collectively telling the story of the community experience of the trauma. 2. Reestablishing routines of daily life for civilian survivors. Children should be returned to or reestablished in safe school environments as soon as possible. Neighborhood and community events and holidays should be celebrated and shared whenever possible.

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3. Communities should band together to establish a positive view for the future. The view for the future should be a shared community vision that comes from the members of the community. Outsiders should avoid telling community members how to engage in the process, but rather, they can facilitate a positive vision for the future.

FLEEING THE COMBAT ZONE Wars used to be conducted between states. In recent decades, war has started to take a frightening new direction, that of states conducting war against civilians (Van der Veer, 1998). Historically, psychology has focused primarily on individuals and combatants in terms of addressing the psychological consequences of war and designing interventions to meet those needs (e.g., Boscarino, 2000; van der Kolk, 1984). The psychological literature on the impact of war stress on civilians is scarce, and there is a lack of theoretical models, assessment tools, and psychologically based models for intervening on a large scale to aid civilian victims (Krippner & McIntyre, 2003). Since the early 1980s

Figure 24.3 16-year-old boy portrays how his older brother was killed and private property was damaged in a regional conflict in northern Nigeria. Illustration published with permission.

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and into the new millennium, wars against civilians have been, and in some cases are still being, carried out in such cultures and regions as Afghanistan, Algeria, Angola, China, Colombia, El Salvador, Ethiopia, Guatemala, Indian Kashmir, East Timor, Israelioccupied territories, Liberia, Mozambique, Myanmar, Nicaragua, Northern Ireland, Peru, the Philippines, Russia, Chechnya, Rwanda, Sierra Leone, Somalia, South Africa, Sri Lanka, Sudan, Timor, the former Yugoslavia, and Zimbabwe (Wright, 1999). The goal of this section is to address the psychological impact of fleeing combat zones and the impact of displacement on civilians. Four broad reactions have been described with reference to refugees’ responses to the stressful experience surrounding their flight from their home country as a result of war: anticipation, devastating events, survival, and adjustment (Papadopoulos, 2001). According to this research, these reactions fit within the three phases of the refugee experience: preflight, flight, and resettlement. The preflight phase refers to the time prior to refugees’ escape from their country of origin, occurring at the onset of political violence or war. During the preflight phase, refugees are faced, at the societal and community levels, with social upheaval and increasing chaos in their region (Rumbaut, 1991). Flight is marked by great uncertainty about the future; refugees must survive displacement from their homes and transit or transitional placement (e.g., a refugee camp; Papadopoulos, 2001). Resettlement occurs when a refugee is relocated to another nation after the other options are determined to be impossible. Contrary to common belief, the vast majority of refugees want to return home, and repatriation is the ideal course of action. Repatriation is contraindicated when returning to a home country would put the refugee in immediate danger. Resettlement to a third country means that a refugee leaves his or her country of asylum and legally travels and settles in another country that has agreed to admit him or her as a refugee and to grant permanent settlement there. Whether a refugee may be resettled depends on the availability of resettlement countries with open quotas for refugee resettlement, admission criteria of the country of resettlement, as well as the cooperation of the country of asylum and the refugee concerned.

Preflight and Flight Stress The impact of war on children and their families has concerned psychiatric researchers for decades. Pioneers in the field have noted comparatively greater impact of war-related separations between children and parents than of exposure to wartime atrocities (Freud & Burlingham, 1943). More recently, researchers have focused on the number and types of atrocities. In Mozambique, one study found that 77% of more than 500 children surveyed had witnessed murders or mass killings (Boothby, 1994; Boothby, Upton, & Sultan, 1991). Elsewhere, Cambodian refugees, who survived the Pol Pot regime “work camps,” endured forced labor. Liberian and Sierra Leonean children, conscripted as child soldiers, were denied a childhood. And women in Afghanistan have been and are being systematically and institutionally denied civil liberties, education, and freedom. The traumatic and stressful events leading up to a refugee’s arrival in a new country are drastic. Refugees often have little time for preparation as they leave their homes. They are in a desperate plight, living moment to moment in despair, fighting poverty, pestilence, and disease. They often carry very little with them except their fragile links to their extended families, their belief systems, and their values. The effects of trauma and the stresses of migration are major psychological factors for refugees. The traumas that many refugees encounter include exposure to war-related violence, sexual assault, torture, incarceration, genocide, and the threat of personal injury and annihilation. The physical and psychological traumas suffered by many refugees contribute strongly to

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the appearance of psychopathology in this population (Friedman & Jaranson, 1994). Even considering the difficulties of a cross-cultural diagnosis, higher-than-expected rates of depression, anxiety, and PTSD are found among refugee populations (Orley, 1994). Trauma is only one aspect of the complex experience of a refugee before, during, and after resettlement.

Life as a Refugee Although many new arrivals to Western countries come as undocumented immigrants who may later seek asylum, others come through refugee camps where they may be accorded refugee status. Refugee camps have been described as “total institutions, places where, as in prisons or mental hospitals, everything is highly organized, where the inhabitants are depersonalized and where people become numbers without names” (Harrell-Bond, 2000, p. 1). At some point, psychological defenses no longer work, as the political and social conditions worsen (Horowitz, 1998). Camp residents witness friends and family members being taken, detained, and dehumanized. Competent farmers, for example, can no longer farm, and a state of learned helplessness becomes ingrained into once productive communities and individuals; self-sufficiency is out of the question in camps that are run predominantly by International NGOs with mandates to care for the needs of refugees. Interviews with young Sudanese in a Kenyan refugee camp revealed that severe deprivation, that is, a lack of adequate water, food, and medical care, was common, while acute malnutrition among toddlers in nine Sudanese camps ranged from 20% to 70% (Harrell-Bond, 2000). However, the greatest trauma is the uprooting of the refugees’ physical, psychological, cultural, and social past (Carson, Butcher, & Mineka, 2000; Horowitz, 1986). Refugees are no longer in the comfortable, familiar setting of home, but are living on the outskirts of another culture, one that is often fearful, distant, and even hostile toward their uninvited guests. Sadly this stunted, marginalized existence is still better than the fears and memories engrained in refugees’ minds about their war-ridden home country and oftentimes about families. The refugees choose to stay in these remote stifling environments, even after peace agreements have been signed at home, out of fear of retraumatization or worse when returning home. For example, the Budaburam Liberian Refugee Camp in Ghana is still populated by Liberian refugees; and although they have been informed that it is safe to go home, they refuse out of fear, sadness, grief, health concerns, and identify confusion. Those who escape to a safe haven in another country generally suffer many hardships, not the least of which is the escape process. Life in exile entails a wide variety of psychological and social adjustment issues (Curtis, 1982; Sue & Sue, 1999). During this phase of resettlement, new belief systems, values, and mores challenge a refugee’s adjustment to a host country and its culture (Papadopoulos, 2001). Refugee children often have one foot in two worlds, living in a state of limbo between their home culture and their host culture, feeling torn between family and community. Oftentimes, these children act as cultural liaisons for other generations because of their educational experiences and rapid language acquisition; unfortunately, this can lead to more stress and anxiety (Birman, 1998; Coll & Magnuson, 1997).

Resettlement Stress During the resettlement phase, many refugee children and families reestablish their lives and encounter Western traditions, culture, mores, and values for the first time (Rousseau, 1995). People seeking political asylum generally experience extended periods

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of gut-wrenching anxiety as to whether they will be accepted by a host country or will be sent back to their home country. This anxiety and complex acculturation and adjustment process is superimposed on war trauma and symptoms consistent with posttraumatic stress. Refugees escaping war and political persecution are at particularly high risk for mental health problems (Ahearn & Athey, 1991; Marsella, Bornemann, Ekblad, & Orley, 1994; Williams & Berry, 1991) and, yet, it is likely that they never have heard of the concept of mental health before, let alone sought services in a mental health clinic to treat their experienced symptoms of distress. Numerous studies have documented a high prevalence of symptoms of PTSD and other mental disorders among refugee children and have linked these symptoms to exposure to trauma prior to migration (Boothby, 1994; Mollica, 1988; Mollica, Poole, Son, Murray, & Tor, 1997). Difficulties faced as a result of their complete personal uprooting and from living in exile have been characterized as “culture shock” (Sue & Sue, 1999). The consequences for individuals that characterize this upheaval are feelings of insignificance and a sense of being lost in the world. Sue and Sue (1999) pose the following reasons for this existentially profound upheaval: (a) They have lost the love and respect they formerly experienced with friends and family (b) They have lost their former social and cultural status (c) They have lost their cultural environment and the many obligations and dependencies that gave their lives meaning (d) They are adrift amongst the values of the new cultural environment, those not recognized in their native culture, and those they bring with them that are not valued in the new (pp. 258–265) This suggests that a person undergoes intense and usually prolonged emotional upheaval once they realize how different their adopted new culture is and how difficult it is to adjust to it (Paulson, 2003).

COUNSELING IMPLICATIONS Counseling services have a vital role to play in many settings across the globe. Effective responses to disaster situations, for example, have involved the whole of government, NGOs, and community members. At any given phase in a country’s development (postconflict, disaster recovery, poverty reduction, resettlement, education advancement, etc.), mental health counseling services can play a key role in supporting necessary community stabilization, health programs, and expansion efforts. In 1999, in Yugoslavia, the United Nations Inter-Agency Needs Assessment Mission identified trauma recovery needs to be widespread and relatively unattended. Unfortunately, there was little in the way of adequate direct services or local training being provided in trauma treatment (United Nation Security Council, 1999), then or now. In the two sections that follow, the importance of culture and the specific needs of resettled refugees are emphasized. In the first, culturally sensitive approaches are explored; and, in the second, the need to make such services available is emphasized.

The Importance of Culturally Sensitive Approaches A culturally relevant, developmental, theoretical foundation is essential to understanding the experience of civilian war survivors in the context of individual experiences,

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flight, displacement, and resettlement. With respect to cultural uses, a large body of literature has emerged on culturally and linguistically appropriate services for ethnically diverse clientele. In fact, in the U.S. context, a number of innovative approaches, focused on the needs of specific ethnic groups, have been created and researched. For example, Kinzie and colleagues (1980) and Mollica (1988) have described service models for Southeast Asian refugees in the 1970s and 1980s. These ethnically based clinics have proven to be successful with relatively large, homogeneous groups. However, today’s migration patterns have shifted in ways that bring new challenges to the field of refugee mental health. New refugee arrivals are extremely diverse, with the largest place of origin today being Africa, a continent with overlapping national and tribal boundaries. As a result, multiple treatment approaches must be developed, building on prior work addressing the needs of diverse multicultural and multilingual populations. Counseling services have been proven to help reduce the severity of traumatic reactions, for example, and to facilitate peace-building activities; they also have been used to improve medication compliance in the health sector. In addition, counseling has served to help support national and civic development in many countries and to incorporate sustainable economic and employment opportunities into community practices following stabilization after a disaster event. In an industrialized context not directly affected by war, it is not unusual for people to seek counseling to improve self-esteem, to explore issues related to quality of life, or simply to promote self-development. However, in a war or postwar context, it is usually more the case that individuals enter into counseling in response to some cataclysmic life event. Although this may not always be true, it usually has been the case, because the reality is that most civilians in countries affected by war do not have the luxury of engaging in counseling services. Perhaps the two major exceptions to this are: (a) disaster mental health services periodically offered immediately after a disaster event (e.g., the critical incident debriefing and mental health services offered following the tsunami in Southeast Asia), and (b) HIV and AIDS counseling offered in environments affected by this global pandemic. However, the latter type of counseling generally focuses almost exclusively on medication adherence and offers limited support or training related to grief, loss, death, dying, relationship issues, and individual or family adjustment to a positive status.

Counseling for Resettled Refugees Historically, researchers and analysts have viewed assimilation and acculturation as primary goals. Successful adaptation meant success, whereby a refugee worked through four broad phases: contact, conflict, crisis, and eventually adaptation (Williams & Berry, 1991). The authors of this chapter suggest that we try to “reframe” the conversation around integration, so as to examine the experiential possibility of diversity. As it stands, we view immigrants as “assimilated” when they have acquired enough new customs and attitudes, through contact with the majority culture, that they become indistinguishable from them. This “standard” is narrow and void of opportunities for cross-cultural sharing and learning experiences for the receiving communities. A truly culturally sensitive refugee resettlement program would create an environment where differences can flourish and various worldviews can inform one another, while individuals find their unique places through dialogue, each educating the other. Such an environment could teach not only the minority but also the majority by not singling out the refugee as the “other.” In a world without conflict, everyone is teacher as well as student, thereby reducing social isolation and marginalization on the one hand and inspiring curiosity and openness on the other.

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CONCLUSION In this chapter, we have addressed the impact of war on civilian populations, starting first with the individual and then examining the impact of war on children, families, and communities at large. We also examined relevant historical and cultural issues related to the common stressors affecting civilians when they are living in or fleeing from a combat zone, and we explored current interventions for survivors of armed combat and refugee children and families. Finally, we explicated the significance of reframing the current conversation regarding refugee integration, and we encouraged the reader to examine the experiential possibility of diversity. The human condition of war is one of the most damaging, if not the most damaging, phenomena known to man, resulting in immense death and casualties. The psychological or invisible scars of war are widespread among civilian survivors. However, there is a dearth of information gleaned from the lived experiences of survivors; systematic investigations are needed regarding the effects of war on civilians. Perhaps the reluctance to research this topic speaks to human fears. We, as civilians, fear war. What would happen if we were to lose the haven of our homes one day, and our family and neighbors were to be systematically attacked and killed? How would we survive the worst of it? Would our lives be worth living in the end? Perhaps part of the human condition is that it is better to ignore our worst fears. We are afraid that it could happen to us, and we therefore are afraid to look at the experience of others. However, it is not until we truly acknowledge and understand the experience that we can begin to understand the pressing need to design a different, better, and less lethal manner to resolve our conflicts as members of the human race. We cannot overcome that which we do not understand.

APPENDIX 24.1 Case Study From Liberia Liberia’s civil war lasted from 1989–2003. This war was filled with extreme violence committed against the civilian population, and hundreds of thousands of Liberians fled the country and sought asylum in Sierra Leone, Guinea, Ivory Coast, or Ghana. Various rebel groups emerged during the war, destabilizing the whole country. Some historians have suggested that Liberia witnessed some of the most violent atrocities seen in Africa to date (Berkley, 2002). It also has been suggested that ritual elements like cannibalism cast Liberia’s violence in a fundamentally different light from that of more “conventional” violence seen in other war-torn environments (Huband, 1998). Heads of families were targeted and brutally murdered in front of their families, and surviving children were forced to witness these heinous acts and then find new support systems in which they could trust. Children were abducted, and boys were forced to join forces fighting on the war front while girls were sexually exploited and used as sex slaves. By the end of the war, approximately 200,000 Liberians had been brutally killed during the crisis (roughly 10% of the population) (Huband, 1998). The following case study captures one of many trauma and torture stories that clinical and local peer-support counselors heard during their tenure with The Center for Victims of Torture (CVT), a community mental health program in Bong, Lofa, and Monsteraddo counties in Liberia. This is the narrative of Fatima Sworay, a 32-year-old (continued)

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APPENDIX 24.1 (continued) female, whose occupation is noted as housewife, and who has not had any formal education. Of course, the client’s name and identifying information were changed to protect the client’s confidentiality. She was identified during a mass sensitization in the Lelekpayea Community in Gbarnga, Bong County, Liberia.

Personal History Fatima was captured by the Liberian Peace Council (LPC) rebel forces in 1994 when she was 9 months pregnant. Immediately following her detainment, Fatima, her mother, and a small group of women from the village were gang raped by the rebels. During the same attack, Fatima’s father and 10 other men in the community were captured and killed in front of the women and children. The older women, including Fatima’s mother, were forced to bury the dead bodies. The younger women were collected and mandated to “join” the rebels. Fatima was among the women abducted and was forced to become a “wife” to the rebel leader. Fatima delivered her child 3 weeks after being abducted. Seven days after delivering her baby, Fatima was able to escape with her newborn baby and took refuge in the nearby bush for three days. After traveling alone for three additional days, Fatima discovered a group of Internally Displaced Person’s (IDP’s) from another village and stayed with them in a makeshift camp deep in the forest for 10 days. From there, Fatima returned to her family home; even though she was extremely fearful of returning, she faced her fear out of a desire to find her mother. Fortunately, she returned safely and was reunited with her mother. Given that fighting was still occurring in the area, Fatima, her baby, and her mother chose to hide in the bush for a few weeks, in order to avoid contact with the fighting factions.

Impact Because of the rape as well as the stressful delivery, Fatima reported suffering from severe abdominal problems (bleeding, irregular menstruation, intense cramping, etc.) for months following the attack. Although her condition improved marginally, and her cycle became more regular after having an operation at a medical clinic established by an international aid organization, she continued to report unexplainable episodes of severe pain in her abdomen. Because the medical doctors could find no medical reason for the continued pain, she was referred to our community mental health center for a psychological assessment. Psychologically, Fatima suffered from a number of consequences of her traumatic experience. She reported sleepless nights, feelings of worthlessness, chronic worries, and problems concentrating. She also reported experiencing episodes of severe anxiety and panic when visiting the local markets or attending community events. After a few weeks of individual counseling, Fatima discussed her rape experience in more detail and reported that the hardest part of the experience was the fact that many members of her community had witnessed the attack; she felt stigmatized and ostracized, this being secondary to her victimization. On more than one occasion she overheard people talking about her attack and pointing her out when walking through the market. Her uncle frequently told her she would never be given the chance to marry again because she was “used goods.” Although she was dating someone and (continued)

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APPENDIX 24.1 (continued) considered the relationship to be important and serious, she noted that he had a hard time accepting her past and refused to have a formal marriage ceremony with her as a result. Following the rape, Fatima was unable to experience any kind of sexual satisfaction, which only added to the challenges of her relationship. A few weeks prior to seeking psycho-social support, Fatima’s boyfriend had become so frustrated about her rigidity and resistance to sexual intimacy that he started insulting her in public. He also discussed her problem with some of the community leaders, who advised him to end the relationship, which then led to further stigmatization.

Intervention Fatima joined a survivor support group counseling session with group members who had experienced similar traumatic incidents. In this support group, the members provided each other with various types of help for their shared, burdensome traumas of gender-based violence tied to wartime experiences and current gender inequality experiences. The help took the form of providing and evaluating relevant information, relating personal experiences, listening to and accepting others’ experiences, providing sympathetic understanding and establishing social networks. This support group ended with the creation of a group for support-group graduates, who worked to inform the public about women’s issues that they felt were important to examine in the community environment. Listening to other women with similar problems in the past but also in the here and now (relationship problems, stigma, etc.) helped Fatima realize that her past trauma was not her fault, and that she was not to blame for the events. She also realized that she was not alone with her sense of guilt, shame, and feeling responsible for what had happened.

Outcome Upon completion of the support group, Fatima was able to make and maintain friendships with other women in the group, and they started to meet once a month to discuss their community concerns. She reported feeling much less isolated through the support of her fellow group members; she indicated that she was proactive in the group and that she has been identified to be the member to air concerns to the community leaders. Fatima reported improved self-confidence and increased socialization. Her situation with her current partner remained strained; however, Fatima reported she was preparing (saving money, identifying housing, talking to her children) to end the relationship and move out with the support of the women in the group.

Follow-Up Fatima successfully completed the support group sequence and reported a decrease in her abdominal pain and in the symptoms of her stress reaction. Follow-up sessions were planned for 3, 6, and 12 months. The local team of peer-support counselors identified Fatima’s boyfriend at an outreach event, and he agreed to participate in the men’s group that was scheduled to begin in two weeks. It has been the counselor’s goal to engage men in groups in order to minimize their risk of future domestic violence, whether within the same relationship or in a new one. Treatment for these men emphasizes minimizing risk to the victim, and may be modified depending on the (continued)

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APPENDIX 24.1 (continued) men’s history, risk of engaging in violent acts, and personal trauma history. Support groups are standardized to be gender specific (male only), as it has been demonstrated that domestic violence offenders maintain a socially acceptable façade to hide abusive behavior, and therefore accountability needs to be one of the main focuses of the group. Other topics of exploration include anger management, recognizing abusive patterns of behavior, and reframing communication skills.

RESOURCES Websites Impact of War on Civilians Links (http://www.mccsc.edu/~rcourtne/wareffec.htm) National Center for Posttraumatic Stress Disorder. (2010). Mental health aspects of prolonged combat stress in civilians. Retrieved from http://www.ptsd.va.gov/professional/pages/combat-stress-civilians.asp SalusWorld (http://www.SalusWorld.org)

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CHAPTER 25

The Impact of War on Military Veterans ROGER P. BUCK

INTRODUCTION This chapter focuses on the most salient factors that have an impact on military combatants and their experience of warfare. The circumstances and the environment associated with combat causes a set of complex and unique responses. Due to an immense diversity of experience, it is extremely difficult to identify all the variables associated with human responses to warfare. This chapter is an introduction to the potential psychological jolts that war trauma has on the military combat veteran. There is a complex anatomy of human responses to war trauma to consider. Detailed in this chapter are five areas that reveal the complexity of this topic: (a) there are five major areas of research related to human responses to war trauma; (b) there are diverse populations of military personnel; (c) there are numerous and contrasting war experiences; (d) resilient individuals appear to adjust and reintegrate into daily society more easily; and (e) physiological brain structure changes occur in some veterans as a result of traumatic war experiences. Readers will learn that posttrauma reactions are much more comprehensive than the label of anxiety disorder, and that traumatizing events affect the whole person. Physical adaptations, cognitive thought processes, emotional responses, behavioral changes, and subjective interpretations are all part of the psychological makeup of the person who experiences war trauma. Recovery, resilience, and reintegration are three major components in psychological adjustment following combat. The devastating cost of warfare can be measured objectively through the number of lives lost, homes destroyed, damage to cities, agricultural carnage, and environmental destruction. The subjective and potentially devastating toll on the character of military combatants who experience the “sensory” reality of warfare is much more difficult to measure. Significant psychological, physical, emotional, and spiritual changes occur in individuals who experience traumatic war events. Permanent damage to a person’s character does not have to occur following combat trauma. The purpose of this chapter is to identify the unique issues, problems, themes, and predictable human responses to military combat. This aim is accomplished through the discussions that appear in the major sections of the chapter that follow: (a) psychosocial context, (b) complex nature of trauma responses, (c) treatment modalities, and (d) implications for counselors. These sections are followed by a summary of the chapter and relevant resources related to trauma and military veterans.

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PSYCHOSOCIAL CONTEXT Many male and female veterans of the U.S. military returning from the Vietnam War suffered problematic readjustment to civilian life (Buck, 1998; Ettedgui & Bridges, 1985; Evans & Sullivan, 1990; Everstine & Everstine, 1993; Figley, 1978; Foy, Carroll, & Donahoe, 1987; Foy, Osato, Houskamp, & Neumann, 1992; Goodwin, 1987; Herman, 1992; Kormos, 1978; Sandecki, 1987; Shatan, 1978; Strayer & Ellenhorn, 1975; van der Kolk, 1984, 1987, 1989; Williams, 1987; Wilson, 1978; Worthington, 1977). The unconventional warfare unique to Vietnam is thought to have caused an estimated 500,000 psychological casualties among soldiers, sailors, and airmen. Lack of popular support for the war in conjunction with war protests is considered a major contributor to problematic psychological adjustment of Vietnam veterans (Buck, 1998; Scott, 1993; Wilson, 1978). With the appearance of posttraumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association [APA], 1980) in 1980 came a change in focus. Psychological symptoms were first attributed to the traumatic events instead of individual weakness (Friedman, 2003). This new diagnosis recognized the potential for long-lasting psychological problems as a direct result of a specific trauma event or events (Fairbanks, Schlenger, Caddell, & Woods, 1993). The uniqueness of PTSD is its direct link to an etiological stressor or trauma event (Breslau, 2002; Breslau, Davis, & Anreski, 1995). War is a traumatic event, and the predictable psychosocial responses and unique phases of adjustment are discussed in this chapter.

Understanding Psychosocial Responses to War In 1983, a congressional mandate prompted further investigation of PTSD and other postwar psychological problems among Vietnam veterans. The National Vietnam Veterans’ Readjustment Study (NVVRS) was conducted to obtain data identifying the prevalence of postwar psychological problems. The prevalence of PTSD among “Vietnam theater veterans” (veterans deployed to the war zone) was an estimated 15.2% (male) and 8.5% (female). Those individuals who had higher war zone exposure to the “sensory” reality of warfare had higher rates of PTSD at 35.8% (male) and 17.5% (female; Schlenger et al., 2002). More than 1.6 million U.S. troops have been deployed in support of Operation Iraqi Freedom (OIF; Iraq) and Operation Enduring Freedom (OEF; Afghanistan) since October 2001. The all-volunteer force has been experiencing an unprecedented pace of deployments, including multiple deployments to combat with infrequent breaks between deployments (Belasco, 2007; Bruner, 2006; Hosek, Kavanagh, & Miller, 2006). Casualty rates (killed and wounded) for these deployments have been fewer because of advances in medical technology and the use of body armor (Regan, 2004; Warden, 2006). Psychological and stress reactions develop in soldiers because of the following factors: multiple deployments, dangers of combat as exemplified by improvised explosive devices (IEDs), and exposure to the uncertainties associated with nonconventional guerilla warfare. There have been a range of estimates of mental health problems among OIF and OEF veterans over the past several years. In 2008, a RAND corporation monograph (Tanielian & Jaycox, 2008) indicated that of OIF and OEF veterans, 14% screened positive for PTSD, and 14% screened positive for major depression. Another 19% report a probable traumatic brain injury (TBI) experience. These percentage estimates suggest that in 2008, approximately 300,000 military veterans suffered from PTSD or major depression, and another 320,000 veterans experienced a probable TBI during deployment (Tanielian & Jaycox, 2008). These percentage estimates by RAND are conservative

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for 2011, as the all-volunteer military forces have continued to experience 3 more years of multiple combat deployments. The Defense and Veterans Brain Injury Center (DVBIC) indicate that over the 10-year period of 2000–2010, a total of 188,270 military veterans who have experienced TBI have received services from their treatment facilities.

Phases of Adjustment As the military continues its rapid schedule of deployments, the ever-increasing psychological casualty statistics continue to reflect the physical, cognitive, emotional, behavioral, and spiritual (PCEBS) costs of warfare among our combat veterans. The immediate impact of the war may not be debilitating for many, but there is evidence that soldiers who witness horrific events are at risk for chronic mental health problems over their lifespan (National Center for Posttraumatic Stress Disorder [NCPTSD] & Walter Reed Army Medical Center [WRAMC], 2004). PTSD symptoms are only some of the many manifestations of traumatic war experiences. An extensive library of related research is available online and explores such war experiences in detail (see U.S. Department of Veterans Affairs as well as NCPTSD in the Resource section at the end of the chapter). Symptom intensity, rate of recovery, and support needs for each veteran are all part of an elaborate and personally meaningful reintegration process that varies for each military veteran. Human traumatic response includes an intricate array of factors, and the complexities of human responses to military combat, relevant issues, and evidencebased practices are explored in the following section.

COMPLEX NATURE OF TRAUMA RESPONSES Human beings respond to danger through a “complex, integrated system of reactions, encompassing both body and mind” according to Judith Herman (1992). When attempting to assess the impact that crisis experiences have on the individual, the evaluator needs to consider three “interactive components” (Webb, 1991). According to Webb, the three components that determine individual responses to traumatic events are the following: (a) individual factors, (b) the nature of the crisis events, and (c) factors in the support system. Herman and Webb’s early PTSD research provide an historical basis to organize and conceptualize more recent research findings. There are five major research areas of human traumatic response to warfare: (a) personal characteristics of the individual, (b) psycho-physiological and other somatic factors including TBI, (c) social factors, (d) characteristics of the trauma events, and (e) treatment modalities.

Personal Characteristics of the Individual to Consider There are significant personal variables that determine an individual’s responses to traumatic events, such as age, sex, cognitive level of function, moral and spiritual beliefs, previous trauma experiences, precrisis adjustment, cultural beliefs/background, and previous behavioral health issues (Buck, 1998; Janoff-Bulman, 1992; Herman, 1992; Webb, 1991). Included in these factors are subjective influences that are difficult to identify and categorize objectively. Students of trauma must recognize these subjective issues in order to gain a more comprehensive understanding of the human responses to traumatic war events. Three subjective existential issues are discussed in the following sections: the psychology of warfare, conceptualization of war, and resistance to killing.

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The Psychology of Warfare There are a myriad of psychological, economic, and social group theories that aim to explain why nations and human beings find it necessary to go to war (LeShan, 2002). Two major existential concepts related to the psychological response to warfare are examined here. First, LeShan argues that the manner in which nations and individuals conceptualize warfare should be studied as a way of understanding the underlying psychology of warfare. He believes that understanding how people conceptualize war leads to a deeper understanding of the function of war and the meaning that individuals and governments construct from participating in war. Second, Grossman (2009) suggests that there is a basic human resistance to killing another human being. To become more efficient in war and kill more of the enemy, contemporary military and police training methods differ from those used prior to the Korean War. Because of these training changes, soldiers of today are more likely to kill during combat than the soldiers in World War II and in previous wars. Grossman suggests focusing on efficiency in killing has resulted in more severe psychological damage to the modern soldier. Both authors emphasize that the existential as well as the trauma-specific issues that arise are important. Sensory combat experiences must be incorporated within the individual’s perceptions and understandings of those objective events. LeShan and Grossman provide a framework for understanding the subjective interpretations that human beings make as a direct result of the objective experiences of war.

Conceptualization of War LeShan (2002) suggests that the various psychological, economic, and social group theories of why nations and individuals allow themselves to get involved in war are limited in their views about the causes of warfare. He articulates the existence of a new conceptual framework that previously has been unavailable and unexplored. For the past 30 years, a new field of thought has developed that examines the diversity of how human beings perceive reality (LeShan, 2002). Perception of reality is altered when one nation goes to war with another. These perceptions do not necessarily represent the truth about the world and its structure; they are just perceptions. Perceptions that allow for warfare to develop are based on a bias or belief system that may or may not be accurate. To comprehend the full psychological motivation behind the behavior of warfare, LeShan asserts the centrality of basic human “drives,” which potentially lead to the belief that war is the only way to resolve conflicting beliefs. In his book, The Psychology of War, LeShan explores human beings and the psychological tension of being a separate and unique individual, while simultaneously feeling the need to be accepted and to belong to a group. LeShan (2002) refers to the Roman mystic Plotinus, who suggests that we have an “amphibious nature” (LeShan, 2002, p. 27), and that we must find a way to integrate both the way of the one and the way of the many. War is one way that human beings simultaneously can fill these fundamental needs. When a group/nation has the following three perceptions about the world and about another group/nation, then they have the necessary conditions to see war and violence as a viable option: (a) there is an enemy nation that is evil, and if they were destroyed, then the world would be a better place; (b) glory can be realized if action is taken against this evil enemy; and (c) everyone within the “tribe” must agree with this understanding about the evil enemy, or he or she is seen as a traitor to the group. If these three danger signs are present, then armed conflict may result. What is created by the previous perceptions is a “mythic reality” of war, one in which a nation and its populace rally around a cause for the eradication of evil. This is

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what the nation perceives, but it is not at all what the soldier experiences. The combat soldier experiences the “sensory reality” of warfare. Initially, soldiers go into battle with the same mythic reality. However, the soldier is faced with the visceral horrors of war; the senses are overwhelmed with the sights, sounds, smells, tastes, and touches of war. There is a crisis in perception due to the incongruence associated with the mythic reality of war and the sensory experiences the soldier is subjected to. There is a series of expectations or beliefs associated with the mythic reality. The soldier expects to engage an evil enemy and, along with his or her fellow soldiers, survive. When a soldier witnesses the death and suffering of fellow soldiers, it does not fit the expectations associated with the mythic reality. The death or severe injury of a fellow soldier is seen as a violation of the mythic rules of war. Within the mythic reality, there are two sets of morals: Soldiers judge the killing and combat behavior of enemy soldiers as evil. Killing the evil enemy is acceptable, righteous, virtuous, and good. The more time a soldier spends in sensory combat, the more quickly the mythic reality begins to erode. Witnessing unconventional combatants such as women and children participating in the killing does not fit into the mythic reality of war. For U.S. military soldiers to kill women and children, even if it is in self-defense, takes its toll on the sensory perceptions of moral constructs associated with acceptable combat. When confronted with sensory warfare, soldiers begin to question why the country is at war and their own participation in the fighting and killing. Once a soldier is unable to maintain the mythic reality that the nation uses to justify the killing, then a “meaning” or “spiritual” crisis occurs, and the soldier can no longer justify his or her personal participation in killing, combat, and warfare. The individual soldier’s perception of the “evil enemy” is potentially transformed into recognizing that the people being killed are human beings. The “glory” of killing the evil enemy begins to fade, and the “sensory reality” (sights, sounds, smells, taste, and touch senses of death and destruction) begins to permeate the soldier’s total awareness. Disenchantment replaces the mythical cause. Combat soldiers experience these changes in an environment of misunderstanding. Military planners and the U.S. populace do not fully understand the sensory experiences of combat soldiers and the resulting shift in their perceptions. Because of this difference in perception, many combatants tend to isolate themselves both emotionally and physically. As a result, war’s objective experiences begin to invade, wound, and transform the soldier’s spirit and subjective understanding of self, others, and the world. These objective sensory experiences erode the “mythic beliefs,” and the combat veteran struggles with understanding life events in an environment of self-imposed isolation. Every human characteristic that the individual attributes to a sense of “self” must be reshaped in order to make sense out of seemingly senseless sensory experiences. Some of these human characteristics include the following transitions: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

How the individual perceives personal power and control Perceptions about the world and safety How the mind organizes information The mind’s total functioning is altered How an individual loves, relates, and connects intimately with others What the individual believes about the world and about the self Values and ethical beliefs come into question What is judged as good and evil is reviewed What is right and what is wrong What is feared and what is loved becomes confusing

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It is important for the student of war trauma to realize that there is a deep personal transformation that soldiers go through as a result of the sensory experiences of warfare. This transformation cannot be fully explained by using just one label such as PTSD. Reactions to combat and war trauma are definitely a stress reaction to traumatic experiences, but it is potentially an identity and whole-person crisis, depending on a complex set of factors that is explained in the following section.

Resistance to Killing Comprehending the human responses to war requires a fuller realization and understanding of the psychology behind the human capacity to create and conduct warfare, and more specifically, the killing of another human being. In his book, On Killing, Lt. Col. Dave Grossman indicates that there is a significant psychological factor in most human beings, describing it as “an intense resistance to killing their fellow man. A resistance so strong that in many circumstances, soldiers on the battlefield will die before they can overcome it” (Grossman, 2009, p. 4). He refers to U.S. Army Brigadier General S. L. A. Marshall’s experience and inquiry/questioning of World War II veterans and the fact that “only 15 to 20% would take any part with their weapons” ( as cited in Grossman, 2009, p. 3). According to Grossman, the lack of enthusiasm for killing “causes soldiers to posture, submit or flee, rather than fight; it represents a powerful psychological force on the battlefield; and it is a force that is discernible throughout the history of man” (Grossman, p. 29). He explains that “looking another human being in the eye, making an independent decision to kill him, and watching as he dies, due to your action, combine to form one of the most basic, important, primal and potentially traumatic occurrences of war” (Grossman, p. 31). Marshall’s research with World War II veterans revealed that many soldiers fired in the general direction of the enemy, in an attempt to appear as if they were participating in killing enemy soldiers, and that most would not openly admit that they resisted the opportunity to kill the enemy. Many soldiers during WWII openly volunteered to reload weapons for others, but the actual act of killing another human being was performed by approximately onefifth of our U.S. combat soldiers (Marshall as cited in Grossman, 2009). Those soldiers who fired weapons that were designed to kill from a distance such as mortar, rocket, cannon, or aircraft had a very high rate of participation because they were not face to face with their enemy. So until the Korean and Vietnam wars, it is estimated that only about 20% of our military combat-experienced infantry veterans actually shot at and intended to kill enemy soldiers. According to Grossman (2009), Marshall’s findings largely have been ignored by the academic fields of psychology and psychiatry, but the U.S. Army has taken Marshall’s discoveries seriously and after the end of World War II instituted several new training methods. Because of these training changes, various studies of Korean War veterans indicate a jump to a 55% firing rate, and in Vietnam, the firing rate increased to between 90% and 95%. The programming or conditioning training methods used that increased the firing rate for Vietnam War veterans was classical and operant conditioning. Training methods include the following strategies: desensitization, conditioning, and denial defense mechanisms. In the desensitization process, the idea of “killing” an enemy who is evil, different, and dehumanized begins as early as boot camp and continues throughout the training process. By dehumanizing the enemy and continuously making them appear evil, the soldier has little resistance to killing when the opportunity presents itself. Conditioning occurs with repeated practicing of “quick shoot” on a firing range that includes human-shaped targets. There is competition and also immediate gratification when the

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target falls or explodes. There is continuous reinforcement when the gunman is recognized by superiors and peers as an expert shooter. Expert shooters often graduate with honors from the training program and receive further reinforcement with other forms of personal recognition. Failure to complete the firing range activities results in delay of graduation and possible chastising by peers and superiors. There is extensive rehearsal, with nearly exacting battlefield conditions. Soldiers are taught to shoot reflexively and instantly as they “engage” the target. The word “engage” of course means to “kill” the enemy. The word “target” is used to represent the human enemy. This neutralizing, de-humanizing, and denial language originates in training but also carries over into combat. This nonspecific language becomes part of combat. Soldiers have rehearsed shooting at “the target” so many times that when they actually shoot at a human being, they are just “engaging a target.”

Psycho-Physiological and Other Somatic Factors to Consider Significant investigations have been conducted regarding how the body responds to the extreme stresses that are associated with traumatic experiences; some of this research shows that the body’s complex biochemistry becomes deregulated. Brain chemicals designed to protect us may become harmful due to the amount or dosage our body creates. The alertness of the brain, memory enhancement, and rapid heartbeat caused by increases in norepinephrine and epinephrine (adrenaline) benefit the human being as the fight-or-flight response to danger. Too high a level of these chemicals may cause learning and memory impairment and may induce confusion. The repeated infusion of excessive amounts of these chemicals appears to sensitize brain chemistry and results in increasing amounts of adrenaline release at lower stimulation thresholds. Emotional reactivity caused by the dysregulated nervous system results in hypersensitivity, exaggerated behavior responses, and more intense susceptibility to sensory triggers such as smells, sounds, and sights. This overabundance of chemicals potentially triggers a cinematic, even seizure-like, reliving of trauma referred to as a flashback (van der Kolk, 1984, 1987, 1989; Vasterling & Brewen, 2005). The negative effects of high levels of these chemicals may occur immediately following traumatic events and continue for a long time. In addition to the chemical influences within the brain, there is also potential damage to the structure of the brain. Long-lasting damage to the hippocampus may occur, which is then linked to the development of short- and long-term memory. There is a significant 8% reduction in hippocampus size among military trauma victims ages 18 to 24 years (Bremner et al., 1995, 1997, 2002; Villarreal et al., 2002). In a related study of women with history of childhood sexual abuse, there was a 12% decrease in left hippocampal volume (Bremner et al., 2003). Symptoms of PTSD are more pronounced for those individuals with a smaller hippocampus (Bremner, 2001; Gilbertson et al., 2002; Osuch et al. 2001; Shin, Orr, et al. 2004; Shin, Shin, et al., 2004). High cortisol levels have been linked to hippocampus shrinkage; as a result, high levels of cortisol, for longer and more chronic periods of exposure to danger, potentially produce more and longerlasting damage to the brain. If the body attempts to compensate for this overuse of cortisol, and levels are overreduced, the outcome could be brain-cell death in the dentate gyrus region of the hippocampus, where long-term memory and recall are created (Vasterling & Brewen, 2005). The potential symptoms that manifest as a result of this brain damage are fragmentary memories, amnesia, short-term memory lapses, verbal recall deficits, dissociation, and an inability to describe horrific experiences (Vasterling & Brewin 2005; van der Kolk, 1984, 1987). These are just a few examples of brain chemistry alteration and structural brain changes due to chronic traumatic stress.

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Social Factors to Consider Another significant support strategy for recovery from traumatic experiences is the social network available to combat veterans such as nuclear family, peers with shared experiences, supportive others, churches, school/educational institutions, personal friends, and extended family members. Military support systems are a unique population with variables significantly different than any other organization (Brunner, 2006; Buck, 1998; Hutchison, 2010; LeShan, 2002; Tick, 2005; Wilson, 1978). Some of these unique circumstances are presented here so that the military trauma student recognizes the distinctive differences in this population of trauma victim. An all-volunteer force has staffed the military since the end of the Vietnam War in 1973. In the 1990s and just prior to the war activities in the Middle East, the number of U.S. Army personnel reached an all-time low of 500,000 soldiers. The military of today is much more diverse than at any other time in U.S. history. For example, there are ethnic minorities ranging from 24% in the Air Force to 40% in the Army, and 16% of all active duty military personnel are women. Over 50% of all military personnel are married, and 11% of those are married to other military service members (NCPTSD & WRAMC, 2004). There are also several different components within the five major military organizations of the Army, Navy, Marine Corps, Air Force, and Coast Guard. Because of the Global War on Terrorism (GWOT), many National Guard and Reserve units from all five branches of the military have been called to active combat duty multiple times. Several resources available on soldiers’ home bases support regular military units and their families who often reside either on those bases or in the immediate area. Because of geographic distance, a military base does not routinely support reserve units. National Guard and Reservist’s families are isolated from military supports while the service member is deployed. Deployed reservists and/or guardsmen often lose their jobs or experience financial loss when they return from combat. More detailed information related to deployment, family issues, and unit integrity are examined in the Iraq War Clinician Guide (NCPTSD & WRAMC, 2004) and should be reviewed by any professional who anticipates working with military war veterans.

Characteristics of the Trauma Events to Consider There are many aspects about the specific traumatic event that influence the response that an individual has to the event. The diversity of war and military experiences has a major impact on individual responses. For example, if the individual is exposed to a single traumatic event, the symptoms associated with this event are potentially less debilitating than chronic and long-term recurring events (Buck, 1998; Herman, 1992). The individual who experiences a single-event trauma may feel “not him/herself,” while the chronic trauma victim may feel a total and irreversible loss in sense of “self” (Herman, 1992). If a trauma is experienced in solitary, the individual may feel unprotected, alone, and abandoned; hence, the option of social supports, through a shared experience, may not be available to this person. There is also a direct correlation between the severity of loss and the number and intensity of symptoms that develop (Everstine & Everstine 1993). The loss and death of a family member or friend can intensify the trauma symptomatic response. Variables that determine how survivors react to death include the following: death due to misconduct or natural causes, age of the deceased, and circumstances related to the death. The most devastating psychological trauma occurs when the survivor believes that they contributed to death due to neglect, misconduct, or intent (Buck, 1998).

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Other issues to consider relate to the nature of the crisis. These include the following factors: the proximity and level of exposure to the traumatic event; the presence of a loss in status, personal power, and control; and the loss of bodily function through physical injury or pain. During military operations, there are a multitude of differing experiences with which the individual soldier may be faced: predeployment, deployment, types of conflict, medical evacuation, psychological stresses and responses, psychiatric care needs, postdeployment, administrative discharges, and so forth (NCPTSD & WRAMC, 2004). This section of the chapter focuses on the types of conflict that military combatants must endure and their psychological responses. Different experiences that occur in warfare include low-intensity combat, high-intensity combat, terrorist activities and guerilla warfare tactics, other unique issues, and military sexual trauma. Human responses to these various experiences differ significantly.

Low-Intensity Combat Low-intensity combat in a wartime or combat environment, where fear of death or injury is less imminent, often includes a chronic strain on the individual. The person is subjected to harsh living conditions, family separation, extremes of hot or cold, and long hours of being on duty with little to no respite. The combatant experiences isolation, minimal communication with family, boredom, and a chronic awareness of the potential dangers that exist in this environment. These human stressors often foster the development of mood and anxiety disorders, separation anxiety, and adjustment and personality crises. Preexisting conditions may be exacerbated by this level of combat. Development or recurrence of alcohol and drug abuse may occur depending on availability of these substances.

Intensive Combat Intensive combat includes emotional responses to combat experiences. These often are viewed in a multiphase trauma response continuum (NCPTSD & WRAMC, 2004). Immediate Phase. The immediate phase of response includes “normal” and predictable reactions to extreme stressors and would include disbelief, strong emotions, confusion, fear, and autonomic arousal and anxiety. Various forms of adjustment disorder or maladaptive traits often manifest during this phase due to the extreme nature and immediacy of combat. Any preexisting conditions may be exacerbated, such as depression, previous PTSD symptoms, and substance abuse. Additional issues related to nonconventional warfare such as biological agents and chemical warfare can add additional disruption for the military combatant (DiGiovanni, 1999). Delayed Phase. The delayed phase occurs following intense combat stressors and may result in unexplainable physical symptoms or other PTSD symptoms followed by substance abuse. These symptoms might include persistent autonomic arousal characterized by somatic symptoms, intrusive recollections, irritability, apathy, persistent anger, dissociation, mourning, and social withdrawal (NCPTSD & WRAMC, 2004). Chronic Phase. The chronic phase includes continued arousal and intrusive symptoms with infusion of existential questions and personal discovery. A mix of depression and anxiety or other mood disturbance often manifests during this phase. Substance abuse may become more entrenched, legal problems may emerge, and pervasive distrust of

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self and others often develops. Due, in part, to this lack of trust, many combat veterans avoid all reminders of the traumatic events and isolate themselves both physically and emotionally. In this phase, the individual is attempting to make sense out of senselessness and is assigning some form of meaning to the objective events that have been experienced (Buck, 1998; DiGiovanni, 1999; NCPTSD & WRAMC, 2004).

Terrorist Activities/Guerilla Warfare The increase in hypervigilance and stress related to tactics of terror such as remotely detonated explosive devices, car bombings, and mortar and rocket attacks cause additional psychological stress for the individual. The fear and surprise associated with this kind of warfare takes a psychological toll on an individual’s sense of power and control within his or her environment. A crisis of meaning and senselessness begins to invade the individual’s purpose for being in this environment. Enemy combatants often are not readily identifiable, as women and children often participate in this type of warfare. Not having a clearly identifiable enemy, coupled with uncertainty and doubt as to personal power to keep self and fellow soldiers safe, causes the soldier to remain ever vigilant and on guard (NCPTSD & WRAMC, 2004).

Other Unique Issues to Consider U.S. military forces must follow rules of engagement, especially while fighting where civilian populations are present. To limit civilian casualties, the U.S. military command structure requires justification for each violent interaction with the enemy. All fighting incidences are subject to retrospective analysis by command leadership. Commanders often require postaction justification of violent action taken against an enemy. Many soldiers see this process as ridiculous and accusatory. If the combatant interprets this retrospective review in this manner, then the military commanders may appear uncaring, unreliable, and unsupportive. The combatant who feels betrayed by command often experiences more severe psychological symptom development (Grossman, 2009). There are incidences where U.S. military units mistakenly fire on their own personnel, resulting in injury and death. Incidences of “friendly fire” have occurred because of miscommunication, error, and confusion on the battlefield. Those who are responsible for such friendly fire incidences, as well as the victims of these mistakes, potentially suffer more negative perceptions about the war. It is very difficult for soldiers to make sense out of the war and its purpose when a military action or mistake costs the lives of fellow soldiers (Buck, 1998; Grossman, 2009; Tick, 2005).

Military Sexual Trauma Both sexual harassment and sexual assault are included in the category of military sexual trauma. Military sexual trauma means that either harassment or assault occur in a military setting and may involve both male and female victims. As reported in the Iraq War Clinician Guide, the Department of Defense (NCPTSD & WRAMC, 2004, p. 66) conducted a study in 1995 and found that the sexual harassment rate for women was 78%, and for men it was 38%. Sexual assault, both attempted and completed, was 6% for women and 1% for men. Other studies, conducted by the Veterans Administration and reported in the Guide (NCPTSD & WRAMC, 2004), indicate that female veterans reported sexual assault rates as high as 23%. Other studies (NCPTSD & WRAMC, 2004) suggest that the rates of sexual assault among active duty military personnel

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are higher during wartime than peacetime. Sexual assault victims experience higher rates of lifetime PTSD symptoms. Trauma (PTSD) symptoms among male victims of sexual trauma last across the lifespan at 65%, which is higher than combat-related PTSD, at 38.8%. Female victims of sexual assault have lifetime symptoms of PTSD at 46%. Sexual trauma occurs most often where the victim works or lives. In many cases, the victim must continue to live or work with the perpetrator or friends of the perpetrator. Potential impact on the victim includes the disruption of career goals, low performance evaluations, delayed promotions, continued contact with the perpetrator because of unit mission, and the need to maintain unit cohesion (NCPTSD & WRAMC, 2004).

TREATMENT MODALITIES Before identifying the “best practice treatment methods” for military veterans, it is important to understand who is being treated. The need for accurate and comprehensive assessment cannot be overstressed when evaluating the individual’s personal attributes (strengths/weaknesses) as well as the specifics of the traumatic event. It is important to assess the level and intensity of exposure, type of experience, duration of experience, and the social supports provided/available. It is extremely important to recognize the possibility of TBI caused by explosions, impact wounds, and other concussion-type experiences. The OIF and OEF campaigns have been identified as the TBI wars, and symptoms related to this type of injury can be temporarily or totally debilitating (Chemtobet al., 1998; Cifu, Cohen, Lew, Jaffee, & Sigford, 2010). The environment often determines the subjective and somatic responses that an individual may have. For example, veterans of the OIF and OEF campaigns have been subjected to the following stressors: extended periods of constant stress; unavailability of any “safe zone”; constant exposure to danger (mortar/rocket attack and explosive devices planted along road and walk ways); constant “hyperarousal”; a rigid, highly structured military environment; exposure to multiple types of terrorism; and an enemy not readily identifiable (women or children combatants). Because this environment requires constant hypervigilance, soldiers are often too exhausted to process war events, emotionally and psychologically, until they leave the battlefield. Many soldiers report a hypnotic aspect to war and combat. Combat is perhaps the most exhilarating and energizing experience of a soldier’s life. While witnessing and participating in multiple atrocities of warfare, they have experienced the excitement and thrill of combat. The ethical and spiritual incongruence of witnessing death and destruction, while simultaneously experiencing the physiological excitation of warfare, is difficult for many combat veterans to assimilate. They struggle with coming to terms with their own emotional responses of excitement in an environment where they witnessed and felt the moral decay of a society through death and destruction (Grossman, 2009). Another poignant actuality of war relates to psychiatric and psychological casualties and the presumption that they are caused by fear of death and injury. There is little evidence that fear of death is the cause of such casualties. More important variables that increase the soldier’s symptom formation are the fears of letting others down or not being able to meet the expectations of combat (Grossman, 2009). Many soldiers face the loss of a comrade, which is emotionally devastating and often leads to prolonged, unresolved grief, mourning, and anger. Survivor guilt is often intense, and veterans who blame themselves for the death of a comrade, due to their

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own inaction or wrong action, are potentially at higher risk for psychological or psychiatric casualty, including increased risk of suicide (NCPTSD & WRAMC, 2004). Treatment considerations for veterans are driven by the symptoms that are displayed and revealed through extensive assessment. The whole person is affected by traumatic events and as a result, the individual experiences PCEBS symptoms. The symptoms displayed by returning veterans are detailed later, in the section entitled Counseling Implications. Review of the primary treatment modalities that have extensive research bases include trauma-focused individual cognitive behavioral therapy, interpersonal group therapy, peer-support groups, family and couples counseling, pharmacological approaches, primary medical care, and integrated treatment for co-occurring mental illness and substance abuse (Matsakis, 1994; President’s New Freedom Commission on Mental Health, 2003; Department of Defense Task Force on Mental Health, 2007). There are also relevant emerging best practices and innovative therapies that are showing significant benefit for individuals with PTSD. Exposure therapies for trauma include eye movement desensitization and reprocessing (EMDR), emotional freedom techniques (EFT), and thought field therapy (TFT; Feinstein, Eden, & Craig 2005). The NCPTSD and the NCTIC provide commentary and relevant research on these and the following therapies. Bodywork therapies are being explored, such as acupuncture, acupressure, and healing touch. Animal therapies such as equine therapy and pet therapy (e.g., psychiatric service dogs) are showing promise in helping PTSD patients to expand their social interaction and emotional healing. Expressive therapies allow patients to use various forms of nonverbal communication to express themselves creatively and to aid in recovery. Art therapy, sand tray, music therapy, and drumming are just a few of these expressive therapies. Lifestyle and nature therapy techniques such as healthy lifestyle counseling, nutritional awareness, recreational activities, and connecting with nature and spiritual well-being are additional techniques used to augment traditional therapeutic interventions. Physical therapy and exercise that promotes overall wellness helps to realign mind, body, and spirit through activities such as yoga, physical therapy, personal training, soft-style martial arts like tai-chi, dance, and other movement therapies. Relaxation and stress reduction techniques are also useful and include biofeedback, guided imagery or visualization, and massage therapy.

Recovery Early trauma research focused on two basic areas in an attempt to explain problematic psychological symptoms after exposure to traumatic events. First was the literature suggesting that people who developed problematic psychological symptoms had a predisposition or susceptibility to psychological breakdown (Ettedgui & Bridges, 1985; Worthington, 1977). Second was the opposing literature that focused on the analysis of the traumatic event as the appropriate predictor of problematic human response (Boulanger, 1986; Foy et al., 1987). Figure 25.1 illustrates how these opposing views align with the more holistic views of Buck (1998), Cohen (1993), and Webb (1991), who suggested there are important personal traits and characteristics of the event that determine individual responses to traumatic events. The whole person is affected by traumatic experiences and consists of internal and external variables. The internal variables include personal characteristics and the circumstances of the trauma. The external variables include personal support systems (e.g., family, friends, peers, school, and churches) and professional support and treatment services.

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Figure 25.1 Four Central Dimensions of Recovery Self

Problem

Internal (The self that does the action)

Others

System

External (The self is acted upon)

“Self”

“Others”

Is based on: • Beliefs • Fears • Identity−Who I am in this world • Health • Attitude−Positive or negative • Knowledge−Self Recognizes about world • Meaning−Way self interprets world

Significant people & events: • Family • Peers • Providers • Larger society

“Problem”

“System”

• The (what happened) or the thing that the person must recover • From the problem we derive: A. Cause B. Effect C. Possible Solutions

Primarily the Mental Health System: • Diagnosis • Medications • Facilities/Programs • Professionals • Disincentives Other systems that affect recovery: • Educational • Legal/Penal • Human services • Larger society

Variables for Recovery, Resiliency, and Reintegration Recovery, resiliency, and reintegration are the three essential aspects of the military veteran’s life-adjustment process that need to be considered by clinicians and students of military trauma. These three aspects are detailed in the following text.

Recovery Variables Explaining the recovery process is perhaps best understood by identifying what an individual is attempting to recover. I propose that the traumatized military veteran is trying to reestablish the following seven characteristics: 1. Recover a sense of personal “competency.” 2. Recover a sense of personal “autonomy” (understand the “self” and how to relate to the world as a result of the changes to self).

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3. Understand the impact of the objective traumatic experience as well as their subjective responses and symptom formation. 4. Recover a sense of intimacy and trust, enough to be vulnerable and flexible in intimate relationships with significant others. 5. “Trust” self and one’s capacity for building trusting relationships with peers, co-workers, and society in general. 6. Develop a deep understanding about the trauma and the subjective interpretations about the meaning the experience has had on a sense of connection to the outside world. 7. Recover a positive personal identity, personality, and self-image, recognizing how each has been affected by traumatic events.

Resiliency Variables Human beings are adaptable and have various innate strengths that can carry them through adversity and dangerous experiences. Like recovery, resiliency is best defined through the various indicators that demonstrate success in adjustment. The Army National Guard (ARNG, 2010) has developed a leader’s guide for assessing and ensuring support for soldier resilience (ARNG Leader’s Guide: Soldier Resilience). This guide provides extensive information on how to build resilience in the individual, the military unit, and the family during deployment. The following 12 indicators of resiliency are a comprehensive listing of concepts included in the ARNG Leader’s Guide and have been skillfully compiled and summarized by the Ohio Department of Mental Health (2008) in their Youth and Family Consensus Statement on Resiliency and Children’s Mental Health. 1. Validation and valuing: Appreciate life circumstances and life realities experienced. 2. Safety and basic needs: Recognize and meet personal needs through personal strength and seeking supports as needed. 3. Sanctuary: Identify a personal and protected space. 4. Justice: Recognize that one has personal rights, voice, respect, and dignity. One needs to fight stigma and stereotype while making a commitment to self and others. 5. Competencies: Recognize one’s unique strengths, skills, talents, and abilities. 6. Self-wisdom: As in recovery, recognize self as expert in one’s own experiences and develop practical knowledge about coping/managing behavioral/emotional challenges. 7. Courage and confidence: Personal courage and bravery to deal with life stressors. 8. Supportive connections: Resiliency is nurtured by family, friends, peers, and professionals. 9. Expectations: Maintain expectations that are reasonable and achievable and that maximize functioning and potential. 10. Participation: People thrive when given opportunities to contribute, participate, and maintain positive involvement. 11. Hope and optimism: Opportunities that challenge emotions often result in development of hope for a positive future. 12. Sense of meaning and joy: Seek and find happiness, meaning, and joy in life events that bring satisfaction and quality to life.

Reintegration Variables Military veterans experienced extensive training and preparation for the events that occur during time of war and in combat situations. During deployments and training

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exercises, military individuals are transformed into an elite fighting force whose mission is to overpower and destroy enemy forces. Changes have occurred within the veteran and in the family that must be assimilated. Being prepared for these changes is an important process, just as preparation for war is an important process. Military veterans with extensive traumatic experiences may have a more difficult time adjusting due to symptom formation. All military veterans potentially experience some need for reintegration training.

COUNSELING IMPLICATIONS It is important for counselors and supportive others to recognize the PCEBS symptoms that manifest following traumatic events. Veterans and their families must realize that they may observe the veteran pacing, acting impulsively, walking aimlessly, distrusting others, being jumpy or startled by loud noises, spacing out, or having erratic movements that they did not have previous to deployment. It also is extremely important for veterans and their significant supporters to notice if there is an increased use of alcohol or drugs as a way of self-medicating for some of these symptoms. How the veterans feel, both physically and emotionally, determines their success at reintegrating into family, work, college, or other civilian environments. Physical feelings such as muscle tension and pain, dizziness, headaches, grinding of teeth, stomach upset, chest pains, incessant thirst, fatigue, or fainting may all impact adjustment. Emotional feelings will also impact this adjustment process. Mood disturbances such as fear, panic, emptiness, sleep disturbance, uncertainty, anger/hostility, blame, grief, guilt, high anxiety, or flashback experiences may all be present within the combat veteran. Cognitive distortion such as intrusive thoughts, memory and concentration difficulties, recurring nightmares, confusion, preoccupation, self-blame, and distorted body image may interrupt the recovery process. These symptoms potentially cause relationship strain as well as personal isolation and withdrawal by the veteran. Many veterans report an extreme desire to connect intimately with others, but they often are reluctant because of lack of trust in self and others.

Trauma-Related Triggers Triggers are usually external environmental sensory data such as sights, smells, sounds, tastes, or touch that stimulate an internal response. The internal response is usually an increased negative symptom, as listed previously, and is uncomfortable or disturbing for the individual. This sense of negativity is potentially interpreted subjectively as an indication that the person is “damaged” or “diminished” in some way because of the inability to control that reaction (Buck, 1998). Some typical triggers for combat veterans include the anniversary of the traumatic event, smells, loud noises, excessive stress, extreme guilt, feeling left out, work or school stress, relationship breakup, traffic, financial problems, being overly tired, sexual harassment, hearing others argue, being judged or criticized, spending too much time alone, and intimacy. Making sense out of senseless life experiences is a truly monumental task for war zone veterans who have witnessed atrocity and loss of life of a comrade. A “crisis of faith” (Herman, 1992) may develop that potentially disrupts a trauma survivor’s ability to create any positive meaning to life. Some of the spiritual responses experienced by many veterans include having anger at God; stopping attendance at religious services; experiencing emptiness or meaninglessness; feeling God has failed; questioning basic beliefs about self, the world, and God; and being angry or cynical toward clergy.

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Counseling professionals who are trauma-informed understand that these are “normal” responses to “abnormal” wartime events.

Healing Through Meaning Ultimately, recovery from military and war zone traumatic events is an individual, personal, and private process that a soldier/veteran experiences. Veterans may not fully share themselves with others who do not understand the sensory reality of war. For many veterans, there is a lack of trust, a sense of personal damage, and alienation from others. Veterans typically desire to regain the capacity to connect intimately with others; however, their PCEBS symptoms interrupt their ability to do so. To “recover” from traumatic events, some veterans find meaning or make sense out of their war trauma through personal accounts of their experience. Telling their stories can provide significant cathartic relief for many veterans. Numerous examples of these narratives exist in the literature (e.g., Hedges, 2002; Hutchison, 2010; Kraft, 2007; Tick, 2005). Finding positive meaning in the face of traumatic events is a first step in the recovery process. Frankl (1955, 1963, 1978) warns that personal meaning derived through suffering must take place only when suffering is inescapable or unavoidable. Combat veterans experienced an environment in which suffering was unavoidable. It is essential that those who are recovering from traumatic events create a positive subjective interpretation and understanding of those traumatic life experiences. Through resiliency, as outlined previously in this chapter, military veterans may find positive meaning in their suffering. Trauma victims who make sense of their experience and understand their reactions/symptoms are in the process of recovery (Buck, 1998; van der Kolk, 1984).

CONCLUSION This chapter has examined a complex anatomy of war trauma and the unique issues, problems, and challenges that military veterans must address in their recovery process. Personal characteristics of the individual, specific variables related to the trauma event, and the availability of social supports interact to determine the degree of adjustment success following wartime experiences. Professionals who provide counseling services and other supports for military veterans must ensure that a comprehensive and accurate assessment of the various issues, problems, and challenges is conducted; at the same time, professionals must work toward a holistic understanding of the individual, as well as assuring that the individual’s recovery and reintegration needs are met.

APPENDIX 25.1 Ohio Cares Ohio Cares is an initiative by the Ohio Governor’s Office and was led by Major General Gregory L. Wayt, the adjutant general of the Ohio National Guard. The “Ohio Cares Committee” is composed of military veterans, active duty members of the Ohio National Guard, representatives of the Ohio Department of Mental Health, and the Ohio Department of Alcohol and Drug Addiction Services, along with representatives (continued)

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APPENDIX 25.1 (continued) of the Ohio Association of County Behavioral Healthcare Authorities and the Ohio Council of Behavioral Healthcare Providers. The purpose of Ohio Cares is to identify community resources and provide all the collaborative resources necessary for military veterans to return home successfully. This group supported the creation and publication of Returning Home: A Guidebook for Service Members and Their Families by Michael Witzky, Ph.D. and Edgardo Padin-Rivera, which identifies the process of adjusting to civilian life, following military service as a public health issue. This short guidebook provides a recovery action plan for military veterans and addresses the relevant issues that the veteran and his or her family members should consider in this reintegration process. There are significant mental and emotional differences in the military culture that are no longer needed, or indeed, no longer effective in the civilian culture; this guidebook is designed to help the veteran and the family to recognize the mental changes needed for successful transition. The guide reviews the following four areas of change that may have occurred with the veteran and potential triggers that foster increased symptom formation that need to be addressed by the veteran and supportive others: how the veteran thinks, how the veteran acts, how the veteran feels, and triggers that can cause increased intensity of symptoms. Spiritual beliefs or interpretations of war zone and traumatic experiences are also an important part of the transition process. Specifically, the guidebook helps the veteran explore how thoughts have changed and that his or her thoughts are normal responses to abnormal events and not a sign of weakness and that it is normal to re-experience events, be impatient and irritable, avoid painful thoughts and feelings, and question oneself. It helps the military survivor to know that relationships may be strained because of these thought changes, and that depression may set in as an individual experiences grief and loss as a result of the events that occurred in the war zone. It is also helpful in recognizing one’s own actions and how they differ from those things that the individual did prior to being deployed to a war zone. More information about this stellar program can be found online at http://www.ohiocares.ohio.gov/

RESOURCES An essential resource for students who want to study and explore psychological concerns and TBI in a more comprehensive manner is the “Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.” (http://www.dcoe.health.mil) Other essential resources for students interested in the impact that warfare has on the psychological health of combatants are the continuous investigations being conducted by the RAND Center for Military Health Policy and Research. (http://www.rand.org/multi/military.html) NCPTSD (http://www.ncptsd.va.gov) NCTIC (http://www.mentalhealth.samhsa.gov/nctic/) National Child Traumatic Stress Network (NCTSN) (http://www.nctsn.org) Iraq War Clinician Guide (June 2004) was written and compiled by the NCPTSD and WRAMC. The guide provides an extensive overview of the issues and struggles faced by veterans in adapting successfully to the stressors of being in a war zone. (http://www.ptsd.va.gov/professional/manuals/ iraq-war-clinician-guide.asp)

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REFERENCES American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. Army National Guard. (2010). ARNG leader’s guide: Soldier resilience. Retrieved from http://chaplain. ng.mil/resources/Warrior%20Care/WC_Docs/Leaders%20Guide%20to%20Resilience%20 %2829%20Sep%2010%29.pdf Belasco, A. (2007). The cost of Iraq, Afghanistan, and other global war on terror operations since 9/11. Washington, DC: Congressional Research Service. Boulanger, G. (1986). Predisposition to posttraumatic stress disorder. In C. Kadushin & G. Boulanger (Eds.), The Vietnam veteran defined: Fact and fiction (pp. 37–50). Hillsdale, NJ: Lawrence Erlbaum Associates. Bremner, J. D. (2001). Hypotheses and controversies related to effects of stress on the hippocampus: An argument for stress-induced damage to the hippocampus in patients with posttraumatic stress disorder. Hippocampus, 11, 75–81. Bremner, J. D. (2002). Neuroimaging studies in posttraumatic stress disorder. Current Psychiatry Reports, 4, 254–263. Bremner, J. D., Innis, R. B., Ng, C. K., Staib, L. H., Salomon, R. M., Bronen, R. A., . . . Charney, D. S. (1997). Positron emission tomography measurement of cerebral metabolic correlates of Yohimbine administration in combat-related posttraumatic stress disorder. Archives of General Psychiatry, 54, 246–254. Bremner, J. D., Randall, P., Scott, T. M., Bronen, R. A., Seibyl, J. P., Southwick, S. M., . . . Innis, R. B. (1995). MRI-based measurement of hippocampal volume in patients with combat-related posttraumatic stress disorder. American Journal of Psychiatry, 152, 973–981. Bremner, J. D., Vythilingam, M., Vermetten, E., Southwick, S. M., McGlashan, T., Nazeer, A., . . . Charney, D. S. (2003). MRI and PET study of deficits in hippocampal structure and function in women with childhood sexual abuse and posttraumatic stress disorder. American Journal of Psychiatry, 160, 924–932. Breslau, N. (2002). Epidemiologic studies of trauma, posttraumatic stress disorder, and other psychiatric disorders. Canadian Journal of Psychiatry, 47, 923–929. Breslau, N., Davis, G. C., & Andreski, P. (1995). Risk factors for PTSD-related traumatic events: A prospective analysis. American Journal of Psychiatry, 152, 529–535. Brunner, E. F. (2006). Military forces: What is the appropriate size for the United States? Washington, DC: Congressional Research Service. Buck, R. P. (1998). The meaning six Vietnam veterans attach to war trauma. Unpublished doctoral dissertation. Kent State University, Kent, OH. Chemtob, C. M., Muraoka, M. Y., Wu-Holt, P., Fairbank, J. A., Hamada, R. S., & Keane, T. M. (1998). Head injury and combat-related posttraumatic stress disorder. Journal of Nervous and Mental Disease, 186, 701–708. Cifu, D. X., Cohen, S. I., Lew, H. L., Jaffee, M., & Sigford, B. (2010). The history and evolution of traumatic brain injury rehabilitation in military service members and veterans. American Journal of Physical Medicine & Rehabilitation, 89(8), 688–694. Cohen, R. P. (1993). The role of self-continuity in Vietnam combat veterans’ recovery from trauma. Unpublished doctoral dissertation. University of Michigan, Ann Arbor. Department of Defense Task Force on Mental Health. (2007). An achievable vision. Retrieved from http://www.health.mil/dhb/mhtf/mhtf-report-final.pdf DiGiovanni, C., Jr. (1999). Domestic terrorism with chemical or biological agents: Psychiatric aspects. American Journal of Psychiatry, 156, 1500–1505. Ettedgui, E., & Bridges, M. (1985). Posttraumatic stress disorder. Psychiatric Clinics of North America, 8, 89–103. Evans, K., & Sullivan, J. M. (1990). Dual diagnosis: Counseling the mentally ill substance abuser. New York, NY: Guilford Press. Everstine, D. S., & Everstine, L. (1993). The trauma response: Treatment for emotional injury. New York, NY: W. W. Norton.

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Sandecki, R. (1987). Women veterans. In T. Williams (Ed.), Post-traumatic stress disorders: A handbook for clinicians (2nd ed., pp. 159–168). Cincinnati, OH: Disabled American Veterans. Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M., Wilson, D., . . . Kulka, R. A. (2002). Psychological reactions to terrorist attacks. Findings from the national study of Americans’ reactions to September 11. Journal of the American Medical Association, 288, 581–188. Scott, W. J. (1993). The politics of readjustment: Vietnam veterans since the war. New York, NY: Aldine De Gruyter. Shatan, C. F. (1978). Stress disorder among Vietnam veterans: The emotional content of combat continues. In C. R. Figley (Ed.), Stress disorders among Vietnam Veterans: Theory, research, and practice (pp. 43–55). New York, NY: Brunner/Mazel. Shin, L. M., Orr, S. P., Carson, M. A., Rauch, S. L., Macklin, M. L., Lasko, N. B.,. . . Pitman, R. K. (2004). Regional cerebral blood flow in amygdala and medial prefrontal cortex during traumatic imagery in male and female Vietnam veterans with PTSD. Archives of General Psychiatry, 61, 168–176. Shin, L. M., Shin, P. S., Heckers, S., Krangel, T. S., Macklin, M. L., Orr, S. P.,. . . Rauch, S. L. (2004). Hippocampal function in posttraumatic stress disorder. Hippocampus, 14, 292–300. Strayer, R., & Ellenhorn, L. (1975). Vietnam veterans: A study exploring adjustment patterns and attitudes. Journal of Social Issues, 31(4), 81–93. Tanielian, T., & Jaycox, L. H. (Eds.). (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Monograph, RAND Center for Military Health Policy Research. Retrieved from http://www.rand.org/content/dam/rand/pubs/monographs/2008/ RAND_MG720.pdf Tick, E. (2005). War and the soul: Healing our nation’s veterans from posttraumatic stress disorder. Wheaton, IL: Quest Books. van der Kolk, B. A. (1984). Introduction. In B. A. Van der Kolk (Ed.), Posttraumatic stress disorder: Psychological and biological sequelae (pp. i–vi). Washington, DC: American Psychiatric Press. van der Kolk, B. A. (Ed). (1987). Psychological trauma. Washington, DC: American Psychiatric Press. van der Kolk, B. A. (1989). The compulsion to repeat the trauma: Re-enactment, re-victimization, and masochism. Psychiatric Clinics of North America, 12(2), 389–411. Vasterling, J. J., & Brewin, C. (2005). Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives. New York, NY: Guilford Press. Villarreal, G., Hamilton, D. A., Petropoulos, H., Driscoll, I., Rowland, L. M., Griego, J. A., . . . Brooks, W. M. (2002). Reduced hippocampal volume and total white matter volume in posttraumatic stress disorder. Biological Psychiatry, 52, 119–125. Warden, D. (2006). Military TBI during the Iraq and Afghanistan wars. Journal of Head Trauma Rehabilitation, 21, 398–402. Webb, N. (1991). Play therapy with children in crisis: A casebook for practitioners. New York, NY: Guilford Press. Williams, T. (1987). Posttraumatic stress disorders: A handbook for clinicians. Cincinnati, OH: Disabled American Veterans. Wilson, J. P. (1978). Identity, ideology and crisis: The Vietnam Veteran in transition. Part II: Psychosocial attributes of the veteran beyond identity: Patterns of adjustment and future implications. Forgotten Warrior Project, Cleveland State University, 1978. Reprinted by the Disabled American Veterans, Cincinnati, OH, 1979. Now out of print. Dr. Wilson’s findings are updated and summarized in C. R. Figley’s: Strangers at Home: Vietnam Veterans since the War. Praeger Press, 1980. Worthington, E. R. (1977). Post-service adjustment and Vietnam era veterans. Military Medicine, 142, 856–866.

CHAPTER 26

Disaster Behavioral Health: Counselors Responding to Terrorism JUNE ANN SMITH AND JO ANN JANKOSKI

With the gift of listening comes the gift of healing, because listening to your brothers or sisters until they have said their last words in their hearts is healing and consoling. Someone has said that it is possible “to listen a person’s soul into existence.” I like that. —Catherine de Hueck Doherty

INTRODUCTION This chapter focuses on a variety of concepts related to disaster behavioral health. We continue to live in a violent world; however, the difference between the violent world of today and that of, say, 50 years ago is the immediacy with which the social media brings news into our lives. We can be in our homes, dorms, vehicles, or visiting the mall, park, or gym; and, through the various media devices we possess, we are immediately connected to the traumatic event and to those being directly affected by it. When a disaster, either human-made or natural, strikes, we, as a society, become engrossed in what is happening; the event pulls at our emotions, our social consciousness kicks in, and we begin to question ourselves—What can I do? How can I help? This chapter introduces the concepts and skills required during disaster and crises response, particularly to threats or acts of terrorism. Whereas appropriate agencies assess and address the national or local threat of terrorist activity, counselors are responding, as with any disaster, to the effects of the disaster on the populace. The concepts and skills discussed in this chapter are somewhat different from those of the traditional mental health spectrum. After reading this chapter, students and professionals should be able to identify the phases of a disaster, understand the protocol of the disaster process, and have greater awareness about the nature of various disaster aid programs. It should be very clear that not all mental health professionals possess the capacity to perform professionally in response to disasters. This is not to be construed as a weakness; rather, we must all recognize our own personal strengths and weaknesses and use them appropriately. Disaster mental health is an evolving field of clinical practice that is carried out by a combination of clinicians and volunteers. Typically, disaster mental health consists of a set of interventions for use after a disaster or humanitarian emergency; such that these interventions normalize the responses people have to the event. These situations include human-made disasters (e.g., acts of terrorism, kidnapping, assassination

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attempts, technological disasters, school and workplace suicides or shootings, and so forth), natural disasters (e.g., hurricanes, tornadoes, floods, large-scale fires, and so forth), or any situation in which groups of people are believed to have been subjected to danger or exploitation (e.g., civil or human rights abridgments, cultural dislocations, and so forth). The philosophy behind disaster mental health presupposes that most people experience common or normal reactions to traumatic events and that only a few will develop pathological symptoms that require extensive treatment. The interventions employed by disaster mental health practitioners usually consist of outreach, public education, and screening for greater problematic reactions to the event. People who show symptoms of major psychological disorders (such as depression, anxiety, or posttraumatic stress disorder [PTSD]) are referred to clinicians offering longer-term treatment services (Bulling & Abdel-Monem, 2009). The aims of this chapter are achieved through the discussions in the following major sections of the chapter: (a) Disaster Behavioral Health, Terrorism, and Counseling; (b) The Disaster Process; (c) Disaster Behavioral Health and the Effects of Terrorism; and (d) Counseling Implications. These sections are followed by a summary of the chapter, a list of essential terms and acronyms, and relevant resources.

DISASTER BEHAVIORAL HEALTH, TERRORISM, AND COUNSELING To understand terrorism as a facet of disaster behavioral health, along with the role played by counselors, it is important to be aware of the history of emergency responses by human service personnel, including counselors. The individual who wishes to respond to disasters must understand the structure established by the U.S. government and her or his position in that structure. The terminology used in disaster response may be new to nonresponders, as well as the methods that are used in such responses. First, we take a look at the federal network that responds to disasters.

History of the Federal Emergency Management Agency To respond to any disaster—natural, human-made, or acts of terrorism—we must understand how the agencies with which we will be interacting and cooperating operate. The origins of the Federal Emergency Management Agency (FEMA) can be traced to 1803 when the first piece of disaster legislation was passed to provide assistance to a town in New Hampshire following a structural fire. Since 1803, this particular legislative act has been amended more than 100 times in response to a variety of natural disasters (U.S. Department of Homeland Security, 2010a). The response by the federal government became so popular that in the 1930s the Reconstruction Finance Corporation was granted permission to offer disaster loans for repair and reconstruction of certain public facilities following a natural disaster. In 1934, the country witnessed the creation of the Bureau of Public Roads, which was given funding for highways and bridges damaged during a disaster. At that time, the country also saw the creation of the Flood Control Act, which provided the U.S. Army Corps of Engineers more authority to implement flood control projects. The federal government quickly learned that this “piecemeal” approach to disaster response was problematic; this forced legislation that would require better cooperation between federal agencies (U.S. Department of Homeland Security, 2010a). It was not until the 1960s and 1970s that the United States again experienced massive disasters throughout the country. Hurricane Carla struck in 1962, Hurricane

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Betsy in 1965, Hurricane Camille in 1969, and Hurricane Agnes in 1972. The Alaskan earthquake hit in 1964, and the San Fernando earthquake rocked Southern California in 1971. Massive flooding was experienced in 1972. These events served to focus attention on the issue of natural disasters and brought about increased legislation. In 1968, the National Flood Insurance Act offered new flood protection to homeowners, and, in 1974, the Disaster Relief Act firmly established the process of Presidential Disaster Declarations (U.S. Department of Homeland Security, 2010a). With hundreds of different groups responding to any given disaster, this fragmented system proved how ineffective the federal government’s disaster response was. It was not until the National Governors Association sought to decrease the number of agencies responding to disasters that the group approached President Jimmy Carter to centralize emergency functions. In 1979, President Carter issued executive order 12127, which merged many of the separate disaster-related responsibilities into FEMA (U.S. Department of Homeland Security, 2010a). FEMA is a complex system; many events have tested the agency’s response. In 1983, President Bill Clinton appointed James Witt, the only director of FEMA who had any experience as a state emergency director. Witt initiated sweeping reforms that streamlined disaster relief and recovery operations, insisted on a new emphasis regarding preparedness and mitigation, and focused agency employees on customer service. In 2001, President George W. Bush appointed Joe M. Allbaugh as the director of FEMA. Within months of Allbaugh’s appointment, the terrorist attacks of September 11, 2001 focused attention on the agency so that it once again changed its focus to that of national preparedness and homeland security (U.S. Department of Homeland Security, 2010a). Since the attacks of 9/11, FEMA and 22 other federal agencies and programs joined forces to become the Department of Homeland Security in which Secretary Tom Ridge coordinated approaches to national security, emergencies, and disasters—both natural and human-made. The United States and its people believed we had lived through the worst of times (having survived the 9/11 attacks) only to be confronted with Hurricane Katrina in 2005. On October 4, 2006, President George W. Bush signed into law the PostKatrina Emergency Reform Act. This act significantly reorganized FEMA; providing it with substantial new authority to remedy gaps that became apparent in the response to Hurricane Katrina—the most devastating natural disaster in U.S. history—and included a more robust preparedness mission for FEMA. After years of transformation and over 30 years after its creation, FEMA’s mission remains—to lead America to prepare for, prevent, respond to, and recover from disasters—with a vision of a nation prepared (U.S. Department of Homeland Security, 2010a).

Disaster Mental Health Versus Traditional Mental Health Within the continuum of community mental health, counselors work in a variety of areas ranging from outpatient services to family-based mental health, work in adult/ children partial hospitalization programs, community treatment teams, domestic violence or rape centers, as well as many other arenas. Clients have to meet certain criteria such as a psychiatric diagnosis, a recent discharge from an inpatient unit, or a recent discharge from the correctional system to access services. We work within a structured schedule depending on where a counselor works. For example, an outpatient therapist may work from 8:30 a.m. to 4:30 p.m., or a counselor who works for a partial hospitalization program may be scheduled to work from 7:30 a.m. to 5:00 p.m. Although it may be the case that some counselors cannot wait until quitting time to pack up their belongings 30 minutes before the day ends, as counselors, we are taught the importance of “being with” our clients—of establishing a therapeutic relationship and earning a client’s trust.

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We conduct a 50-minute session followed by writing case notes, completing billing, or returning client phone calls. It is our daily routine. There is nothing routine about responding to acts of terrorism or other disasters. Disaster mental health is a specialized service in which counselors are deployed by a responding organization and are assigned to specific areas of coverage. The responder must meet multiple demands and work in conditions that are unfamiliar—in shelters, recovery service centers, compassion centers, a morgue, a death notification unit, or mass care facilities with individuals of different cultures. The major goal of disaster mental health operations is to deploy a team to the disaster site so that the team can attend to the emotional needs of survivors or individuals who have been displaced. There are several key concepts related to disaster mental health: ■ No one who sees a disaster—natural, human-made, or terroristic—is

untouched by it. ■ There are two types of disasters—individual and community—that may occur

at the same time. ■ Stress and grief are normal reactions to abnormal situations; they should be

anticipated. ■ Most people work together and function as a unit during and after a disaster;

however, their effectiveness slowly diminishes with time. ■ Some survivors may reject all types of assistance. ■ Many emotional reactions of disaster survivors stem from problems of daily

living brought on by the disaster. ■ Disaster mental health is much more a practical approach rather than a psycho-

logical one. ■ Following the disaster, many people do not see themselves as needing mental

health services, and will not seek such services. ■ Disaster mental health workers must abandon traditional mental health

approaches and language and use more outreach activities. ■ Social supports are crucial to recovery (Centers for Disease Control and

Prevention [CDC], n.d.). Although the cited key concepts relate to disaster mental health, we as counselors must question how responses to a natural disaster differ from responses to acts of terrorism. In a natural disaster, there is a beginning. The beginning of a natural disaster occurs when the public receives warnings (such as those issued days before Hurricane Katrina slammed into the Gulf Coast). There also is an end to a naturally occurring event (when Hurricane Katrina dissipated into a tropical storm). Although a naturally occurring event has ended, the disaster continues through the aftermath of the event. This includes the emotional toll—intense feelings of loss, grief, and confusion; the loss of human lives and property. All these affect those who survived and are left to pick up the pieces of their lives. With Hurricane Katrina, we knew what was coming; we watched and listened to the news reports regarding this category five hurricane that was bearing down on the Gulf Coast. What we did not know was the devastation that would occur as a result of that hurricane. How is an act of terrorism different from a natural disaster? We have seen pictures of hurricanes, tsunamis, flooding, earthquakes, structure fires, forest fires, and other naturally occurring disasters. We also have seen pictures of acts of terrorism—bus and building explosions, assassination attempts, kidnapping of reporters, the holding of hostages, and planes being used as weapons. Acts of terrorism, however, are less predictable than natural disasters; the next act of terrorism could be something we have

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never yet experienced or viewed. The goal of a terrorist attack is to create fear, disrupt normal daily activity, and to instill a sense of helplessness and vulnerability. Acts of terrorism are associated with individuals or groups who wish to cause harm. We try to put a face to terrorism. Yet, can we do so? What is the face of a terrorist— a White woman, a Black man, a White male, or a person of Middle Eastern descent? The truth is that we cannot put a definitive face to terrorism. We as counselors must be mindful to not react with hate, fear, or anger against a specific cultural, ethnic, or religious group because of the act of a few individuals. A backlash is occurring in this country against Muslims or anyone who looks Middle Eastern because of the acts of Khalid Sheikh Mohammed, one of 12 men who assisted in planning the 9/11 attacks. Do we view all “White men” as terrorists? No! Yet, on a sunny April 19, 1995, Timothy McVeigh, a domestic terrorist, bombed the Alfred P. Murrah Federal Building. We, as a country, did not view every White man as a terrorist. We, as professionals, must assist others to not hate the whole because of the actions of a few. Many people believe terrorism began on September 11, 2001; in fact, terrorism is not a new subcategory of disaster mental health—acts of terrorism have been recorded from the beginning of time. According to the United Nations CounterTerrorism Committee (2010), “almost no week goes by without an act of terrorism taking place somewhere in the world, indiscriminately affecting innocent people who just happened to be in the wrong place at the wrong time.” There is no universal definition of terrorism. The FEMA defines terrorism, as the “use of force or violence against persons or property in violation of the criminal laws of the United States for purposes of intimidation, coercion, or ransom.” The definition continues to state that terrorists often use threats to (a) create fear among members of the general public, (b) try to make the public believe that their government is powerless to prevent or predict terrorism, and (c) get immediate publicity for their cause. The Pennsylvania Emergency Management Agency (PEMA) definition states that acts of terrorism include “threats of terrorism; assassinations; kidnappings; hijackings; bomb scares and bombings; cyber attacks (computer-based); and the use of chemical, biological, nuclear, and radiological weapons” (PEMA, 2011). Any act of terrorism threatens the independence, autonomy, culture, and lifestyle of the group being terrorized (Stebnicki, n.d.) and violates our basic assumptions through shock, intentionality, and the use of noncombatants as victims. The victims of terrorism experience feelings of fear and helplessness. We cannot sense that an act of terrorism is coming toward us; we cannot see the faces of the perpetrators; we do not know who, what, when, or where the next attack will occur. It is this unknowing that causes anxiety for many people. Disaster mental health counselors and other first responders face human suffering, fatalities, and individuals with serious physical injuries. They may be confronted by survivors who are angry, very demanding, and shouting at the responder, seeking answers. The responder must cope with a continuum of stressors— the number of losses, causalities, the destruction of property, the intense emotional pain of survivors, and bereaved individuals who have lost loved ones. When responding to a disaster, the counselor works in environments associated with hardships—the lack of water and electricity; sleeping in a sleeping bag or on a cot, often in a public area; eating when food is available and when time allows; needing to carry all of one’s belongings in a 50-lb backpack; needing to stand for at least 4 hours without a break; and working 10- or 12-hour shifts. When responding to a disaster, there is no structured schedule; there are no “packing up” and “going home” at 4 or 5 p.m. When we respond to a disaster, we are responsible for more than the individuals who have been displaced; we also are responsible to check in with our supervisor, who is responsible for our mental and physical health. We also must inquire about the health

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and well-being of other responders who may or may not be mental health responders. Anyone who has anything to do with the disaster—the first responders, the police, chaplains, doctors, nurses, other medical personnel, community members, and each other—are possible victims in the disaster. In responding to a disaster, counselors must be willing to be flexible, patient, and able to multitask. It sounds easy, does it not? The truth of the matter is that it is not easy. Everything that counselors see, hear, smell, and touch may affect them in a variety of ways, both personally and professionally. Not all counselors can respond to disasters, and this is okay. We all have our gifts; we must be willing to be a reflective counselor and look within to determine where our strengths lie and how we can best use them. We strongly recommend that anyone interested in disaster mental health seek out the local chapter of the American Red Cross and become a member of the Disaster Action Team (DAT). As a new volunteer, a counselor is called out on local disasters, most of which are small in nature, and new volunteers are accompanied by seasoned volunteers. The Red Cross offers a variety of training programs, including those that are specific to disaster mental health and needed to become a disaster mental health specialist.

THE DISASTER PROCESS A major disaster declaration, including terrorist activity, usually follows a prescribed set of steps and structures. Each state has an Emergency Management Agency whose mission is to coordinate state agency responses, including the Office of the State Fire Commissioner and the Office of Homeland Security, which provide support to county and local governments in the areas of civil defense, disaster mitigation and preparedness, planning, and response to and recovery from acts of terrorism or natural disasters (U.S. Department of Homeland Security, 2010b). It should be noted that there is one additional element in the case of terrorist activities. While the local, state, and federal agencies are responding to the disaster, the Federal Bureau of Investigation (FBI) begins a systematic inquiry into the criminal act. The FBI does not appear on-site for non-terrorist-related disasters. In the event of any disaster—terroristic in nature or not—the first response is the responsibility of local government emergency services with support from local municipalities and volunteer agencies. The volunteer agencies include but are not limited to the American Red Cross, the Salvation Army, St. Vincent De Paul Society, and the local or regional Critical Incident Stress Management team (CISM). Each of these volunteer agencies is an important component in any disaster. Counselors, counseling students, and other human service professionals have the ethical responsibility to become well acquainted with the resources that are located within the community and county/ parish in which they live and work. When local government and nearby communities are overwhelmed or resources are depleted, local governmental officials can request assistance from the state. The state’s response is the second step in this process. In response to the local request, the governor can deploy the National Guard or other state agencies to assist in the disaster. The third step in the disaster process is damage assessment, which is conducted by local, state, federal, and other volunteer organizations that can determine the losses and recovery needs of the affected community or communities. In general, volunteers are deployed by their respective organizations and are given official documentation that allows them to assist in the disaster process. The fourth step in this process is a request from the governor to the federal government for a major disaster declaration. This declaration is based on the damage

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assessment report, the agreement to commit funds, and the state’s ability to recover. Once this request reaches FEMA, the agency evaluates the disaster and recommends action to the White House, based on all the information FEMA was able to gather. The recommendation includes an impact report of disaster and an indication of the ability of the community and the state to recover (U.S. Department of Homeland Security, 2010b). In the fifth stage of the disaster, the president of the United States either approves federal intervention or FEMA informs the state’s governor that the request has been denied. When the president approves FEMA’s request, a Presidential Major Disaster Declaration puts into action long-term federal recovery programs, all designed to assist the victims of the disaster, businesses, and other public entities (U.S. Department of Homeland Security, 2010b). In 2011, this level of disaster relief was reached in catastrophic disasters that occurred in Joplin, Missouri; Tuscaloosa, Alabama; Mississippi; and Vermont. President Barack Obama signed the disaster declarations.

DMH Eligibility Criteria Responders must be licensed in the state in which they live. ■ Independently licensed, master’s level (or higher) mental health professionals ■ State-licensed or state-certified school counselors and school psychologists

DISASTER BEHAVIORAL HEALTH AND THE EFFECTS OF TERRORISM In 1976, Kia Erikson wrote that there are two types of traumas that occur jointly and continuously in most disasters; Erikson’s words are valid today: survivor trauma has “two closely related but . . . distinguishable facets—‘individual trauma’ and ‘collective trauma’” (p. 153). Individual trauma is a “blow to the psyche that breaks through one’s defenses so suddenly and with such brutal force that one cannot react to the event effectively,” (p. 153) and collective trauma is “a blow to the basic tissues of social life that damages the bonds of attaching people together and impairs the prevailing sense of community” (p. 154). One of the first major acts of terrorism perpetrated in the United States was the bombing of the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma. This event affected the citizens of Oklahoma City, the state of Oklahoma, indeed, the entire nation. A similar, even greater, response followed the terrorist attacks of September 11, 2001. In 1973, Geertz pointed out that culture may be viewed as an environment of symbols and meanings that people create and recreate for themselves during the process of social interaction. All cultures have two aspects: externally through artifacts, roles, rituals, and institutions—both public and private—and internally through values, beliefs, attitudes, identities, knowledge, and worldview. Terrorism threatens the autonomy, safety, independence, and way of life of the victimized culture; it leaves the citizens of the culture with intense feelings of helplessness, shock, and fear. Project Heartland, created by the Oklahoma Department of Mental Health and Substance Abuse (ODMHSA), was the first community mental health response to a large-scale terrorist event in the United States. Mental health responders found that “there was no previous experience to guide and establish the appropriate services for terrorists-caused psychological trauma,” and the “traditional crisis counseling techniques” were insufficient (U.S. Department of Justice, 2000, p. 19). An act of terrorism will change the lives of those involved; the unexpected violence may leave many people with lasting physical, emotional, and spiritual wounds.

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Terrorism instills a sense of fear and uncertainty in individuals and communities. The way in which terrorism and other disaster’s affect individuals, the stages of reactions, and the phases of a disaster are discussed in the following two sections.

Individuals Affected by the Traumatic Event The CDC (n.d.) discusses an impact pyramid of which we, as Disaster Mental Health Responders (DMHR), must be mindful. The impact pyramid in Figure 26.1 is separated into five horizontal segments, with each segment being of equal height; however, each segment grows larger in width and depth as the pyramid proceeds from the top to the bottom. At the top of the pyramid are the individual victims; they represent, as so aptly put by the CDC, only the tip of the iceberg. The segment below the first one is larger and represents the family and social networks of the individual victims. We can begin to visualize how the incident has an impact on an increasingly larger segment of the population. According to the CDC (n.d.), the third segment of the pyramid represents the entrance of the rescue workers, the medical care providers, and the families and social networks of these individuals. The effects of the disaster are spreading and touching a larger segment of the population. Next, in the fourth segment of the pyramid, are the affected businesses and other vulnerable populations. The disaster may not have

Figure 26.1 Centers for Disease Control and Prevention Impact Pyramid

Individual victims

Family and social networks of individual victims

Entrance of rescue workers, medical care providers

Affected businesses and other vulnerable populations

Ordinary people and communities who experience the disaster vicariously

Source: Centers for Disease Control and Prevention. (n.d.).

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touched them directly, but food supplies, daily living needs, and so forth are no longer immediately available, thus affecting an even larger segment of the population. These individuals may not even know any of the original individual victims; however, the event has now touched their lives. And the pyramid continues to grow. At the bottom of the pyramid (CDC, n.d.) are ordinary people and their communities, who experience the disaster vicariously through the news media or by word of mouth. The number of individuals who have been affected by the disaster has grown exponentially. Like a stone cast into a pool of water, the ripples of a disaster spread through the pool and can affect the entire community (Ayalon, 1992), where the “community” may even refer to the world. When responding to a disaster, whether it be local, national, or international, we must remember that the impact is both visible and invisible. We are most aware of the effects a disaster has on the individuals on scene; yet, there is a group of people whom we might call the invisible victims—those individuals who are not present at the event but who experience the same emotions. They are individuals who may or may not know any of the victims, yet they also suffer traumatic symptoms because of what they have heard and seen.

Phases of a Disaster When working within a disaster, there are phases that individuals may experience. With this said, it must be understood that every disaster is different, and that we, as counselors, must be mindful of the environment in which the disaster occurred. According to the U.S. Department of Health and Human Services (2003), “people’s reactions to disaster and their coping skills, as well as their receptivity to crisis counseling, differ significantly because of their individual beliefs, cultural traditions, and economic and social status in the community” (p. 1). The CDC (n.d.) has issued a set of guiding principles for those who might be facing a disaster (e.g., an approaching hurricane) or preparing to respond to a disaster (e.g., disaster mental health volunteers). ■ No one who experiences a disaster is untouched by it. This includes the individual

■

■

■

■

who reports to the responders that he or she is “OK” and the responders who are “tough” and “can handle” the situation. Most people pull together and function during the disaster; however, it must be remembered that their effectiveness is diminished by the disaster. Picture someone who, on a normal weekend, works to remove a deteriorating shed from her or his property. Now, picture this same person working to remove debris from the same shed after losing all standing buildings on the property to a tornado. Quite a difference exists. Not all victims may want or need your help. Responders may be recognized as outsiders to the community. In many closed or closely knit communities, outsiders are not easily accepted and unknowingly may cross cultural barriers. Disaster stress and grief are normal reactions to an abnormal event. Volunteers can expect anger, crying, and expressions of fear and grief. But volunteers also need to remember that something terrible has happened to other humans; the volunteers are at the disaster site to help the victims. Volunteers must be careful to not become primary victims themselves. Volunteers should remember that survivors will respond best to active, genuine interest, concern, and factual information. Disaster mental health assistance is often more than psychological in nature. Some of the best gifts that can be offered to a victim of disaster are as simple as

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the use of a phone; a cup of coffee; or a word of encouragement, reassurance, or comfort. ■ Disaster relief assistance can be confusing to some individuals who have been displaced. They may feel frustration, anger, and a sense of helplessness related to the appearance of federal, state, and nonprofit agencies. In their anger and frustration, they may reject all relief services. ■ Disaster mental health specialists may have to refer individuals who survived a terrorist attack to long-term mental health services for posttraumatic response to the criminal event. ■ Disaster mental health responders may be asked to provide education for managers, employers, and supervisors to understand PTSD and ways in which they may support victims who are returning to the workplace. According to the CDC (n.d.), disasters may be experienced in seven different phases; these phases are illustrated in Figure 26.2 and are meant to be a general description of the phases of a disaster. The timelines in the illustration are not exact and may be different for all involved. The fi rst phase is the predisaster phase. The warning of a threat may range in duration from weeks (e.g., an approaching hurricane) to no advance notice at all (e.g., a suicide bomber). The brevity or lack of warning can make survivors feel vulnerable, unsafe, and fearful. The second phase is the actual onset of the disaster. The timeline of this second phase varies (e.g., the slow, low-threat buildup associated with some floods to the violent and destructive nature of a plane crash). Depending on the characteristics of the disaster, reactions can be gauged on a continuum from confusion, disbelief, and anxiety, to shock and hysteria. The third phase is that of

Figure 26.2 Centers for Disease Control and Prevention Phases of Disaster

Phases of Disaster HONEYMOON HEROIC PREDISASTER

RECONSTRUCTION A NEW BEGINNING

DISILLUSIONMENT

Threat Warning

(COMMUNITY COHESION)

Impact

Inventory

S) IEF RM GR E T H TO UG O G R IN M TH O G (C KIN R O W Trigger Events and Anniversary Reactions

_1 TO 3 DAYS __ Time ___________ 1 T0 3 YEARS____________ Source: Centers for Disease Control and Prevention. (n.d.).

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rescue. In this phase, one may witness heroic behavior; individuals tend to watch out for, protect, and even risk their own safety to protect and save strangers. In the fourth phase of a disaster, people initially “pitch in” and collaborate for the collective good. In this honeymoon phase, there is community cohesion. In the fifth phase, external resources begin to appear; those affected often watch as others (outsiders) take control of the situation. In the sixth phase, the disillusionment phase, the victims see resource allocation as too little too late. They see the resources as being poorly distributed. In the seventh and final phase, reconstruction and recovery, people move beyond their own self-interests and start to rebuild (CDC, n.d.). These seven phases are seen and experienced on all levels of response—local, national, or international. Within this process, safety must be established. Once this is accomplished, crisis intervention responders can help victims to mitigate the effects of and responses to the event, to reduce the severity of trauma experienced, or even to reduce the potential for developing PTSD or acute stress disorder (ASD). Well-executed crisis intervention has the potential to offset the need for long-term trauma counseling. For example, children whose friends lost their parents also may be traumatized, particularly if these children were not referred for counseling or if their parents did not seek treatment for them. Children in this situation may feel guilty because their parents survived and the parents of their friends did not. Such individuals may carry lifelong psychological scars or emotional wounds for which they never received services. It is clear that immediate crisis intervention or subsequent trauma counseling could have mitigated the experience of trauma and lessened the associated suffering. Having to watch and listen to the sights and sounds of death also can cause vicarious trauma (see Chapter 31) in children and adults. It is therefore important to identify and consider their proximity—physical, geographical, social, and psychological—to the site of the incident (Ochberg & Soskis, 1982).

COUNSELING IMPLICATIONS A number of implications arise for counselors responding to acts of terrorism and other disaster situations. These are discussed next in the sections regarding psychological triage and responder self-preparation.

Psychological Triage Counselors who choose to respond to disasters and incidents of terrorism must add “tools” to their toolboxes to help those in need. Each day, we are being challenged by a variety of disasters that affect those we serve. Disaster is used in this context as an inclusive term to identify all the varieties of ways people can be harmed—at the hands of a loved one, from natural disasters or from acts of terrorism. A person who is experiencing a crisis—their own personal disaster—does not care what counseling theory we use or the techniques associated with that particular theory. They just need our help. To answer that need, we must prepare for the unexpected. We must learn to stay calm in the midst of chaos; we must become better listeners; we must refrain from trying to create a treatment plan or solve their problems. These are not long-term clients; they do not have months, or even weeks, to spend with us; they are living in the moment, with us, and trying to make sense of what just occurred. We need to revisit Maslow’s hierarchy of needs; this is where we start with people who are survivors of disasters. Never probe for sensory details; this could provoke a strong emotional reaction that an individual does not need/nor has a desire to share the information with you. We are

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not providing treatment; we are responsible to listen, empower, connect victims with other resources, build on their strengths, and assist them in discussing how they want/ need to move forward. In the aftermath of disaster, psychological first aid, triage, assessment, and basic support are the most common and appropriate interventions. Psychotherapy is not appropriate. Instead, early intervention is primarily focused on assisting disaster survivors and response workers in meeting their most basic needs. This includes helping people to feel safe and secure; to obtain food and water; to address their physical health needs (first aid and access to their medications); and to connect to their family, friends, and other social support networks. Providing emotional comfort and support and helping individuals focus on their disaster-related needs are the most important mental health interventions that can be provided at the time of disaster. The National Organization for Victims Assistance (NOVA, 2010) reported that crisis intervention (disaster mental health) is “more than a shoulder to cry on, a hand to hold, or an ear with which to listen” (p. 13). Crisis intervention involves skill, language, and knowledge combined in a simple but powerful way. According to NOVA, “providing victims with a sense of safety and security; allowing them a chance for ventilations and validation; and giving them accurate prediction and preparation for the future” (p. 13) are the skills they need from you. As professions, counselors have competencies that are in great demand during a time of crisis. However, in order to engage in the disaster response process, we need to join forces with at least one organization that responds to disaster and become a part of the organization’s response structure. The American Red Cross, NOVA, CISM, the Salvation Army, and the Disaster Response Network are viable organizations with which to begin your work.

Responder Self-Preparation For any counselor, psychologist, social worker, or other helping professional thinking about volunteering their services as disaster mental health responders, a series of important questions needs to be posed. Is the counselor prepared in the event of a local disaster? What types of disasters can occur within the counselor’s own community? Can the volunteer sustain self and family for at least three days? How many gallons of water are needed per family member? Are emergency kits ready? What emergency plan does the volunteer have for her or his family in the event of a fire in the home? Is the plan practiced? Has a safe meeting place been established? How are pets attended to in the middle of a disaster? Is an alternative heat source available? What plan is in place if the adult responder gets separated from his or her children? The American Red Cross has a saying: Don’t be scared! Get prepared! Is the reader prepared? If the reader experienced a disaster, what would be the reader’s reaction?

CONCLUSION This chapter has provided a brief overview of disaster responses to local, state, and federal crises and emergencies. In addition, this chapter has provided a brief overview of the history of FEMA, the impact pyramid, and the phases of disasters. We live in a time in which we are experiencing natural disasters and living with the threat of additional terrorists’ attacks, increased reports of physical and sexual abuse, domestic violence, suicide, and military fatalities; the list goes on. As counselors,

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we must be prepared for the unexpected. We need to become more involved in our own communities, volunteering and educating ourselves, our family members, and our colleagues about the types of emergencies one can face. Each state now has some agency responsible for disaster preparedness. It is our professional responsibility to know about what our community disaster plan is and, for those who can, to become a part of it, contributing our expertise. Counselors and other human service professionals have training in cultural competency, working with the older adults or special needs populations, or within the school systems. We need to become partners with local agencies by planning, practicing, and communicating in everyday language the need for disaster preparedness. The only way to truly learn about Disaster mental health is to get involved and seek training, which includes disaster services, from organizations such as the American Red Cross. A disaster services course can provide information about the ways in which participants can help their community to prevent, prepare for, and respond to emergencies and disasters. To become engaged as a disaster mental health responder, concerned counselors can do the following: become cardiopulmonary resuscitation/ automated external defibrillator (CPR/AED) certified, take a basic first aid class, specialize in disaster mental health, or become credentialed through NOVA and their National Crisis Response Credentialing Program. As a minimum standard of ethical practice, all professionals need to investigate and understand the big picture structure of the disaster and crises organizations that exist in their own states. No one is useless in this world who lightens the burdens of others. —Charles Dickens

TERMS AND ACRONYMS There are many terms and acronyms with which professionals must be familiar if they choose to respond to disasters. These terms are listed next. The professional who is serious about responding to disasters is strongly encouraged to become familiar with the list. It should be noted that this list may, and in all probability will, change before this volume is published. Keeping up to date with disaster terminology is important in an ever changing field where necessary action is as rapid as the change in terms and acronyms. When in the field, there is no time to check a reference list for an acronym used in a directive from one’s team leader. Acute Stress Disorder (ASD) – a psychological diagnosis used to explain extreme reactions to stress above what is often expected as normal American Red Cross (ARC) – a congressionally chartered, humanitarian organization led by volunteers; it provides relief to victims of disasters and assists people in preventing, preparing for, and responding to emergencies Base – the location from which primary logistics and administrative functions are coordinated and administered Centers for Disease Control and Prevention (CDC) – governmental agency that prepares for and responds to public health emergencies, keeps the public informed about public health emergencies, and provides information needed to protect and save lives

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Center for Mental Health Services (CMHS) – a federal agency contained within the Substance Abuse and Mental Health Services Administration (SAMHSA); mandated to adopt a leadership role in mental health services delivery and deployment; it has developed a branch specifically to focus on disasters Community Emergency Response Team (CERT) – a collection of individuals who are trained in basic disaster response skills, such as fire safety, search and rescue, team organization, and disaster medical operations; members can assist others in their neighborhoods or workplaces following an event when professional responders are not immediately available Crisis Counseling (CC) – short-term interventions focused on assisting disaster survivors in understanding their current situation and reactions, mitigating additional stress, assisting those individuals in reviewing their options, promoting the use or development of additional coping strategies, providing emotional support, and encouraging linkage with other agencies that can assist survivors in recovering to their predisaster level of functioning Crisis Counseling Assistance and Training Program (CCP) – a program funded by the Federal Emergency Management Agency (FEMA); its purpose is to support shortterm interventions with individuals and groups experiencing psychological distress from a large-scale disaster Critical Incident Stress Debriefi ng (CISD) – a technique specially designed to assist others in dealing with the physical and psychological symptoms that are generally associated with traumatic exposure Critical Incident Stress Management (CISM) – a formal, highly structured intervention protocol for assisting those exposed to a traumatic event so that they may share their experiences and emotions, learn about stress reactions and associated symptoms, and receive referrals for further help, if needed; a peer-driven program with mental health support (not counseling) Department of Homeland Security (DHS) – umbrella organization that oversees and coordinates all national emergency services Deployment – a term that indicates that a credentialed volunteer has received notification that he or she will be assigned to respond to a disaster Disaster Application Center (DAC) – the specified location to which disaster victims must report in order to apply for disaster aid Disaster Action Team (DAT) – the name given to a response team, whether it be large or small, of the American Red Cross Disaster Crisis Outreach and Referral Team (DCORT) – Pennsylvania volunteer county initiative that responds to county or commonwealth disasters Disaster Field Office (DFO) – the primary location of the command center for response operations for a disaster

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Disaster Mental Health (DMH) – specialty field mental health with professionals who respond to disasters Disaster Relief Operations (DRO) – operations and conditions that are applicable to disaster relief efforts and provides leaders with appropriate controls and prevention measures Emergency Manager (EM) – the individual with the responsibility of having an emergency operation plan in place for the jurisdiction for which he or she is responsible Emergency Medical Services (EMS) – first responders responsible for the physical health of victims Emergency Operation Center (EOC) – central command and control facility responsible for carrying out the principles of emergency preparedness Federal Emergency Management Agency (FEMA) – federal organization for disaster mitigation, preparedness, response, recovery, education, and references. Hazard – any situation with the potential for causing harm or damage to people, property, or the environment Hazardous Materials (HAZMAT) – substances that are flammable, corrosive, or reactive; toxic chemicals; infectious biological agents; or radioactive materials Helibase – the location from which helicopter-centered operations are conducted Helispots – temporary locations at the incident, where helicopters can land/take off Immediate Response – the action taken from the time a disaster/emergency strikes or is imminent to the time Mental Health Response Teams arrive on scene Incident Commander (IC) – individual who has overall responsibility for managing the incident by establishing objectives, planning strategies, and implementing tactics Incident Command Post (ICP) – the location from which the Incident Commander oversees all incident operations Incident Command System (ICS) – a standard approach to incident management that enables coordinated responses among various jurisdictions and agencies; it establishes common processes for planning and managing resources and allows for the integration of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure National Incident Management System (NIMS) – provides a systematic, proactive approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector to work seamlessly to prevent, protect against, respond to, recover from, and mitigate the effects of incidents, regardless of cause, size, location, or complexity, in order to reduce the loss of life and property and harm to the environment National Organization for Victim Assistance (NOVA) – a private, non-profit organization comprised of victim and witness assistance programs, agencies, and practitioners

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and others committed to the rights of and service to victims. This national advocacy group provides direct services to victims and assistance to professionals. National Response Framework (NRF) – a guide indicating how the nation conducts all hazards responses, from the smallest incident to the largest catastrophe; establishes a comprehensive, national, all-hazard approach to domestic incident response; identifies the key response principles, roles, and structures that organize a national response National Voluntary Organizations Active in Disaster (NVOAD) – the forum where organizations share knowledge and resources throughout the disaster cycle— preparation, response, and recovery—to help disaster survivors and their communities; members of NVOAD form a coalition of nonprofit organizations that respond to disasters as part of their overall mission Presidentially Declared Disaster (PPD) – any natural catastrophe (including flooding, hurricanes, tornado, storm, high water, wind drive, tsunami, landslide, snowstorm, or drought), regardless of cause, which, in the determination of the president of the United States, causes damage of sufficient severity and magnitude to warrant major disaster assistance under the Federal Disaster Relief Act Psychological First Aid (PFA) – developed jointly with the National Child Traumatic Stress Network, PFA is an evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism to reduce initial distress and foster short and long-term adaptive functioning; it is for use by first responders, incident command systems, primary and emergency health care providers, school crisis response teams, faith-based organizations, disaster relief organizations, Community Emergency Response Teams, Medical Reserve Corps, and the Citizens Corps in diverse settings Recovery Service Center (RSC) – a facility where a variety of agencies set up operations so that survivors can connect with community partners that will assist them in their recovery; often called one-stop connecting Salvation Army – officially recognized by federal, state, and local governments across the country as a sanctioned disaster relief and assistance organization within NVOAD; involved in the development of and recognized within the FEMA’s recently released national response framework; provides relief services to communities impacted by both natural and human-made disasters until the service is no longer needed by the community Staging Areas – locations where personnel and equipment are gathered while waiting to be assigned

RESOURCES Additional resources are available for those interested in becoming disaster behavioral health responders. The following is a list of applicable websites. American Red Cross (http://www.redcross.org) Disaster Assistance (http://www.disasterassistance.gov) A website that provides information about disaster preparedness. The Disaster Center (http://www.disastercenter.com) An all-inclusive website regarding national security threats, information about preparedness, etc.

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Federal Emergency Management Agency (http://www.fema.gov/index.shtm) International Critical Incident Stress Foundation (http://www.icisf.org) National Organization for Victims Assistance (http://www.trynova.org) Ready (http://www.ready.gov) A website to assist anyone to get prepared, plan, and stay informed.

REFERENCES Ayalon, O. (1992). Rescue: Community oriented prevention education for coping with stress. Ellicott City, MD: Chevron Publishing. Bulling, D., & Abdel-Monem, T. (2009). Disaster mental health: Clinical practice and legal exposure. In A. Jamieson & A. Moenssens (Eds.), Wiley Encyclopedia of Forensic Science. Hoboken, NJ: Wiley. Centers for Disease Control and Prevention. (n.d.). Disaster mental health primer: Key principles, issues and questions. Retrieved from http://www.bt.cdc.gov/mentalhealth/ primer.asp Erikson, K. T. (1976). Everything in its path: Destruction of community in the Buffalo Creek flood. New York, NY: Simon & Schuster. Geertz, C. (1973). The interpretation of cultures. New York, NY: Basic Books. National Organization for Victim Assistance. (2010). An introduction to crisis intervention protocols. Retrieved from http://www.trynova.org/victiminfo/readings/CrisisIntervention.pdf Ochberg, F., & Soskis, D. (Eds.). (1982). Victims of terrorism. Boulder, CO: Westview. Pennsylvania Emergency Management Agency. (2011). Terrorism. Retrieved from http://www.readypa. org/potentialemergencies/terrorism/ Stebnicki, M. A. (n.d.). Psychological response to terrorism as an extraordinary stressful & traumatic life-event: Coping with the traumatic stressors. Retrieved from http://www.ncpublicschools.org/schoolsafety /resources/crisis/national/psychologicalresponse United Nations Counter-Terrorism Committee, Security Council. (2010). Our Mandate. Retrieved from http://www.un.org/en/sc/ctc/ U.S. Department of Health and Human Services. (2003). Developing cultural competence in disaster mental health programs: Guiding principles and recommendations (DHHS Publication No. SMA 3828). Retrieved from http://store.samhsa.gov/shin/content//SMA03-3828/SMA03-3828.pdf U.S. Department of Homeland Security. (2010a). FEMA History. Retrieved from http://www.fema .gov/about/history.shtm U.S. Department of Homeland Security. (2010b). FEMA: The disaster process and disaster aid programs. Retrieved from http://www.fema.gov/hazard/dproc.shtm U.S. Department of Justice. (2000). Responding to terrorism victims: Oklahoma City and beyond. Retrieved from http://www.ojp.usdoj.gov/ovc/pdftxt/NCJ183949.pdf

Section V: Clinical Assessment and Treatment Issues CHAPTER 27

Assessment in Psychological Trauma: Methods and Intervention F. BARTON EVANS

INTRODUCTION The purpose of this chapter is to introduce the reader to the wide variety of available clinical psychological assessment methods that can aid the counselor in understanding the experience of the adult trauma victim. This chapter gives a brief overview of psychological assessment in general. A review of the available psychological assessment instruments for psychological trauma follows, along with a discussion of how psychological assessment can aid counseling with individuals suffering from the effects of psychological trauma. This chapter further addresses how to use psychological assessment in counseling and especially to introduce the reader to a powerful and evidencebased treatment called therapeutic assessment (Finn, 2007). To meet the aim of this chapter, these issues are detailed in the following sections: (a) context for assessment, (b) psychological assessment methods and issues, and (c) implications of trauma assessment for counseling. These major sections are followed by a summary discussion and helpful resources.

CONTEXT FOR ASSESSMENT The context for assessing traumatic experience is broad, ranging from combat experiences to sexual assault, automotive accidents to life-threatening illness. Yet survivors of psychological trauma frequently express their experience in comprehensible ways that can be accurately assessed. The following discussions in this section aim to illuminate the context for assessing survivors of trauma: (a) What Is Psychological Assessment? (b) Why Psychological Assessment for Posttraumatic States? and (c) What Are the Faces of Trauma?

What Is Psychological Assessment? For the purposes of this chapter, psychological assessment refers to the use of psychological tests and interviews (structured or unstructured) to measure personality attributes, psychological symptoms, or cognitive functions with an eye toward developing hypotheses and predictions about the person’s inner experience, interpersonal behavior, and performance. There are considerable advantages for counselors to incorporate psychological assessment into their clinical practice, either through consultation

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with an assessment professional or receiving the education and training on how to administer, score, and interpret psychological assessment in a professionally ethical manner. Perhaps the major advantage is that psychological assessment is empirically grounded (see Kubiszyn et al., 2000; Meyer et al., 2001), providing objective information that considerably enhances the accuracy of clinical judgment. Additionally, psychological assessment makes considerably more information available about the client’s psychological functioning than the counselor can gain from unstructured clinical interviews alone. Further, as is described at the end of this chapter, personalized, collaborative feedback using psychological assessment has been increasingly used as a powerful therapeutic treatment intervention (Finn, 2007; Fischer, 1985/1994). Psychological assessment instruments include clinical interviews, symptomspecific tests, and comprehensive personality tests. Clinical interviews are naturally at the heart of all mental health practice. They provide counselors with a powerful way to understand their client’s history, interpersonal relationships, personal experience, and subjective reactions to these experiences and relationships. However, relying on unstructured clinical interviews alone has some important disadvantages, the first of which is that it runs the risk of missing important information. Additionally, as noted by Garb (1998) and Rogers (1995), all mental health professionals have their set of biases based on their own experience, education, and values. Structured interviews (as well as psychological testing in general) improve accuracy and reliability of clinical judgments and reduce bias. Interviews can be seen on a continuum from a completely unstructured interview all the way to carefully constructed and highly structured interviews. Harry Stack Sullivan’s (1954) classic work, The Psychiatric Interview, skillfully introduced the idea of increasing reliability through a standard interview. With the advent of the Structured Clinical Interview for DSM III-R (Spitzer, Williams, Gibbon, & First, 1990), the structured interview has become increasingly a gold standard for the most reliable diagnosis of mental disorder for research and clinical purposes. Symptom-specific tests are psychological assessment instruments, which include straightforward, face-valid instruments measuring a particular disorder or clinical phenomenon. They range from highly specific instruments (e.g., Beck Depression Inventory II [BDI-II]; Beck, Steer, & Brown, 1996) and the Beck Anxiety Inventory (BAI; Beck, 1997) for depression and anxiety to comprehensive assessment measures for psychological trauma (e.g., Briere’s 1997 excellent Trauma Symptom Inventory [TSI] and Briere’s 2001 Detailed Assessment of Posttraumatic Stress [DAPS]). Among the most useful psychological assessment instruments are personality assessment tests, which are designed to assess cognitions, attitudes, emotions, and psychological symptoms, as well as behavioral predispositions and inner experiences. Examples of personality tests include self-report tests, that is, inventory-type, question-and-response tests, such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and the Personality Assessment Inventory (PAI; Morey, 2007); performance-based tests such as the Rorschach Inkblot Method (see Exner, 2003; Weiner, 2003); and storytelling tests (see Teglasi, 2010) such as the Thematic Apperception Test (TAT; Murray, 1943). The value of these comprehensive personality assessment measures is that they assess a wide variety of psychological states, allowing the counselor to better understand comorbid mental disorders and underlying personality issues as well as posttraumatic states.

Why Psychological Assessment for Posttraumatic States? When a counselor first sees a person with psychological trauma, she or he is faced with a complex and daunting task. What is the nature of her or his trauma, and how severe

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was it? Who was the perpetrator—a stranger or someone the client counted on for protection? How long ago did it occur? Was the trauma a single episode or a series of repeated events over an extended period? What are the trauma victim’s vulnerabilities and strengths? How has the inner experience and outer behavior manifested, both in terms of symptoms of psychopathology and disturbed interpersonal relations? These are but a few of the many issues and concerns that confront us when we enter the lives of individuals facing the impact of overwhelming, terrifying, horrific, and often incomprehensible life experiences. Psychological trauma is so profoundly destabilizing that it may be hard to imagine mistaking, overdiagnosing, or entirely ignoring it. Yet trauma disorders present in different and confusing ways, often with symptoms similar to other mental disorders, creating complex diagnostic and treatment challenges. To provide some groundwork for understanding the complexity of assessing psychological trauma, a brief description of trauma theory is presented here along with implications for trauma assessment. Prevalence studies of psychiatric patients show rates of trauma exposure that range from 60% to more than 80% (Bryer, Nelson, Miller, & Krol, 1987). Carlson’s (1997) review concludes that counselors can expect at least 15% of their adult clients to have current or past trauma symptoms. As stated in the following text, presentations of psychological trauma can range from straightforward and clear to complex and disguised. As such, it is likely that counselors may be challenged with understanding clients with a wide variety of psychological trauma presentations. Therefore, counselors who become acquainted with a range of psychological assessment tools can increase their ability to understand and treat a wide range of trauma responses. When faced with this daunting task, psychological assessment methods can help quickly and reliably to provide a comprehensive view of the person and their struggles. In effect, as suggested by Finn and Tonsager (1997), psychological testing can serve as an “empathy magnifier.” In particular, there are two circumstances under which traumatized people come to the attention of counselors. First, individuals seek treatment following a clearly identified trauma such as a natural disaster, assault, rape, or life-threatening accident, illness, or injury. In these instances, the presenting psychological trauma is overt. Yet, posttraumatic stress disorder (PTSD) is only one of many possible ways in which traumatic experience presents itself (van der Kolk & McFarlane, 1996), and it not infrequently presents with comorbid mental disorders such as depression (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Further, the client may have past traumatic experiences that are activated by the current traumatic experience. Psychological assessment can shed light on the client’s view of herself or himself, ability to regulate emotions, interpersonal capacities, and coping mechanisms. In doing so, the counselor can better address the complexities of different trauma presentations in terms of symptoms, diagnosis, and, most importantly, effective treatment. Second, counselors may see individuals with past psychological trauma, in which their trauma presentation is less obvious. In this instance, the clients may be unaware of the link between past traumatic experiences and their current suffering and symptoms and may not even see such experiences as relevant. For adult clients with past chronic childhood abuse and neglect, traumatic dissociation has likely been used to cope with and survive the ordeal, which can limit clear memory of traumatic events and make it difficult for such clients to express their experiences in a coherent fashion. In such instances, psychological assessment, especially performance-based measures such as the Rorschach or Adult Attachment Projective (Finn, in press), can provide the counselor with the fi rst indication of such buried trouble.

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What Are the Faces of Trauma? The word “trauma” is used increasingly in the common parlance as a word to indicate an unpleasant event, for example, “My girlfriend is giving me a lot of trauma these days about going out with the guys.” Therefore, a more precise definition of psychological trauma is important. Unlike a distressing experience, the trauma response involves specific psychophysiological responses that are more extreme and enduring than the psychophysiology of distress (see Southwick, Rasmusson, Barron, & Arnsten, 2005). Such traumatic physiological reactions underlie the biphasic psychological response to trauma, which is the phasic alternation between intrusive (flashback/nightmares) and constrictive (avoidance/numbing) symptoms (van der Kolk & Ducey, 1984). Assessing the biphasic trauma response is critical in determining how to approach the client in treatment. The best known definition of the traumatic stressor is the stressor criteria used for PTSD described by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000). Criterion A-1 PTSD stressor criterion describes trauma exposure as “the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others” (APA, 2000, p. 467). Experiencing such an event is not sufficient for the diagnosis but also requires Criterion A-2, “the person’s response involved intense fear, helplessness, or horror” (APA, 2000, p. 468). Following these criteria are three symptom clusters: flooding/ reexperiencing; avoidance/numbing; and hyperarousal, which must cause stress and/ or social and emotional impairment. The advantage of this definition is that it is relatively easy to quantify and therefore provides criteria that are reliable and researchable. The disadvantage is that it focuses on symptoms rather than experience and does not capture the terrible reality of protracted traumatic experience such as torture, domestic violence, and child abuse, where understanding the impact of captivity, degradation, and emotional abuse is critical. A second, more liberal, and perhaps more satisfactory, definition is found in the International Classification of Diseases, Tenth Revision (ICD-10; World Health Organization, 1992), which defines PTSD in the following way: . . . [A] delayed and/or protracted response to a stressful event or situation (either short- or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone (e.g. natural or man-made disaster, combat, serious accident, witnessing the violent death of others, or being the victim of torture, terrorism, rape, or other crime). (World Health Organization, as cited in Houghton College, 1998, para. 1). The three symptom clusters are largely similar to those in the DSM-IV. This stressor definition is closer to the one in DSM-III-R but was rejected for a more narrow definition in DSM-IV because it was harder to quantify. The emphasis on a stressor that would cause pervasive distress in almost everyone provides a broader understanding of the power of events that are not strictly life threatening or integrity threatening (see van der Kolk, McFarlane, & Weisaeth, 1996, for an excellent comprehensive book on PTSD). A third definition arises from the work of Herman (1992a, 1992b), who indicated that current PTSD diagnosis frequently does not capture the severe psychological harm from prolonged, repeated trauma and suggested a new diagnosis, complex PTSD, or disorders of extreme stress not otherwise specified (DESNOS), to describe the pervasive psychological and physiological effects of long-term trauma. The stressor criterion for diagnosis of complex PTSD is that the individual experienced a prolonged period (months to years)

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of total control by another. Six clusters of symptoms have been suggested for diagnosis of complex PTSD: (a) alterations in regulation of affect and impulses, (b) alterations in attention or consciousness, (c) alterations in self-perception, (d) alterations in relations with others, (e) somatization, and (f) alterations in systems of meaning (Pelcovitz et al., 1997). While DSM-IV field trials indicated that 92% of individuals with complex PTSD/ DESNOS also met criteria for PTSD, complex PTSD was not added as a separate diagnosis (Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). On the other hand, because of the different and more severe symptom pattern, assessment of complex PTSD is critical for determining special psychotherapeutic approaches. See Herman (1992a), Chu (1998), and Courtois and Ford (2009) for a more comprehensive discussion regarding the etiology, clinical phenomena, and treatment approaches of complex PTSD. In addition to these three specific diagnostic presentations of PTSD, other symptoms commonly found in individuals experiencing trauma include somatization, panic reactions, emotional lability, anxiety, agitation, depression, hopelessness, loss of life purpose, sleep problems, inability to self-soothe, and disturbances in thinking and reality testing. Symptoms of physiological dysregulation in chronic trauma and emotional lability can mask accurate diagnosis because they are core symptoms in many other psychological disorders, such as bipolar disorder, panic disorder, and borderline personality disorder. Affective dysregulation can increase cognitive confusion, intrusions can be experienced on a cognitive level as hallucinatory flashbacks, and psychoticlike thinking has been observed in traumatized people who were previously clinically normal (Weisaeth, 1989), giving the impression of a psychotic disorder. Efforts to avoid reexperiencing traumatic memories may make traumatized clients appear withdrawn, uncooperative, and exhausted, causing difficulties connecting with them and complicating counselors’ efforts to understand. It is important to remember that not all individuals experiencing trauma show clinical signs and symptoms. There is no one-to-one relationship between an external trauma and the person’s psychological response. Researchers estimate that only 25% to 30% of those exposed to trauma develop PTSD (Kessler et al., 1995; Ozer, Best, Lipsey, & Weiss, 2003), although risk rates vary depending on the kinds of stressors such as combat, rape, childhood abuse, or assault with a weapon. The studies indicate that women consistently show higher risk rates than men. However, many people spontaneously resolve the trauma and, in the process, may even develop greater coping skills (Solomon, Mikulincer, & Avitzur, 1988). Such findings underscore the importance of assessing individuals’ strengths as well as vulnerabilities (Sullivan, 1954), further complicating the counselor’s task.

PSYCHOLOGICAL ASSESSMENT METHODS, CONCERNS, AND PRACTICES Several methods of psychological assessment are best indicated for use with survivors of trauma, and several important practice issues arise when considering relevant methods. These methods and associated issues and practices are discussed in the following sections: Clinical Interview, Trauma-Specific Scales, Personality Assessment Instruments, Malingering, Best Practices in Assessing Psychological Trauma, and Collaborative and Therapeutic Assessment.

Clinical Interview The clinical interview is the most common psychological assessment strategy used by counselors, psychiatrists, social workers, psychiatric nurses, and psychologists alike.

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During interviews at the beginning of counseling, the counselor forms an initial opinion on the client’s problems, subjective reactions to these problems, symptoms, diagnosis of mental disorder(s), and treatment strategy. Throughout the course of treatment, the counselor reassesses initial hypotheses about problems and alters the treatment course accordingly. Although the clinical interview is the core tool used for assessing and understanding the client, as stated earlier, all counselors are vulnerable to their biases and the limitations of understanding from a single source of data. George Miller’s (1956) classic article on the limits of our capacity to process information indicates that at any one time, we can hold seven pieces of information, plus or minus two. The implication for this psychological reality is that in order to deal with the complexity of psychological trauma, the counselor does well to operate from multiple information sources beyond a structured clinical interview. The assessment of symptoms and reactions to psychological trauma is aided by additional methods such as structured interviews. Four of the major structured interviews for the assessment of psychological trauma, along with several supporting methods, are described later. Although there are many others, it is beyond the scope of this chapter to be exhaustive.

Dimensional, Scale-Based Structured Interviews When the presenting problem includes a clear description of a traumatic stressor, structured interviews of posttraumatic stress employing dimensional rather than categorical (presence/absence) rating scales can be invaluable in understanding the severity and nature of PTSD symptoms. Two examples of such interviews include the gold standard Clinician-Administered PTSD Scale for DSM-IV (CAPS-DX; Blake et al., 1995) and the PTSD Symptom Scale-Interview Version (PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993). Clinician-Administered PTSD Scale for DSM-IV. Of all the structured interviews for PTSD interviews, the CAPS is the most comprehensive for assessing core and associated symptoms of PTSD. Weathers, Keane, and Davidson’s (2001) literature review of more than 200 studies indicated impressive evidence of its reliability and validity. Several advantages of the CAPS over other structured interviews for PTSD is that it assesses the frequency and intensity of each symptom; has excellent prompt questions to elicit clinical examples; assesses both current and lifetime PTSD symptoms; and provides explicit, behaviorally anchored rating scales. The CAPS can be scored, providing both continuous and dichotomous scores with several scoring rules to assist the counselor (Weathers, Ruscio, & Keane, 1999). The CAPS’s primary disadvantage is its long assessment time of about 50 to 60 minutes. The Life Event’s Checklist (LEC; Gray, Litz, Hsu, & Lombardo, 2004) is a brief, 17-item self-report measure designed to screen for potentially traumatic events in a respondent’s lifetime. The LEC was developed concurrently with the CAPS and is administered before the CAPS. PTSD Symptom Scale—Interview Version. When time is at a premium, PSS-I is a reasonable alternative. Studies indicate that the PSS-I is reliable and valid in civilian trauma survivors, making it a good instrument for most clients in the counselor’s usual practice. In a comparison study with the CAPS (Foa & Tolin, 2000), the PSS-I performed about equally well in arriving at a diagnosis of PTSD, decreasing assessment time without sacrificing reliability or validity. On the other hand, what is gained in time savings is lost in providing a detailed rich description of the client’s past and present psychological trauma.

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Structured Interviews for Complex Posttraumatic Disorder and Dissociation If the counselor has a practice involving adult victims of child abuse, the PTSD structured interviews mentioned earlier are likely not sufficient to assess the pervasive and complex psychological sequelae of complex PTSD. A groundbreaking study by Herman, Perry, and van der Kolk (1989) found a strong association between a diagnosis of borderline personality disorder and a history of abuse in childhood, including physical abuse, sexual abuse, and witnessing serious domestic violence. This research was instrumental in developing the diagnoses formerly called DESNOS and now more commonly called complex PTSD. Structured Interview for Disorders of Extreme Stress. As part of the field trials for DSM-IV (Roth et al., 1997), the aforementioned research team developed the Structured Interview for Disorders of Extreme Stress (SIDES; Pelcovitz et al., 1997), a validated structured interview assessment for complex posttraumatic stress, which subsequently was found to have considerable clinical utility (van der Kolk & Pelcovitz, 1999). The SIDES is a 45-item interview that consists of six subscales corresponding to the six complex PTSD symptom clusters. Like the CAPS, the SIDES measures current and lifetime presence of complex posttraumatic stress symptoms as well as symptom severity. In a recent study of individuals diagnosed with borderline personality disorder using the SIDES, McLean and Gallop (2003) concluded that “some women with a history of childhood sexual abuse may be extricated from the diagnosis of borderline personality disorder and subsumed under that of complex PTSD” (p. 371). Dissociation and the SCID-D-R. Dissociative responses and disorders (formerly called multiple personality disorder) account for additional clinical phenomena closely associated with psychological trauma and its assessment. Dissociation is a state of fragmented consciousness involving amnesia, a sense of unreality, and a feeling of being disconnected from oneself or one’s environment. Dissociation is a psychological process common to everyone, although in the extreme, it can become a severe disorder with fragmented identity states, previously and inaccurately referred to as multiple personalities. Putnam (1997) estimated that most, if not all, dissociative disorders are caused by severe sexual, physical, and emotional abuse in childhood. Because of the complex and shifting affective and identity states in dissociative disorder, comprehensive evaluation provides the counselor with a significant advantage over the simple clinical interview. One of the best methods for the comprehensive assessment of dissociative states and disorders is Steinberg’s (1994) Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R). Rigorously developed through the National Institute of Mental Health (NIMH) field trials, the SCID-D-R is a structured diagnostic interview that is specific to the assessment of DSM-IV dissociative disorders and acute stress disorder. It provided a careful and detailed decision tree approach, arriving at accurate DSM-IV diagnosis of dissociative amnesia, depersonalization disorder, dissociative disorder not otherwise specified, acute stress disorder, and dissociative trance disorder. Perhaps of more importance to counselors, the SCID-D-R assesses a broad variety of posttraumatic dissociative symptoms that clients may not spontaneously share in unstructured interviews. Many dissociative clients have long learned that their dissociative experiences are treated by others as strange and bizarre and indeed some counselors may feel this way toward the clients as well. As a result, such clients have learned to avoid discussion, automatically, of these symptoms. Careful and empathic administration of the SCID-D-R can help dissociative clients better share their experiences

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and can reveal symptoms and psychological states that can be the focus of treatment intervention. Steinberg and Schnall’s (2001) book is an approachable overview of dissociative disorder.

Trauma-Specific Scales The next set of assessment tools, for use with psychological trauma, is the traumaspecific scales, a group of self-report instruments that focuses specifically on the symptoms and phenomena of PTSD and psychological trauma. They range from instruments with high “face validity”—that is, instruments that assess specific symptoms of PTSD—to more subtle instruments, which include associated traumatic symptoms and experiences as well as, in some instances, validity scales. The advantages of trauma-specific scales include the following features: (a) they focus on specific psychological trauma symptoms and phenomena; (b) they provide ratings of symptom severity and frequency; and (c) they allow the counselor to select specific scales that best match specific populations, for example, sexual assault, combat trauma, and partner or domestic abuse. Such instruments allow the counselor to focus treatment on specific symptoms that are most distressing to the client. As mentioned earlier, there are variations in posttraumatic symptom presentation, that is, the biphasic response in which the client may have predominantly avoidant/numbing presentations; intrusive/flooding presentations; or, in some instances such as with torture victims, alternations between the two. For example, some trauma victims may so repress trauma memories that they do not have current intrusive symptoms. As Foa and Rothbaum (1998) report, rape victims with an avoidant presentation have poorer treatment outcomes generally than, and require a very different approach from, victims with active intrusive symptoms. Trauma-specific assessment tools can alert the counselor early on to the client’s particular dilemmas, increasing the counselor’s understanding and empathy for the client and developing a more specific treatment approach.

Frequently Used Scales Two commonly used PTSD specific scales are the clinical version of the PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993) and the Posttraumatic Stress Diagnostic Scale (PDS; Foa, 1995). These are described briefly on the following sections. PTSD Checklist. The PCL is a brief, 17-item self-report measure of the 17 DSM-IV symptoms of PTSD that assesses both symptoms and their severity. The PCL can be used for screening individuals for PTSD, diagnosing PTSD, and assessing symptom change during treatment. Blanchard, Jones-Alexander, Buckley, and Forneris’s (1996) study of motor vehicle accident victims and sexual assault victims found a high correlation with the CAPS, concluding that the PCL is effective as a brief screening instrument for core symptoms of PTSD. Because of the high incidence of trauma victims in individuals presenting for psychotherapy, the PCL also can be used as an important screening tool during intake with all clients. A problem with the PCL is that it assesses only PTSD symptoms and not the specific trauma causing the symptoms. It assesses only severity of symptoms (i.e., “How much you have been bothered by each PTSD symptom?”) but not frequency of symptoms (i.e., “How often you have experienced these symptoms?”). The PCL asks about symptoms in the past month, so lifetime incidence is not assessed. The PCL even can be significant for individuals going through severe life events that

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do not specifically meet DSM-IV stressor criteria for PTSD (Robinson & Larson, 2010), making it a sensitive but not specific assessment instrument. Posttraumatic Stress Diagnostic Scale. The PDS is a 49-item self-report measure best used when assessing the severity of PTSD symptoms related to a single identified traumatic event. The PDS is one of only two among specific trauma self-report inventories to specifically assess all of the DSM-IV criteria for PTSD (i.e., Criteria A–F), assisting in a clear, formal diagnosis. Further, it asks about the presence and frequency of symptoms in the past month, although other time frames can be used. Unlike the CAPS and PCL, the PDS does not ask about severity of PTSD symptoms. It does not assess for past traumatic events or their impact on the client’s current life.

Assessing Combat-Related Trauma Since the Vietnam War, and most recently Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom, no survey of PTSD assessment would be complete without mention of the assessment of combat-related trauma. Since 1989, the U.S. Department of Veterans Affairs (USDVA, 2011) and its research and training arm, the National Center for PTSD (NCPTSD), have sought to better understand and therefore better assess the needs of veterans with military-related PTSD. Particularly, NCPTSD’s Behavioral Science Division, headed by Dr. Terence Keane, has been the world’s leader in the development and research of psychological assessment instruments for combat-related trauma. A core battery for the assessment of combat related to PTSD would include the following instruments: the Combat Exposure Scale (CES; Keane et al., 1989), the PTSD Checklist-Military (PCL-M; Bliese et al., 2008), and the Mississippi Scale for CombatRelated PTSD (M-PTSD; Keane, Caddell, & Taylor, 1988). Combat Exposure Scale. The CES is a 7-item self-report measure that assesses wartime combat stressors experienced by combatants. Respondents are asked to respond based on their exposure to various combat situations, such as firing rounds at the enemy and being on dangerous duty. The CES is easily administered and scored, providing a classification over combat exposure that ranges from light to heavy and provides the counselor with information that the veteran may find difficult to fully describe. PTSD Checklist-Military. The PCL-M is a military version of the PCL mentioned earlier, although it asks specifically about symptoms in response to stressful military experiences (Bliese et al., 2008; Weathers et al., 1993). It is often used with active service members and veterans to gauge the presence and severity of symptoms of PTSD. Mississippi Scale for Combat-Related PTSD. The M-PTSD is a 35-item self-report measure that assesses combat-related PTSD in veteran populations. Veterans rate how they feel about each item using 5-point scale. These items are added together to provide an index of PTSD symptom severity, with cutoff scores for a probable PTSD diagnosis, for use primarily for veteran populations. Not only does it assess primary symptoms of PTSD, but it also taps features often associated with PTSD such as substance abuse, suicidality, and depression.

Disadvantages While the trauma-specific self-report assessment methods mentioned earlier are very useful, these measures also have several notable disadvantages, which are shared in

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common with all other self-report assessment measures. Self-report measures depend on the clients’ ability both to understand themselves sufficiently to respond accurately to the questions and to be willing to report what they experience. In the case with clients who are emotionally shut down, they may not realize and report symptoms that are obvious to others. Alternatively, other clients may carelessly respond or underreport or overreport symptoms and experiences on self-report measures for a variety of motivations such as compensation for injury or worries about who will see the clients’ records if they report fully and honestly. These tendencies are known in assessment circles as response styles, that is, test-taking approaches that can bias or skew the interpretation of self-report measures.

Additional Inventories Following the lead of major self-report inventories such as the MMPI-2 and PAI, Dr. John Briere has created several excellent, comprehensive trauma-specific self-report inventories, which not only measure traumatic experience comprehensively but also assess response style. The most widely used and best researched of his scales are the DAPS (Briere, 2001) and the TSI (Briere, 1995), both of which take about 20 to 30 minutes to administer and are easily scored. Briere’s inventories include validity scales that assess defensiveness (denial of difficulties) and symptom overendorsement (endorsement of atypical symptoms not common to PTSD). Additionally, the TSI includes a validity scale for inconsistent, random reporting. Detailed Assessment of Posttraumatic Stress. The focus of the DAPS, like the PDS, is on assessing the severity of PTSD symptoms related to an identified traumatic event, which allows the counselor to establish a reliable DSM-IV diagnosis of PTSD. The DAPS goes beyond other such PTSD instruments in that it comprehensively assesses 1. the client’s history of possible traumatic exposure and identification of a specific current traumatic event; 2. immediate posttraumatic reactions, such as thoughts and feelings about the event as well as peritraumatic dissociation; 3. presence and severity of PTSD symptoms (intrusion, avoidance/numbing, and hyperarousal) and psychosocial impairment in response to the traumatic event; and 4. three supplementary scales of frequent comorbid difficulties, including ongoing dissociation, suicidality, and substance abuse. As a result, the DAPS provides the counselor a broader perspective of the client’s experience of posttraumatic stress beyond simple diagnosis. As a result, it is a more powerful “empathy magnifier” (Finn, 2007), allowing the counselor to better understand a wide variety of issues relevant for focusing treatment interventions. Trauma Symptom Inventory. Briere’s TSI is based on a well-conceptualized and well-researched understanding of traumatic phenomena and yields excellent information about the client’s experiences and behaviors that is exceptionally useful for framing empathic interventions. It surveys on both acute and chronic posttraumatic symptoms and experiences and has been widely used to assess the effects of sexual assault, domestic partner abuse, physical assault, combat experiences, major accidents, and natural disasters. In particular, the TSI is an excellent instrument to use with adults subjected to childhood abuse and other early traumatic events. In addition to assessing common PTSD symptoms such as angry/irritable affect, intrusive symptoms, avoidance/numbing, and

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hyperarousal, the TSI also assesses comorbid symptoms of both mood and cognitive distortions found in trauma-related depression, as well as dissociative symptoms. Further, this measure goes beyond the immediate posttraumatic symptoms and evaluates the long-term self-disturbance and interpersonal difficulties frequently found as part of chronic sequelae of earlier psychological trauma. The self-scales include sexual concerns (sexual dissatisfaction and distress), dysfunctional sexual behaviors (indiscriminate and self-harming sexual relations), impaired self-reference (identity confusion and poor self-care), and tension-reducing behavior (external ways of reducing inner tension such as suicidal threats, self-mutilation, and dysregulation of anger). Dissociative Experience Scale II. No brief survey would be complete without mention of Dissociative Experiences Scale II (DES II; Bernstein & Putnam, 1986), the widely used screening instrument for the frequency of dissociative experiences. As noted earlier, severe dissociative reactions are common in adult survivors of severe childhood trauma. Identification of these experiences is important diagnostically and therapeutically for treatment of such disorders as dissociative identity disorder. The DES is a brief self-report measure that assesses a continuum of dissociative experiences with normative data for normal, traumatized, and dissociative clients. It can be obtained online from the Sidran Institute at http://www.sidran.org. Abusive Behavior Observation Checklist. The Abusive Behavior Observation Checklist (ABOC) is a powerful assessment measure for counselors working with both women and men who are the victims of domestic battery. Often, such individuals have extreme difficulty articulating their domestic abuse experience in interviews with even experienced counselors (see Dutton, 2000; Walker, 2000). Mary Ann Dutton’s (2000) ABOC was developed to document the types and degree of interpersonal violence in domestic abuse such as physical, sexual, and psychological abuse, as well as victims’ behavioral and cognitive adaptation to such abuse. The ABOC provides an exhaustive survey of the ways in which batterers abuse their spouses and spouses’ adaptations to these abuses. Used together with the TSI, the ABOC provides an important avenue for battered spouses to share their traumatic experiences and effects on their functioning and view of themselves. It should be noted that there are many trauma-specific self-report inventories for psychological trauma, although it is beyond the scope of this chapter to survey most of them. The reader is referred to two excellent books (Briere, 2004; Wilson & Keane, 2004) for a more detailed survey of psychometric issues as well as a wide variety of self-report trauma instruments for both adults and children.

Personality Assessment Instruments Psychological trauma occurs in the context of the person and her or his personality. Individuals undergoing distressing life experiences may adapt in a variety of ways depending on their past experiences and common patterns of response (Sullivan, 1953). While factors such as intensity of traumatic experience and a history of prior traumatic events clearly influence posttraumatic response (van der Kolk, 1987), Miller’s (2004) review highlighted the intricate interplay between personality and the development and expression of PTSD. Personality assessment methods can be useful in helping to understand the impact of psychological trauma on the person, especially the long-term effects found in individuals with severe past trauma. As stated earlier, there are two kinds of personality assessments methods: self-report tests (formerly called “objective tests”) and performance-based tests (formerly called “projective tests”). See Meyer and Kurtz (2006) for their explanation of why this previous distinction did

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not accurately communicate the nature of these tests. As discussed in the following text, training for the use of the major personality tests requires a significant level of education, supervision, and experience, although in my opinion, it is well worth the effort.

Self-Report Tests The most widely used and researched personality instrument is the MMPI-2. Based on the client’s response to 567 True/False items, it yields 10 clinical scales and three primary validity scales, as well as literally hundreds of other scales. For the well-trained assessor, the MMPI-2 provides a rich palate of personality variables to understand the complexities of the client’s personal functioning. Further, the strong actuarial base of the MMPI-2 deeply enhances the accuracy of clinical judgment with some psychologists, even arguing for the superiority of actuarial methods (see Grove, 2005). While it is beyond the scope of this chapter to discuss the psychometric properties of the MMPI-2, there are many excellent books on the MMPI-2, including Friedman, Lewak, Nichols, and Webb (2001); Greene (1999); and Graham (2006). Understanding psychological trauma on the MMPI-2 can be a daunting task without adequate knowledge of how the instrument captures traumatic experience, and perhaps most importantly, how traumatic experience interacts with the individual’s personality. It is important to remember that the MMPI-2 and its predecessor, the MMPI, were not developed with the assessment of psychological trauma in mind. Traditional interpretation of MMPI-2 clinical scales with trauma victims can be extremely misleading. A common code type (i.e., a configuration of significantly elevated clinical scales; see Greene, 1999) for traumatized individuals is a highly elevated 2-8/8-2, often with other scales elevated in the clinical range. The traditional interpretation for this configuration, especially when it is highly elevated, suggests an individual with serious and chronic psychopathology. Common diagnoses are bipolar disorder and schizoaffective disorder. Without careful analysis of subscales and supplementary scales, the traumatized individual with hallucinatory and dissociative flashbacks, vivid nightmares, and intrusive daydreams could readily be misdiagnosed with a psychotic disorder with severe depressive features using standard interpretations on the MMPI-2. One approach to the MMPI-2 has been to find a code type that definitively diagnoses PTSD. The results of this endeavor have been mixed and elusive, largely because the approach is nomothetic, that is, looking at group level findings. For example, Wilson and Walker (1990) found a 2-8/8-2 code type with an elevation on F to be the most common profile, whereas Lyons and Wheeler-Cox (1999) noted a 2-7-8 code type to be the most prominent. Glen et al. (2000) found different predominate code types for Gulf War and Vietnam era veterans (1-8/8-1 and 2-8/8-2, respectively). Elhai, Frueh, Gold, Gold, and Hamner (2000) found that adult survivors of child sexual abuse and combat veterans were more similar than not on the MMPI-2. Griffith, Myers, Cusick, and Tankersley (1997) found an 8-4 code type with women with histories of childhood sexual abuse, although scales 1, 2, 6, and 9 were elevated as well. Additionally, there have been several supplementary subscales developed to identify PTSD, the most enduring being the Keane PTSD Scale (Keane, Malloy, & Fairbank, 1984). The disadvantage of the PTSD subscales is that they were developed without specific PTSD items, and they do not include the specific symptoms common to PTSD. Another approach to the MMPI-2 is Caldwell’s (2001) adaptive approach, which focuses on how psychopathological behaviors measured by the test are positive adaptations to painful or overwhelming life experience. He stated that “[u]nderstanding all

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such behaviors as adaptive leads to a notable enhancement of empathy” (p. 1). Caldwell reframed several of the classic MMPI-2 scales, thus providing important insight into traumatic experiences. For example, his description of Scale 8 (Schizophrenia) emphasizes the mental confusion that frequently is attendant with early traumatic experiences. Caldwell elaborates, If, at an early age, your body was the object of someone’s sexual gratification, someone who was cold to your distress or—worse yet—excited to greater sexual aggression by your pleadings that he or she stop, you end up deeply alienated and knowing yourself to be permanently damaged goods. (p. 13) Such an approach is preferable for an individual-based (idiographic) interpretation of the MMPI-2, as it is ideally suited for giving feedback (Finn, 1994) and providing powerful assessment-based therapeutic intervention such as the therapeutic assessment (TA; Finn, 2007). Another important and increasingly popular comprehensive self-report personality assessment instrument is the PAI (Morey, 2007). The PAI has fewer items and takes less time to complete than the MMPI- 2. Instead of the True or False format of the MMPI-2, the PAI rates items on a 4-point scale, ranging from false to very true. It has 22 nonoverlapping full scales, including 4 validity scales, 11 clinical scales, 5 treatment scales, and 2 interpersonal scales. The 11 clinical scales were developed to be consistent with current diagnoses in mind, making for an easier diagnostic description. The 10 clinical scales also contain conceptually derived subscales. Among the most useful of the clinical subscales is traumatic stress, which uses items more directly indicative of symptoms of posttraumatic stress disorder.

Performance-Based Tests As stated earlier, the performance-based (PB) personality assessment measures include what have previously been called projective tests. Through either storytelling methods such as the TAT and the AAP (George & West, 2001) or inkblot methods such as the Rorschach, PB personality tests are more open structured and elicit individuals’ powerful inner narratives and emotional experience. Such instruments can allow the trauma victim a path to reveal inner experiences that are not readily available to conscious verbalization. Of these PB methods, the Rorschach is the most researched and best conceptualized. In my opinion, the Rorschach is one of the most powerful personality assessments when used by a sensitive examiner trained in the Rorschach comprehensive system (CS; Exner, 2003), an empirically based method for administration, scoring, and interpretation. The advantage of the CS over other Rorschach methods is that interpretation is based on a very large body of literature confirming the reliability and validity of the variables. Rorschach CS is therefore an idiographic instrument with normative data to assist in understanding the highly individualized results. The Rorschach has been used extensively with individuals with psychological trauma, and the reader is referred to Armstrong and Kaser-Boyd (2003) and KaserBoyd and Evans (2007) for a comprehensive overview of its use. The CS has an important trauma indicator called the Trauma Content Index (TCI; Armstrong & Loewenstein, 1990), which has been used to help identify victims of sexual abuse (Kamphuis, Kugeares, & Finn, 2000) and individuals with dissociative identity disorder (Brand, Armstrong, & Loewenstein, 2006). Recent work by Finn (in press) has hypothesized that the Rorschach and other PB measures in particular allow access to unconscious

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negative affect states and implicit models of the self that result from traumatic experience, especially early developmental trauma. He contrasts PB measures with self-report tests, which are more sensitive to explicit models of the self and to conscious affect states. Because an important dilemma in the treatment of victims of trauma is accessing their damaged view of themselves and easily triggered fear, the Rorschach and other PB tests hold a unique place in the assessment and treatment of individuals with psychological trauma.

Malingering No discussion regarding the assessment of psychological trauma would be complete without mentioning potential problems for overreporting and outright malingering of posttraumatic symptoms. For example, Frueh et al. (2003) found up to 50% significant overreporting of symptoms among disability compensation seeking among veterans evaluated for PTSD. Rosen (2006) cautions that overreporting of PTSD in compensation cases is so common that it raises concern about inflating rates in the epidemiological PTSD database. While most individuals entering treatment for psychological trauma or for psychological problems that eventually may find their root cause in traumatic experience, some individuals seek counseling, often on the advice of their attorneys, as part of legal proceedings in which they are claiming PTSD as a consequence of an accident, personal injury, or disability claim. The alert counselor is aware of this possibility and understands that there are important differences between clinical and forensic assessment (see Greenberg & Shuman, 1997). Many well-meaning counselors have been drawn into complex and contentious legal matters, making expert opinions without proper basis, which are readily and successfully attacked by skillful defense attorneys. Such experiences often are painful and humiliating for the counselor and may lead to a loss of status in the professional community and even to malpractice suits. It is my advice that counselors always ask on intake whether the client is involved with or anticipates being involved with a legal matter related to his or her psychological state. If this is the case, I strongly advise developing a policy regarding the counselor’s willingness to participate in such matters and only to become involved in such matters with extensive and rigorous training and supervision in forensic assessment.

Best Practices in Assessing Psychological Trauma Having introduced the reader to the various kinds and benefits of assessment methods for psychological trauma, I would like to address the important issue of what constitutes best practices in psychological assessment and testing, especially the training necessary to engage in competent practice. Psychological assessment is a practice requiring special care because of the impact that it could have on clients’ lives. As noted in the Society for Personality Assessment’s (2006) Standards for Education and Training in Psychological Assessment, unlike counseling or psychotherapy, where the counselor gets to know the client through many hours of interaction, psychological assessment may be a brief encounter in which mistakes can be magnified by misinterpretation. Further, psychological test reports usually become a part of clients’ records, and mistakes may influence their entire lives. Additionally, psychological assessment can have a significant influence on important decisions about clients’ lives, such as a need for hospitalization, assessment of dangerousness, custody of children, and employment situations. As such, inadequately trained psychological assessors can cause considerable emotional and personal damage.

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Professional societies for psychology and counseling have provided important guidance on what constitutes ethical practice in psychological assessment. Some of the key resources are listed on the following text: ■ see the American Psychological Association’s Guidelines for the Qualification of

Test Users (Turner, DeMers, Fox, & Reed, 2001), ■ the Standards for Qualifications for Test Users (American Counseling Association,

2003), ■ the Responsibilities of Users of Standardized Tests (Association for Assessment in

Counseling, 2003), and ■ the interdisciplinary Standards for educational and psychological testing (American

Educational Research Association, American Psychological Association, & National Council on Measurement in Education, 1999). Knowledge of these guidelines and standards are necessary for any mental health professional wishing to engage in psychological assessment and testing. Unfortunately, these professional societies have not addressed what constitutes acceptable levels of education, training, and practice, leaving individuals who have not had a specific psychological assessment training sequence in graduate school with little place to turn for guidance. With this in mind, the Society for Personality Assessment (2006) promulgated a set of standards for education and training in psychological assessment to provide interdisciplinary guidance for mental health professionals in any jurisdiction with licensure permitting independent practice of psychological assessment. This document arose from the Society’s concern about what it saw as an increasing number of individuals using psychological testing without proper knowledge of its complexities. The standards outline necessary courses, practicum, and supervisory experiences that can provide a basic education for adequate practice in psychological assessment. The standards also emphasize the important distinction between psychological appraisal and psychological assessment. The standards are publicly available on the Society’s website, which is listed later in the Resources section. Three other topics regarding the adequate practice of psychological assessment are important to mention. First, as stated earlier, all individuals practicing psychological assessment should take into consideration the importance of response style in interpreting psychological tests, such as underreporting, overreporting, and inconsistent or confused reporting. Without some measure of response style, it is difficult to understand the true meaning of psychological test data. Second, the importance of a multimethod assessment (e.g., Erdberg, 2007; Meyer, 1996, 1997) cannot be overemphasized because of problems inherent in using only one test or one type of tests, especially without at least one test with a measure of response style. Third, extreme caution should be used in relying solely on computer interpretive reports for interpretation of clients’ problems. The direct use of computer interpretive statements in psychological assessment reports (often referred to as “plug and chug”) is not an adequate practice. Greene (1999) reports research indicating that 15% to 20% of statements of MMPI-2 computer interpretative reports do not give an accurate interpretation of clients’ psychopathology when additional scales and client history are taken into account. This is especially true with interpretation of the MMPI-2 with psychological trauma, in that computer interpretive reports are not trauma specific. As stated earlier, common code types for trauma victims give a very different picture, depending on whether psychological trauma is taken into consideration.

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Collaborative and Therapeutic Assessment In recent years, psychological testing has been unharnessed from its informationgathering roots (Finn & Tonsager, 1997) and has become integrated into powerful therapeutic models including collaborative assessment (Fischer, 1985/1994; Handler, 2007) and TA (Finn, 2007). Collaborative and therapeutic assessment use psychological assessment to guide the clinician in developing empathic and focused treatment interventions and have been effectively used with individuals experiencing psychological trauma. Clients frequently report transformative experiences resulting from these assessmentbased approaches. Further, collaborative and therapeutic assessment increasingly has been recognized as an evidence-based treatment model. In their recent meta-analysis, Poston and Hanson (2010) found that clinically meaningful change occurs when psychological assessment procedures are combined with individualized, collaborative, and personally meaningful test feedback. In TA, assessors and clients collaborate together to explore clients’ problems in living by using individualized psychological testing to assist in answering their questions. TA begins with eliciting and assisting clients’ psychological questions about themselves and, as such, comes from the interpersonal and client-centered traditions of Harry Stack Sullivan (1954) and Carl Rogers (1961). Next, clients complete a battery of psychological tests that is individualized to the clients’ particular problems and questions. For example, if the client’s question involves the effect of a traumatic event on her current interpersonal relationships, she may be given the TSI, MMPI-2, and Rorschach with the explanation that these measures have been shown in research to assess the impact of psychological trauma. The assessor next scores and interprets the relevant tests without regard to the clients’ questions, then reviews the results again with the clients’ questions in mind. From these data, the assessor develops the assessment intervention session, perhaps the most creative element of TA. Assessment intervention sessions involve using psychological tests or other techniques to elicit experiences and enactments that can assist clients in reaching deeper emotional understanding of their assessment questions. For example, in working with a traumatized client who dissociates and whose main question is how to manage this, the assessor might show her emotionally arousing TAT cards that are likely to elicit dissociation in a controlled fashion. Then, if the plan works, the assessor can help the client to recognize the dissociation, learn how to manage it, and become regrounded (such an assessment intervention is described in Finn & Kamphuis, 2006). The assessor and the client can then step back and together discuss and analyze how the experiences in the assessment intervention are relevant to the client’s outside life. Next, in the summary/discussion session, the client and assessor collaboratively explore the psychological test findings and the light they shed on the client’s questions. Unlike feedback sessions in the information-gathering model of psychological assessment, the summary/discussion session is a highly collaborative venture, where psychological test findings are presented as hypotheses to be explored rather than truths to be pronounced. The assessor is careful to respect the client’s defenses and approaches this aspect of TA with the therapeutic skill that one would use in ongoing counseling or psychotherapy. After the summary/discussion session is completed, the assessor sends the client a letter summarizing in plain language the main points of the feedback, making sure to include the client’s modification and input regarding the assessor’s hypotheses derived from the psychological testing. Often, a follow-up session is scheduled 4 to 6 weeks later to discuss the client’s reactions to the TA and to find out if new questions have arisen. It should be noted that TA can be used as a method for short-term therapeutic intervention or as a consultation with referring mental health professionals who have come to an impasse in their treatment of their clients.

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COUNSELING IMPLICATIONS The issue of assessing survivors of trauma raises several implications for counselors. Perhaps most important is that careful assessment of psychological trauma can lead to clearer and more focused treatment interventions. Counselors are better able to assist their clients if they tailor their treatment to the problems in living that are troubling their clients. For example, focused assessment can let the counselor know if a client is struggling with intrusive experiences, upsetting her or his daily living, or if the client is emotionally shutdown and socially detached because of a preponderance of numbing and avoidant symptoms. The client might be severely dissociated and disconnected in the treatment. Each of the psychological trauma presentations calls for a different treatment approach, and careful use of assessment instruments can assist the counselor in becoming more empathically linked to the client. As Finn (2007) pointed out, psychological assessment is an empathy magnifier. Indeed, as stated earlier, therapeutic assessment uses psychological assessment as a powerful and empirically valid treatment approach in its own right. Another important implication is that more powerful assessment instruments provide more incisive information about the trauma survivor. Whereas clinical interviews are the “meat and potatoes” of counseling practice, structured interviews and face-valid PTSD scales add greater specificity in assessing the client’s dilemmas in living. More elaborate measures such as comprehensive PTSD scales and the TSI allow the counselor to see the client’s difficulties in a more complex way, whereas personality assessment measures such as the MMPI-2 and the Rorschach allow the counselor a better understanding of how the individual’s psychological trauma fits into the overall picture of the personality. As the counselor employs more powerful psychological assessment instruments, she or he has a greater responsibility to receive advanced training in these methods that perhaps were not part of the graduate training curriculum. Best Practices in Assessing Psychological Trauma was presented earlier to provide guidance for the counselor desirous of advanced practice in the psychological assessment of trauma. Finally, while Poston and Hanson’s (2010) meta-analysis found promising results regarding psychological assessment as a therapeutic intervention, more research is necessary that is specific to the value of careful psychological assessment in the treatment of psychological trauma. In particular, such research needs to demonstrate the cost-effectiveness of assessment of psychological trauma above and beyond the clinical interview and standard counseling practices.

CONCLUSION In closing, I have tried to present a brief overview of the importance and potential power of psychological assessment with victims of trauma. Apart from presenting the many useful methods of assessing psychological trauma, it is my hope that counselors reading this book will see ways in which assessment can enhance their practice by assisting in more accurate and focused ways to intervene with trauma victims. Working with the broken narrative of psychological trauma is complex and challenging, but ultimately highly rewarding, when the counselor can help trauma victims repair deeply damaged views of themselves and their relationships with others. While becoming proficient in psychological assessment may appear daunting at first, there is a large and responsive professional community to support this learning. I wish to personally extend an invitation for counselors to embrace this challenge.

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RESOURCES The following resources may be helpful to students, clinicians, and instructors. For an extensive list of relevant publications, see http://www.johnbriere.com/tsi.htm National Center for PTSD (http://www.ptsd.va.gov/) The assessment link of the National Center for PTSD is an indispensable resource for anyone interested in psychological trauma. Some instruments can be obtained for free from: http://www .ptsd.va.gov/professional/pages/assessments/list-adult-self-reports.asp Sidran Institute: Traumatic Stress Education and Advocacy (http://www.sidran.org) Society for Personality Assessment. (2006). Standards for education and training in psychological assessment (located under publications tab). Retrieved from http://www.personality.org More information about training in Therapeutic Assessment can be found at http://www.therapeutic assessment.com

REFERENCES American Counseling Association. (2003). Standards for qualifications of test users. Alexandria, VA: Author. American Educational Research Association, American Psychological Association, & National Council on Measurement in Education. (1999). The standards for educational and psychological testing. Washington, DC: Authors. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Armstrong, J. G., & Kaser-Boyd, N. (2003). Projective assessment of psychological trauma. In M. J. Hilsenroth & D. L. Segal (Eds.), Comprehensive handbook of psychological assessment. Vol. 2: Personality assessment (pp. 500–512). Hoboken, NJ: Wiley. Armstrong, J. G., & Loewenstein, R. J. (1990). Characteristics of patients with multiple personality and dissociative disorders on psychological testing. The Journal of Nervous and Mental Disease, 178 (7), 448–454. Association for Assessment in Counseling. (2003). Responsibilities of users of standardized tests (3rd ed.). Baltimore, MD: Author. Beck, A. T. (1997). Beck Anxiety Inventory manual. San Antonio, TX: Psychological Corporation. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory manual (2nd ed.). San Antonio, TX: Psychological Corporation. Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. The Journal of Nervous and Mental Disease, 174 (12), 727–735. Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8 (1), 75–90. Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD checklist (PCL). Behaviour Research and Therapy, 34 (8), 669–673. Bliese, P. D., Wright, K. M., Adler, A. B., Cabrera, O., Castrol, C. A., & Hoge, C. W. (2008). Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. Journal of Consulting and Clinical Psychology, 76(2), 272–281. Brand, B. L., Armstrong, J. G., & Loewenstein, R. J. (2006). Psychological assessment of patients with dissociative identity disorder. The Psychiatric Clinics of North America, 29 (1), 145–168. Briere, J. (1995). Trauma symptom inventory professional manual. Odessa, FL: Psychological Assessment Resources. Briere, J. (2001). Detailed assessment of posttraumatic stress (DAPS). Odessa, FL: Psychological Assessment Resources.

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Briere, J. (2004). Psychological assessment of adult posttraumatic states: Phenomenology, diagnosis, and measurement (2nd ed.). Washington, DC: American Psychological Association. Bryer, J. B., Nelson, B. A., Miller, J. B., & Krol, P. A. (1987). Childhood sexual and physical abuse as factors in adult psychiatric illness. The American Journal of Psychiatry, 144 (11), 1426–1430. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A. M., & Kaemmer, B. (1989). MMPI-2: Manual for administration and scoring. Minneapolis, MN: University of Minnesota Press. Caldwell, A. B. (2001) What do the MMPI scales fundamentally measure? Some hypotheses. Journal of Personality Assessment, 76, 1–17. Carlson, E. B. (1997). Trauma assessments: A clinician’s guide. New York, NY: Guilford Press. Chu, J. A. (1998). Rebuilding shattered lives: The responsible treatment of complex posttraumatic and dissociative disorders. New York, NY: John Wiley & Sons. Courtois, C. A., & Ford, J. D. (2009). Treating complex traumatic stress disorders: An evidence-based guide. New York, NY: Guilford Press. Dutton, M. A. (2000). Empowering and healing the battered woman. New York, NY: Springer Publishing. Elhai, J. D. Frueh, B. C., Gold, P. B., Gold, S. N., & Hamner, M. B. (2000). Clinical presentations of posttraumatic stress disorder across trauma populations: A comparison of MMPI-2 profiles of combat veterans and adult survivors of child sexual abuse. Journal of Nervous and Mental Disease, 88, 708–713. Erdberg, P. S. (2007). Multimethod assessment as a forensic standard. In C. B. Gacono & F. B. Evans (Eds.), The handbook of forensic Rorschach assessment (pp. 561–566). New York, NY: Routledge. Exner, J. (2003). The Rorschach: A comprehensive system, basic foundations (4th ed.). Hoboken, NJ: Wiley. Finn, S. E. (1994). Manual for using the MMPI-2 as a therapeutic intervention. Minneapolis, MN: University of Minnesota Press. Finn, S. E. (2007). In our clients’ shoes: Theory and techniques of therapeutic assessment. Mahwah, NJ: Lawrence Erlbaum Associates. Finn, S. E. (in press). Journeys through the valley of death: Multimethod psychological assessment and personality transformation in long-term psychotherapy. Journal of Personality Assessment. Finn, S. E., & Kamphuis, J. H. (2006). Therapeutic assessment with the MMPI-2. In J. N. Butcher (Ed.), MMPI-2: A practitioners guide (pp. 165–191). Washington, DC: American Psychological Association Books. Finn, S. E., & Tonsager, M. E. (1997). Information gathering and therapeutic models of assessment: Complementary paradigms. Psychological Assessment, 9, 374–385. Fischer, C. T. (1985/1994). Individualizing psychological assessment. Mahwah, NJ: Lawrence Erlbaum Associates. Foa, E. B. (1995). Posttraumatic Stress Diagnostic Scale (PDS) manual. Minneapolis, MN: Pearson Assessments. Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473. Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York, NY: Guilford Press. Foa, E., & Tolin, D. F. (2000). Comparison of the PTSD symptom scale-interview version and the clinician-administered PTSD scale. Journal of Traumatic Stress, 13, 181–191. Friedman, A. F., Lewak, R., Nichols, D. S., & Webb, J. T. (2001). Psychological assessment with the MMPI-2. Mahwah, NJ: Lawrence Erlbaum Associates. Frueh, B. C., Elhai, J. D., Gold, P. B., Monnier, J., Magruder, K. M., Keane, T. M., & Arana, G. W. (2003). Disability compensation seeking among veterans evaluated for posttraumatic stress disorder. Psychiatric Services, 54 (1), 84–91. Garb, H. N. (1998). Studying the clinician: Judgment research and psychological assessment. Washington, DC: American Psychological Association. George, C., & West, M. (2001). The development and preliminary validation of a new measure of adult attachment: The adult attachment projective. Attachment & Human Development, 3, 30–61. Glenn, D. M., Beckham, J. C., Sampson, W. S., Feldman, M. E., Hertzberg, M. A., & Moore, S. D. (2000). MMPI-2 profiles of Gulf and Vietnam combat veterans with chronic posttraumatic stress disorder. Journal of Clinical Psychology, 58, 371–381. Graham, J. R. (2006). MMPI-2: Assessing personality and psychopathology (4th ed.). New York, NY: Oxford University Press.

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CHAPTER 28

Models for Trauma Intervention: Integrative Approaches to Therapy LISA LOPEZ LEVERS, ELIZABETH M. VENTURA, AND DEMOND E. BLEDSOE

INTRODUCTION Many of the contributors to the corpus of theory, research, and practice literatures regarding the effects of traumatic events have indicated that the best clinical models for intervention employ an integrative therapies approach to counseling survivors of trauma (e.g., Bradshaw, Cook, McDonald, 2011; Briere, 2002; Briere & Lanktree, 2008; Briere & Scott, 2006; Finkelstein et al., 2004; Foa, Keane, Friedman, & Cohen, 2009; Lanktree & Briere, 2008; van der Kolk, McFarlane, & Weisaeth, 1996). The purpose of this chapter is to outline, briefly, some of the key integrative approaches and to identify salient implications for counselors; these discussions are followed by a chapter summary and a list of practical resources.

CLINICAL INTERVENTIONS AND INTEGRATIVE APPROACHES Psychotherapists have been helping survivors of trauma to deal with the impacts of traumatic experiences for over a century; however, the emergence of the field of traumatology and the organization of treatment practices having an emphasis on efficacy have been relatively recent events. Regarding trauma treatment, Briere and Scott (2006) have suggested the need for attachment-relational processes along with cognitive behavioral activities. They note the following: The need for both relational and cognitive-behavioral interventions in the treatment of chronic and/or complex posttraumatic disturbance is not particularly surprising, especially when real-world clinical practice is examined. Probably all good trauma therapy is cognitive-behavioral, to the extent that it involves exploration of traumatic material (exposure) in a safe relationship (disparity) wherein the client is encouraged to feel and think about what happened to him or her (emotional and cognitive activation and processing). On the other hand, most effective therapy for complex trauma effects is also relational and “psychodynamic,” involving the effects of activated attachment relationships and interpersonal processes. (Briere & Scott, 2006, p. 232) Once considered more or less anecdotal or at the periphery of therapy that is focused on seemingly more salient presenting problems, understanding and addressing the

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presence of trauma is now considered to be a critical element in the therapeutic process. Clinicians have identified the need for trauma treatment to be linked with the use of specific strategies within the mental health system (Ko et al., 2008), along with the need for more contextual perspectives of trauma (Droždek, 2007). Although therapists and clinicians working to provide trauma-sensitive services to clients with trauma histories is a progressive step in providing adequate care, attention also must be paid to the overall systems in which clients are served. Integrated approaches can provide a more systemic structure for and understanding of matters pertaining to trauma, ensuring a greater likelihood that clients do not reexperience trauma and that they return for needed services. According to the National Center for Trauma-Informed Care (NCTIC; n.d.b., para. 4), service systems that are attuned to clients’ traumatic experiences need to shift from the institutional or medical model of care that asks “What is wrong with you?” to a more relational model of care that is grounded in the question “What has happened to you?” In this section, we offer discussions regarding trauma-informed and trauma-specific care, cognitivebehavioral therapy, and observed and experiential integration, along with brief descriptions of other integrative models aimed at treating the sequelae of trauma.

Trauma-Informed and Trauma-Specific Care Trauma-informed care represents a means to address trauma throughout a system of care. Hodas (2006, p. 32) states that “trauma informed care must begin with the provision of safety, both physical and emotional.” Without the ability to feel safe in treatment, clients are unable to choose to change the way they make decisions, to be open to new ideas, and to be able to accept assistance from therapists and staff at treatment centers. Initially borne out of providing better services for children in service delivery systems, the concepts of trauma-informed care apply and are used across treatment settings. As we learn more about traumatic events across the lifespan, along with the lifelong effects of some trauma, it becomes increasingly evident that all care systems share the need and the responsibility for identifying and responding to trauma. The NCTIC (n.d.a, para. 2) has identified the following trauma-specific interventions that have been used extensively in public mental health system settings: ■ ■ ■ ■ ■ ■ ■ ■

Addiction and trauma recovery integration model (ATRIUM) Essence of being real Risking connection Sanctuary Model Seeking safety Trauma, addictions, mental health, and recovery (TAMAR) Model Trauma affect regulation: guide for education and therapy (TARGET) Trauma recovery and empowerment model (TREM and M-TREM)

Although it is beyond the scope of this chapter to present detailed information about all forms of trauma-informed care, in this section, we offer a general description of trauma-informed care and a brief discussion of one example of trauma-informed care, the Sanctuary Model.

Trauma-Informed Care As our understanding of the prevalence and significance of trauma has grown, the literature has begun to reflect, in more salient ways, the need to address the traumatized

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person in a more holistic fashion. Trauma-specific and trauma-informed practices are discussed frequently in the literature but are not always clearly delineated. For the purpose of this chapter, these terms are defined in the following ways: (a) Traumaspecific therapy refers to the actual interventions, therapies, or treatment program designed to address the particular traumatic events and the resulting concerns that have resulted from the incidents; (b) Trauma-informed models are centered on reassessing and restructuring all aspects of a treatment system to address how trauma may affect a client’s interaction with a particular part of the system (Jennings, 2004). Trauma-informed models of care are systemic by design; these approaches have considered trauma to be the primary precipitator leading many clients to seek counseling, and thus have focused on the traumatic experiences of clients. Jennings (2004) has offered the following systemic perspective: The new system will be characterized by safety from physical harm and retraumatization; an understanding of clients and their symptoms in the context of their life experiences and history, cultures, and their society; open and genuine collaboration between provider and consumer at all phases of the service delivery; an emphasis on skill building and acquisition rather than symptom management; an understanding of symptoms as attempts to cope; a view of trauma as a defining and organizing experience. (p. 15) Creating a trauma-informed system of care requires each aspect of the system to be scrutinized and changed so that it meets the needs of traumatized consumers. Training is an essential function in a trauma-informed service system. Providing adequate information about the pervasiveness of the psychological and neurobiological effects of trauma to program staff is essential if employees are expected to begin to conceptualize the range of possible responses by their clients to activating stimuli. This training is equally important for all employees. Let us consider a receptionist who has no clinical training but interacts with clients as they enter the office and wait for appointments or visits. If a client becomes agitated at what appears to be nothing or reacts to something that seems inconsequential, a receptionist typically may become angry or upset because of what may appear to be a tantrum or other inappropriate behavior. Let us reconsider this same receptionist’s ability to understand the client’s reaction after receiving adequate instruction about the effects of trauma and how to respond within a trauma-informed system of care. Organizational processes need to be adapted to reflect a more trauma-informed model of care. Policies and procedures must state that the organization follows trauma-informed practices. Hiring and selection practices need to be based not only on education and on previous work experience, but they also need to include a candidate’s knowledge and understanding of concepts and practices designed to support client wellness from a trauma-informed framework. Admission criteria, screening, and assessment directly need to reflect and address a client’s history of trauma. This constitutes a paradigm shift, which places trauma as the central issue in a client’s recovery, as opposed to the antiquated models in which trauma is viewed as a secondary concern in treatment (Hodas, 2006). The need cannot be emphasized enough for trauma-specific treatments to be delivered by trained clinicians; this is a critical factor in supporting the recovery of the clients.

The Sanctuary Model The authors of this chapter do not particularly endorse any specific model; however, we believe that it may be beneficial to explore briefly a model that has many of the

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attributes of a trauma-informed system of care, as described beforehand. The Sanctuary Model (Bloom, 2005) was developed in an inpatient hospital setting providing acute care to adult survivors of childhood trauma. Although it is understood that clients who are traumatized often may respond to stimuli or triggers that are based on their traumatic histories, the Sanctuary Model has applied the same concepts of trauma to organizations and institutions designed to work with traumatized populations as well as to employees. The Sanctuary Model explores the parallel processes that may emerge among traumatized clients, staff, and organizations in an effort to manage the traumatic symptoms across all levels by creating a shared, more democratic community (Bloom). Bloom has identified the following seven main characteristics of a Sanctuary Model program: ■ Culture of Nonviolence – helping to build safety skills and a commitment to

higher goals ■ Culture of Emotional Intelligence – helping to teach affect management skills ■ Culture of Inquiry & Social Learning – helping to build cognitive skills ■ Culture of Shared Governance – helping to create civic skills of self-control, self-

discipline, and administration of healthy authority ■ Culture of Open Communication – helping to overcoming barriers to healthy

communication, reduce acting-out, enhance self-protective and self-correcting skills, and teach healthy boundaries ■ Culture of Social Responsibility – helping to rebuild social connection skills and establish healthy attachment relationships ■ Culture of Growth and Change – helping to restore hope, meaning, and purpose (Bloom, 2005, p. 71) Programs such as the Sanctuary Model allow for organizations and staff to reestablish norms. These norms promote mutual respect and responsibility for all levels of the organizational structure, new expectations for the manner in which consumers are treated, and alternate strategies for managing negative and disruptive behaviors; having norms also provides a structure for managing program violations. Creating a new norm of tolerance and understanding minimizes the possibility of an occurrence in which negative dynamics activate events that consequently result in traumatic responses. With such a norm, the focus, then, shifts to treatment interventions as opposed to behavior management.

Cognitive Behavioral Therapy and Other Conjunctive Therapies Cognitive behavioral therapy (CBT) long has been the treatment of choice for depression- and anxiety-related symptoms (Bryant, Harvey, Dang, Sackville, & Basten, 1998; Dobson, 1989; Follette & Ruzek, 2006; Taylor, 2004). In relation to trauma, the overarching goal of CBT is to help clients understand how certain thoughts, related to the traumatic event or trauma history, can cause associated stress and exacerbate traumarelated symptoms. Through CBT, clients can learn to identify negative thoughts about the world and about themselves that often make them feel at risk or even retraumatized. Through therapy, clients learn ways to replace such automatic negative thoughts with more accurate and less distressing thoughts. A CBT approach can be used to reduce negative emotional and behavioral responses following traumatic events. The treatment is based, fundamentally, on learning and cognitive theories that address distorted beliefs and attributions related to the traumatic events experienced by an individual. Such treatment provides a supportive

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environment in which clients are encouraged to talk about their traumatic experiences. CBT also helps the individuals within a survivor’s support system, those who were not affected directly by the trauma, to cope effectively with their own emotional distress and to develop skills for supporting their loved ones. One difficult task for clients who have been traumatized is to learn to deal with the residual emotions that are left after the event. Through CBT, the therapeutic relationship seeks to help clients better manage their emotions. Through homework, clients can learn ways to practice and apply skills learned in therapy; these new skills can assist clients in dealing with feelings like anger, fear, sadness, frustration, and guilt. Meta-analyses of the literature have suggested the efficacy of CBT in combination with other therapeutic approaches, for example exposure therapy (e.g., Institute of Medicine & Committee on Treatment of Posttraumatic Stress Disorder, 2008), eye movement desensitization and reprocessing (EMDR; Seidler & Wagner, 2006), or dialectical behavior therapy (DBT). With its flexibility in and adaptability to other conditions, CBT is an integrative approach, which is used widely by many clinicians, and clearly is considered a best practice for aiding in the recovery process of traumatized clients. According to the National Center for Posttraumatic Stress Disorder (NCPTSD), CBT is the treatment of choice used for posttraumatic stress disorder (PTSD) and is used almost exclusively for veterans through the Veteran Affairs health care systems (United States Department of Veteran Affairs & Department of Defense, 2010; treating military veterans with PTSD is discussed in Chapter 25 of this book). As an integrative approach, CBT includes several specific approaches for helping clients to deal with the aftermath of traumatic events. Although specific CBT-based strategies and techniques are identified and discussed in greater detail in Chapter 29 of this book, the following parts of this section offer brief overviews of several approaches commonly used in conjunction with CBT or as part of an overall integrative approach: exposure therapy, EMDR, and DBT.

Exposure Therapy Exposure therapy aims to reduce or eliminate the fears that clients have associated with the traumatic event or have paired with their traumatic memories. Grohol (2009) provides the following characterization of exposure therapy: In PTSD, exposure therapy is intended to help the patient face and gain control of the fear and distress that was overwhelming in the trauma, and must be done very carefully in order not to re-traumatize the patient. In some cases, trauma memories or reminders can be confronted all at once (“flooding”), while for other individuals or traumas it is preferable to work gradually up to the most severe trauma by using relaxation techniques and either starting with less upsetting life stressors or by taking the trauma one piece at a time (“desensitization”). A therapist works with the client to determine which method is best suited for the particular client and their trauma. (para. 2) The underlying purpose of exposure therapy is to empower clients by using techniques that allow them to gain control of their thoughts and feelings that are related to the trauma. By repeatedly talking about the event, therapeutic interventions allow clients to regain control over their emotions and eventually to abandon the feelings of helplessness that often accompany the aftermath of traumatic events. One technique that often is used as a part of exposure therapy is “desensitization.” According to Grohol (2009), this therapeutic technique can allow clients to process certain selected memories,

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before moving on to more severe or detailed memories of the event. Conversely, exposure therapy also employs another technique that does not require gradual acquisition of control over one’s emotions. Rather, therapists may employ the technique referenced as “flooding,” whereby clients are asked to recall several memories at once, so that the learned response over time is not to feel overwhelmed. Although both techniques have been viewed as useful in aiding in the recovery process, training and supervision are required in order to practice either technique. If done without training and adequate supervision, clinicians unwittingly and unintentionally may compromise the client’s sense of safety, thereby placing the client at risk for being retraumatized.

Eye Movement Desensitization Reprocessing Developed relatively recently by Shapiro (1990) and Shapiro and Forest (1997), EMDR is a method of psychotherapy that has shown promise in treating PTSD. Although EMDR has a cognition-focused dimension, it also focuses on bodily sensations and eye movement (Shapiro, 1990; Spates, Koch, Cusack, Pagoto, & Waller, 2009). Similar to the other interventions discussed in this section, EMDR helps to reshape how a client views a traumatic event. In short, the dynamics surrounding EMDR involve thinking of or talking about memories, concurrently focusing on other stimuli like eye movements, hand taps, and sounds. EMDR techniques involve the therapist guiding the client in vividly, but safely, recalling distressing past experiences (desensitization) and gaining new understandings (reprocessing) of the events, the bodily and emotional feelings, and the thoughts and self-images associated with them (Shapiro & Forrest, 1997; 2001). The “eye movement” aspect of EMDR involves the client moving his or her eyes in a back-and-forth (saccadic) manner, while recalling the event(s). Because of the relatively new literature (Shapiro, 2011) that exists on this topic, many researchers still are exploring the mechanisms and efficacy of EMDR. Initial observations by Shapiro and Forrest (1997) have revealed a reduction in PTSD symptoms by clients who have undergone the treatment; recent research supports Shapiro’s earlier investigations, and a metaanalysis of the relevant literature has indicated that EMDR and CBT are equally efficacious (Seidler & Wagner, 2006). EMDR has been shown to be effective with children and adults alike who have suffered from various traumatic experiences (the use of EMDR is further discussed in Chapter 10 of this book).

Dialectical Behavior Therapy With the integration of DBT as a treatment option for trauma survivors, clinicians are able to use a multifaceted approach toward helping to empower individuals, via the client’s own skill-building efforts and engagement in the therapeutic relationship. This integrative approach is ideal for targeting the complexities of trauma; the literature supports the promotion of DBT as a best-practice approach for trauma recovery and as an essential tool for counselors working within the field of trauma. DBT includes components of CBT; however, the emphasis in DBT is on the acceptance and validation of behaviors, as they exist in the “here and now.” The foundational aspects of DBT lie in the integration of Eastern Mindfulness practices, CBT, and Rogerian constructs (acceptance and validation, as they exist, in the moment). Therefore, for trauma survivors, behaviors are addressed as they exist in the present, and very little is relived or reexperienced as part of the past. For example, individuals who have suffered childhood abuse (sexual, physical, or emotional) often use maladaptive means to cope as adults. This can lead to self-injurious behaviors such as cutting, substance abuse,

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eating disorders, impulsivity, and other para-suicidal behaviors. Although many may view these behaviors as a defense mechanism or as a means for coping with traumatic revivification, others may view these behaviors as indicative of Axis II conditions, like borderline personality disorder (BPD). The implications for misdiagnosing a traumarelated response as something like BPD can be detrimental to a client and actually can lead to mistreatment. The overarching goal of DBT is to increase skills that are aimed at dealing with emotion regulation difficulty in clients who have suffered traumatic experiences. The skills taught through DBT target the maladaptive behaviors that are used to relieve the pain temporarily and that are caused by traumatic triggers in the environment. Four skill sets are taught in DBT: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness (Linehan, 1993). Through these skill sets, clients can feel empowered to take control over their lives once again and to manage their emotions in more self-affirming ways. The techniques associated with and the advantages of using this integrative approach are discussed in more depth in Chapter 29.

Observed and Experiential Integration A newly articulated integrative model, originated by Audrey Cook (Bradshaw et al., 2011), has emerged from Canada. The observed and experiential integration (OEI) model incorporates present-focused experiential therapies with neurobiological, cognitive, affective, recall, enactment, and educational kinesiology therapies, among others. The model has some parallels with EMDR but differs in technical and procedural ways. A major aim of OEI is to bring the clients’ traumatic issues to the surface, while restoring their ability to function and assisting them to regain a sense of control. The OEI model has been based on extensive research (Bradshaw et al.) and tens of thousands of hours of clinical observation. In addition to its success in treating PTSD, OEI also has been used successfully in resolving other anxiety-based disorders and addictions. Although the details of the model are far too technical to unpack in this chapter, it seems that OEI may be promising as an effective practice in resolving the sequelae of traumatic experiences.

Other Integrative Modalities Additional integrative approaches exist but are too numerous for exhaustive inclusion here. However, several of these integrative modalities deserve mention and include crisis- and disaster-focused models, substance abuse-focused models, Herman’s recoveryfocused model, and Briere’s self-trauma model. Brief descriptions are offered in the following text.

Crisis- and Disaster-Focused Models Yeager and Roberts (2003) have asserted the importance of clinicians being able to differentiate among the important constructs of stress, acute stress disorder, crisis episodes, trauma, and PTSD (the intersections of these constructs have been discussed in Chapters 1 and 19 of this book). Several models of crisis and disaster intervention offer an integrative approach. For example, critical incident stress management (CISM is discussed in Chapter 22 of this book) is a comprehensive, integrative, multicomponent crisis intervention system (Mitchell & Everly, 1996). Roberts’ (2002) assessment, crisis intervention, and trauma treatment (ACT) model, detailed in Chapter 1, offers an integrative intervention approach aimed at brief treatment and crisis intervention.

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Substance Abuse-Focused Models The relationship between interpersonal violence and substance abuse, especially as this affects women, has been well documented over the past decade (e.g., Campbell, 2002; Felitti, 2002; Liebschutz et al., 2002; Stuart, Moore, Ramsey, & Kahler, 2003). According to Finkelstein et al. (2004), “The prevalence of physical and sexual abuse among women in substance abuse treatment programs is estimated to range from 30% to more than 90%, depending on the definition of abuse and the specific target population” (p. 1). Extrapolating from the Substance Abuse and Mental Health Administration’s (SAMHSA) Women with Co-occurring Disorders and Violence Study (WCDVS), which used four trauma-specific integrative models for substance abuse clients who also had trauma histories or exhibited PTSD symptoms, Finkelstein et al. reported on these four and one additional model. The models are described briefly below: 1. The ATRIUM (Miller & Guidry, 2001), offers a 12-week curriculum and is bioecological in nature, addressing the impact of trauma across physical, mental, and spiritual dimensions. 2. The Helping Women Recover (HWR; Covington, 2000) program provides a 17-session curriculum that addresses issues of self, relationships, sexuality, and spirituality. 3. Seeking safety (Najavits, 2002) is a present-focused approach, intended to facilitate safety and recovery, and has been used in a wide variety of settings. 4. The TREM (Harris, Anglin, & the Community Connections Trauma Work Group, 1998) consists of multiple group interventions with traumatized women experiencing either substance abuse or other mental health problems and focuses on empowerment, trauma issues, and skill building. In addition to being integrative approaches, commonalities across these models include a focus on safety, the use of traumasensitive services, and an orientation toward trauma-informed care. 5. The Triad women’s trauma model engages a four-phase, CBT-oriented group format. The Triad perspective is that complex disorders can arise from unaddressed trauma, and the primary treatment goal is to reduce trauma-related symptoms.

Herman’s Recovery-Focused Model Recovery-focused models of mental health therapy emphasize the client’s potential for recovery or healing. Herman (1992/1997) has articulated an integrative recovery process aimed at helping survivors of trauma to heal from the negative consequences of their experiences. Herman’s recovery model addresses what she has identified as the core experiences of trauma (Herman’s theory is discussed more fully in Chapter 1 of this book) and employs the following three stages: establishing safety, reconstructing the trauma story, and reconnecting with ordinary life. Various compatible therapeutic approaches are incorporated to accomplish the recovery or healing process.

Briere’s Self-Trauma Model Briere (1996, 1997, 2002) has developed an integrative model of treatment, the selftrauma model, which is based on trauma theory and uses CBT and self psychology. This model relies upon a combination of psychoeducation, stress reduction, affect regulation training, cognitive interventions, emotional processing, improving identity problems, and facilitating relational functioning (Briere & Scott, 2006). The selftrauma model has been used with adults and is especially effective with adult clients

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who have experienced childhood trauma (the issue of adult survivors is discussed in Chapter 10 of this book). The efficacy of the self-trauma model also has been demonstrated with children (Lanktree & Briere, 2008) and with adolescents (Briere & Lanktree, 2008).

COUNSELING IMPLICATIONS The major implication drawn from the aforementioned discussions regards the contemporary clinical view that integrative approaches to trauma treatment represent the gold standard. As clinicians continue to work with trauma survivors, better understand the phenomenology of trauma, and become acutely more aware of issues of complex trauma, the need for multimodal and integrative therapies is more obvious. The very nature of traumatic events and their core experiences affect victims on multiple personal and systemic levels. The process of recovering and healing from trauma then necessitates therapeutic interventions that are capable of addressing the victim’s responses, simultaneously, on physical, cognitive, affective, and spiritual or existential levels. By considering the array of integrative approaches to trauma therapy and learning to use them efficaciously, we are better positioned to help the survivors of trauma who seek counseling from us.

CONCLUSION This chapter has articulated the clinical relevance of integrative approaches to trauma. We have discussed several integrative interventions, including trauma-informed care, trauma-sensitive services, CBT, exposure therapy, EMDR, DBT, and OEI. Additionally, we have examined several other integrative models, including crisis- and disasterfocused models, substance abuse-focused models, Herman’s recovery-focused model, and Briere’s self-trauma model. The major implication of this chapter is the agreement across clinical fields that integrative interventions constitute a best-practice approach to counseling survivors of trauma.

RESOURCES Briere, J., & Lanktree, C. (2008). Integrative treatment of complex trauma for adolescents (ITCT-A): A guide for the treatment of multiply-traumatized youth. MCAVIC-USC, Child and Adolescent Trauma Program, National Child Traumatic Stress Network. Retrieved from http://www.johnbriere.com/ Adol%20Trauma%20Tx%20Manual%20-%20Final%208_25_08.pdf Jennings, A. (2008). Models for developing trauma-informed behavioral health systems and traumaspecific services: 2008 update. Prepared for the Center for Mental Health Services (CMHS) and the National Center for Trauma Informed Care (NCTIC), funded by Substance abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Retrieved from http://www.annafoundation.org/Models%20for%20 Developing%20Traums-Report%201-09-09%20_FINAL_.pdf Lanktree, C., & Briere, J. (2008). Integrative treatment of complex trauma for children (ITCT-C): A guide for the treatment of multiply-traumatized children aged eight to twelve years. MCAVIC-USC, Child and Adolescent Trauma Program, National Child Traumatic Stress. Retrieved from http://www. johnbriere.com/Child%20Trauma%20Tx%20Manual%20%28LC%20PDF%29.pdf

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REFERENCES Bloom, S. L. (2005). The sanctuary model of organizational change for children’s residential treatment. The International Journal for Therapeutic and Supportive Organizations, 26(1), 65–81. Bradshaw, R. A., Cook, A., McDonald, M. J. (2011). Observed & experiential integration (OEI): Discovery and development of a new set of trauma therapy techniques. Journal of Psychotherapy Integration, 21(2), 104–171. Briere, J. (1996). A self-trauma model for treating adult survivors of severe child abuse. In J. Briere, L. Berliner, J. A. Bulkley, C. Jenny, & T. Reid (Eds.), The APSAC handbook on child maltreatment (pp. 140–158). Thousand Oaks, CA: Sage. Briere, J. (1997). An integrated approach to treating adults abused as children with specific reference to self-reported recovered memories. In J. D. Read & D. S. Lindsay (Eds.), Recollections of trauma: Scientific evidence and clinical practice (pp. 25–48). New York, NY: Plenum Press. Briere, J. (2002). Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model. In J. E. B. Myers, L. Berliner, J. Briere, C. T. Hendrix, T. Reid, & C. Jenny (Eds.), The APSAC handbook on child maltreatment (2nd ed., pp. 175–202). Newbury Park, CA: Sage Publications. Briere, J., & Lanktree, C. (2008). Integrative treatment of complex trauma for adolescents (ITCT-A): A guide for the treatment of multiply-traumatized youth. MCAVIC-USC, Child and Adolescent Trauma Program, National Child Traumatic Stress Network. Retrieved from http://www.johnbriere.com/Adol%20 Trauma%20Tx%20Manual%20-%20Final%208_25_08.pdf Briere, J. N., & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage. Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, T., & Basten, C. (1998). Treatment of acute stress disorder: A comparison of cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 66, 862–866. Campbell, J. C. (2002). Violence against women II: Health consequences of intimate partner violence. Lancet, 359 (9314), 1331–1336. Covington, S. S. (2000). Helping women recover: A comprehensive integrated treatment model. Alcoholism Treatment Quarterly, 18 (3), 99–111. Dobson, K. S. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 57(3), 414–419. Droždek, B. (2007). The rebirth of contextual thinking in psychotraumatology. In B. Droždek & J. P. Wilson (Eds.), Voices of trauma: Treating psychological trauma across cultures (pp. 1–26). New York, NY: Springer Publishing. Felitti, V. J. (2002). The relationship of adverse childhood experiences to adult health: Turning gold into lead. Retrieved from http://www.acestudy.org/files/Gold_into_Lead-_Germany1-02_c_Graphs.pdf Finkelstein, N., VandeMark, N., Fallot, R., Brown, V., Cadiz, S., & Heckman, J. (2004). Enhancing substance abuse recovery through integrated trauma treatment. Sarasota, FL: National Trauma Consortium. Retrieved from http://www.nationaltraumaconsortium.org/documents/IntegratedTrauma.pdf Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.). (2009). Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies (2nd ed.). New York, NY: Guilford Press. Follette, V. M., & Ruzek, J. I. (Eds.). (2006). Cognitive-behavioral therapies for trauma (2nd ed.). New York, NY: Guilford Press. Grohol, J. M. (2009). What is exposure therapy? Retrieved from http://psychcentral.com/lib/2009/whatis-exposure-therapy/ Harris, M., Anglin, J., & Community Connections Trauma Work Group. (1998). Trauma recovery and empowerment: A clinician’s guide for working with women in groups. New York, NY: The Free Press. Herman, J. L. (1992/1997). Trauma and recovery. New York, NY: Basic Books. Hodas, G. R. (2006, February). Responding to childhood trauma: The promise and practice of trauma informed care. Pennsylvania Office of Mental Health and Substance Abuse Services, Harrisburg. Institute of Medicine, & Committee on Treatment of Posttraumatic Stress Disorder. (2008). Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.

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Jennings, A. (2004). Models for developing trauma-informed behavioral health systems and trauma-specific services. Retrieved from http://www.theannainstitute.org/MDT.pdf Ko, S. J., Ford, J. D., Kassam-Adams, N., Berkowitz, S. J., Wilson, C., Wong, M., ... Layne, C. (2008). Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice. Professional Psychology: Research and Practice, 39 (4), 396–404. Lanktree, C., & Briere, J. (2008). Integrative treatment of complex trauma for children (ITCT-C): A guide for the treatment of multiply-traumatized children aged eight to twelve years. MCAVIC-USC, Child and Adolescent Trauma Program, National Child Traumatic Stress. Retrieved from http://www.john briere.com/Child%20Trauma%20Tx%20Manual%20%28LC%20PDF%29.pdf Liebschutz, J., Savetsky, J. B., Saitz, R., Horton, N. J., Lloyd-Travaglini, C., & Samet, J. H. (2002). The relationship between sexual and physical abuse and substance abuse consequences. Journal of Substance Abuse Treatment, 22(3), 121–128. Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Miller, D., & Guidry, L. (2001). Addiction and trauma recovery: Healing the body, mind and spirit. New York, NY: W. W. Norton. Mitchell, J., & Everly, G. S. (1996). Critical incident stress debriefing: An operations manual for the prevention of stress among emergency service and disaster workers. Ellicott City, MD: Chevron Publishing. Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press. National Center for Trauma-Informed Care. (n.d.a). Trauma-informed care and trauma services. Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved from http://www. samhsa.gov/nctic/trauma.asp National Center for Trauma-Informed Care. (n.d.b). Welcome to the National Center for Trauma-Informed Care. Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved from http://www.samhsa.gov/nctic/ Roberts, A. R. (2002). Assessment, crisis intervention, and trauma treatment: The integrative ACT intervention model. Brief Treatment and Crisis Intervention, 2(1), 1–21. Seidler, G. H., & Wagner, F. E. (2006). Comparing the efficacy of EMDR and trauma-focused cognitivebehavioral therapy in the treatment of PTSD: A meta-analytic study. Psychological Medicine, 36(11), 1515–1522. Shapiro, F. (1990). Eye movement desensitization and reprocessing procedure: From EMD to EMDR a new treatment model for anxiety and related trauma. Behavior Therapist, 14, 133–135. Shapiro, F. (2011). EMDR Institute, Inc. Retrieved from http://www.emdr.com Shapiro, F., & Forrest, M. S. (1997). EMDR: The breakthrough therapy for overcoming anxiety, stress, and trauma. New York, NY: Basic Books. Spates, C. R., Koch, E., Cusack, K., Pagoto, S., & Waller, S. (2009). Eye movement desensitization and reprocessing. In E. B. Foa, T. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies (2nd ed., pp. 279– 305). New York, NY: Guilford Press. Stuart, G. L., Moore, T. M., Ramsey, S. E., & Kahler, C. W. (2003). Relationship aggression and substance use among women court-referred to domestic violence intervention programs. Addictive Behaviors, 28 (9), 1603–1610. Taylor, S. (2004). Advances in the treatment of posttraumatic stress disorder: Cognitive-behavioral perspectives. New York, NY: Springer Publishing. United States Department of Veterans Affairs, & Department of Defense. (2010). VA/DoD Clinical practice guideline for management of post-traumatic stress. Retrieved from http://www. healthquality.va.gov/PTSD-FULL-2010c.pdf van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (Eds.). (1996). Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York, NY: Guilford Press. Yeager, K. R., & Roberts, A. R. (2003). Differentiating among stress, acute stress disorder, crisis episodes, trauma, and PTSD: Paradigm and treatment goals. Brief Treatment and Crisis Intervention, 3 (1), 3–25.

CHAPTER 29

Strategies and Techniques for Counseling Survivors of Trauma ELIZABETH M. VENTURA

INTRODUCTION Trauma is a difficult and complex construct to understand, and treating it can be even more daunting for counselors who do not have extensive training in treating or conceptualizing trauma. According to Pearlman and Saakvitne (1995), [w]orking as a trauma therapist is subversive work; we name and address society’s shame. There are and will continue to be forces within society that work to silence this work and the clients. When we do not recognize the social and political context for our work, we unwittingly participate in this return to silence, denial, and neglect. (p. 2) Throughout this book, authors have explored a number of perspectives and definitions for conceptualizing trauma. Although the various definitions chosen to highlight the construct of trauma may be worded differently, the premise is basically the same. Traumatic events, although subjectively experienced, emotionally change people; their reactions to daily life are altered. What once seemed to be a safe world abruptly seems unsafe; the person who once was considered trustworthy suddenly seems deceitful. After a traumatic event, the world looks quite different, and many victims seek therapy to make sense of this new world and to find assistance from someone able to navigate this new territory. Within the therapeutic relationship, counselors can provide several intentional interventions that are trauma sensitive and foster safety within the client– counselor relationship. The purpose of this chapter is to explore best-practice treatment interventions when dealing with trauma. To meet this aim, relevant issues are discussed in the following sections: The Treatment of Trauma, Selected Best-Practice Treatment Approaches, and Counseling Implications. These sections are followed by a summary of the chapter and a list of helpful resources for students, clinicians, and instructors.

THE TREATMENT OF TRAUMA Similar to what was stated earlier regarding the various definitions associated with trauma theory, theoretical counseling orientations use different language and interventions to explain certain behaviors and thoughts, but ultimately the premise behind these theories remains quite consistent. In order for clients to change, they first must

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want to change and, second, they must feel safe in doing so. Thus, important aspects of the treatment of trauma center primarily on the therapeutic relationship between the client and counselor. Although approaches may vary, dependent on the theoretical orientation of the treating counselor, the literature suggests that some form of help is beneficial when treating trauma (Ledray, 1986; McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). McCann and Pearlman (1990) offer the following four goals for traumatized clients in therapy: 1. The individual will be able to explore the meanings of the traumatic event at will, experiencing emotions that are appropriate to the situation without being overwhelmed. 2. The self that has been damaged or disrupted as a result of trauma will be restored over the course of posttrauma therapy. 3. Overgeneralized negative schemata will become less rigid and maladaptive, and more positive schemata will emerge. 4. As the individual works through the traumatic material, there will be an appropriate balance between approach and avoidance and between assimilation and accommodation. (p. 99) McCann and Pearlman’s (1990) goals may seem a bit systematic and formal, but they imply the importance of the client establishing relationship and being connected. Herman (1992/1997) has outlined what is perhaps a more fluid understanding of the importance of the therapeutic relationship in the treatment of trauma. Because the client enters treatment with a severe impairment in the ability to trust, “. . . both therapist and patient should be prepared for repeated testing, disruption and rebuilding of the therapeutic relationship. As the patient becomes involved, she re-experiences the longing for rescue that she felt at the time of the trauma” (Herman, 1992/1997, p. 148). Herman (1992/1997) reiterates that trauma is the affliction of the powerless and that it is the quality of the client/counselor relationship that can help to move the trauma victim toward empowerment. Safety and trust are essential in establishing the therapeutic relationship. The process of reestablishing a sense of safety and trust while building the therapeutic relationship is the therapy for trauma survivors (Kahn, 1991; Pearlman & Saakvitne, 1995). Therapists are required to have the confidence that they are “good enough” and to be grounded in a theoretical orientation that recognizes that the therapeutic relationship is the work of the therapy. Good trauma-related therapy is first and foremost good theorybased therapy. Upon considering the various techniques for treating trauma, some consistent treatment themes emerge. The discussions in this chapter highlight such clinical issues as the quality of the therapeutic relationship, facilitation of the client’s positive thinking, promotion of the client’s positive self-affirmations, safety, trust, and validation within the counseling relationship (Covington, 2003a; Dalenberg, 2000; Najavits, 2002). Likewise, some of the clinical challenges that arise for the client during the therapeutic process are highlighted, such as unhealthy coping mechanisms, comorbidity with substance abuse, and relapse. These various clinical dynamics are discussed in the following parts of this section: Present- and Past-Focused Approaches, Therapeutic Alliance, and Trauma and Addiction.

Present- and Past-Focused Approaches Overall, trauma treatment can be divided into two distinct categories: present-focused trauma care and past-focused approaches. These two paradigms use significantly different means for treating clients. Present-focused approaches are designed to teach clients

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to build skills, correct distorted thinking, and instill hope (Covington, 2003a). These present-focused approaches do not attempt to recreate the past nor do they attempt to have victims relive their experiences in real-time sessions. Examples of present-focused approaches are anxiety management therapy and stress inoculation therapy (Najavits, 2006). Examples of past-focused approaches include exposure therapy and psychodynamic recall therapies. According to Najavits (2006), “Research indicates, overall, that both present- and past-focused models are effective, neither outperforms the other, both outperform treatment-as-usual, and the combination of both models does not outperform either one alone” (pp. 248–249).

Therapeutic Alliance The cornerstone for therapeutic success lies in the working alliance between the counselor and the client. The therapeutic milieu needs to be intentional, in that it respects the space of the traumatized client and fosters genuine safety in the client’s presence. The milieu needs to echo safety, trust, attachment, communication, and empathy. According to Pearlman and Saakvitne (1995), trauma survivors in therapy typically are acutely attuned to the therapist’s most subtle signs of “inattention, abandonment, or betrayal in their therapist’s demeanor; they will also be influenced by her communication of compassion and respect” (p. 16). Because of the acuteness of the client’s awareness, the level of counselor self-awareness needs to be as acute. This often is particularly critical when therapists are charged with piecing together the many contributing factors that clients bring into a session. It is not unusual for a traumatized client to present with a problem that is associated with a contributing factor, rather than with the trauma itself. A prime example of this occurs when traumatized clients encounter addiction, and consequently seek services for the presenting substance use disorder, only to find out that the underlying condition is trauma related. Although issues concerning addictions and trauma are more fully covered in Chapter 13 of this book, because some type of addiction or other compulsive behavior so frequently accompanies trauma, a brief treatment-related discussion is warranted here.

Trauma and Addiction Trauma and substance use disorders are so closely intertwined that the standard of care for working with these clients is composed of an integrated approach. In fact, researchers and clinicians consistently have recommended an integrated approach to treating substance use disorders and trauma as “more likely to succeed, more effective, and more sensitive to clients’ needs” (Najavits, Weiss, & Shaw, 1997, p. 279). According to a study conducted by Covington and Kohen (1984) that compared alcoholic and nonalcoholic women, 74% of the alcoholic women had experienced sexual abuse, 52% had reported physical abuse, and 72% had reported emotional abuse. Furthermore, statistics have revealed that upward of 75% of women in substance abuse treatment programs have a history of physical and/or sexual abuse. Because of the comorbidity of mental disorders and substance use disorders with trauma, an integrated treatment approach is suggested as a way to acknowledge both problems as primary at once (integrated treatment approaches are more fully discussed in Chapter 28). Clients who enter treatment presenting with substance use disorders cannot ignore the in herent triggers related to their traumatic events, ultimately causing numerous relapses. Conversely, treating the trauma as primary and avoiding client substance use can prevent the trauma work from being successful, as it is numbed by the addiction. An integrated approach, as proposed by Covington (2003b), attempts to acknowledge

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the connection between substance abuse and traumatic events. Two issues that are germane to trauma and addiction, that is, gender and unhealthy coping mechanisms, are discussed briefly in the following texts.

Gender The occurrence of traumatic events does not discriminate according to gender, but the symptoms and treatment needs of men and women may differ. Especially among children, survivors may require gender-sensitive therapy. Males typically manifest their traumatic experiences outwardly through anger, whereas females tend to be more withdrawn or self-deprecating. Although the outward expression of traumatic symptoms and treatment needs may be distinct in males and females, basic treatment-dynamic considerations may be similar, including the quality of the therapeutic alliance, sensitivity to trust issues, validation, and so forth. In addition, societal gender stereotypes may have an effect on how clients respond to treatment options.

Unhealthy Coping Mechanisms Although various treatment modalities purport to be effective in treating trauma with intentional interventions and distinct therapeutic traits, Bloom (1999) suggests a more simplistic approach to understanding effective trauma care. We know that people can learn to be helpless too, that if a person is subjected to a sufficient number of experiences teaching him or her that nothing they do will affect the outcome, people give up trying. This means that interventions designed to help people overcome traumatizing experiences must focus on mastery and empowerment while avoiding further experiences of helplessness. (p. 4) Trauma victims may have learned unhealthy coping mechanisms to deal with the triggers that infiltrate their daily lives. Many women who have suffered from traumatic events, for example, may turn to self-injury to relieve the pain of reexperiencing the trauma. If these clients come to treatment and are shamed for using these maladaptive coping mechanisms, yet are not offered healthier alternatives, the relationship fails. Bloom (1999) suggests that trauma treatment should offer opportunities for teaching new ways of adapting to the pain that can occur in everyday living. Although not specific to the treatment of trauma but easily adapted to the client issue, Linehan (1993a) offers various alternatives to dealing with maladaptive behaviors that the trauma victim can use to self-soothe the pain. Through the treatment model of Dialectical Behavior Therapy (DBT), clients learn various skills to regulate and manage the emotional distress that can occur in everyday life from emotional triggers. DBT serves to increase the skills that deal with difficulties in emotion regulation. One of the major goals of using DBT with trauma-related cases is to help clients avoid the reprocessing of traumatic experiences until they have the skills to regulate their emotions. Similar to Bloom’s (1999) notion of learned helplessness, Linehan (1993a) illustrates how trauma victims have learned emotional responses. One of the major goals of using DBT for trauma-related cases is to help clients break the associations between cues in the environment and these learned emotional responses. Ultimately, this aspect of the treatment centers on challenging and changing thinking patterns that have been maladaptive and distorted for the client. At this point in the treatment, clients may begin to feel safe and open to learning healthier coping mechanisms, and they can begin to reduce the need for their learned maladaptive behavioral patterns.

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SELECTED BEST-PRACTICE TREATMENT APPROACHES As with so many issues associated with trauma counseling, intervention choices abound with complexity. Various interventions have been proven efficacious in working with trauma victims; however, for the purpose of this chapter, only certain interventions have been selected for emphasis here. Several treatment interventions are arguably more intentional in nature than others. This section highlights the treatment approaches that have been shown most effectively to reduce posttraumatic stress disorder (PTSD) and other trauma-related symptoms. Although cognitive behavioral therapy (CBT) is one method of counseling that is arguably the most effective for reducing trauma-related symptoms, it is not the only technique option for therapists to have in their counseling toolboxes. In this section, the following treatment modalities are explored: CBTs, group psychotherapy, DBT, eye movement and desensitization reprocessing (EMDR), and expressive arts therapy (AIT).

Cognitive Behavioral Therapies The utility of CBT in counseling survivors of trauma cannot by overemphasized. Techniques associated with CBT have been enumerated in a number of other chapters in this book, in association with specific types of traumatic events. The implications of CBT that are specific to this chapter speak directly to the usefulness of CBT in effectively reducing trauma-related symptoms. To quickly review, therapists who employ CBT-related techniques target the thoughts that clients have regarding the traumatic event along with the effects of the trauma on everyday living following the event. The goal of the therapist is to help the client realize that the thoughts, which often are automatic, trigger behaviors that can feel threatening or re-traumatizing. Negative automatic thoughts can become repetitious and can often result in exacerbating trauma-related symptoms to the point wherein clients are not able to cope with everyday living experiences. Through the use of CBT-related techniques, therapists can help clients address and label these detrimental automatic thoughts and begin to process the associated feelings that are attached to these thoughts. With consistent work, these thoughts begin to be replaced by thoughts that are less threatening, and thus, the client begins to feel safe. Retraining the thought process away from the once-defeating automatic thoughts helps clients to feel empowered and less victimized. Cognitive techniques are often delivered through individual sessions; however, effective CBT can be conducted in a group format or with the help and support of family.

Group Psychotherapy Group psychotherapy can be an instrumental technique in counseling survivors of trauma. Irving Yalom (1995) cites the following curative factors associated with group treatments that are specifically related to working with traumatized clients in a group setting: ■ Instillation of hope—faith that treatment can and will be effective. ■ Universality—demonstration that we are not alone in our misery or our “problems.” ■ Altruism—opportunity to rise out of oneself and help somebody else; the feeling

of usefulness. ■ Development of socializing techniques—the development of interpersonal skills. ■ Imitative behavior—taking on the manner of group members who function

more adequately.

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■ Catharsis—opportunity for expression of strong affect. ■ Direct advice—receiving and giving suggestions for strategies for handling

problems. ■ Interpersonal learning—receiving feedback from others and experimenting

with new ways of relating. The implications of Yalom’s (1995) curative factors related to trauma survivors are significant. Given the commonalities that exist among survivors, the ability to share with one another and experience these curative factors can be a profound part of the healing process. Clients have the chance to feel connected to someone that has “been there” and can even feel empowered by helping someone else to recover. According to Cohen (2006), group members achieve greater understanding and resolution of traumatic themes; they often feel more confident and able to trust. Furthermore, Cohen acknowledges that members collaboratively work through feelings related to safety, shame, guilt, rage, fear, doubt, and self-condemnation, suggesting that they have prepared themselves to focus on the present rather than the past. A feeling that often is evoked in group work is the sense of relief that comes from being able to tell one’s story to others who have similar experiences. This “trauma narrative” can be extremely cathartic, as it generally does not open one up to feel vulnerable and overexposed, because the audience often can relate directly to the experiences of the story teller. Overall, the therapeutic tool of group cohesiveness—that is, the connectedness that individuals feel within a group, often resulting in trust and confidence—is healing for many trauma survivors and enables clients to live again in the present and not remain stuck in the past, chained by fear. As is true with other therapeutic interventions, a group intervention is not a onesize-fits-all way of dealing with something as complex as trauma. For individuals who are so overwhelmed with shame and guilt that they may inflict harm on themselves, exposing these truths in a group setting can seem unbearable. Self-injury is a symptom that many individuals experience following traumatic experiences, especially in the case of sexual abuse (Pearlman & Saakvitne, 1995). Therefore, given the prevalence of self-injury that results from traumatic experiences, it is no wonder that DBT has been recently introduced as a treatment of choice for individuals suffering from traumarelated symptoms, especially self-injury.

Dialectical Behavioral Therapy DBT certainly falls under the umbrella of cognitive therapies because DBT is an eclectic combination of cognitive behavioral practices, Zen principles, and acceptance (Linehan, 1995). The term “dialectics” really refers to opposites. Briefly, one of the major tenets of this treatment modality is accepting the person (client) for whom he or she is, in the moment, and at the same time, asking him or her to change a defeating behavior (Linehan, 1995). Although originally formulated to treat borderline personality disorder (BPD), DBT has shown its efficacy across multiple populations and conditions, including that of trauma. Given the labile emotions that clients suffering from BPD often experience and the self-injurious behaviors that often result, the implications for trauma survivors becomes clear. However, the major aspect of Linehan’s (1995) intervention that is of most utility for traumatized clients rests in the Eastern philosophical concept of mindfulness. Mindfulness is a skill that has been used for centuries to help individuals become centered and aware of the present. Mindfulness skills are “here-and-now” focused, allowing individuals to concentrate on the present moment, often alleviating

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distractions, urges, or anxiety-provoking thoughts that cause distress. Mindfulness skills allow us to be less reactive to what is happening in the moment. It is a way of relating to all experiences—positive, negative, and neutral—such that overall suffering is reduced and a sense of well-being increases (Germer, 2009). The actual practice of mindfulness is difficult for most to achieve. Because of the many distractions that people encounter on a daily basis, to remain present focused is a skill that needs to be practiced and refined. For clients who have suffered a trauma, this can be even more difficult to do. According to Linehan (1993a), this task generally requires an individual to possess the awareness to take a step back from the situation and separate the negative emotions that may be triggered by stimuli in the environment. Linehan (1993) states that “The focus on experiencing the moment is based on both eastern psychological approaches and Western notions of nonreinforced exposure as a method of extinguishing automatic avoidance and fear responses” (p. 145). The focus on “experiencing the moment” is based on the notion that automatic avoidance of certain events that trigger fear or traumatic reexperiencing will be extinguished. When working with traumatized clients, the focus is on allowing them to live in the moment, realizing that the past provokes fear and the future provokes anxiety. This focus on the present, through mindfulness exercises, can help the client to feel safe and aware that there may be no real imminent threat present. Linehan (1993a) has identified “what” and “how” skills of mindfulness that are useful in helping clients remain in the present. The first is the mindfulness “what” skill that includes learning to describe, observe, and participate in the world with awareness and not judgment. According to Linehan, clients need to be able to observe events, emotions, and other behavioral responses, even if they are distressing. This teaches clients to experience the event with awareness as opposed to terminating the emotion or leaving the event, because either is too painful. By teaching clients to experience an emotion, they learn to cope with the associated behavioral reactions of the emotion. Continued exposure to distressing emotions, coupled with healthy coping mechanisms, allows for clients to increase their level of functioning. This is not to say that counselors should teach clients to minimize fear in situations where fear is necessary. For example, if a client is working with a client who was assaulted in a dark alley, the counselor would not encourage this client to remain in the dark alley to help extinguish the emotion of fear. In this case, fear is justified. However, if the client is in an otherwise safe environment, in which fear is not justified, and begins to feel a negative emotion, this would be an opportunity for the client to practice mindfulness skills. Linehan (1993b) explicates the second type of “what” skill, which is that of description, in the following way: The ability to apply verbal labels to behavioral and environmental events is essential for both communication and self-control. Learning to describe requires that the individual learn not to take her emotions and thoughts literally—that is, as literal reflections of environmental events. (p. 145) For example, feeling afraid does not necessarily mean that a person’s life is in danger, so in practicing the mindful skill of describing, clients can learn to describe, without judgment, their fears or thoughts so that these emotions can be processed with support. The third type of “what” skill is that of participation. Clients learn to participate fully in the moment and appreciate the event, for what it is, without judgment. Clients who have a history of trauma often find themselves unable to participate in activities seamlessly. All too many times, the traumatic memories are pervasive and cause any

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otherwise enjoyable activity to become daunting. This skill helps to teach clients to interact smoothly with the environment, without separating themselves from the event (Linehan, 1993b). Linehan (1993b) includes “how” skills in contributing to mindful behaviors. These sets of skills focus on teaching the client to observe, describe, and participate in the environment in a nonjudgmental way. According to Linehan (1993a), “Mindfulness in its totality, has to do with the quality of awareness that a person brings to activities in the environment” (p. 146). In learning to focus the mind and awareness on the current moment’s activity, rather than splitting attention among several activities or between current activities and thoughts about something else, allows the client to immerse himself or herself in the moment and reduce distraction or unwanted thoughts and emotions. Overall, mindfulness skills are taught within the context of the therapeutic relationship, but are then adaptable to many, if not all, life situations in one form or another. Clients who have suffered a trauma often find it difficult to remove the traumatic memories from current life events. Because these traumas are engrained into the fabric of the human being, it becomes a daunting task to reintegrate into life in a way that separates out the traumatic memories from enjoyable events. The practice of mindfulness helps to reorient the trauma survivor. This practice certainly does not eliminate the pervasive thoughts that trauma survivors often feel; however, it can help clients learn to “turn their mind” toward the present moment, and ultimately, to find some relief.

Eye Movement and Desensitization Reprocessing Developed by Francine Shapiro (1990), EMDR has been empirically validated in more than 20 randomized clinical trials using trauma survivors. Research conducted by Shapiro beginning in 1990 has demonstrated a significant reduction in trauma-related symptoms for PTSD sufferers. EMDR is conducted across eight phases of treatment. According to Shapiro (1990), the amount of time taken to complete treatment depends on the history of the client. She says that “Complete treatment of the targets involves a three pronged protocol (1-past memories, 2-present disturbance, 3-future actions), and are needed to alleviate the symptoms and address the complete clinical picture” (Shapiro, 2011, para. 1). The goal of EMDR therapy is to reprocess completely the experiences that are causing problems. Clients are then able to integrate new experiences and reprocess emotions, events, and other issues that are not linked to the original memories, and consequently, are less threatening. Unlike traditional psychotherapy, this idea of processing is not linked to talk therapy. Rather, according to Shapiro (2011) it means setting up a learning state that will allow experiences that are causing problems to be “digested” and stored appropriately in your brain. That means that what is useful to you from an experience will be learned, and stored with appropriate emotions in your brain, and be able to guide you in positive ways in the future. The inappropriate emotions, beliefs, and body sensations will be discarded. (para. 1) Many clients may report a reduction in hypervigilance, feeling more able to cope with traumatic triggers, feeling less tense or irritable, and feeling less depressed. As is true with all therapeutic interventions, the goal is to help clients live their lives in ways that are not buried in the past. The goal is not to erase the past, but rather, to begin to reframe the past so that it does not become a hindrance to the future.

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EMDR is a technical intervention that has an eight-phase systematic delivery method, which is needed to achieve its efficacy. Delivering this type of intervention requires extensive training. Many clinicians are excited to learn of newer interventions that are on the cutting edge of research and are eager to become trained to deliver interventions like EMDR. This is always a reassuring sign that the profession is dedicated to continuing to improve the health and well-being of those who need it the most. However, although the promise of research and new techniques gives hope and excitement to the profession, we cannot overlook those other techniques that have been with us for some time and that have empirical, anecdotal, and transcultural credibility on which much of our profession has laid its foundation.

Expressive Arts Therapy EAT uses dance, drama, music, visual arts, and writing to help clients make contact with their authentic self. Through the use of these media, clients are able to bridge the distance between the literal and rational world and their imagination. Clients are able to use these expressive forms to connect with emotions that are difficult to articulate, thereby making these techniques especially useful for children and adult trauma survivors. This process allows for nonverbal expression of emotion, at the same time allowing for verbal reflection to make sense of and more deeply understand emotions as part of the art-making process. The International Community for Creative Arts Therapists (ICCAT) acknowledges the differences between art-for-entertainment and AIT. According to the ICCAT (2010) mission and purpose, The term “expressive arts” is used to distinguish this way of working from entertainment or purely aesthetic uses of art making. The purpose is to make art that is a container for the suffering and conflicts of a life; and give voice to life’s joy and grandeur as well. By engaging in the art making activity, the client participates in his/her own healing, using the language of his/her own healing, and using the language of his/her own psyche. (para. 1) Because of the sensitivity of trauma-related topics, many clients prefer to use art as a medium for discussing their emotions related to the trauma, because it is easier to talk about the image created than it is to focus directly on a wounded self. It is through these images that the disclosure of important information can be used for assessment and meaning-making purposes by the art therapist. AIT encompasses several processes that are driven from within. These processes are projective in nature and thereby tend to allow uninhibited expression. Often clients have not even begun to explore their trauma at the time of therapy, so they are not able to label or verbally express the depth of their pain. For some traumatized clients, the pain is incomprehensible; therefore, to articulate it verbally is not readily possible. Through the use of the various media discussed, clients can begin to heal, through creative means, and to reach a part of their psyche that words cannot reach; this ultimately can empower them to make meaning out of their suffering and to initiate the healing process. The education of AIT is diverse. Interdisciplinary instruction informs their work and largely is grounded in philosophy, psychology, studio art, drama, dance, and counseling theory. The diversity of art therapists’ disciplinary backgrounds allows for greater sophistication in helping clients to navigate the various expressive arts media and to interpret outcomes in a reflexive and self-enhancing manner. Several expressive

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art therapies are outlined briefly in the following discussions: Dance and Movement Therapy, Drama Therapy, Sand Tray Therapy, Psychodrama, and Bibliotherapy.

Dance and Movement Therapy Dance and movement therapy allows for clients to express emotion through body language. Dance and movement therapists are specially trained in analysis and observation of the conscious use of body language. This type of kinesthetic empathy is developed through the psychodynamic interpretation of movements, thereby helping to strengthen the client/therapist relationship. According to Hopkins (1990), the whole client participates in the therapy, including body and mind, and verbal and nonverbal streams of experiencing and expression. This type of intervention is particularly useful from a cultural perspective because it can be adapted for culturally relevant interventions. It also is applicable to clients with all levels of physical and cognitive abilities and deficits who can benefit from dance/movement therapy, because the techniques and nonverbal communication methods used by the movement therapist are specific to the clients’ needs and capacities (Hopkins, 1990).

Drama Therapy Drama therapy is the intentional use of drama/theater processes to achieve therapeutic goals. The National Association for Drama Therapy (NADT) was established in 1979 to uphold strict standards for professional competence of drama therapists. In order to become a registered drama therapist, several organizational requirements need to be fulfilled, including continuing education credits that supplement the therapist’s master’s degree, attained from an accredited program in drama therapy. The NADT is a member of the larger organization of the National Coalition of Arts Therapies Association (NCATA) and advocates for expressive arts in therapy. Through the use of drama, clients are able to participate actively in their healing process through experiential techniques. Drama therapy allows clients the opportunities to tell their stories, solve problems, express feelings, and use both verbal and nonverbal means for reaching a therapeutic catharsis. This technique also allows for interpersonal skills to be enhanced, which can be valuable for trauma survivors who experience difficulty reaching out for support after a traumatic event. Landy (n.d.) offers the following description: Through drama, the depth and breadth of inner experience can be actively explored and interpersonal relationship skills can be enhanced. Participants can expand their repertoire of dramatic roles to find that their own life roles have been strengthened. Behavior change, skill-building, emotional and physical integration, and personal growth can be achieved through drama therapy in prevention, intervention, and treatment setting . . . . Drama therapy can take many forms depending on individual and group needs, skill and ability levels, interests, and therapeutic goals. (para. 2-4)

Sand Tray Therapy Sand play is an expressive play therapy tool used by children, adolescents, adults, families, couples, and groups. Miniature images, sand, and water are used in a tray of sand to create patterns and express dramatic play processes. The sand play process promotes self-expression, shared visions, healing, and community with others (De Domenico, 1998). The origins of using sand trays for expressive purposes can be traced back to

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H. G. Wells, who noticed that his sons worked through their problems as they played with miniature toy figures. Inspired by a reading of H. G. Wells, Margaret Lowenfeld adapted the use of the miniature figures, sand, and water in her London play therapy clinic in the 1920s. Because of the limited resources that children have for comprehending their worldviews, Lowenfeld understood that children often need tools other than language to communicate and make sense of their experiences. She used this medium to facilitate client/therapist communication. The sand tray became useful for children to make sense out of their own life experiences, much like the work of other creative art therapies discussed earlier in this chapter. De Domenico (1998) offered the following testimonial to the use of sand trays: The apparatus was inviting, versatile, and multidimensional. It required no particular skills. During the more than 75 years that have passed since Lowenfeld integrated sandplay into her clinic therapists, teachers, consultants, and researchers with very diverse theoretical orientations have provided the apparatus to their clients and research subjects. Over time, sandplay has been used to help people connect and be mindful of the personal, interpersonal, archetypal, terrestrial, and transpersonal realms of reality. Practitioners have used it to promote increased capacity for consciousness, self-healing, teaching, learning, creativity, communication, and healthy interpersonal relationship. (para. 7) According to Webber and Mascari (2008), sand tray therapy is increasingly recognized as an effective therapeutic tool in trauma and grief counseling. The tactile, nonverbal experience promotes awareness of deeply personal emotional issues within a safe and therapeutic environment. Sand tray therapy provides a powerful therapeutic medium to establish safety, reconstruct the trauma story, and restore connections with the community (Herman, 1997). Clients report that they feel drawn to certain figures and are surprised at the power of sand tray in promoting their disclosure of sensitive issues (Webber & Mascari, 2008). Webber and Mascari (2008) note that the very . . . arrangement of miniature figures in sand reflects the client’s inner world and evokes spontaneous metaphors and healing narratives that provide understanding of the trauma story. Individuals begin to find solace and healing in the sand tray experience without using words. (2008, para. 2) In understanding the implications for using sand trays in the treatment of traumatized clients, the medium allows for clients to reconstruct the trauma story in a safe and protected environment (Gil, 2006). According to Webber and Mascari (2008), counselors should evaluate carefully the appropriateness of sand tray as a therapeutic technique and the readiness of the client for trauma and grief work. They offer these guidelines for using sand trays: 1. 2. 3. 4. 5.

When tactile, multisensory, or holistic modalities may be more accessible to the client; When talk therapy is not appropriate for jump-starting treatment without using words; When safe distance and physical boundaries are needed to deal with emotional pain; With clients who are very resistant or fearful; With clients who need control and power over the environment to address graphic memories of abuse, injury, or death; 6. When the trauma is so unmentionable and unspeakable that the client cannot begin the process of healing through traditional verbal interventions. (Webber & Mascari, 2008, slide)

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Sand tray theorists suggest that universal themes are reflected in how the tray is organized, how the space is occupied, and whether human figures are included in the tray (Homeyer & Sweeney, 1998; Turner, 2005). Even though each sand tray creation is unique, there are several universal traits that each holds, which allows interpretation by the therapist. As with many projective measures, these universal traits are interpreted by the therapist, but validated by the client. Webber and Mascari (2008) outline the following themes to observe in sand tray work: 1. 2. 3. 4. 5. 6.

Empty world symbolizing sadness and depression; Unpeopled world symbolizing pain or abuse; Fenced world or closed world symbolizing compartmentalized or protected issues; Rigid or schematic world or world of rows symbolizing control or hiding abuse; Disorganized world, incoherent world, or chaotic world symbolizing chaos; Aggressive world, with no humans except soldiers, symbolizing violence, anger.

As is true with expressive art interventions that produce tangible results, to destroy the sand tray reconstruction in the presence of the client would be invalidating. In the trauma healing process, photographs can be taken to provide the developmental history of the sand tray process and to remind the client of the work done in therapy. Sand tray as a therapeutic approach offers numerous ways for clients to initiate the healing process. The use of the sand tray is expansive, and while it was once thought to be exclusive to children, research has demonstrated its use with all ages. An example is the work using sand trays with traumatized veterans who have difficulty expressing their emotions through traditional modalities. Another example is the sand tray work with victims from natural disasters (Hurricane Katrina, 9/11, Haitian Earthquake) who have repressed many of the memories of the events and are not able to use words to label their complex emotions. Overall, sand tray work may offer the safe therapeutic environment needed to assist in the various healing processes of traumatized clients. Webber and Mascari (2008) suggest that sand trays can evoke cathartic experiences, thus enabling survivors to integrate trauma experiences into current life schemas through symbols and stories. Trauma narratives can transform into new stories and be held in new perspectives.

Psychodrama Psychodrama is one of the earliest developed forms of art therapies and is used, primarily, to explore client issues through role play. Originating in the late 1930s by Jacob L. Moreno, MD, psychodrama employs guided dramatic action to examine problems or issues raised by an individual (psychodrama) or a group (sociodrama). Using experiential methods like role play, psychodrama facilitates insight, personal growth, and integration on cognitive, affective, and behavioral levels (Moreno, 1953/2007). The basic components of the psychodrama techniques developed by Moreno include the following (American Society of Group Psychotherapy and Psychodrama, 2007, para. 2): 1. The protagonist: Person(s) selected to “represent the theme” of group in the drama. 2. The auxiliary egos: Group members who assume the roles of significant others in the drama. 3. The audience: Group members who witness the drama and represent the world at large. 4. The stage: The physical space in which the drama is conducted. 5. The director: The trained psychodramatist who guides participants through each phase of the session.

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In addition, the progressive technique occurs across phases. The following outlines the three distinct stages of psychodrama: 1. The warm-up: The group theme is identified, and a protagonist is selected. 2. The action: The problem is dramatized, and the protagonist explores new methods of resolving it. 3. The sharing: Group members are invited to express their connection with the protagonist’s work. As with sand tray work, psychodrama affords participants a safe, supportive environment in which to experience new and more effective roles and behaviors. In relation to trauma work, clients are able, experientially, to work through trauma-related issues that have not been addressed by traditional therapeutic modalities. At first glance, many therapists may feel that psychodrama does not differ from drama therapy. However, while several similarities exist, there are also significant differences that make the two distinctly different. Although both use drama as a vehicle for psychotherapy, psychodramatists generally have no background as theater artists, and drama therapists do. Psychodramatists are generally psychotherapists who have gone on to subspecialize in a particular approach to therapy, just as other therapists subspecialize as analytical psychologists, psychoanalysts, and cognitive behavior therapists (Blatner, 2005). Drama therapists are generally theater artists who take extra training in psychology and psychotherapy in order to apply drama in a therapeutic fashion (Blatner, 2005). Finally, according to Blatner, “Psychodrama generally works with the protagonist in role as himself, in various situations, while drama therapists often work with patients in a more ‘distanced’ role, a role not of the individual in his actual life situation” (para. 1 ). Psychodrama works because clients are able to closely approximate life situations in a structured environment. In doing so, the participant is able to recreate and enact scenes in a way that allows both insight and an opportunity to practice new life skills. In psychodrama, the client (or protagonist) focuses on a specific situation to be enacted. One can see the sensitivity of this when related to trauma work. It is clear that without proper education and training, therapists could risk retraumatizing clients. Because of the sensitivity of this technique, in order to practice ethically and to implement this technique with clients, therapists must become certified. The American Board of Examiners in Psychodrama, Sociometry and Group Psychotherapy is a national organization that sets and promotes standards for this discipline.

Bibliotherapy Bibliotherapy is a guided process that uses literature to promote insight, healing, and personal growth. By using literature as a catalyst for change and growth, the client is able to extend the work done in therapy through therapist-guided instruction for additional reading outside of the session. The bibliotherapist is able to work with the client on identifying characters, systemic processes, and scenarios that can help create a cathartic therapeutic experience. The client achieves heightened awareness of the therapeutic issues by vicariously experiencing the book characters or situations. According to Weekes (1996), bibliotherapy and poetry therapy are similar therapeutic adjuncts; in both cases, all types of literary genres are applied to the therapeutic process, including printed and nonprinted matter and audiovisual aids. The goal of bibliotherapy is to broaden and deepen the client’s understanding of the particular problem that requires treatment. The written materials may help the client learn about the disorder itself or may be used to increase the client’s acceptance

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of a proposed treatment. Many people find that the opportunity to read about their problem outside the therapist’s office facilitates active participation in their treatment and promotes a stronger sense of personal responsibility for recovery. With the use of bibliotherapy, clients often feel a sense of connection. Clients understand that there is support and a sense of belonging in knowing that other people have struggled with similar experiences. Clients who have been traumatized may find comfort in knowing that other people have been able to cope effectively with the aftermath of a traumatic event. Trauma survivors may find comfort in reading about others’ resilience in the face of what may feel like insurmountable grief or sadness. By supplementing the therapeutic process with a technique like bibliotherapy, clients may feel empowered to take control of their own recovery and healing process. To this end, however, some clients may use bibliotherapy as a form of do-it-yourself treatment rather than seeking professional help, or cease therapy in the event that they feel that they can replace the therapeutic process with self-help manuals. Like many of the other trauma-related interventions discussed throughout this chapter, bibliotherapy is another medium to consider when working with trauma survivors. Using various literary sources to facilitate the healing process requires first and foremost that a therapeutic relationship has been established and that a client feels safe to explore trauma-related issues. Therapists who do not understand the impact of this technique on their client’s therapeutic process may risk retraumatization and endanger the psychological safety of the client and his or her trust in the therapeutic process.

COUNSELING IMPLICATIONS According to Pearlman and Saakvitne (1995), trauma work is subversive work; therapists are charged with addressing society’s shame. It is complex, confusing, maddening, and empowering all at the same time. Counselors who have worked with trauma survivors for their entire careers often report that it remains this way—that it is never easy. To date, trauma training in graduate programs is a relatively newer addition. For graduate counseling programs, for example, even when professional training standards address crisis, trauma, and disaster training/interventions (e.g., Council of Accreditation of Counseling and Related Educational Programs [CACREP], 2009), actual preservice training often fails to address adequately the traumatic issues that enter counseling offices on a daily basis. Because of this lack of training, counselors, psychologists, social workers, and other professionals who enter the field need to be aware of the severe issues and complexities that await them in relation to traumatized victims. Awareness of one’s own limitations and areas of countertransference becomes paramount when considering interventions in therapy. Because of the lack of specialized training in graduate programs, mental health professionals have an ethical obligation to ensure that they are competent in the treatment interventions chosen for clients specifically relative to trauma (ethical issues related to trauma are discussed in Chapter 30 of this book). Misuse of interventions can cause serious harm to clients and may prevent them from seeking services in the future. Although the demands of the clients must be in the forefront of our minds, counselors also need to consider the ethical and legal repercussions of any incompetence in treating this population. Therefore, in conjunction with training and continuing education, clinicians need to seek supervision (supervision is discussed in Chapter 33 of this book). Effective supervision has many facets, but when related specifically to trauma, although supervisors need to help clinicians with the multiple ways to intervene with and help trauma survivors, nothing is more important than the therapeutic alliance. To this end,

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therapists need to be self-reflective of their own thoughts, processes, emotions, and reactions when dealing with complex trauma cases. In order to help another, we must attend to our own needs and, in effect, model behavior to our clients that speaks to a healthy and balanced lifestyle. It is imperative to note that although the treatment interventions that were discussed in this chapter have been presented as best-practice approaches for the treatment of trauma, they certainly must be considered in light of the needs of the individual client. Therapists are urged to be trained and competent in each of these interventions, so as to avoid retraumatizing clients. This becomes especially important when newer treatment interventions are introduced in the field. For example, as was discussed in this chapter as well as in Chapter 28, EMDR is a relatively new counseling technique that relates specifically to traumatology. Researchers still are not confident when discussing exactly how or why EMDR works; however, it is clear that there is a significant reduction in trauma-related symptoms following certain EMDR interventions. Because of this groundbreaking research, it is important to note the process of EMDR for traumarelated conditions, yet we need to be cautious in the use of this technique. Several different treatment modalities were discussed in this chapter. None can be properly and ethically implemented without training and supervision. In conjunction with each of these interventions is an inherent belief that the trauma victim can become a trauma survivor. Counselors need to understand that the life that the client is living currently may be filled with despair and hopelessness; however, counselors do not need to feel charged with instilling hope for each client. It is with the client’s outlook that hope is possible and that life can be worth living again that clients can begin the healing process. Clients who feel trust, compassion, genuineness, and confidence from their counselor tend to feel safer and desire those similar traits within themselves. If we, above nothing else, can be models of hope, then we have achieved a foundation for therapy and a trusting alliance that can facilitate healing.

CONCLUSION The promise for change comes from counselors delivering intentional interventions. Interventions that have an empirical basis for healing trauma-related symptoms have been explored throughout this chapter. Regardless of the theoretical orientation of the clinician, the techniques need to be chosen with the client’s best interest first. According to Pearlman and Saakvitne (1995), “Too often, therapists, counselors, trauma workers, and researchers lack conceptual frameworks, practical approaches, and supportive environments for either examining their role in relationships with trauma survivors or for understanding the impact their work has on them” (p. 1). Even though there has been an increase in supervision and consultation training at the graduate level, it is clear that in order to minimize retraumatization, therapists need considerable training in the field of traumatology to aid in the healing process of traumatized clients, especially considering the complexity of certain cases. The best-practice approaches for the treatment of trauma have been established out of committed counselors who not only appropriately deliver these techniques, but have done so in therapeutic forums that established trust. Clients who have trauma histories are highly aware of any signs of mistrust, abandonment, betrayal, or incongruence in their therapists, thus necessitating a demonstration of keen self-awareness on the part of therapists. Such a task is difficult, even for the most seasoned clinicians. Therefore, in choosing the best-practice approach that fits the needs of the client, the counselor

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also needs to remember the implications that this intervention has on the therapeutic alliance. Ethical and appropriate therapeutic relationships ensure that the client’s safety is of paramount importance and that the integrity of the established alliance is maintained in the most respectful ways. For survivors of trauma, if the safety within a therapeutic relationship is threatened or compromised, it may be impossible to reestablish it. However, if it is preserved, it can be the most healing and curative factor within the therapeutic relationship.

RESOURCES The following resources can help to elucidate the best standard approaches outlined in this chapter and will serve to provide further direction for continuing education in the area of traumatology. Websites Blatner, A. (2005). Psychodrama resource website: http://www.blatner.com/adam/pdntbk/PsychodramaFAQ.html Figley, C. R. (2003). Compassion fatigue: An introduction. Retrieved from http://www.greencross.org/ Research/CompassionFatigue.asp Linehan, M. M. (2011). Behavioral tech, LLC dialectical behavioral therapy training website: http:// www.behavioraltech.org/index.cfm?CFID = 48744996&CFTOKEN = 99431049 U.S. Department of Veterans Affairs. (2011, July). Treatment overview. (http://www.ptsd.va.gov/ professional/pages/fslist-tx-overview.asp) Publication Figley, C. R. (1985). Trauma and its wake. New York, NY: Brunner/Mazel.

REFERENCES American Society of Group Psychotherapy and Psychodrama. (2007). Psychodrama. Retrieved from http://www.asgpp.org/pdrama1.htm Blatner, A. (2005). Using role playing in teaching empathy. British Journal of Psychodrama & Sociodrama, 20 (1), 31–36. Bloom, S. A. (1999). Trauma theory abbreviated. Lecture presented at Community Works. Retrieved from www.sanctuaryweb.com Cohen, H. (2006, April 8). Differential diagnosis of PTSD symptoms. Retrieved from http://psychcentral.com/lib/2006/differential-diagnosis-of-ptsd-symptoms/ Council for Accreditation of Counseling and Related Educational Programs. (2009). Counsel for Accreditation of Counseling and Related Educational Programs (CACREP): The 2001 (2009) standards. Alexandria, VA: Author. Covington, S. S. (2003a). Beyond trauma. Center City, MN: Hazelden. Covington, S. S. (2003b). A healing journey: A workbook for women. Center City, MN: Hazelden. Covington, S. S., & Kohen, J. (1984). Women, alcohol, and sexuality. Advances in Alcohol & Substance Abuse, 4 (1), 41–56. Dalenberg, C. L. (2000). Countertransference and the treatment of trauma. Washington, DC: American Psychological Association. De Domenico, G. S. (1998). The Sandtray Network. Retrieved from http://www.sandtray.org Germer, C. K. (2009). The mindful path to self-compassion. New York: Guilford Press. Gil, E. (2006). Helping abused and traumatized children: Integrated directive and nondirective approaches. New York: Guilford Press. Herman, J. (1992/1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York, NY: Basic Books.

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Herman, J. (1997). Trauma and recovery (2nd ed.). New York, NY: Basic Books. Homeyer, L. E., & Sweeney, D. S. (1998). Sandtray: A practical manual. Canyon Lake, TX: Lindan Press. Hopkins, C. E. (1990). Does physical contact lead to talking? Dance-movement therapy with geriatric psychiatric inpatients. New York: New York University. International Community for Creative Arts Therapists. (2010). Retrieved from http://www.artsin therapy.com Kahn, M. (1991). Between the therapist and the client: The new relationship. New York, NY: Freeman. Ledray, L. (1986). Recovering from rape. New York, NY: Henry Holt. Linehan, M. M. (1993a). Cognitive behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press. Linehan, M. M. (1995). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press. McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131–149. Moreno, J. L. (1953/2007). Who shall survive? Foundations of sociometry, group psychotherapy and psychodrama. Beacon, NY: Beacon House. Retrieved from http://www.asgpp.org/docs/WSS/WSS%20 Index/WSS%20index.html (Original work published 1953) Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford Press. Najavits, L. M. (2006). Present-versus past-focused therapy for posttraumatic stress disorder/substance abuse: A study of clinician preferences. Brief Treatment and Crisis Intervention, 6(3), 248–254. Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link between substance abuse and posttraumatic stress disorder in women: A research review. The American Journal on Addictions, 6(4), 273–283. Pearlman, L. A., & Mac Ian, P. S. (1995). Vicarious traumatization: An empirical study of the effect of trauma work on trauma therapists. Professional Psychology: Research and Practice, 26 (6), 558–565. Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist. New York, NY: Norton. Shapiro, F. (1990). Eye movement desensitization and reprocessing procedure: From EMD to EMDR a new treatment model for anxiety and related trauma. Behavior Therapist, 14, 133–135. Shapiro, F. (2011). EMDR Institute, Inc. Retrieved from http://www.emdr.com Turner, B. A. (2005). The handbook of sandplay therapy. Cloverdale, CA: Temenos Press. Webber, J., & Mascari, J. B. (2008). Sand tray therapy and the healing process in trauma and grief counseling. VISTAS 2008 Online. Retrieved from http://counselingoutfitters.com/vistas/vistas08/ Webber.htm Weekes, C. (1996). Bibliotherapy. In C. G. Lindemann (Ed.), Handbook of the treatment of the anxiety disorders (2nd ed., pp. 375–384). Northvale, NJ: Jason Aronson. Retrieved from http://www.amazon. com/dp/1568218052?tag=theguidetosel-20&link_code=as3&creativeASIN=1568218052&creative =373489&camp=211189 Yalom, I. (1995). Theory and practice of group psychotherapy. New York, NY: Basic Books.

Section VI: Collaborative Work in the Area of Trauma Counseling CHAPTER 30

Ethical Perspectives on Trauma Work VILIA M. TARVYDAS AND HELENA K. Y. NG

INTRODUCTION In earlier chapters, trauma is examined in depth and breadth: by context, type, and setting. All of the information conveys a clear message that trauma is inevitably a profound and complex experience—for survivors and responders alike. For counselors who seek to provide care in trauma and disaster situations, the ethical challenges are both profound and of a nature for which they may be ill-prepared. Sommers-Flanagan and Sommers-Flanagan (2008) articulated a basic truth about the stark ethical context of crisis work: “It has been said that the truest test of morality is how people behave when no one is looking and no one will know. The compelling human dimensions of crisis heighten every human emotion. The chaos of crisis obscures accountability” (p. 266). Apart from its profundity and complexity, traumatic experience can be a source of excruciating pain and suffering to victims and survivors. Counselors involved in trauma work must attune to the taxing and daunting effects of trauma. Besides, counselors need to be aware of and confront ethical challenges and dilemmas that can seep into important facets of their lives. Ethics is an important aspect of competent counseling practice. Professionals in the field must strive to be fluent with the ethical codes of professional associations (e.g., the American Counseling Association [ACA], the American Psychological Association [APA], the National Association of Social Workers, and so forth) and of other organizations that may provide additional ethical guidance in the specialized circumstance of trauma or disaster mental health counseling (see the discussion of the Green Cross’s Standards of Self-Care and the American Red Cross’s Code of Conduct at the conclusion of this chapter). Members of the various helping professions need to be knowledgeable of the ethics codes and integrate these codes into their professional lives. On a more sophisticated level, members are asked to model their ethical practices to clients, peers, and colleagues, living out what they promote and embrace. This chapter facilitates mental health practitioners’ awareness of traumatic situations that pose challenges to their ethical practice. This chapter also inspires professionals to reflect on and examine their helping intentions. This chapter culminates in the discussion of developing an ethical character consistent with the trauma professionals’ aspirations in their professional work in trauma. Specifically, there will be eight topics, which guide the process of discussion. These topics are (a) understanding ethical principles in trauma practice, (b) trauma and the clinician, (c) survivors as consumers of services, (d) transformation from victim to survivor, (e) survivor input to therapy and recovery,

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(f) survivor mission, and (g) implications for counselors. These major sections are followed by a summary of this chapter and useful resources. Cases of violation of ethics are illustrated in the latter part of this chapter. Cottone and Tarvydas (2007) discuss two types of governance in ethical practice: mandatory and aspirational. Mandatory ethics functions at the most basic level, where counselors must attend to ethical standards and parameters of their practice through standards that are binding upon them by virtue of their memberships in an organization, or holding of a credential (Cottone & Tarvydas, 2007). The aspirational level of ethical governance is the more sophisticated level of practice, which voluntarily guides mental health practitioners to center on the welfare of clients and to act in the best interests of the entire helping profession (Cottone & Tarvydas, 2007). Aspirational ethics is the level of practice characterized by professional helpers’ indigenous character and attitudes as supplemented by advanced knowledge of ethical practices as informed by nonbinding ethical standards and professional knowledge. The level of aspirational ethical practice is pivotal in guiding professionals in making pertinent decisions in trauma work because limited mandatory guidance is available that applies specifically to work in this area of practice. As a result, it is imperative that trauma work professionals also become knowledgeable and adept in the use of a credible, scholarly ethical decision-making model that can bear public scrutiny. Many and diverse models exist, and practitioners are urged to develop a deep familiarity with the use of one suitable to their needs prior to becoming involved in the ethically charged, complex situations that trauma counseling entails. Because this important aspect of preparation for ethical trauma counseling is outside the scope of this chapter, readers are referred to the original work of some authorities who have published useful ethical decision-making models (Cottone, 2001; Garcia, Winston, Borzuchowska, & McGuire-Kuletz, 2004; Kitchener, 1984; Tarvydas, 2012). Accordingly, discussions in this chapter will gravitate toward practice at a level above mandatory ethics. Observing and living out the ethical codes are core elements of professionalism (Bernard & Goodyear, 2009). In effect, trauma helpers’ hearts and minds are key factors that motivate counselors to observe and live out their professional practices. The mindset in this context relates to prudence. Cimperman (2005) summarized prudence as “the fruit of who we are at a given point in time as embodied relational agents” (p. 59). Aquinas (as cited in Cimperman, 2005) argued that prudence is legitimate logic toward one’s actions. The “virtue of prudence,” a value described by James Keenan, a theologian, accompanies fidelity, self-care, and justice (Cimperman, 2005). Prudence appears to be a fitting compass for counselors to navigate the ethical journey; safeguarding them from violating professional boundaries and inciting them to discern clients’ best interests. Wholehearted commitment to service makes a remarkable contribution to professionalism, and it is not uncommon to hear that people are drawn to the counseling profession because of their burning desire to offer care and support to those who are in need. Their good natures inspire them to work with clients with empathy and unconditional positive regard. These genuine qualities are essential to ethical practice at the aspirational level, but if not properly harnessed they can also contribute to circumstances that compromise the ethical quality of service.

UNDERSTANDING ETHICAL PRINCIPLES IN TRAUMA PRACTICE This chapter highlights understanding of trauma from the ethical perspective. The pillars of ethical guidelines, the traditional five moral principles identified by Kitchener (1984) are integrated into the examination of ethical dilemmas and challenges in trauma work. Understanding and reflecting on these principles, which are comprised

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of autonomy, justice, beneficence, nonmaleficence, and fidelity help trauma helpers to negotiate ethical conflicts that arise in counseling situations, including those faced in crisis and humanitarian interventions (Sommers-Flanagan, 2007).

Autonomy Autonomy refers to “a right to self-determination of choice and freedom from the control of others” (Cottone & Tarvydas, 2007, p. 26). According to Cottone and Tarvydas, professional responsibility refers to professional helpers’ commitment to clients and to the mental health profession. In the aftermath of a traumatic event, a common feeling among victims is helplessness. The way things have happened might make them feel a loss of control over their lives. It is extremely difficult, if not impossible for them to make decisions. They may tend to count on someone to speak and act on their behalf. Challenging as it may be, counselors must refer to clients’ rights and freedom, and adhere to the profession’s ethical codes that emphasize client informed choice (Tarvydas, 2012). For immediate resolution to clients’ pressing needs, it may seem pragmatic to furnish clients with some answers, and the initial phases of trauma work involve a great deal of practical assistance and assisting the client in reestablishing natural, supportive contact with valued others. Even the initial step of professionals clearly identifying themselves as a mental health professional who will be working with the survivor, making sure that the survivor who wishes to talk reestablishes a base level of control, and allows the survivor to—in some way—make a choice about what they choose to discuss. The principle of autonomy in ethical practice places a clear focus on providing clients with proper informed consent and confidentiality, tasks that may be difficult, at best, in the conditions in which trauma and disaster mental health practitioners may find themselves. There may not be an office or private space in which to arrange for privacy, sessions may be on demand or spontaneous, record keeping may not be possible, or keeping records confidential may involve extraordinary efforts, and conditions may not allow for more structured interactions and explanations in a traditional sense. Counselors should ensure as far as they are able that they adhere to their ethical obligations by taking such measures as (a) identifying themselves clearly as a mental health professional, (b) providing a practical and abbreviated form of informed consent, (c) looking for and using as private a space as possible given the available surroundings, and (d) emphasizing and modeling keeping survivor information confidential with other workers and staff. Sommers-Flanagan (2007) cautioned that counselors must not succumb to the disaster myths of the stunned or frozen victim, but rather must assume survivors’ knowledge and competence to make their own choices. Counselors are responsible to ensure that survivors are given the encouragement, conditions, resources, and opportunity to understand and voluntarily consent to any decision affecting them. In this way, counselors must think and act in accordance with clients’ well-being because clients are the ones who bear consequences of their decisions. Counselors also can impair the immediate and longer-term autonomy of survivors if issues of control and empowerment are mishandled. For individuals who have experienced loss of control through trauma and disaster, the manner in which matters of autonomy are managed is likely to have profound therapeutic significance. The use of empowerment-oriented interventions is seen as key in calling forth the necessary resiliency to potentiate healing from traumatic experiences. For this reason, counselors must honor the principle of autonomy by facilitating clients to make decisions in accordance with clients’ own values including sensitivity to issues of cultural diversity. In a nutshell, the principle of autonomy entails counselors practicing on both their mandatory

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Table 30.1 Best Practices to Enhance the Autonomy of Trauma Survivors 1. Presume that survivors are capable of making decisions unless there is a specific pre-disaster or pretrauma condition that could suggest otherwise. 2. Think in terms of the types of decisions and match between the competency of the survivor to decide in that specific moment. 3. Think through how confidentiality issues might be handled in a disaster or trauma situation, and inform survivors as appropriate; strive to ensure privacy of conversations and help survivors understand differences between confidential versus casual conversations. 4. Develop protocols of how informed consent will be obtained and include provisions for when survivors’ decision-making capacities become impaired (e.g., use of substitute decision makers who are most likely to know what the survivor may wish to decide for himself/herself). 5. Understand cultural dynamics that may reflect the survivors’ differing ideas about who participates in decision making.

Source: Adapted from Sommers, 2007

and aspirational levels. Sommers-Flanagan (2007) offered some specific suggestions for ethical best practices that conform to the principle of autonomy in working with survivors of trauma (see Table 30.1).

Justice Justice in the context of counseling refers to “fairness and equality in access to resources and treatment” (Cottone & Tarvydas, 2007, p. 28). The principle of justice requires counselors to treat clients equally and impartially. The nature of disaster or trauma response assumes thoughtful allocation of services and resources to address the circumstances experienced by the survivors. It implies equal treatment of persons who are equal in status and resources, although this is rarely the case. The questions raised in the response to Hurricane Katrina are illustrative of the power of issues that can be raised concerning fairness and justice, challenging both survivors’, interveners’, and society’s assumptions about fairness. These are questions of distributive justice, or the model used to determine how scarce resources are allocated, which is particularly problematic for vulnerable persons (Hartley, in press). This dynamic is especially salient in stages of disaster response beyond its initial phase in that as the crisis unfolds it often unmasks issues of unequal treatment of those of unequal status. It is important that counselors understand that the tendency to blame or avoid is a natural aspect of the stress response cycle for those in traumatic circumstances for workers and survivors, alike, and factor this possible reaction into their analysis of the situation. Counselors both must be aware of and sensitive to their own potential tendencies to place blame or to blame some survivors, and also address others’ reactions affecting survivors and assist in advocacy efforts survivors may undertake or advocate on their behalves. Paradoxically, counselors must be mindful of a potential to alleviate the unfairness they observe through becoming unfair to others (Sommers-Flanagan, 2007). It is for these and other practical and sociopolitical considerations that the principle of neutrality despite worker disillusionment is ascribed to in the disaster responder community when the values of the intended beneficiaries conflict with those of the helping institutions. On the individual level, experience of trauma might make people perceive that life is unfair. Very often trauma victims ask questions of meaning such as “Why me?” or “Why did this happen to me?” Counselors can assist clients move through the irrepressible “why” questions by listening to their search for meaning through exploring issues

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of fairness and equality through an existential or meaning-making framework (DassBrailsford, 2010). People’s worldviews are changed and they may perceive the world as unjust. In cases of murder or homicide, it might be difficult for surviving family members to see justice in society. It may aggravate pain or produce a retraumatizing effect when counselors do not offer fair treatment to clients. Simple gestures such as scheduling appointments can precipitate clients’ feeling of injustice. Counselors need to ponder the meanings of fairness and quality from clients’ point of view. Care must be practiced when exploring with clients issues that are sensitive to justice, fairness, and equality. However, the professional traditions of trauma and disaster work include advocacy on behalf of the survivors if, after careful analysis, the individual is not receiving the services that are normal and ones that are intended by the service effort or agency.

Beneficence Beneficence “involves a more active concept of contributing to the well-being of others” (Cottone & Tarvydas, 2007, p. 27). In the context of trauma, the principle of beneficence requires counselors to develop sensitivity to clients’ needs and serve clients in their best interests. Counselors must prioritize clients’ concerns and issues rather than their own. Counselors’ chief concern is their ability to help clients, rather than responding to their own feelings of anger, pity, or righteousness (Becker, 1985). They must respect clients and exhibit their support for the benefit of their clients. Besides, counselors must operate at their professional level of competency, and even in trauma or disaster situations they must take care not to provide services outside of their scope of ability (International Emergency Medical Response Agency, 2011). If asked to provide care in an emergency where no other care is available, counselors may do so until the incident is over and/or more skilled care is available. In doing so, they should use the applicable skills and training they do possess, while taking care that no harm is done to the survivor. With the increasing prevalence and awareness of traumatic events and disasters, it is important that counselors increase their specialized knowledge, training and experience of crisis, and trauma and disaster mental health counseling techniques to competently and ethically work with their clients (Webber & Mascari, 2009). Whether ever deployed to a disaster or involved in the acute treatment of a trauma survivor, counselors working in diverse types of community-based practices will be seeing an array of trauma survivors, whether they initially reveal these experiences or not. As a result, counselors must gain the knowledge, skills, and emotional capacity to work with clients on their posttraumatic growth and well-being.

Nonmaleficence Nonmaleficence refers to the avoidance of behaviors that might create harm— intentionally or unintentionally (Cottone & Tarvydas, 2007). Harm is a particularly sensitive matter to people who experienced trauma. Understandably, victims of trauma seem emotionally fragile, and counselors must demonstrate care and sensitivity to clients’ emotions. It is fundamental that counselors seek to understand what harm means for clients. Also, they must learn about clients’ cultural and spiritual values as these values are related to their thoughts and emotions. Counselors need to be vigilant of their words and actions that may be sources of affliction to clients. For instance, counselors must recognize that certain labels and terms can cause painful feelings for clients. Also, their insensitive probing can retraumatize clients. Counselors must refrain from practicing disaster response or trauma counseling beyond the extent of their competencies. For example, Figley (2007) has expressed concern that well-meaning counselors who are not appropriately trained might do

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more harm than good in their attempts to assist the many combat veterans who have posttraumatic stress disorders (PTSDs) that are reentering our communities at the present time. Another issue involving the ethical obligation of nonmaleficence, counselors should not pressure clients into engaging in unreliable or unproven treatments. Sommers-Flanagan and Sommers-Flanagan (2008) have placed special emphasis on the use of evidence-based interventions as a specific ethical requirement of crisis counseling. For example, the application of such specialized crisis interventions such as critical incident stress debriefing (CISD; Everly, Lating, & Mitchell, 2005) must be undertaken only after a thorough study of the evidence-based literature that examines its effectiveness, and conforms to the appropriate manner in which it is done, lest individuals be harmed by a CISD intervention. One of the difficulties in assuring that the trauma counselor’s actions do not harm others involves carefully monitoring the frequent tendency of disaster and trauma professionals to form social or nonprofessional relationships with coworkers and survivors because of the especially intense emotional climate surrounding the experiences and the work they share. This climate interacts with the counselors’, workers’, and survivors’ very human reactions to exposure to stress and trauma for reassurance and positive human contact. Yet, the survivor may be at his or her most vulnerable point, traditional boundaries are not clear, and the counselor–client power differential is at its height. It is for these and other compelling reasons that romantic or other intimate relationships with client-survivors, coworkers, and other parties to the trauma or disaster deployment or situation are not ethically appropriate during the period of service. A final and overarching ethical concern involving nonmaleficence is that of not overpathologizing survivors’ reactions or prematurely diagnosing individuals who are exhibiting normal reactions to severely abnormal circumstances. Psychological triage may be performed with an initial psychological screening in disasters to assess psychological status of the person and provide information on who should be served next or in what manner. However, disaster and trauma counselors do not typically focus on assigning a diagnosis of mental illness in early stages of intervention, but rather work to provide assistance, support, and/or referrals for those experiencing the most extreme reactions, and to normalize and support strength-based or resilient disaster or trauma responses (Halpern & Tramontin, 2007). Such an approach avoids the possibility of future negative effects to the survivor by assigning an inaccurate or overly negative diagnosis to a person, and exposing him or her to negative effects of stigmatization or erosion of sense of self-esteem, competence, and coping capability.

Fidelity Fidelity is about keeping promise and commitment, and exemplifying honesty and loyalty (Cottone & Tarvydas, 2007). This principle entails counselors to honor their words and to be true to their relationship with clients. In the aftermath of trauma, victims often relate their experiences to loss of control and to violations of trust. They lose a sense of their trust in others, self, and even their higher powers. As they see the world in a different light, they need help to reframe the notion of trust. Apart from facilitating clients to reestablish trust, counselors must be vigilant of their role in modeling trust. Counselors must practice genuineness and caution. Their words must be consistent with their actions, and experienced disaster and trauma counselors take particular care to promise only those things that they are certain that they can deliver, and to take extraordinary pains to assure that these obligations are met. By the same token, counselors must demonstrate trust in clients and encourage clients to keep their words, as it is crucial for them to learn to reestablish trust in themselves. Counselors’ abilities to maintain proper boundaries with their clients and survivors, although related to the ethical principle of

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nonmaleficence as discussed earlier, also are integral to assisting the clients in reestablishing a sense that relationships are safe, stable, secure, and can be trusted even in the aftermath of tragedy and trauma. Disaster and trauma survivors are not in a position to protect themselves from exploitation, fraud, and incompetence, so the obligations of counselors to retain the objectivity and concern for the integrity of the client-survivor– counselor relationship assume added importance (Sommers-Flanagan, 2007).

TRAUMA AND THE CLINICIAN It is apparent in the earlier discussion of the ethical principles that obligate the disaster and trauma counselor, that ethical violations are more likely when counselors do not monitor and address their personal vulnerabilities through such steps as assessing their own motivations for helping, and monitoring their levels of self-care and wellness (Cottone & Tarvydas, 2007; Sommers-Flanagan, 2007). It would be ideal if wounded healers could use their own wounds as a source of healing (Nouwen, 1972). Some people have entered the counseling field as a result of their experience of suffering, which inspires them to help people alleviate pain and affliction. They believe that what they have gone through will help them understand their clients’ agonies. No doubt, wounded counselors’ experiences can be valuable and helpful. Yet, counselors must first become aware of their vulnerabilities and be prepared to manage them to enhance rather than detract from their capacities to help their clients. More important, they must recognize that trauma work, especially, can take a physical and emotional toll on them and erode their abilities to maintain appropriate levels of wellness and professional presence. More specifically, ethical counselors need to be mindful of projecting their own traumatic experience onto clients (McGee, 2005). ACA’s Code of Ethics demands that counselors be aware of their impairments and be psychologically healthy and well for their work. Paradoxically, empathy can be counselors’ most profound gift as well as a burden. Counselors who offer empathy attempt to enter into clients’ worlds. This empathic movement into the experiential and emotional world of clients can put counselors at high risk for developing secondary trauma or compassion fatigue (Shallcross, 2010). Ethical practice requires trauma counselors to become informed about the very specific risks of secondary trauma, to discern their risk of becoming “wounded healers,” to explore effective and palatable means to deal with compassion fatigue, and to incorporate professional and personal self-care practices into their daily routines (Cottone & Tarvydas, 2007; SommersFlanagan, 2007). Some of these issues are described at further length in the following text.

The Wounded Healer, Compassion Fatigue, and Self-Care The personhood of the clinician is highly relevant when counseling survivors of trauma. For this reason, issues regarding the wounded healer, compassion fatigue, and self-care are examined in this section.

The Wounded Healer One of the acquired skills of counselors is active listening. Simple as it may sound, it is taxing when counselors attempt to listen with the eyes and ears of their hearts to clients’ account of traumatic experiences. The sight of wounds and damage, and the sound of devastating cries flash vividly on counselors’ mental movie screens. This devastating scenario may repeat as clients retell their stories, often accompanied by vivid displays of the emotions and traumatic circumstances they experienced. The impact can be magnified when counselors work with different clients on their debilitating experiences

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within an intense, brief period. Clients’ predicaments incite counselors’ empathic responses to enter mentally into the situation, and to take the risk of becoming psychologically injured themselves (Nouwen, 1972). How far and how deeply can counselors’ involvement go? In circumstances when counselors’ own traumatic issues are not yet resolved, countertransference is more likely to develop, exacerbating the level of risk to both counselor and client. Counselors must ensure that their unresolved issues do not induce harm to themselves, to clients, and to the therapeutic relationship, and accept that everyone has a susceptibility that may render them fragile to boundary crossing (Wicks, 2007). Refer to Chapter 32 for further understanding of wounded healer.

Compassion Fatigue Figley (as cited in Sommer, 2008) describes compassion fatigue as the rippling effects of trauma that are experienced by both the primary survivors and people with whom they are in contact. Compassion fatigue is a term developed by traumatologist Charles Figley, describing the stress developed as a result of helping or being involved with people who experience trauma or extreme predicaments (Figley, 1995). Figley credited Joinson with using the term compassion fatigue to delineate burnout among nurses (as cited in Sommer, 2008). Sommer credited McCann and Pearlman with using the term vicarious trauma. Chapter 31 is dedicated to the discussion of vicarious trauma whereby compassion fatigue will be explored and examined in a detailed fashion. Peter Teahen has had decades of active national and international disaster response experience as president of the International Mass Fatalities Center, and with the American Red Cross and other national and international disaster response agencies. Teahen (2011) underscored the tremendous emotional and practical demands placed on disaster response workers, which expose them to greater risk for ongoing psychosocial difficulties. He placed the additional disaster worker-specific reactions and emotional responses within the context of the overall emotional phases of disaster recovery, originally described by Zunin and Myers (2000), that all participants in a disaster experience in the heroic, honeymoon, disillusionment, and reconstruction phases of disaster (Teahen, 2011). The range and seriousness of the demands and reactions experienced by disaster workers are portrayed in Table 30.2. These disaster worker reactions can be summarized into four emotional phases during a deployment cycle: the alarm, mobilization, action, and letdown phases. As a result of these demands, Teahen has strongly advocated that the needs of responders and their families must be prioritized along with the needs of the survivors and their families in any mass fatalities incident. With regard to compassion fatigue in relation to ethical practice, trauma counselors are asked to pay attention to the effects of their levels of empathy on the internalization of their clients’ traumas (Conrad & Kellar-Guenther, 2006). However, it is important to note that not all counselors experience compassion fatigue. Further, personal developmental levels of experience and other individual traits can protect or affect the individual emotional susceptibility of counselors (Stebnicki, 2008). Wicks (2006) contended that trauma work precipitates another source of stress as counselors stand in the crossroad of ethical dilemma. For instance, counselors may be perplexed by different values that pose a challenge to their ethical concerns. For example, disaster counselors may be dismayed to witness a violent, angry reaction on the part of the local survivors against their insistence that a Red Cross hurricane evacuation shelter be set up without racial division. Such circumstances can be spiritually and emotionally draining for counselors. Another phenomenon that merits attention is selflessness. It is a poignant act when helpers wholeheartedly dedicate their efforts to helping others. Yet, selflessness can work against ethically sensitive practice, through overextension and a lack of self-care, which results in a counselor who is emotionally numb to her

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Table 30.2 Disaster Worker Reactions by Emotional Phases of Disaster Recovery Reactions of All Disaster Participants Heroic Phase Shock Fear Confusion Adrenaline rush Heroic acts Coming together Honeymoon Phase Attendance to basic needs in a chaotic environment Concerns about safety, food and shelter Unrealistic optimism about recovery Community cohesion, sharing of resources, cooperation Denial of needs and emotional impact Disillusionment Phase Reality of impact Realization of losses and work to be done Procedures to get assistance are frustrating Community politics emerge Grieving Health problems Family stress, domestic violence, substance abuse issues Reconstruction Phase Long phase of rebuilding financially, psychologically, physically, and spiritually Light at the end of the tunnel Begin to put disaster behind Renewed feeling of empowerment PTSD, depression, anxiety Return to predisaster activities

Disaster Worker-Specific Experiences (Added to reactions of all participants)

Stress of check-in and orientation Frustration and anxiety to get started Once in action, inability to “let down” or rest Identification with victims Loyalty to fellow responders; living or dead

Long hours for many days Constant exposure to clients and their losses Thinking “but . . . I’m OK”

Overwhelmed by magnitude of losses Pressures of community expectations and self expectations Sleep deprivation and safety issues Interpersonal and organization conflict Staff turnover

Left with follow-up Out-processing Reorientation of thoughts to home and regular job “Let down,” sense of loss, guilt of not doing enough

Source: Adapted from Teahen, 2011

client’s experience of her rape. Professional associations in person-centered disciplines, such as ACA, APA, and the American Medical Association (AMA) require members to be concerned to identify and guard against professional fatigue (Stebnicki, 2008). A healthy and well-grounded professional is needed in order to exhibit competent and ethical healing efforts (Stebnicki, 2008). Emotionally drained counselors are like an overdrawn bank account. Imagine the incredibly high bank charges that the account holder has to pay as a result of regular or prolonged check overdrafts of more money than what is available. The role of counselor educators is to gauge harmful impact on counselors. Counselor educators and professional organization leaders can play a role in diminishing the harmful effects of many of these challenges to counselors through their efforts to provide relevant training for counselors, which must guard against possible harm to clients and counselors (Sommer, 2008). The relatively recent addition of disaster and trauma-counseling educational standards by Council for Accreditation

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for Counseling and Related Educational Programs (CACREP, 2009), in its recent educational program accreditation standards, is a very positive development that furthers this goal in counseling.

Self-Care In addition to training, self-care is an approach that not only supports trauma counselors to cope with compassion or emotional fatigue, but also serves as proactive means to prepare counselors for potential risk of injury. Counselors must learn about the meaning of self-care, and incorporate personal and professional self-care into their life routines. Hamilton (2007) articulated that personal and professional self-care is the central means that helps counselors thwart compassion fatigue. Cottone and Tarvydas (2007) articulated that personal self-care skills include healthy personal habits, attention to relationships, recreational activities, relaxation and centeredness, and self-exploration and awareness. Some examples of personal self-care activities are physical exercises, massage therapy, balanced diet, sufficient sleep, movies, and concerts. Times spent on artwork, social events, and traveling are equally important. Professional self-care skills include continuing education, consultation and supervision, networking, and stress management strategies (Cottone & Tarvydas, 2007). In addition, counselors must strive to balance workload and work hours, pace client meetings and the day to allow for breaks, integrate reflection into the day, and take time off for vacations. Understanding and complying with the ethics code suggest counselors’ honesty to clients and themselves. Counselors’ self-care behaviors are related to their work and their relationship with clients in a very elemental way. Engaging in work that exceeds one’s physical and emotional capacity is a disservice to clients. Seeing too many clients with devastating issues within a short period can lead to burnout and compassion fatigue. For counselors working at agencies where cases are assigned to them, it is both their responsibility and that of the organization to recognize the point when “enough is enough” (Bober & Regehr, 2005). Counselors have the ethical responsibility to advocate for their own health and functionality and to decline assigned workloads that they realize are beyond their limits. They can model self-care only when they are able to demonstrate to clients that they safeguard their own well-being. It is also important that counselors do not deny stress. Knowing that stress is part of their lives, counselors must develop an accepting attitude toward it. Avoiding and limiting emotional fatigue in their own lives allow them to live out the passion in their work (Wicks, 2006). Chapter 32 contains more in-depth discussion on self-care, and readers should reflect upon the personal questions raised in Table 30.3 to better assess their current readiness for trauma and disaster work.

Table 30.3 Questions for Personal Reflection Before Responding to Trauma or Disaster 1. Why am I interested in trauma or disaster response work? 2. How would my responding affect those around me? 3. What strengths do I bring as a responder? 4. What liabilities do I have as a responder? 5. After personal reflection, what stage or type of trauma or disaster response best fits my unique profile of personal and professional characteristics, and still fulfills my healthy humanitarian impulses to help? 6. What activities, learning, or counseling do I need to undertake to either improve or maintain my capabilities to respond? Now? While engaged in response work?

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Clinical Supervision Clinical supervisors have their share of ethical responsibilities in trauma work. There is more scholarly interest in this area, and ACA and the National Board for Certified Counselors (NBCC; 1993) have established ethical guidelines for clinical supervisors that may guide their efforts with counselors in trauma-related work.

Association for Counselor Education and Supervision Guidelines The Association for Counselor Education and Supervision (ACES; 1990) has established ethical guidelines for counseling supervisors, which specify that supervisors must administer ongoing assessment and evaluation of supervisees who must be aware of their personal and professional limitations that relate to their counseling efforts. Thus, supervisors are responsible for examining supervisees’ competency, recommending relevant remedial assistance and service as needed.

National Board for Certified Counselors Code of Ethics for Approved Clinical Supervisors The approved clinical supervisor code of ethics of the NBCC has listed several standards for clinical supervisors relevant to supervisory work in crisis and trauma counseling. For instance, supervisors are to arrange for training procedures with supervisees in connection with crisis management situations. Supervisors must intervene when supervisees are impaired and clients are at risk. In situations where supervisors notice that supervisees are incapable of providing adequate services, supervisors must avoid letting supervisees continue their work with clients.

Trauma-Sensitive Supervisors It is imperative that supervisors incorporate trauma-sensitive supervision into their training. Supervisors of trauma counselors need to be vigilant of changes in counselors’ behaviors and any extraordinary signs of stress or compassion fatigue (Sommer, 2008). For instance, supervisors must recognize when counselors are exhibiting problematic or changed patterns of substance use (Cross & Ashley, 2007). ACA has recognized the critical need to support counselors’ personal and professional growth. In response to this need, clinical supervisors must pay attention to counselors’ integration of self-care into their agendas. Supervisors also can lessen the chance of counselors developing compassion or emotional fatigue by using sound judgment when assigning traumatic cases to counselors, because counselors themselves may feel obligated to take on whatever cases assigned by supervisor or manager even when they are physically or emotionally exhausted. Supervisors too must practice self-care in order to serve as models for counselors. Technicalities and details of clinical supervision with regard to such need are further discussed in Chapter 33.

Multicultural Sensitivity Sensitivity to multicultural perspectives is particularly germane to ethically competent counseling practice in trauma and disaster counseling. ACA’s (2010) defi nition of counseling highlights diversity, which suggests counselors’ sensitivity and respect for differences among individuals. People with traumatic experiences tend to develop their own culture, in addition to whatever pre-event diversity characteristics they may have. Their posttrauma perceptions of the world are different, and their levels of sensitivity to people and events are different. In brief, their beliefs, thoughts, feelings, and actions are characterized by their own culture. Considering trauma as a culture, counselors who are involved in overseas counseling work are simultaneously addressing a constellation

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of multicultural issues. Egan (2010) suggested the understanding of clients and their problem situations be viewed contextually. Cottone and Tarvydas (2007) cautioned counselors to be mindful of being culturally encapsulated. Cultural encapsulation refers to counselors’ using their own socially constructed lens to view clients’ experiences (Cottone & Tarvydas, 2007). First and foremost, counselors need to understand what trauma means for their clients. Counselors must develop sensitivity to understanding of clients’ cultural background and current beliefs and values because these cultural nuances can have substantial impact on the way they respond to traumatic situations. Clients’ cultural heritage also explains the meaning and types of support clients receive or do not receive from their families, friends, and communities. With regard to traumatic treatment, major ethical standards require that counselors be vigilant of their respect for autonomy of culturally different client (Eagle, 2005). As stated earlier, counselors should not coerce clients to try or participate in any service or experience if they are reluctant to do so. Counselors must be sensitive to taboos or cultural traditions that deter clients from receiving treatments other than those consistent with their ethnic origins. For example, it would be culturally inappropriate for a conservative, traditional Muslim woman to have one-on-one counseling from a male counselor, no matter the dire nature of the circumstances. Likewise, counselors must be careful about making judgments of therapeutic treatments that are embraced by clients’ ethnic culture. Also, counselors need to be gentle and culturally tactful when gathering information from clients about their traumatic experience. Cultural stigma attached to clients’ ordeals may make it difficult, if not impossible, to verbalize what has happened. In addition, having some knowledge about clients’ religious beliefs is helpful to trauma counseling work. For instance, some cultures perceive suffering as something relating to one’s spiritual path. Thus, counselors working with clients from different cultural backgrounds must develop sensitivity to the spiritual meaning clients assign to pain and suffering. Also, counselors must prepare their hearts and minds for exposures to a wide spectrum of agonies. In effect, counselors preparing themselves for trauma work in a foreign culture must endeavor to be culturally competent, and be able to identify clients’ capacity and means for healing (Shallcross, 2010). It would be ironic for ill-prepared counselors to receive comfort and solace from people who just experienced trauma, but much worse when counselors’ disturbed reactions to trauma risk, amplifying clients’ afflictions. In summary, counselors must be as well equipped for trauma work in a culturally diverse place before beginning, and once in place they must be open to learning from and relying on the assistance of the survivors themselves, cultural guides and leaders in the cultural community with which they are working to assist them in more fully understanding the cultural context of their clients.

SURVIVOR AS CONSUMERS OF SERVICES Trauma and suffering are common aspects of human life, and it is safe to assume that most adults have experienced or witnessed traumatic events in their lives. Survivors are people who have experienced and endured traumatic events. In the counseling domain, some clients have undergone traumatic suffering, and some of them have recovered from their torment as a result of receiving counseling. Some might not have received therapeutic help; however, family and social support enabled them to function and return to regular routines. For others, the urgency of meeting their basic needs rendered them no time to focus on their suffering. By and by, these individuals all move from victims’ to survivors’ positions. In most cases, people who have not processed their traumatic ailment are not fully aware

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of their changed worldviews, beliefs, and behaviors. When they seek counseling later in life, their unresolved pain may surface somewhere in the process. Ethical practice requires counselors to heighten their sensitivity and awareness of clients’ feelings, thoughts, and behaviors that may be associated with their clients’ previous traumatic experiences. At this juncture, counselors must demonstrate their competency to assess clients’ comfort level in dealing with their unresolved pain. In other words, counselors need to make sensible decisions with regard to clients’ emotional capacity to confront pain and suffering. Consumers of counseling services in trauma and crisis counseling come from different developmental stages; for example, some are children and young adolescents, and others are elderly. From an ethical point of view, counselors must receive training and cultivate skills appropriate for trauma work with specific populations and know how to address their unique needs. For example, it is helpful for them to know how children’s responses to trauma differ from those of adults (Hosin, 2007). Are children more or less resilient to traumatic events? Also, counselors need to know which intervention approaches best suit children and how to apply them. Finally, counselors must ensure that these approaches are palatable to children with culturally different backgrounds.

TRANSFORMATION FROM VICTIM TO SURVIVOR As stated earlier, feelings and interpretations of pain and suffering are unique among individuals. In other words, diversities of culture, belief, experience, and personality make a difference to people’s experience of trauma. Correspondingly, the pace for people to transform from victims to survivors is something unique to the individual. It is not surprising to find some people staying in the victim’s status for a very long period. Likewise, it is not astonishing to come across people who transition from victims to survivors in a matter of days. For some unique reasons, some people seem to enjoy playing the role of victim. Ethically minded counselors must demonstrate prudence in making decisions to offer help. Realizing that transformation is a process, counselors may want to know where their clients stand along the transformation continuum, and make pejorative judgments about the pace and manner with which clients move through this process. Faith serves as the catalyst of change for some people. Therefore, it is helpful to explore with clients their religious beliefs. It is equally important to explore with clients some of the relevant existential aspects of the meaning they have assigned to their traumatic event or disaster experience. There are people whose traumatic experience inspires them to delve deeper into their purpose or meaning of life. For them, trauma brings new perspectives and meaning to life, and they may even view trauma as an opportunity of growth or transformation. Although some trauma victims are able to rise above their predicaments, some may take a while to negotiate their emotions. Anger is another common emotion experienced by trauma victims and survivors. It is a legitimate feeling and healthy expression if it does not cause harm to anyone. Nevertheless, being angry as a result of trauma can consume a lot of the survivor’s energy. Ethical practice inspires mental health practitioners to explore with victims the source of their anger. It is important for these practitioners to work with victims to identify healthy coping mechanisms. Interestingly, some people are able to transfer anger into meaningful work (McGee, 2005). Counselors can encourage clients to express their anger, to let go of their negative energy, and to convert such energy into some positive sources. In the counseling field, it is not surprising to find that the helping intentions of some come from the source of anger. Their anger coupled with their sense of justice may be transformed into an ethical and helping spirit. Such a transformation process is cathartic, but it demands from sufferers a lot of courage and

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strength to negotiate with the painful truth and to confront feelings of loneliness, loss, and guilt. This profound experience provides them with a deeper understanding of the pain associated with this transformation. This is the opportunity for trauma helpers to intervene, facilitating clients to transform their agony into a source of ethical helping spirit. With reference to the discussion of aspirational ethics earlier in the chapter, such opportunity entails trauma helpers to practice the sophisticated level of ethics.

SURVIVOR INPUT TO THERAPY AND RECOVERY It is possibly one of counselors’ most important ethical obligations to avoid nurturing client dependency or prolonging the counseling process when clients can stand on their own. The process of client transformation from victim to survivor is essential to this shift. Ethical counselors need to be aware of and understand this shift. Fritz Perls’ theory of “homeostasis” illuminates the process of transformation whereby people who are traumatized, after going through some stages (such as receiving support from others, getting therapeutic help, or using personal resources), proceed from the stance of victims to survivors, and eventually arrive at the stage of healing. Perls (1973) argued that human living is about the constant play of balance and imbalance in the organism, which is connected to two goals: survival and growth. These goals explain people’s strength to regain balance and to move on with their lives. Beyond survival and growth, some individuals are able to thrive as they persevere the experience of desolation, moving toward consolation. Such experience may become the driving force of their yearning to help others. Also, their sufferings may make them effective role models of trauma survivors as well as agents of change. Meanwhile, Taoist philosophy of the force of yin and yang aligns with the concept of homeostasis. Yin is the negative force and yang is the positive force. The uniqueness of individuals implies the different makeups of these two forces. These forces facilitate human beings to seek and maintain balance. Counselors can refer to these two schools of thoughts when working with trauma victims and survivors. Homeostasis and the forces of yin and yang exemplify the compelling flow of human adaptation, which is a source of strength and survival. In brief, counselors are responsible for helping clients identify and recognize their strengths, and strengths based or empowerment approaches to counseling are most effective in eliciting healing and recovery of survivors of trauma and disaster (Dass-Brailsford, 2007).

SURVIVOR MISSION In the face of torment and life-threatening agonies, who can relate the experience they are going through to something as abstract sounding as a mission? Perhaps only martyrs can identify their suffering with their mission. Unfortunately, these people died, and the only things surviving in them are their spirits. Nonetheless, many trauma survivors eventually discover their meaning of suffering, and some invest their efforts in the helping professions. These survivors help people by providing emotional and spiritual support, by advocating on behalf of the victims, or by offering necessary food and household supplies. One way in which this need for survivors to contribute to the increased well-being of others who experience trauma might be through participation in research studies. As scholarly interest in traumatology grows, it is becoming increasingly common in fields of mental health, education, and counseling that researchers invite people with traumatic experiences to participate in research studies. It is important that people in trauma-focused research exercise their ethical sensitivity when selecting participants,

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conducting surveys or interviews, analyzing, interpreting, and reporting information. In other words, the design, implementation, and summary of the research and findings must adhere to the principles of autonomy, justice, nonmaleficence, beneficence, fidelity, and truth (Newman, Risch, & Kassam-Adams, 2006), and careful consideration to the protection of these vulnerable human subjects must be made. These issues are crucial to the work of researchers and institutional review boards (IRBs) at countless universities. Researchers must weigh the risks against the benefits of the research. In addition, sensitivity to and respect for cultural diversities must be part of the ethical concerns in trauma-related research. Sumathipala and Siribaddana (2005) spoke about trauma survivors who were prone to exploitation in their participation in international research studies cloaked in clinical care. The writers urged journal editors to be adamant about getting the endorsement from the country where research information is gathered. The writers also suggested researchers to refer to the “guidance for postdisaster research” (as cited in Sumathipala & Siribaddana, 2005) and acquire familiarity of the customs of the people and place where information and data are gathered and analyzed. Another group of potential research participants who deserve additional protection is children (Chu, Deprince, & Weinzierl, 2008). There was no specific evidence that trauma-exposed children are more vulnerable to the possible costs of research than their nonexposed peers (Chu et al., 2008). Yet, it is important that trauma-focused researchers make relevant information transparent to parents and guardians.

COUNSELING IMPLICATIONS This chapter does not close with a simple “conclusion” because it is really an opening to an enormous chest of ethical considerations that promotes advancement in counselors’ work in the realm of trauma. The prevalence of suffering in contemporary society is the compelling reality that must be marked and attended to in every way possible (Cimperman, 2005). Traumatic occurrences have become the signs of the times. To respond to these signs, it is crucial for counselors to perceive ethical concern and practice as processes and moral imperatives, rather than technical tasks.

Ethical Behaviors Counselors study and take examinations to obtain the qualifications required to practice in the field. Some people are adept in writing examinations, although others are less skillful. When it comes to ethical practice, what do the examination scores speak for counselors’ ethical standing? Do counselors’ high scores on ethical questions guarantee their ethical practice? One of the most challenging examinations of their ethical competency as counselors might be the examination of their ethical behavior in trauma and disaster counseling when accountability is obscured by the chaos of crisis (Sommers-Flanagan, 2007). As counselors think ahead to the day they retire, when they look back to their trauma work, it would be meaningful to reminisce over the experiences of being present for people when they are helpless and devastated. More importantly, examining past experiences and linking them to planning for future work helps counselors to sharpen their sensitivities and perspectives, as well as minimizing chances of regret. This crucial process is called reflection. Reflection assists counselors in being proactive and ready for possible challenges. Would not it be prudent to check with the mirror before one leaves the house? This proactive attitude resonates with Tarvydas, Cottone, and Saunders’ (2010) argument that a valuable code of ethics must be able “to anticipate emerging problems and issues” (p.3), in addition to guiding counselors to make sound judgments and take ethical courses of action.

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Moral Behaviors Morality can be taught and caught. People learn about moral behaviors at home, in school, at work, and in society. Quite often, people observe others’ practice of morality and recognize its importance to human lives. Complying with ethics is a respect for one’s profession, and practicing morality embodies a respect for self and others. For counselors, it would be ideal to incorporate the principles of autonomy, justice, fidelity, nonmaleficence, and beneficence into their everyday ways of living. Counselors should live out the ethics codes not because of their fear of violating jurisdictions, but because of their ardent desires to protect clients’ well-being and to respect their profession. Counselors can begin by nurturing their ethical hearts and minds. Consider the case where a counselor tells a trauma victim that he cares about her because he is “doing his job.” This counselor might be adept and diligent in observing rules and principles; however, his words might have led the client to think that he is doing what he needs to keep his job or maintain his work status. His words fail to convey genuine care and support to the client. People’s behaviors are lived manifestations of their thoughts and feelings. Counselors who have not fully examined and aligned their ethical thinking processes with their feelings about their work and their skills may exhibit awkward and inconsistent behaviors under the duress of trauma counseling. Counselors’ work with clients can be likened to a dance. In this dance, clients are sensitive to counselors’ moral movements and ethical ideals and aspirations should be likened to the music that harmonizes intention with action, allowing the counselor and client to share in a respectful and dignified dance of recovery and celebration.

CONCLUSION The practice of trauma and disaster counseling is a highly meaningful one for both the counselor and client if the painful, complex, and ethically charged process is successfully navigated. This chapter provides an understanding of the basic aspects of trauma from the ethical perspective. The importance of using a credible ethical decision-making model is emphasized and unique facets of the application of the five core ethical principles to trauma counseling practice were discussed. Understanding and reflecting upon the obligations entailed by the principles of autonomy, justice, beneficence, nonmaleficence, and fidelity will allow counselors to better negotiate ethical dilemmas that arise in trauma contexts. The impact of trauma on the clinician, the wounded healer, and compassion fatigue are considered to develop important understandings of the challenges unique to trauma and disaster counseling. Finally, more specific ethical issues involved in clinical supervision, multicultural sensitivity, and transformation of victim to survivor are reviewed. Finally, resources for further ethical practice are provided to the reader for further study.

RESOURCES Websites Code of Professional Ethics for Rehabilitation Counselors (http://www.crccertification.com/pages/ crc_ccrc_code_of_ethics/10.php) The 2010 Code of Professional Ethics of the Commission on Rehabilitation Counselor Certification is the first code of ethics for counselors that made a concerted effort to include some more specific standards relevant to counseling practice in cases of disaster to supplement the guidance contained in the more general ethical standards of the code. One standard (B.6.f) directs counselors to take

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precautions to protect confidentiality of clients in the event of disaster. In another more far reaching rule (D.3.b), counselors are directed to make “reasonable efforts to plan for facilitating continued services for clients in the event that . . . services are interrupted by disaster” (CRCC, 2010). Standards of Self Care Guidelines (http://www.greencross.org) Green Cross Academy is a non-profit organization that attends to traumatology. Founded by Charles Figley in 1987, the Academy published its first Standards of Self Care in 2005. The Standards maintain that only those who first take care of themselves are eligible to offer traumatology services to people in need. The Standards state that it is the helper’s respect, responsibility, and duty to perform that prompts their self-care needs. Publications American Counselors Association Code of Ethics. (n.d.). Counselors must be familiar with and understand ACA’s Code of Ethics to make sound ethical judgments. In addition, ACA’s conferences, journals and articles, and online resources discuss ethics and include increasing attention on trauma-related content. In trauma work with people with diverse cultural backgrounds, counselors can refer to the ethics code on multicultural aspects. Various sections of the 2005 ACA Code of Ethics underscore relevant guidelines for coping with ethically challenging situations. For instance, Standard A.11.b. (“Inability to Assist Clients”) suggests counselors “avoid entering or continuing counseling relationships” should they fi nd themselves lacking the knowledge or competence to work with the client. Standard A.1.a. (“Primary Responsibility”) states that “the primary responsibility of counselors is to respect the dignity and to promote the welfare of clients.” Another standard pertinent to trauma work is Standard A.4.a. (“Avoiding Harm”), which states that, “Counselors act to avoid harming their clients, trainees, and research participants and to minimize or to remedy unavoidable or unanticipated harm. Standard C.2.a. (“Boundaries of Competence”), which requires that “counselors practice only within the boundaries of their competence . . .” In a related rule, Standard C.2.b. (“New Specialty Areas of Practice”) states that, “Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience . . .” With regard to treatments that are categorized as “pseudoscience” or “inappropriate,” counselors must adhere to Standard C.6.e. (“Scientific Bases for Treatment Modalities”). This code demands counselors to provide to clients an explanation of the “potential risks and ethical considerations of using such techniques/ procedures and take steps to protect clients from possible harm.” Council for Accreditation for Counseling and Related Educational Programs 2009 Standards. (2009). In recognizing that trauma counseling is a growing specialty, CACREP Standards (CACREP, 2009) establish educational requirements that are relevant to counselors’ preparation to do ethical practice related to trauma work. Sommer (2008) argued that counselor educators are ethically obligated to educate counselors regarding the potential risk of trauma-related work. Ethical practice is one of the eight core curricular areas of a CACREP accredited program. One of the items in the Standards relates to counselors’ roles and responsibilities as “members of an interdisciplinary emergency management response during a local, regional, or national crisis, disaster or other trauma-causing event” (CACREP, 2009, p. 10). Following this section is a standard that places emphasis on counseling students’ understanding of the impact of crisis, disasters, and other trauma-causing events as reflected in different specialty areas. Doctoral programs must meet the Standards of providing training in theories pertaining to the principles and practice of counseling because it relates to trauma-causing events. Students in these programs will develop understanding of the effectiveness of models and treatment strategies, leadership roles, and strategies for responding to local, national, and international crises and disasters. Ethical Codes and Relevant Resources. (n.d.). Because the field of trauma and disaster counseling is undergoing a significant period of development and refinement, counselors will need to maintain a watchful eye on resources to help them develop a better knowledge base to bring to their work. Although it is not possible to be exhaustive in discussing resources to ethical trauma practice, several useful resources are highlighted in succeeding texts.

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Organizations American Red Cross. (2005). The American Red Cross requires licensure as a mental health professional to participate in Disaster Mental Health Services training and work. Among other things, their intent to ensure these professionals are therefore bound to follow the ethical standards of their professions and possess at least a basic knowledge of professional requirements to report abuse and intent to harm self or others. Beyond this basic requirement, all volunteers and employees of the American Red Cross are required to follow the Red Cross Code of Conduct (2005) while delivering services for that organization. However, the Code of Conduct is not a professional code of ethics and primarily prohibits volunteers and employees from using their positions with the American Red Cross to their financial or personal benefit or advantage, and not misusing the organization’s information, or otherwise creating a conflict with the interests of the American Red Cross.

REFERENCES American Counseling Association. (2005). Code of ethics (Rev. ed.). Alexandria, VA: Author. American Red Cross. (2005). American Red Cross code of conduct. Washington, DC: Author. Association for Counselor Education and Supervision. (1990). Standards for counseling supervisors. Journal of Counseling and Development, 69, 30–32. Becker, A. H. (1985). The compassionate visitor: Resources for ministering to people who are ill. Minneapolis, MN: Augsburg Publishing House. Bernard, J. M., & Goodyear, R. K. (2009). Fundamentals of clinical supervision (4th ed.). Upper Saddle River, NJ: Pearson Education. Bober, T., & Regehr, C. (2005). Strategies for reducing secondary or vicarious trauma: Do they work? Advance Access Publication, 6(1), 1–9. doi:10.1093/brief-treatment/mhj001 Chu, A. T., Deprince, A. P., & Weinzierl, K. M. (2008). Children’s perception of research participation: Examining trauma exposure and distress. Journal of Empirical Research on Human Research Ethics, 3 (1), 49–58. doi:10.1525/jer.2008.3.1.49 Cimperman, M. (2005). When God’s people have HIV/AIDS: An approach to ethics. Maryknoll, NY: Orbis Books. Commission on Rehabilitation Counselor Certification. (2010). Code of Professional Ethics for Rehabilitation Counselors. Schaumburg, IL: Author. Conrad, D., & Kellar-Guenther, Y. (2006). Compassion fatigue, burnout, and compassion satisfaction among Colorado child protection workers. Child Abuse & Neglect, 30 (10), 1071–1080. Cottone, R. R. (2001). A social constructivism model of ethical decision making in counseling. Journal of Counseling and Development, 79 (1), 39–45. Cottone, R. R., & Tarvydas, V. M. (2007). Counseling ethics and decision making (3rd ed.). Upper Saddle River, NJ: Pearson/Merrill Prentice-Hall. Council for Accreditation of Counseling and Related Educational Programs. (2009). 2009 standards. Retrieved from http://www.cacrep.org/doc/2009%20Standards.pdf Cross, C. L., & Ashley, L. (2007). Trauma and addiction: Implications for helping professionals. Journal of Psychosocial Nursing and Mental Health Services, 45(1), 1–6. Dass-Brailsford, P. (2007). A practical approach to trauma: Empowering interventions. Thousand Oaks, CA: Sage. Dass-Brailsford, P. (2010). Crisis and disaster counseling: Lessons learned from Hurricane Katrina and other disasters. Thousand Oaks, CA: Sage. Eagle, G. T. (2005). Therapy at the cultural interface: Implications of African cosmology for traumatic stress intervention. Journal of Contemporary Psychotherapy, 35(2), 199–209. doi:10.1007/s10879-0052700-5 Egan, G. (2010). The skilled helper: A problem-management and opportunity development approach to helping (9th ed.). Belmont, CA: Brooks/Cole, Cengage Learning. Everly, G. S., Lating, J. M., & Mitchell, J. T. (2005). Innovations in group crisis intervention: Critical incident stress debriefing (CISD) and critical incident stress management (CISM). In A. R. Roberts (Ed.), Crisis intervention handbook: Assessment, treatment, and research (3rd ed., pp. 221–245). New York, NY: Oxford University Press.

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Figley, C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner Mazel. Garcia, J. G., Winston, S. M., Borzuchowska, B., & McGuire-Kuletz, M. (2004). Evaluating the Integrative Model of ethical decision-making. Rehabilitation Education, 18 (3), 147–164. Halpern, J., & Tramontin, M. (2007). Disaster mental health: Theory and practice. Belmont, CA: ThomsonBrooke/Cole. Hamilton, M. (2007). Self care and the school counselor. Guidelines, 41(2), 3–6. Hartley, M. T. (in press). Ethics and accountability in rehabilitation: Implications for education, clinical practice, and research. In P. Torriello, M. Bishop, & P. Rumrill (Eds.), New directions in rehabilitation counseling: Creative responses to professional, clinical, and educational challenges. Linn Creek, MO: Aspen Professional Services. Hosin, A. A. (2007). Responses to traumatized children. New York, NY: Palgrave MacMmillan. International Emergency Medical Response Agency. (2011). Disaster response: Responsibilities and ethical considerations for volunteer healthcare providers and psychological professionals. Retrieved from IEMRA website: http://stores.iemra.net/ETHICAL-CONCERNS-DURING-DISASTER-RESPONSE.html Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counseling psychology. The Counseling Psychologist, 12, 43–55. doi:10.1177/0011000084123005 McGee, T. R. (2005). Transforming trauma: A path toward wholeness. Maryknoll, NY: Orbis Books. National Board for Certified Counselors. (1993). A work behavior analysis of professional counselors. Greensboro, NC: Author. Newman, E., Risch, E., & Kassam-Adams, N. (2006). Ethical issues in trauma-related research: A review. Journal of Empirical Research on Human Research Ethics, 1(3), 29–46. Nouwen, H. J. M. (1972). The wounded healer: Ministry in contemporary society. New York, NY: Doubleday. Perls, F. S. (1973). The gestalt approach & eye witness to therapy. Palo Alto, CA: Science & Behaviors Books. Shallcross, L. (2010). Treating trauma. Counseling Today, 52(10), 26–35. Sommer, C. A. (2008). Vicarious traumatization, trauma-sensitive supervision, and counselor preparation. Counselor Education and Supervision, 48 (1), 61–71. Sommers-Flanagan, R. (2007). Ethical considerations in crisis and humanitarian interventions. Ethics & Behavior, 17(2), 187–202. Sommers-Flanagan, R., & Sommers-Flanagan, J. (2008). Advanced ethical considerations in the use of evidenced-based practices and crisis/humanitarian work. In G. R. Walz, J. C. Bluer, & R. K. Yep (Eds.), Compelling counseling interventions: Celebrating VISTAS’ fifth anniversary (pp. 259–269). Ann Arbor, MI: Counseling Outfitters. Stebnicki, M. A. (2008). Empathy fatigue: Healing the mind, body, and spirit of professional counselors. New York, NY: Springer Publishing. Sumathipala, A., & Siribaddana, S. (2005). Research and clinical ethics after the tsunami: Sri Lanka. The Lancet, 366(9495), 1418–1420. Tarvydas, V. M. (2012). Ethics and ethical decision making. In D. R. Maki & V. M. Tarvydas (Eds.). The professional practice of rehabilitation counseling (pp. 339–370). New York, NY: Springer Publishing. Tarvydas, V., Cottone, R. R., & Saunders, J. S. (2010). Editorial: A new ethics code as a tool for innovations in ethical practice. Journal of Applied Rehabilitation Counseling, 41(2), 3–4. Teahen, P. R. (2011). Mass fatalities: Managing the community response. New York, NY: Taylor Francis. Webber, J. M., & Mascari, J. B. (2009). Critical issues in implementing the new CACREP standards for disaster, trauma, and crisis counseling. In G. R. Walz, J. C. Bleuer, & R. K. Yep (Eds.), Compelling counseling interventions: VISTAS 2009 (pp. 125–138). Alexandria, VA: American Counseling Association. Wicks, R. J. (2006). Overcoming secondary stress in medical and nursing practice: A guide to professional resilience and personal well-being. New York, NY: Oxford University Press. Wicks, R. J. (2007). The resilient clinician. New York, NY: Oxford University Press. Zunin, L. M., & Myers, J. D. (2000). Phases of disaster. In D. J. Dewolfe, Training manual for mental health and human services workers in major disasters (2nd ed.). Washington, DC: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.

CHAPTER 31

Vicarious Traumatization JO ANN JANKOSKI

INTRODUCTION Of all the different careers from which you and I could have chosen, why did we select the professional human services field? What was your thinking or reasoning when you chose to become a professional counselor, social worker, or other human service provider? Each one of us was led by some motivation—wanting to make a difference in the world; advocating for others and promoting social justice issues; responding to emergencies; working in criminal justice; serving as a caseworker for children and adolescents; working with victims of domestic violence; helping returning soldiers; working with victims of physical, sexual, or drug and alcohol abuse; or working to prevent suicides. The list goes on. I know that each one of you has made (or will make) a difference, but to what cost to yourself? Through our educational programs, we all receive the knowledge and skills necessary to care for others and to respond to their emotional needs; however, we receive very little, if any, training regarding care for ourselves. Our master’s programs prepare us with theories, research, interventions, practicums, and internships. One of the most important skills we are taught and which we use on a daily basis is active listening. In fact, the foundation of the human service profession is listening and our willingness to be present with the individuals whom we serve. An interesting side note here is the Chinese symbol for listening; notice that the symbol for “to listen” includes not only you but also your ears, eyes, heart, and undivided attention (Figure 31.1). Active listening, to be more specific, teaches “how to listen” so that we may fully understand the world in which our clients live. What our masters programs often do not teach us is the impact trauma has, not on the victims we serve, but on us—the human service professionals. Were you prepared for the emotional impact of listening, seeing, or responding to the human pain to which you must bear witness each day? Have you ever heard, “how do you do that every day?” or “I couldn’t do what you do.” Have you ever left work in the middle of your workday, screened your calls at home, or continued to think about one of your clients, wondering if he or she is okay? Have you become cynical about those you serve? These are all part of the “occupational hazards” we face for knowing, caring, and acknowledging the reality of trauma (Saakvitne & Pearlman, 1996).

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Figure 31.1 The Aspects of Listening

“TO LISTEN” Ear

You Eyes Undivided Attention

Heart

THE FIELD OF PSYCHOTRAUMATOLOGY Traumatic experiences are one of the few phenomena that have no boundaries, are not culturally specific, ignore age, are not prejudiced or biased, and are not gender specific. In reviewing the literature within the field of psychotraumatology, the continuing controversy about helping-induced trauma is not “can it happen?” but rather, “what shall we call it?” (Stamm, 1997, 2009). Van der Kolk and McFarlane (1996) discussed trauma as it has related to the history of the world: Experiencing trauma is an essential part of being human; history is written in blood. Although art and literature have always been preoccupied with how people cope with the inevitable tragedies of life, the large-scale scientific study of the effects of trauma on body and mind has had to wait till the latter part of this century. (p. 3) In 1997, the former Director of the National Center for Posttraumatic Stress Disorder (NCPTSD), H. B. Stamm, addressed the effects of trauma on those in helping roles. He said “it is apparent that there is no routinely used term to designate exposure to another’s traumatic material by virtue of one’s role as a helper” (NCPTSD, 2007; Stamm, 1997, p. 1). There are four primary terms—countertransference (CT); compassionate fatigue (CF), later renamed secondary traumatic stress (STS); burnout; and vicarious trauma (VT)—which are most commonly used in an attempt to describe the impact of another’s trauma on the helper; however, the debate over terminology continues. The primary focus of that debate is involved in describing the emotional toll of working in high stress, seemingly hopeless situations with people who suffer emotional pain (Corey, Corey, & Callanan, 2010; Figley, 1995; Maslach, 1982; McCann & Pearlman, 1990a, 1990b; Saakvitne & Pearlman, 1996).

THE FOUR CONCEPTS We, as human service professionals, interact with traumatized individuals in our daily work; it is part of the routine, if unwritten, job description. The traumatized individuals

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with whom we work most often seek a safe environment—a therapeutic sanctuary— in which they eventually engage in an interpersonal relationship in order to move toward recovery so that the “stressful” experience is integrated within their ego structure in ways that are no longer disruptive of normal functioning or distressing to the individual (Herman, 1992). As in any therapeutic setting, the establishment of a trusting and safe environment is paramount; however, the helper is not an “outside observer.” Rather, achieving empathy with one’s client requires the ability to project oneself into the “phenomenological world being experienced by another person” (Wilson & Lindy, 1994, p.7). This, indeed, affects the helper. The discussion remains: What shall we call this effect on the helper?

Countertransference One of the terms often used to refer to the effects another’s trauma may have on the helper is countertransference (CT). This term originated with Freud in 1910 and has traditionally referred to “the reciprocal impact that the patient and the therapist have on each other during the course of psychotherapy” (Wilson & Lindy, 1994, p. 9). Although Freud never clearly addressed his meaning of CT, he used the condition in a negative sense. Freud’s two specific references to CT caution the clinician to “overcome” it (1910) and to keep it “in check” (1915). Freud’s position on CT insinuated that the clinician’s reaction was based on his or her own unresolved conflicts (Gorkin, 1987). By the very nature of our humanness, we can become fascinated from hearing the horrific stories our clients have shared with us. Being human, we could become sexually aroused or excited or even curious about our clients’ experiences (Davies & Frawley, 1994). Once this unconscious fascination is brought to the clinician’s attention, he or she often experiences feelings of shame, guilt, and/or shock (Neumann & Gamble, 1995). Karen Saakvitne (1990) introduced the term container countertransference to explain one form of CT experienced by some therapists. Clinicians are often asked to respond to a client’s impaired capacity to manage and tolerate strong affect (Neumann & Gamble, 1995). The clinician may feel defeated when the client is unable to voice his or her inner experience or by the client’s tendency to vacillate between controlling affect regulation and dramatic emotional abreactions. Caseworkers, therapists, and other professionals who work with the traumatized may encounter CT themes which, if left unaddressed, could affect the clinician in various ways. For example, some professionals may experience the “rescue fantasies with intense preoccupation with their clients,” “a strong need not to fail their clients,” or a sense of “insecurity regarding one’s own professional competency” (Neumann & Gamble, 1995, p. 342). Although container CT may explain some emotional problems that affect human service professionals, it does not address all helper issues.

Compassion Fatigue/Secondary Traumatic Stress In an effort to address the stress experienced by human service professionals, Charles Figley (1995) coined the phrase compassion fatigue, later referred to as secondary traumatic stress (STS). Figley stated that there is a “cost of caring” (p. 10); that is, those individuals who care for others often undergo pain as a consequence of their exposure to others’ traumatic material. Figley defined STS as “the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person” (p. 12). In the latter part of the twentieth century, a plethora of studies with references to secondary trauma were conducted. Those studies were

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primarily dedicated to the traumatization of crisis workers, firefighters, police, rescue workers, and emergency medical technicians and therapists (e.g., Horowitz, Wilner, Kaltreider, & Alvarez, 1980; McCann & Perlman, 1990b; Raphael, Singh, Bradbury, & Lambert, 1983–1984; Weiss, Marmar, Metzler, & Ronfeldt, 1985). Figley (1999) stated that STS was a natural consequence of working with individuals who had undergone intensely stressful events, contending that STS developed as a result of two things—the clinician’s exposure to the client’s experiences and the clinician’s empathetic engagement with the client. Figley (1995) proposed that family, friends, and professionals are vulnerable to developing traumatic stress symptoms from being empathetically engaged with victims of traumatic events. Other researchers of the late twentieth century (e.g., Danieli, 1994; Dyregrov & Mitchell, 1992; Herman, 1988; McCann & Pearlman, 1990a, 1990b; McFarlane, 1986; Munroe, 1990; Pearlman & Saakvitne, 1995a; Pynoos & Eth, 1985; Stamm, 1997, 1999) also contended that traumatic stress symptoms were contagious, creating parallel effects in those who work with trauma victims. Professionals who choose to work with individuals and their traumatic material undergo the same cluster of traumatic stress symptoms as do the victims of those traumatic events (Beaton & Murphy, 1995; Dyregrov & Mitchell, 1992; Figley, 1995; Horowitz, 1974; Pearlman & Saakvitne, 1995a; Sexton, 1999; Wilson & Lindy, 1994). The symptoms can include sleep disturbances, flashbacks, nightmares, irritability, anxiety, and a sense of loss of control. Trauma and its impact, frequency, and duration vary from person to person; the impact on the professional community is no different. There is an undeniable relationship between the longevity of a career, high caseloads, the intensity and repeated exposure to clients’ traumatic material, and long hours to stress traumatic symptoms (Beaton & Murphy, 1995; Chrestman, 1999; Cornille & Meyers, 1999; Munroe, 1990; Pearlman, 1999).

Burnout Along with the concepts of CT and secondary trauma, burnout is another idea that has been used to explain the influence of working with people. Burnout has a negative connotation attached to it. Initially, the term burnout referred to the consequences of prolonged drug abuse. Because of this, the concept of burnout is sometimes associated with individuals who are addicted to drugs. Freudenberger (1975) is given credit for introducing the term burnout in the human service realm. His model of burnout emphasized an individual psychology, whereas Christine Maslach (1982) studied burnout from a social-psychological perspective with the focus on the connection between environmental and individual circumstance. Maslach (1982), one of the first psychologists to perform research in the area of burnout, reported more than 30 definitions and descriptions of the term. She stated that burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do “people work” of some kind. It is a response to the chronic emotional strain of dealing extensively with other human beings, particularly when they are troubled or having problems. (p. 3)

Vicarious Traumatization and the Constructivist Self-Development Theory One does not need to be a professional to experience STS disorder. Family members, friends, coworkers, or any individual who hears, sees, or learns about the toll a traumatic

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event has on a victim can exhibit PTSD-like symptoms. Although CT, STS disorder, and burnout are significant concepts to assist us in understanding trauma and its impact, none of these concepts address how knowing about another’s trauma, hearing about it, or seeing a traumatic event changes us as people. We, as human service professionals, have chosen our particular area of specialization so that we may help others. But to what cost to the helpers? How do we make meaning out of the violence inflicted by other humans? What would cause someone to intentionally burn a child with a cigarette on the child’s arm or face, shake a baby so violently that the child suffers cerebral hemorrhaging, or place a child on a hot stove to discipline the child? We, as helpers who empathically engage with our clients as they undertake their healing journeys, must be cognitively aware that we can become “hidden victims” in the healing process of others (Duckworth, 1991; Paton, 1989). Figley (1985) conceptualized trauma as the response rather than the stressor related to a situation. He stated that trauma is an “emotional state of discomfort and stress resulting from memories of an extraordinary, catastrophic experience which shattered the survivor’s sense of invulnerability to harm” (p. 35). McCann and Pearlman (1990a) went further and defined trauma as an individual’s “psychological response” to a situation, adding that it can result in a “paralyzed, overwhelmed state, with immobilization, withdrawal, possible depersonalization, and “evidence of disorganization” (p. 13). McCann and Pearlman (1990a, 1990b) have clearly stated that the concepts of burnout and CT are insufficient when trying to understand the impact of trauma work on clinicians. Instead, they proposed a new concept, vicarious traumatization (VT), in an attempt to describe and articulate the repercussions of trauma and its consequences on therapists. VT refers to the transformation that occurs in a therapist’s persona and results from the therapist’s empathic engagement with the exposure of another person’s trauma material (Pearlman & Mac Ian, 1995; Pearlman & Saakvitne, 1995b). It must be remembered that VT can affect any individual in any walk of life; that is, the affected individual need not be a therapist. We will discuss the impact on therapists and other professional human service workers in this chapter. In the therapist, the trauma and its impact are marked by unique individual reactions to the client’s experience and are determined by the meaning assigned to the trauma by the therapist. Stated another way, this means that the clinician’s response is based on both personal characteristics, including cognitive schemas and situational factors, such as the traumatic material presented by the client (Pearlman & Mac Ian, 1995; Pearlman & Saakvitne, 1995b). The concept of VT itself is based on a theory developed by McCann and Pearlman, the constructivist self-development theory (CSDT), a “developmental, interpersonal theory explicating the impact of trauma on an individual’s psychological development, adaptation, and identity” (Pearlman & Saakvitne, 1995b, p. 152). Hence, VT is an interactive approach to understanding the impact of trauma on the counselor, social worker, or human service professional and may allow for a more detailed understanding of the individual experiences of the professionals. McCann and Pearlman (1990a) stated that “persons who work with victims may experience profound psychological effects, effects that can be disruptive and painful for the helper and can persist for months or years after work with traumatized persons. This process is called ‘vicarious traumatization’” (p. 133). Prior to presenting their theory, McCann and Pearlman reviewed several leading theories—self-psychology (Kohut, 1977), social learning theory (Rotter, 1954), and

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developmental theory (Mahler, Pine, & Bergman, 1975). Although CSDT draws largely from developmental social cognition theories, McCann and Pearlman adopted several ideas from the preceding theories in an attempt to develop a comprehensive personality theory with a constructivist perspective. The major underlying premise of CSDT is that individuals possess an inherent capacity to construct their own personal realities as they interact with their environment. This constructivist position asserts that human beings actively create their representational models of the world” (McCann & Pearlman, 1990a, p. 6). Within CSDT, McCann and Pearlman (1990a, 1990b) focus on three psychological systems: (1) the self (or the individual’s sense of himself/herself as a knowing, sensing, understanding with complete capacities to regulate self-esteem and ego resources to negotiate relationships with others); (2) psychological needs (which motivate behaviors); and (3) cognitive schemas (or conceptual frameworks for organizing and interpreting experience). (p. 6) Their propositions are in agreement with the fi ndings of several following theorists—Julian Rotter (social learning theory; 1954); George Kelly (personal construct theory; 1955); Aaron Beck (cognitive theory of depression; 1967); Jean Piaget (structural theory; 1970, 1971); James Mancuso (whose work synthesizes the work of Kelly and Piaget; 1977); Seymour Epstein (cognitive-experiential self-theory; 1980); Michael Mahoney (cognitive constructivism; 1981); and Mahoney and Lyddon (cognitive constructivism; 1988). Each of these theories focused on an individual’s active participation in making sense of their life experiences through the development of cognitive structures (schemas). Several conceptualizations referring to the self existed prior to McCann and Pearlman’s work (e.g., Jung, 1960; Kohut, 1977). However, McCann and Pearlman (1990a) defined self as a hypothetical construct we use to describe the psychological foundation of the individual. We view the self as the seat of the individual’s identity and inner life. The self comprises: (a) basic capacities whose function is to maintain an inner sense of identity and positive self-esteem; (b) ego resources, which serve to regulate and enhance one’s interactions with the world outside oneself; (c) psychological needs, which motivate behavior; and (d) cognitive schemas, which are the beliefs, assumptions, and expectations, both conscious and unconscious, through which individuals interpret their experiences. The self develops as a result of reflection, interactions with others, and reflection upon those interactions (pp. 16–17) There are five self-capacities within CSDT that allow an individual who has been traumatized to keep a constant sense of identity and self-esteem. The fi rst category is denoted as aspects of the self and their functions ; these regulate self-esteem and include the ability to tolerate strong affect, the ability to be alone without being lonely, the ability to calm oneself, and the ability to regulate self-loathing. The second category is labeled as ego resources and includes those items, which regulate interactions with others—intelligence; introspection; willpower; initiative; empathy; awareness

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Table 31.1 Five Self-Capacities of Constructivist Self Development Theory CSDT Category

Identifying Markers

Frame of reference

Identity, world view, spirituality

Self-capacities

Affect, tolerance interconnections with others, sense of self as viable

Ego resources

Self-awareness, skills, interpersonal, and self-protective skills

Psychological needs and cognitive schemas

Safety, self-esteem, trust, control, intimacy

Memory and perceptions

Narrative, memory, visual images, affective, sensory, interpersonal

of psychological needs; and the ability to strive for personal growth, take perspective, foresee consequences, establish mature relations with others, establish healthy boundaries, and make self-protective judgments. The third category, psychological needs, refers to those items, which motivate behaviors—frame of reference, safety, trust/dependency, esteem, independence, power, and intimacy. The fourth category, cognitive schemas, describes those characteristics that organize one’s experiences of self and the world. Included in this area are beliefs, assumptions, and expectations related to psychological needs. The fi nal category is called memory and perceptions and describes the narrative of one’s experience, which includes the sensory, somatic, visual, affective, and behavioral reactions. This last category is the most disturbing capacity for therapists and the one that most often brings therapists to treatment (McCann & Pearlman, 1990a). These categories and their identifying markers are listed in Table 31.1. The essential premise of CSDT is that human beings construct their own personal realities through the development of complex cognitive structures, which are used to interpret events. These cognitive structures are constantly evolving and become increasingly complicated as individuals interact with their environment (McCann & Pearlman, 1990b). These cognitive structures were described earlier as schemas by Piaget (1971) and include beliefs, assumptions, and expectations about self and world that enable individuals to make sense of their experiences. Therapists working with trauma victims may experience intrusive images and generate a heightened sense of vulnerability (Danieli, 1988; Figley, 1995; Haley, 1974; Herman, 1992; McCann & Pearlman, 1990a). Figley (1995) has stated that working with traumatized clients consists of “absorbing information that is about suffering” and that this process requires “absorbing the suffering as well” (p. 2). VT addresses the interplay between traumatic events, the therapist’s cognitive schemas about self and the world, and their ability to adapt. This concept is not limited to trauma work. Professionals in all human service fields will experience personal and professional changes; the effects of VT are cumulative and may become permanent if not addressed. This is a direct result of the interaction of the traumatic material shared by the client and the personal attributes of the therapists (Pearlman & Mac Ian, 1995; Pearlman & Saakvitne, 1995a). There are various signs and symptoms of VT, which include those listed in Table 31.2. VT affects the way one acts and interacts with others at work, at home, and within the community.

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Table 31.2 Vicarious Trauma: Signs and Symptoms General Changes

Specific Changes

-No time or energy for oneself

-Disrupted frame of reference

-Disconnected from loved ones

-Changes in identity, world view, spirituality

-Social withdraw

-Diminished self-capacity

-Increased sensitivity to violence

-Impaired ego resources

-Cynicism

-Disrupted psychological needs and cognitive schemas

-General despair and hopelessness

-Intrusive image’s, depersonalization

-Nightmares

-Altercations to one’s sensory experiences

-Screening phone calls -Sense of depression -Physical problems (aches, pain, lower GI disturbance, etc.)

COUNSELING IMPLICATIONS We live in a violent world where people of all racial identities, ethnic backgrounds, genders, ages, and sexual preferences can fall victim to some type of trauma—rape, vehicle accidents, casualty of war, racism, bullying, domestic violence, or sexual abuse. The list goes on. Recently, there has been an increase of victims seeking treatment from professionals to assist them in their journey of healing. But at what cost to the therapist, counselor, social worker, psychologist, school counselor, or other helper who serves witness to another individual’s sustained horror? VT has three different, but important, implications for the counseling field. First, the human service professions are currently fighting the ongoing battle of recruitment and retention. Administrators and supervisors must focus on the most important commodity within their agencies—their staffs. Here, the staff includes the professional staff, from administrators and supervisors to frontline workers; support staff, from those who answer the phones and type the reports to the individuals who maintain the physical facility; and ancillary individuals, such as foster parents who provide for displaced children. I have personally served as a consultant with various human service agencies. They have reported low morale, high absenteeism, high turnover rates, and negative attitudinal changes, emotional displays, disclosures regarding changes in familial relationships, shared comments regarding imprinted memories of traumatic events, jaded and cynical attitudes concerning the provision of services, medical disturbances (e.g., lower gastrointestinal pain and high blood pressure), depressive symptoms, and other similar complaints. Comments reported from the staff included: “I can’t do this anymore; I can’t get the pictures of that child out of my mind. I’m even afraid to pick up my own child.” “That family has been in the system before. Why waste our time on them; they are not going to change.” “I don’t trust anyone anymore. This is not a safe world to live in.” “I can’t get the smell of burning flesh out of my head. I smell it everywhere.” To address these and similar issues, we must introduce the concept of VT in the human service professions. This includes any profession in which individuals work with people. VT has gone undetected, unrecognized, and unaddressed (Jankoski, 2002, 2010)

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and is the culprit affecting the human service system and the individuals who work throughout the system. Agencies must offer forums for staff to discuss and share the difficulties of the job and the emotional toil it takes on each individual. They also must establish debriefing teams who can respond or debrief a staff person who may have experienced a traumatic event. A professional who worked in a mental health agency shared an exchange between herself and her supervisor: “I can’t believe no one in my agency asked me if I was okay, after being verbally and physically assaulted by a client. My supervisor told me it was all part of the job, and I was supposed to ‘move on!’” Supervisors are important contributors who not only assist in the development of professionals but also have an ethical responsibility to check in with their supervisees to ensure that each one is mentally, emotionally, and physically well. Supervisors must be aware of the caseloads their supervisees are carrying and the type of clients they are serving. Organizations must provide a venue through which staff may process difficult situations and not view personnel as weak when they use that venue. Organizations also must offer training opportunities on VT, its signs and symptoms, and ways in which it may be ameliorated. As vital as supervisors are, they often become so overwhelmed with administrative tasks that they never recognize the pain—mental, emotional, or physical—experienced by members of their staffs. The time has come for supervisors to vigilantly examine the overall health of their staffs and assist those who need help in maintaining their wellbeing. Although VT is an “occupational hazard,” we, as human service professionals, owe it to each other and those whom we love to not be damaged by the work we chose to do! If agencies/organizations stand back and do nothing, we will continue to experience the “revolving door syndrome,” whereby we are always trying to fill vacancies within our organizations. The second implication for the counseling field is vicarious evil, an invisible condition that has the potential of tearing away the fiber of one’s soul. Unaware of its existence, it can reside in the wounded counselor, social worker, emergency medical technician, teacher, police officer, judge, nurse, doctor, soldier—anyone who deals with people on a daily basis. The evil about which I am speaking is not the evil you associate with serial killers and tyrannical dictators; rather, it is a different kind of evil—one that results in a personality change in which one becomes jaded without realizing it—where we develop a protective shell around ourselves so we cannot feel anything, where we become indifferent and lose our sense of hope, and where we wear invisible blinders so that we cannot see the evil that exists around us. Can you relate to this type of evil? We always “act” as if everything is fine; we are the professionals who are supposed to have all the answers. We are not a brick wall! We have thoughts, feelings, and opinions that must be honored. We, individually and as a profession, must acknowledge that vicarious evil exists. We can no longer ignore the emotional consequences of working with others. We must, as individuals, colleagues, and professionals, combat this complacency that we have regarding self-care because by not doing so, we have the potential of causing harm, thus violating one of our core moral principles—do no harm. This brings us to our third implication, the potential to harm our clients. This third implication is closely tied to the first two. If we do not recognize that we are suffering from VT; have no support in ameliorating it; become so jaded, detached, or cynical that we no longer empathize with our clients; or loose the sense of hope that so many of our clients need to hear, we are doing them a grave disservice. When we professionals become so overwhelmed by the ugliness of the world that we tend to not see the person

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who is sitting before us, we must take the action necessary to heal ourselves. We cannot allow our VT to further harm those whom we are professionally obliged to help.

ESTABLISHING RESOURCES We have a “gift” for working with others, we give freely of ourselves, but are we aware of what is happening within us? Are others aware of the subtle changes within you? “John, you have changed since you started working there” or “You’re not the same person” are comments that have been shared by human service professionals. If you truly wanted to know the impact of you job on your growing self, ask the most important people in your life: What do you notice, if anything, that is different about me? Will you be surprised by their responses? Are all human service professionals changed by their work? I believe they are. How can you not be changed when you are choosing to sit with a person, listening to their struggles and pain? Prevention and intervention for VT requires intentional and comprehensive effort on our part. VT is a process not a one-time event; its effects are cumulative; and it is based on repeated exposure to another’s emotional pain. Ignoring VT will gradually change our beliefs about ourselves and our worldview, and its effects can be permanent. With that said, VT and its effects can be modified! One of the most difficult resources to access for counselors, social workers, and the like is help for themselves. Each one of us tends to believe we can handle anything and everything, particularly when it is someone else’s problem we are trying to help them solve. Let us be honest—we have learned great skills in our graduate programs in order to take care of others, but we learned little regarding the care of ourselves. We are not weak; we are human beings responding to the everyday pain and loss of those we serve. Every good therapist needs a therapist; we are not crazy, we just hurt from the pain we hear and see in others. Self-care is an individualized process. Find what works for you. A good starting place for anyone is by taking the Professional Quality of Life: Compassion Satisfaction and Fatigue (ProQOL) Test Version 5 (2009) created by B. Hudnall Stamm. This self-inventory has 30 questions, which are answered by using a Likert-type scale. It is easy to score and will assist anyone along their journey of self-care. In addition of Stamm’s ProQOL, there are several tools that have been established to assist us in finding a balance between work and emotional health. Constructing a personal self-care plan (PSCP; Norcross & Guy, 2007; Wolpow, 2011; Yassen, 1995) is one such tool, which allows any individual to create a self-care plan. Initially, increasing one’s awareness of the emotional tool to regularly engage in those activities—physical, emotional, cognitive, social, financial, and spiritual—needed foster resilience (Wolpow, 2011) in order to cope with the emotional pain we see on a daily basis. PSCP addresses nine domains that guide you to honestly look at yourself and to set achievable goals; the PSCP includes physical exercise; nutrition and hydration; sleep and rest; assertiveness; centering and solitude; creativity, fun, and enjoyment; providing and receiving support; and the establishment of personal goals. Srdanovic (2007) and Clemans (2004) introduced the ABCs (awareness, balance, and connection) of preventing VT. Awareness (A) involves becoming a reflective practitioner, giving oneself permission to look within and to conduct a self-assessment to determine the effects of VT. Supervision, journaling, peer support, and soliciting feedback from family regarding what they are seeing and experiencing with their loved one are all ways in which the therapist can become a reflective practitioner. The practitioner must determine what is important in his or her life. This includes making oneself a priority in one’s own life and establishing health boundaries. This is all part of the balance (B) one must have in life. Connection (C) is important in anyone’s

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life, particularly that of a therapist who is regularly exposed to others’ trauma. In addition to family and friends, one must establish relationships with colleagues because none of us can do this work alone. To lessen the shame and the isolation felt by clinicians and to increase their coping skills and retention, organizations need to consider providing open forums where VT can be openly discussed. Professionals leave the field because they feel “undervalued” (Jankoski, 2002, 2010). When workers feel “valued” by their administrators and supervisors, there is an increase of job satisfaction. Organizations can establish rapid response teams consisting of trained staff to be mobilized when needed to support other staff members who may have experienced a traumatic event—as defined by them. The goal is to keep the competent, well-trained staff within the organization. We are not robots. For an organization to ignore their staff members’ emotional pain is to do them an injustice.

CONCLUSION You will change by virtue of the work you have chosen to do—work with individuals. Your change may be positive or it may be negative at different times during your career, indeed, at different times of your workday. We all have an ethical responsibility to our families, friends, colleagues, and clients to not be damaged by the work we have chosen to do. You have a special gift to be shared with many people, and every day you will make a difference—one person at a time. With that said, we must take care of ourselves—physically, emotionally, financially, and spiritually. Self-care is not an option; it is our personal and professional responsibility to address our own emotional pain. Each one of us who are committed to making a difference in a life of any individual who are at risk to be affected and to experience VT.

DISCUSSION QUESTIONS Either in groups or as an individual journaling assignment, reflect on the following questions: 1. 2. 3. 4. 5. 6.

How have you changed since you started your job? If so, how? How do you define a traumatic event? What do you do when you experience a traumatic incident? With whom do you process regarding your job? How do you balance self-care and work? What do you do for fun?

RESOURCES Websites Association of Traumatic Stress Specialist (http://www.atss.info) Charles Figley Institute (http://www.figleyinstitute.com/) Green Cross Foundation (http://www.greencross.org/) International Critical Incident Stress Foundation (http://www.icisf.org/) Suzanne E. Harrill inspires (http://www.innerworkspublishing.com/news/vol1/selfcare.htm)

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Publications Baranowsky, J., Gentry, E., & Franklin Schultz, D. (2005). Trauma practice, tools for stabilization and recover. Cambridge, MA: Hogrefe. Rothschild, B., & Rand, M. (2006). Help for the helper: Self-care strategies for managing burnout and stress. New York, NY: Norton. Saakvitne, K., & Perlman, L. A. (1996). Transforming the pain: A workbook on vicarious traumatization. New York, NY: Norton. Stamm, B. H. (1999). Secondary traumatic stress: Self-care issues for clinicians, researchers and educators. Baltimore, MD: Sirdan Press.

REFERENCES Beaton, R. D., & Murphy, S. A. (1995). Working with people in crisis: Research implications. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 51–81). New York, NY: Brunner/Mazel. Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York, NY: Harper & Row. Chrestman, K. R. (1999). Secondary exposure to trauma and self reported distress among therapists. In B. H. Stamm (Ed.), Secondary traumatic stress: Self care issues for clinicians, researchers and educators (2nd ed., pp. 37–47). Lutherville, MD: Sidran Press. Clemans, S. E. (2004). Understanding vicarious traumatization: Strategies for social workers. Social Work Today, 4 (2), 13. Corey, G., Corey, M. S., & Callanan, P. (2010). Issues and ethics in the helping professions (8th ed.). Pacific Grove, CA: Brooks/Cole. Cornille, T. A., & Meyers, T. W. (1999). Secondary traumatic stress among child protective service workers: Prevalence, severity and predictive factors. Traumatology, 5, 1–17. Retrieved from http:// www.fsu.edu/~trauma/art2v5i1.htm Danieli, Y. (1988). Confronting the unimaginable: Psychotherapists’ reactions to victims of the Nazi Holocaust. In J. P. Wilson, Z. Harel, & B. Kahana (Eds.), Human adaptation to extreme stress (pp. 219–238). New York, NY: Plenum Press. Danieli, Y. (1994). Countertransference, trauma, and training. In J. P. Wilson & J. D. Lindy (Eds.), Countertransference in the treatment of PTSD (pp. 368–388). New York, NY: Guilford Press. Davies, J. M., & Frawley, M. G. (1994). Treating the adult survivor of childhood sexual abuse: A psychoanalytic perspective. New York, NY: Basic Books. Duckworth, D. (1991). Facilitating recovery from disaster-work experiences. British Journal of Guidance and Counselling, 19 (1), 13–22. Dyregrov, A., & Mitchell, J. T. (1992). Work with traumatized children—Psychological effects and coping strategies. Journal of Traumatic Stress, 5(1), 5–17. Epstein, S. (1980). The self concept: A review and the proposal of an integrated theory of personality. In E. Staub (Ed.), Personality: Basic issues and current research (pp. 82–132). Englewood Cliffs, NJ: Prentice Hall. Figley, C. R. (Ed). (1985). Trauma and its wake: The study and treatment of post-traumatic stress disorder (Vol. 1). New York, NY: Brunner-Mazel. Figley, C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 1–20). Bristol, PA: Brunner/Mazel. Figley, C. R. (1999). Compassion fatigue: Toward a new understanding of the costs of caring. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, & educators (2nd ed., pp. 3–28). Lutherville, MD: Sidran Press. Freudenberger, H. J. (1975). The staff burn-out syndrome in alternative institutions. Psychotherapy: Theory, Research and Practice, 12(1), 73–82. Gorkin, M. (1987). The uses of countertransference. Northvale, NJ: Jason Aronson. Haley, S. A. (1974). When the patient reports atrocities. Specific treatment considerations of Vietnam veteran. Archives of General Psychiatry, 30, 191–196.

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Herman, J. L. (1988). Father-daughter incest. In F. Ochbery (Ed.), Post traumatic therapy and victims of violence (pp. 175–195). New York, NY: Brunner/Mazel. Herman, J. L. (1992). Trauma and recovery. New York, NY: Basic Books. Horowitz, M. (1974). Stress response syndromes. Character style and brief psychotherapy. Archives of General Psychiatry, 31, 769–781. Horowitz, M., Wilner, N., Kaltreider, N., & Alvarez, W. (1980). Signs and symptoms of post-traumatic stress disorder. Archives of General Psychiatry, 37(1), 85–92. Jankoski, J. A. (2002). Vicarious traumatization and its effect on the Pennsylvania child welfare system. (Doctoral dissertation, Duquesne University, Pittsburgh, PA). Jankoski, J. A. (2010). Is vicarious trauma the culprit? A study of child welfare professionals. Child Welfare Journal, 89 (4), 105–120. Jung, C. G. (1960). The structure and dynamics of the psyche. New York, NY: Pantheon. Kelly, G. A. (1955). The psychology of personal constructs. New York, NY: Norton. Kohut, H. (1977). The restoration of self. New York, NY: International Universities Press. Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York, NY: Basic Books. Mahoney, M. J. (1981). Psychotherapy and human changes processes. In J. H. Harvey & M. M. Parks (Eds.), Psychotherapy research and behavior change (pp. 77–122). Washington, DC: American Psychological Association. Mahoney, M. J., & Lyddon, W. J. (1988). Recent developments in cognitive approaches to counseling and psychotherapy. The Counseling Psychologist, 16, 190–234. Mancuso, J. C. (1977). Current motivational models in the elaboration of personal construct theory. Lincoln: University of Nebraska Press. Maslach, C. (1982). Burnout: The cost of caring. New York, NY: Prentice-Hall. McCann, I. L., & Pearlman, L. A. (1990a). Psychological trauma and the adult survivor: Theory, therapy, and transformation. New York, NY: Brunner/Mazel. McCann, I. L., & Pearlman, L. A. (1990b). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3 (1), 131–149. McFarlane, A. C. (1986). Posttraumatic morbidity of a disaster: A study of cases presenting for psychiatric treatment. Journal of Nervous and Mental Disease, 174, 4–14. Munroe, J. F. (1990). Therapist traumatization from exposure to clients with combat related post-traumatic stress disorder: Implications for administration and supervision. Unpublished doctoral dissertation— Northwestern University, Evanston, IL. National Center for Post-Traumatic Stress Disorder. (2007). Working with trauma survivors: What workers need to know. Retrieved from http://www.ptsd.va.gov/professional/pages/working-with-traumasurvivors.asp Neumann, D. A., & Gamble, S. J. (1995). Issues in the professional development of psychotherapists: Countertransference and vicarious traumatization in the new trauma therapist. Psychotherapy, 32(2), 341–347. Norcross, J. C., & Guy, J. D. (2007). Leaving it at the office: A guide to psychotherapist self-care. New York, NY: Guilford Press. Paton, D. (1989). Disasters and helpers: Psychological dynamics and implications for counseling. Counseling Psychology, 2(3), 303–321. Pearlman, L. A. (1999). Self-care for trauma therapists: Ameliorating vicarious traumatization. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, & educators (2nd ed., pp. 51–64). Lutherville, MD: Sidran Press. Pearlman, L. A., & Mac Ian, P. S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research and Practice, 26(6), 558–565. Pearlman, L. A., & Saakvitne, K. W. (1995a). Trauma and the therapist: Countertransference and vicarious traumatisation in psychotherapy with incest survivors. New York, NY: Norton. Pearlman, L. A., & Saakvitne, K. W. (1995b). Treating therapists with vicarious traumatization and secondary traumatic stress disorders. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 150–177). Bristol, PA: Brunner/Mazel. Piaget, J. (1970). Structuralism. New York, NY: Harper & Row. Piaget, J. (1971). Psychology and epistemology: Towards a theory of knowledge. New York, NY: Viking.

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Pynoos, R., & Eth, S. (1985). Developmental perspective on psychic trauma in childhood. In C. Figley (Ed.), Trauma and its wake (pp. 36–52). New York, NY: Brunner/Mazel. Raphael, B., Singh, B., Bradbury, L., & Lambert, F. (1983–1984). Who helps the helpers? The effects of a disaster on the rescue workers. Omega, 14 (1), 9–20. Rotter, J. B. (1954). Social learning and clinical psychology. Englewood Cliffs, NJ: Prentice Hall. Saakvitne, K. W. (1990, August). Psychoanalytic psychotherapy with incest survivors: Transference and countertransference paradigms. Paper presented at the American Psychological Association Annual Convention, Boston, MA. Saakvitne, K. W., & Pearlman, L. A. (1996). Transforming the pain: A workbook on vicarious traumatization. New York, NY: Norton. Sexton, L. (1999). Vicarious traumatisation of counsellors and effects on their workplaces. British Journal of Guidance & Counselling, 27(3), 393–403. Srdanovic, M. (2007). Vicarious traumatization: An occupational hazard for helping professionals. Visions: BC’s Mental Health and Addictions Journal, 3 (3), 15–16. Stamm, B. H. (1997). Work-related secondary traumatic stress. PTSD Research Quarterly, 8, 2. Stamm, B. H. (1999). Introduction to the second edition. In Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (2nd ed., pp. xix–xxxi). Lutherville, MD: Sidran Press. Stamm, B. H. (2009). ProQOL: Professional quality of life: Compassion satisfaction and fatigue (Version 5). Retrieved from http://www.proqol.org van der Kolk, B. A., & McFarlane, A. C. (1996). The black hole of trauma. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 3–23). New York, NY: Guilford Press. Weiss, D., Marmar, C., Metzler, T., & Ronfeldt, H. (1985). Predicting symptomatic distress in emergency services personnel. Journal of Consulting and Clinical Psychology, 63, 361–368. Wilson, J. P., & Lindy, J. D. (1994). Empathic strain and countertransference. In J. P. Wilson & J. D. Lindy (Eds.). Countertransference in the treatment of PTSD (pp. 5–30). New York, NY: Guilford Press. Wolpow, R. (2011, June). Stress, trauma, vicarious trauma, compassion satisfaction, compassion fatigue, and burnout: Self-care implications for those who work with perpetrators of hate and their victims. Paper presented at the International Conference of Hate, Spokane, WA. Yassen, J. (1995). Preventing secondary traumatic stress disorder. In C. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 178–208). New York, NY: Brunner-Routledge.

CHAPTER 32

Therapist Self-Care: Being a Healing Counselor Rather Than a Wounded Healer CYNTHIA DIANE RUDICK

INTRODUCTION The purpose of this chapter is to explore the role of self-care among counseling professionals and to illustrate the need for healthy self-interest, especially when working with trauma. This chapter highlights the relationship between counselors and their counseling work, with the hope of addressing some of the tensions involving authentic practice. Counselors want to help trauma survivors to heal, yet we are affected by the awfulness of the impact of clients’ traumatic experiences. Developing greater awareness about this sometime subconscious dialectic can be used to create a more congruent way of living and working with people. Yet such awareness development can instigate additional questions. The questions presented in this chapter are not posed merely as rhetorical subjects for idealistic discussion but rather probing questions are intended to encourage the level of self-exploration necessary to self-actualize as well as to initiate the healing of self and others. “As counselors, we don’t always practice what we preach” (Schwarzbaum, 2010, p. 48). Research shows that 20% to 25% of therapists have never participated in their own therapy (Schwarzbaum, 2010). One common myth is that counselors are immune to problems and can serve as their own therapists (Lawson & Venart, 2005). Another myth is that if a counselor acknowledges personal problems, this may be seen as a threat to the counselor/client relationship (Evans & Payne, 2008). If we are imperfect, how can we help others? An additional concern is that counselors do not always get needed clinical supervision: Supervision is mandated in the training and licensing of counselors but not after we become professionals (Lawson & Venart, 2005). This chapter contains a discussion and a possible direction or road map for counselors to follow in an attempt to stay balanced in a difficult and complex world, especially when working with traumatized clients and particularly at a time when communication can be so immediate. We experience so much more stress today because disaster and tragic events are a click away; however, it is possible to discover an inner strength to combat or insulate us against outer circumstances. Once we distinguish our inner focus, we can then set some goals for our personal discipline. We must spend some time exploring dimensions of our lives to be fully present to others. Balance is a direction, not a destination. And over time, small steps can produce big results. The aim of this chapter is met through discussions of relevant issues that are presented in the following main sections: (a) counselor

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self-care and (b) self-care implications for counselors working with trauma. These main sections are followed by a summary of the chapter and a list of relevant resources.

COUNSELOR SELF-CARE In some ways, counselors are almost like our society’s medicine men and medicine women. They work in uncharted territories to bring comfort and healing to emotional, mental, spiritual, and physical suffering. Often times they neglect an important step in the helper/helping equation: They forget that balance or lack of it is essential in the effectiveness of their work, and balancing self-care and other care is difficult (Skovholt, Grier, & Hanson, 2001). No other profession is so intimately connected to the joys and sorrows, heights and depths of human existence on a daily basis. Due to the intimacy of this work, counselors can be overstimulated to their own parallel pain and grief experiences. Without working on areas that are activated from past wounds and without freeing their levels of awareness to experience life in the present, impairment and burnout can occur. This can have a profound effect on how a counselor is able to balance self and other needs. Even Carl Rogers struggled with this question of balance. He stated that “I have always been better at caring for and looking after others than I have been in caring for myself. But in these later years I made progress” (Rogers, 1995, p. 80). Ours is a profession emphasizing one-way caring and repeatedly creating empathy (Skovholt et al., 2001). This easily can lead to burnout, as selflessness can be exhausting, and intentions alone do not keep us healthy. In fact, research has shown that many counselors experience the same stress and anxiety as their clients (Stebnicki, 2008). The American Counseling Association’s (ACA) Taskforce on Counselor Impairment asserts that “[u]ltimately the care that counselors provide others will only be as good as the care they provide themselves” (ACA, n.d., para. 9). Counselors can teach and preach from an authoritarian perch and separate themselves from the “shoulds” they verbally or nonverbally impose on others. But it seems dishonorable to neglect their own work when telling others to do theirs. The deeper they work with clients, the more devastated they are by life, and the more their own core pain can be triggered if they have not cleared their own paths. Working with severe trauma can be traumatizing for helpers in many ways. Old wounds can be reopened; thus, one’s own work must hopefully be a lifelong process. Counselor self-care raises a number of social and existential issues. In the remaining parts of this section, I discuss the stigma of therapy work, the role of the counselor in the healing process, and how trauma work can be traumatic.

The Stigma of Therapy Work The helping profession is an honorable work, and mental health workers are engaged in serving others. In counselor training programs, encouragement to address therapeutic issues may be present. However, when participants admit vulnerability to their own internal problems, there is often a stigma attached. A complex relationship exists between the encouragement to do one’s work and the acceptance or lack of judgment by self and others if one actually embarks on that journey. It is interesting that self-help is emphasized so much in our society. It is a lucrative business. Yet, again, counseling professionals have a complicated, ambivalent

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relationship with their own self-help. It is as if doing this work may imply a defect. Attending personal therapy is often seen as a failure (Norcross & Brown, 2000). Psychotherapy can be a demanding calling. Freud said it best (1933): “No one who, like me, conjures up the most evil of those half-tamed demons that inhabit the human breast, and seeks to wrestle with them, can expect to come through the struggle unscathed” (p. 184). And he encouraged revisiting personal therapy (Freud, 1937/1964): Every analyst should periodically—at intervals of five years or so—submit himself to analysis once more, without feeling ashamed of taking this step. This would mean, then, that not only the therapeutic analysis of patients but his own analysis would change from a terminable into an interminable task. (p. 249)

The Role of the Counselor in the Healing Process The role counselors believe they must fill in their work dictates their therapeutic approach. For this reason, counselors must examine the personal, ethical, and philosophical meanings that they ascribe to life, as these underlie counseling work. And a counselor’s view of human nature influences belief or lack of belief in the healing process. The early psychotherapists such as Freud and the behaviorists had a more pessimistic and predetermined view of human nature. They saw us being driven by animal instincts and repetitive behaviors that were set early in development. But psychodynamic and learning theorists were more encouraging about the possibility of change. For example, Rogers believed that people have what they need to become whole if given the proper conditions in the therapeutic relationship. New research indicates that much about us is hardwired, yet our brains allow us simultaneously to be fluid and to be responsive to external stimuli.

Trauma Work Can Be Traumatic Clients come to therapy in a state of upset. Often the degree of disturbance is extreme. Counselors must find a curative way to connect with pain. The hardest thing in life is to have compassion for others, if we do not have it for ourselves. Thus, our healing work, or lack of it, is affected by our ability to feel our own pain. Yet uncovering our own trauma can be traumatizing. The ability to be present is of the utmost necessity when working at the deep, suffering end of the pool, when others are drowning in severe loss and hurt. Often, counselors quickly close this open wound, as it reactivates wounds that exist in their own inner landscapes. Therapy can be a parallel process, and if counselors are not open and present, they can hinder others from resolution. We just cannot be present to others if we have lost connection and integration in our own lives; burnout is a real possibility. Osborn (2004) defines burnout as “the process of physical and emotional depletion resulting from conditions at work or, more concisely, prolonged job stress” (p. 319). One of the dangers of the reoccurrence of posttraumatic stress symptoms is the effect on our internal physiology. When painful events are remembered, an arousal response is repeatedly reactivated. The original wound may be from an external source, but the relieving of this wound reinjures a person over and over again (Allen, 2005). This repeated conditioning is difficult to extinguish. Thus, our work with trauma can be traumatic on physical and emotional levels. The risks in working with trauma are great, as are the rewards. The risks are external and internal. Many realities of a counselor’s job could strain a counselor’s cognitive

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and physical resources (Lee, Cho, Kissinger, & Ogle, 2010). The external risks are situational in the environment and systems in our workplaces. We have little control over these factors such as organizational issues, mandates from departments of mental health and counseling boards, dictates from funding sources such as managed care agencies and insurance companies, financial cuts, and large caseloads (O’Halloran & Linton, 2000). The internal risks are factors residing in us—our state of health, life experiences, sensitivities, boundaries, compassion, and resilience. The constant drain on our inner resources, coupled with external factors over which we have no control, can leave us vulnerable. The inner risks can be the very wounds, which we sustained in childhood, that sensitize us to empathize with others and draw us to the helping profession. These, however, need to be addressed, balanced, and mitigated. Stress is caused by a life event, which interferes with a person’s balance (Figley, 1995). The stress response can be adaptive, in that it may assist in making needed adjustments to a situation, or maladaptive, when it compromises our ability to adjust. Figley (1995) claims that trauma occurs when stress responses cause a failure to readjust our prestress lifestyle balance. If the mechanisms of stress response are at play long enough for counselors, burnout may be a reality. Research on burnout concentrates on the three components of exhaustion, cynicism, and inefficacy (Maslach, Schaufeli, & Leiter, 2001). The first symptom is exhaustion, and it may exacerbate the other two. A protective emotional withdrawal from clients and their concerns is a natural reaction to stress; yet, this detachment can be counterproductive. Additional research shows that therapists who work with victims of sex crimes, for example, report diminished hope, increased cynicism and pessimism, emotional hardening, and exhaustion (Farrenkopf, 1992). Counselors listening to trauma can become traumatized. This vicarious experience affects us through empathic concern for others (Saakvitne, Pearlman, & Staff of TSI/ CAAP, 1996). We tend toward self-blame when we cannot be effective. This concern and compassion and the desire to assist can become frustration and secondary trauma. Bride, Hatcher, and Humble (2009), at the University of Georgia’s School of Social Work, found that 19% of surveyed counselors met clinical criteria for PTSD resulting from secondary trauma. The Governing Council of ACA established a second Taskforce on Impaired Counselors in the spring of 2003. They surveyed all state licensing boards to investigate formal definitions of counselor impairment. In many states, no distinction was found between impairment and unethical behavior. It is true that impairment can lead to ethical violations. However, professional hazards can lead to counselor wear and tear, and few intervention programs have been established to help counselors. ACA’s taskforce studied counselor risk factors, and the essential myth of “counselor, heal thyself” is present. We spend time healing others and may believe that we carry immunity or at least resistance to pain. Yet it is the repeated exposure to suffering that wears on us (Figley, 1995). In addition, national and state standards for professional counseling training address the need for crisis preparation and response, but do not offer solutions for the risk to caregivers or strategies for recovery (McAdams & Keener, 2008). The ACA Code of Ethics (2005) suggests that “counselors engage in self-care activities to maintain and promote their emotional, physical, mental, and spiritual well-being to best meet their professional responsibilities” (Section C, para. 9). Thus, it is a philosophical tenet of our profession to stay on a personal balance beam while working in unbalanced situations and conditions. However, ironically, counselor education programs may emphasize but do not mandate self-care (Newsome, Christopher, Dahlen, & Christopher, 2006).

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Norcross (Norcross & Brown, 2000) encourages us to increase our awareness of the hazards of our profession, asserting that we should: “Begin by saying it out loud: Psychotherapy is often a grueling and demanding calling” (p. 710). Studies show that depression, anxiety, exhaustion, and broken relationships can result from a career in psychological practice (Brady, Healy, Norcross, & Guy, 1995).

WOUNDED HEALER AND INNER CHILD Carl Jung (1985) first used the term “wounded healer” to address the unconscious pain an analyst may have, which could be triggered by a client’s experience. Many even contend that, in some ways, all counselors and healing professionals are wounded healers. Existentially, we are searching for our wholeness and a way out of our personal pain. Pain is a universal experience, and in sharing, it dissipates and frees us from darkness and bondage. And our pain is what breaks the shell enclosing our awareness. So must we be free to help others find freedom, or do we need only to be just a bit further up the tunnel? Counselors surely cannot use clients for their own personal gain, but this often happens, as one easily can see from reading the lists of those who have been sanctioned and lost counseling privileges and licenses. This sets up a transference and countertransference process that could be useful in therapy. Yet therapists often are uncomfortable with the emotional reactions that can be released in this unconscious identification process. Without understanding and integration, this resistance and defensiveness can lead to therapist burnout. Countertransference is an emotional reaction that a therapist may have toward a client, which is triggered by a therapist’s unconscious reaction to a client’s transference (Freud, 1959). This is a process of seeing self in the client (awareness enhancing), or meeting needs through the client (pathology). A more contemporary definition of countertransference involves the sum total of emotional reactions a counselor might have toward a client (Johansen, 1993). Because we are all imperfect human beings, we would never, in theory, be so clear as to be unaffected in our work with clients. However, it is believed that if we could make more of our unconscious material conscious, we would not be reactive when working with others, and our awareness of our own defenses would not be detrimental to the healing process. In fact, the more conscious we are of our countertransference, the more adept we may become in productively using the countertransference in a particular case. Aligned with the concept of the wounded healer is the concept of the inner child or the blind side of trauma. This happens when our blind spots or unprocessed traumatic events prevent us from protecting and assisting others in similar situations. For example, unresolved trauma can sustain an intergenerational abuse cycle. It is known that parents who have experienced sexual abuse and not worked on this trauma often are unable to protect their children from the same. In parallel fashion, the places that counselors avoid in their own awareness can blind them to the present reality of others’ victimizations. Erik Erikson (1950) observed that there are developmental stages in the life cycle, and that certain tasks are to be mastered with each stage on the journey from child to adult. It is suggested that what is not learned with each progression can later become inappropriate responses in adult behavior, as when the inner child’s needs supersede proper adult responses. If, in childhood, we learned improper responses to have our needs met, then as adults, these needs may remain incomplete. To heal the adult self, we must become one with the child within. Jung called this archetype the divine child, a concept of innocence and perfection before life events wrote a negative script.

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If counselors have not uncovered their own trauma, how can they be with others in ways that are clear and present? If we are not committed to healthy lifestyles, how can we encourage others to do their work? In the remaining parts of this section, I discuss the following issues: wellness, mind-versus-body symptom presentation, and the holistic model and wellness paradigm.

Wellness—Noun Versus Verb The need for professional helpers to attend to their own health and wellness has been noted in the literature (Mahoney, 1997). Many schemata of the facets of wellness exist. Hettler (1984) was one of the pioneers who outlined components of a wellness lifestyle. Yet the first counseling-based model of wellness was not developed until 1991 by Witmer and Sweeney (1992). Myers, Sweeney, and Witmer (2000) have defined the concept of a holistic, balanced lifestyle as: A way of life oriented toward optimal health and well-being in which body, mind, and spirit are integrated by the individual to live life more fully within the human and natural community. Ideally, it is the optimum state of health and well-being that each individual is capable of achieving. (p. 252) Myers and Sweeney (2008) claim that the following ingredients are necessary for a wellness-oriented lifestyle: a good self-concept, clarity of role definition, and job satisfaction. However, the concept of balance in life is more complicated to achieve than simply to discuss. We can address some personal factors while others are out of reach. Yet, what might be a somewhat lofty goal for some becomes a must if we are to encourage others to find their own life fulcrum. It is good to have understanding and insight to outline changes for others to execute, but it is more difficult to make these changes in ourselves. Jung (1961, p. 132) clearly states that “[t]he psychotherapist, however, must understand not only the patient; it is equally important that he must understand himself.” I may be a therapist (noun) but am I being therapeutic (verb)? I like to use a metaphor with my clients, that of comparing our lives to a house with various rooms: We each have many rooms within our structures of being and understanding. Some of these rooms inhabit the spaces of physical, mental, emotional, and spiritual or philosophical dimensions. To stay balanced, we need to look into each room every day—even if it is only simply opening the door to each facet of our life. Wellness models can become very elaborate. I try to keep things simple. I often ask clients which room they most frequently avoid. Invariably, it is the emotional room. It is almost as if we have become a world of “smart” people and being emotional implies a weakness or inadequacy. Our emotions often are avoided like vestiges of ugly prehensile tails and treated with that much hatred and resistance. People are upset that they are upset. And as therapists, we are upset that we cannot fix them. Perhaps we need to look in our own hearts before we try to treat others. Therapy can be an ugly or shadowy place for all to hide.

Mind Versus Body Symptom Presentation Psychological disturbances often remain unrecognized by medical doctors. Yet, frequently, people who are suffering psychologically first go to their medical practitioners. One report revealed that 11% of U.S. adults (18 or older) experienced serious psychological illness, but that only 44.6% of these received any kind of mental health

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services. This amounts to approximately 24.3 million people who are untreated. These data were released by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2008) and are available online. Individuals have a tendency to express physical or psychological distress in an idiosyncratic fashion. Whereas one person may choose to describe turmoil in purely physical terms, regardless of whether the origin is physical or psychological, another may express this turmoil in purely psychological terms. This constitutes a single dimensional view of illness, which perhaps has been prestaged by physicians and mental health professionals. Traditions and, in many cases, current practice, have clearly communicated to the consuming public that physicians deal only with physical illness, and that psychological problems are left to the mental health professionals. This has been an unfortunate circumstance. Researchers slowly have come to recognize the impact of one’s psychological state upon physical functioning and vice versa (Smith, 1990). The dualistic orientation to health is not the sole property of the medical doctor: “Mental health professionals are trained to accept that 98% of what they encounter is psychological in origin” (Smith, 1990, p. 2). Many mental health professionals may believe that assisting individuals with physical concerns is beyond the purview of their interests. However, physical concerns can affect the duration and intensity of psychological symptomatology, especially if a person suffers from a real physical problem that has not been recognized or has been misdiagnosed (Smith, 1990). The omission during graduate training of studies concerning physiological and biochemical disturbances and imbalances can leave the professional counselor with only part of the picture. To complicate the diagnostic issue, those suffering from psychological illness often report their symptoms as physical complaints. This may be the norm rather than the exception. This preset view of diagnosis affects treatment when working with trauma victims. There are often deep wounds on more than one layer of being. A counselor must be able to assess and understand all the facets of a client’s problems (all the rooms of his or her house that may be affected). Yet, we are not trained across the relevant multiple dimensions in which we need to be trained. We are instructed to be expert in addressing only part of a human being’s existence, not the whole gestalt. An additional complication of the diagnostic issue is the therapist’s own view of human nature. How do we see a human being? Is this definition a part or a whole? How do we understand being human? Do we see a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis, a body, a soul, a heart, and a brain? Our views largely determine our treatment choices for our clients. For example, Freud saw us as a mass of instincts; Jung saw us as spiritual beings; the behaviorists saw us in terms of our actions, and so on. Counselors purport to view human beings from an holistic perspective. The definition of holism implies whole versus a part. The medical model emphasizes parts; likewise, we have become increasingly more specialized in our training and diagnosis. The conceptualization of human problems and pathology affects treatment. Can we see how all the parts work together? Can we address all the rooms in a person’s house? Or do we stay in only one room? An even more important question to ask is: What is our philosophy of health and healing? Do we even believe that people can change? Can they be well? Is our approach to the whole or part, disease or wellness? The implication here is for a holistic model that encourages wellness. But how can we see health potential when we are trained to diagnose parts of illness? How can we see the whole?

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A Holistic Model and the Wellness Paradigm ACA’s (n.d.) Taskforce on Counselor Wellness and Impairment has defined therapeutic impairment as occurring . . . when there is a significant negative impact on a counselor’s professional functioning which compromises client care or poses the potential for harm to the client. Impairment may be due to: substance abuse or chemical dependency, mental illness, personal crisis (traumatic events or vicarious trauma, burnout, life crises) or physical illness. (Definitions, para. 2) This highlights the need for wellness awareness and programming, as again, traumatic events or vicarious trauma can impair counselors. In view of this explanation of impairment, counselors are on the continuum from wellness to impairment at any moment in time. According to the U.S. Department of Health and Human Services (USDHHS, 1999), the U.S. Surgeon General estimates that 21% of our population suffers from mental or emotional disorders, and that the risk for counselors may be even greater. Just as an example, therapists working with sexual abuse “reported diminished hope, increased cynicism and pessimism, emotional hardening and exhaustion” (Farrenkopf, 1992). How can counselors take care of the self? How can they develop a more dynamic view of human beings? What is wellness? What is holistic health? Is wellness just the absence of illness? I see wellness as a choice. It is one’s own philosophical stance, which includes how we feel about ourselves. Traumatic events shatter lives. How can counselors work to reassemble the parts? How can we assist others? We must first ask questions about our own fragmented lives. As noted earlier, there are many models of wellness. The dimensions can include physical, mental, emotional, spiritual, social, work, leisure, and so forth (e.g., Hettler, 1984; Witmer & Sweeney, 1992); however, these are merely the parts or facets of our whole lives.

WELLNESS SELF-ASSESSMENT As I stated earlier, I like to keep the therapeutic process simple when possible. Therefore, I like to use this wellness self-assessment with my clients. The dimensions of wellness include the following questions: ■ ■ ■ ■ ■ ■

What area/areas is/are comfortable? Why? What area/areas is/are uncomfortable? Why? What dimensions need to be added? Was there a time when I was more in balance? When? What happened? What can I do right now? What can I plan for the future?

As clients’ lives and traumatic experiences must be examined across all facets for healing to occur, so must counselors’ lives if we are to stay healthy and strong enough to do counseling work. If we follow a rubric of our living that is composed of facets or pieces of a whole, we more easily can examine and develop integration in a selfregulatory manner.

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To continue this exploration of the dimensions of wellness, I refer back to the metaphor of physical, mental, emotional, and spiritual or philosophical rooms of our lives. More advanced taxonomies are described and can be explored in Witmer and Sweeney’s (1992) work; however, I think that it is constructive to establish a simple initial working map with clients. In drawing or visualizing multiple dimensions of life, we again can conceptualize these aspects as rooms. It is important to ascertain which room is most avoided, as this is often the place to start the real discussion. The rest of this section is devoted to an exploration of the various rooms, including the physical room, the mental room, the emotional room, and the spiritual or philosophical room; the section concludes with a discussion about connecting the rooms.

The Physical Room Our physical room is the most easily accessible, and the state of our physical health can be affected by all the other facets of our being. The lack of physical balance also can impair emotional and cognitive functioning. Many studies show the relationship between stress and illness. Our knowledge about physical health is vast, but our lifestyle practices are not always consistent with what we know. As such, Americans have become increasingly overweight and unhealthy. So much tension can be stored in our physical body that finding healthy ways to release it becomes essential. If possible, some aerobic exercise and stretching is ideal. Most counseling work is sedentary and not too healthy. And as we sit, lots of pain is dumped onto our laps, which adds to our health security risks. Simple health remedies are abundant and commonplace. These include drinking water, dietary intervention, food choice, and exercise. Alternative health regimes have become increasingly popular as the baby boomers are aging. These include yoga, tai chi, meditation, massage, and acupuncture. Breathing exercises and creative visualization techniques are helpful to relieve stress and can be used in conjunction with walking as form of physical meditation and tension release. We are living longer, and thus we are increasingly more interested in the quality of our lives. I advise others to find some type of exercise that they really like to do, to keep it simple, and to keep doing it. This is more easily said than done. We all know that we must exercise, but we just do not always keep our commitments. Yet how can we remain balanced in an unbalanced world if our physical structure is not healthy? Research has shown that healthy people make healthy choices. This highlights the role of self-esteem issues in healthy lifestyle commitments. We must think we are worthy to make healthy choices. Self-esteem is the driver here. Health is a direction that we create. I often ask people to change one small thing and then add another only after some time has passed (minimum of 90 days). Diets and fads do not work. We need to commit to a direction that takes us on a healthy path.

The Mental Room Our thoughts are consciously or unconsciously present. It is said we have 63,000 thoughts per day, yet, we often do not access the chatter that is our constant companion. What are we saying and is this important information? Our memories connect us with the past and our worries with the future. Yet, we often are unable to focus on the present in a way that is meaningful and effective.

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Journalizing is a wonderful, noninvasive way to be with our thoughts and feelings. A nonjudgmental, noneditorial writing stream can be a therapeutic and effective means of self-connection. Other activities for mental connection with self include reading, meditation, hobbies, and movies (ACA, n.d.).

The Emotional Room We often are uncomfortable with our emotions. Feelings are “facts,” and even if lacking in factual content, they are undeniable. Emotional acceptance is paramount in healing processes. Yet this area often is avoided. We think we should not be upset that we are upset. Interventions for emotional access are journalizing, crying, screaming (into a pillow), punching a punching bag, and talking. Laughter and tears are both very therapeutic. Life causes us to experience the fullness of the emotional spectrum. Grief has no shelf life. I often work with clients who have traumatic experiences that occurred long ago, and yet their wounds seem fresh. I liken trauma to an iceberg. Only a small portion is above the surface and easily accessible. Yet, if one can work with what is obvious, then awareness can surface from below. Some of my first work in graduate school was with clients who were grieving. Even though the shock of grief had occurred years earlier, their reactions were frozen. The trauma of grief has a domino effect and can become complex as it touches previous wounds (American Psychiatric Association, 2000).

The Spiritual or Philosophical Room The spiritual room contains our philosophical meaning or purpose in life. We need to reflect and find a connection here. This may require a time commitment, but even a few quiet moments in a day can have a great impact on quality of life. Suggestions for access to this area are meditation, prayer, reflection, reading inspirational literature, gardening, spending time in nature, and finding a community of like-minded people. A fellow therapist and mentor told me long ago that without a transcendent purpose, it was difficult to suffer the slings and arrows of life. Some say that philosophy is merely a form of rationalization. But it can be a framework that gives direction and purpose for living. Counseling work for me is very spiritual. There is quite a distance between religion and spirituality. Religion can be merely dogma unless we give individual meaning to ritual. We are trained to be nonjudgmental as counselors. This is idealistic because we all have formed biases. We need to be clear of our beliefs, however, so that we are integrated and do not need to proselytize in the counseling room. In working with trauma, our philosophy of life must remain intact, as it is often challenged to the limit.

Connecting the Rooms An interesting aspect of this multifaceted conceptualization of life is that all the rooms are connected by doorways. For example, our physical health can be altered by mental and emotional stress, and thoughts and feelings can be influenced by the state of physical health. Our self-concepts can affect the choices we make for our health, and our healthy choices are affected by the strength of our self-concepts. I have seen people stand in healing lines over and over again, reaching out for solutions to their

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problems, and wondering if there were some simple physical actions they could execute to improve their maladies. I always search for some feet to place under my prayers. In addition to the concept of the rooms of our homes, or the facets of our beings, is the idea of floors or levels to the areas of our wellness. Our basement floor is the physical foundation of a home but can also signify the lower or underground, unconscious level of awareness. The upper levels of a home can signify a vertical ascent into consciousness. An attic is usually the highest place in a home and can signify a clear, high state of being. Much as our outer physical home needs cleaning and dusting, surely it is as essential to clean out the debris in all the rooms of our inner beings. I believe we have an ability to improve our lives. Counseling is truly a high calling. It is an honor to do the work and a responsibility to stay healthy doing it. As traumatic event(s) must be examined across all aspects for healing to occur, so must our lives and dimensions, if we are to stay healthy and strong enough to do this counseling work. If we follow a rubric of life as being composed of facets or pieces of a whole, we can examine and develop ways to thus integrate our life experiences in a self-regulatory manner.

COUNSELING IMPLICATIONS Freud (1937/1964) posed the following question and answer: “But where and how is the poor wretch to acquire the ideal qualification which he will need in this profession? The answer is in an analysis of himself, with which his preparation for his future activity begins” (p. 246). Research shows that most therapists have participated in personal therapy at least one time in their careers (Norcross & Guy, 2005). Yet, burnout often creates a resistance to change (Cherniss, 1980). Perhaps this offers a clue as to why the proclamation of “physician heals thyself” may not be practiced as widely as we might like to think among those working in our profession. Stress and burnout should be studied as a likely occurrence in the profession and not the result of personal limitation (Savicki & Cooley, 1982). Instruction in selfcare should be part of graduate studies. In addition, the importance of supervision, especially in trauma work, needs to be emphasized. The unfortunate reality is that supervision is not mandated once professionals are licensed. Yet, the creation of professional relationships that address case study and collaboration is instrumental in counseling work. Our counseling work is demanding and rewarding. We have been traumatized by its demands and by the idea about whom we think we have to be. Stress comes from a reactivation of our own issues and one-way caring relationships. It is difficult to stay balanced and be fully present when working with others. Our lives are multifaceted, and holism and wellness are just concepts if we do not systematically integrate meaning into all of our parts. Our clients are upset that they are upset; they cannot integrate their emotional trauma, and instead, they try to stay removed by expending energy and not feeling the pain. Trauma often is multilayered, and its magnitude is daunting to experience and digest. For example, change, loss, illness, death, divorce, unemployment, natural disasters, and acts of terrorism can be mind altering and must be assimilated in small bits and pieces. Trauma work can encourage the care for self at an extreme level. And self-care is not selfishness. Events in our lives and the lives of our clients are traumatic and traumatizing. The systems in which we work may not be healthy. Powerlessness leads to more stress reactivity. The way out of our dilemma is to find a place within from which to

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operate and live our lives. Trauma can cause fragmentation, and the work of health, the direction of wholeness, is toward integration. We are complex creatures and the only way to be present in the face of adversity is to have the courage to work on our own issues so that we can be present for and with others.

CONCLUSION The challenge of being a therapist is in actually being therapeutic, first to self and then to others. It is possible to preach, without sufficiently practicing what we preach, but the effectiveness of our work and our personal health and balance may be diminished in the process. As mental health professionals, our validation is defined by client progress, and yet we often have little control over outcomes in therapy. We have more dominion over our own growth and investment in the counseling relationship, and the more present we are, the more responsive we can be. We can become traumatized by our professional engagements as well as the idea of who we think we have to be in facing the enormity of the devastation we see in the lives of others. Or we can be energized by the stimulation of challenge and encouraged to grow as people and professionals as we stand by others and assist in the human repair process, which we have been honored to perform.

APPENDIX 32.1 A Case Study I would like to elaborate upon the exploration of self-care and wellness dimensions with a case study. My early counseling work began in a medical office with chronically ill patients. I recall one widow who was 70 years old. Her son brought her to me because he had heard that I would help others fight to recover their health. At our first session, this woman was suffering from leukemia and cancer of her lymph nodes, and medical opinion was that she had only 6 months to live. I began by assessing her life experiences and dimensions. She was recently widowed, after being married 50 years; she had one son; she recently lost a job that she had held for 30 years to a younger person; she was eating only fast foods; she was reading murder mysteries; she was watching soap operas; and she no longer participated in civic organizations. We explored every room of her life’s world, and I gave her feedback. The interventions were lifestyle changes: better dietary choices, exercise, adjusting reading material, and journalizing. She later told her son that she was overwhelmed with all the changes: “It was too much.” Her beloved son got very quiet and remarked, “Well, Mother, then I guess you are saying you will just die.” Giving her that choice was very powerful. Six months later, her cancer was in remission. She went on to make many lifestyle changes and experienced a full recovery from her disease. Many years later, I ran into her son who told me she died at the age of 80 (10 years later) from a heart condition. Even though she was suffering from an advanced illness, her depth of self-exploration and ability to make lifestyle changes improved the quality and tenor of her life.

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RESOURCES The following resources may be helpful to students, clinicians, and instructors who are interested in trauma and self-care. Websites Curtis Graf, PhD Person-centered counseling (http://www.person-centered.org/counseling.html) Peggy Natiello, PhD Person-centered counseling (http://www.person-centered.com/) SAMHSA. Serious psychological distress and receipt of mental health services. SAMHSA’s 2007 National Survey on Drug Use and Health (http://www.oas.samhsa.gov/2k8/SPDtx/ SPDtx.htm) Publications Chodron, P. (2002). When things fall apart. Boston, MA: Shambhala. Hesse, H. (1922). Siddhartha. New York, NY: New Directions. Hesse, H. (1923). Demian. New York, NY: Harper Classics. Tolle, E. (1999). The power of now. Novato, CA: New World Library. Travis, J., & Ryan, R. (1988). Wellness workbook (2nd ed.). Berkeley, CA: Ten Speed Press. West, W. (2004). Spiritual issues in therapy. New York, NY: Palgrave Macmillan. Woodman, M. (2000). Bone: Dying into life. New York, NY: Viking.

REFERENCES Allen, J. G. (2005). Coping with trauma: A guide to self-understanding. Washington, DC: American Psychiatric Press. American Counseling Association. (2005). ACA code of ethics. Retrieved from http://www.counseling. org/files/fd.ashx?guid= ab7c1272-71c4-46cf-848c-f98489937dda American Counseling Association. (n.d.). ACA taskforce on counselor wellness and impairment. Retrieved from http://www.counseling.org/wellness_taskforce/index.htm American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Brady, J. L., Healy, F. L., Norcross, J. C., & Guy, J. D. (1995). Stress in counselors: An integrative research review. In W. Dryded (Ed.), Stress in counseling in action (pp. 1–27). Newbury Park, CA: Sage. Bride, B. E., Hatcher, S. S., & Humble, M. N. (2009). Trauma training, trauma practices, and secondary traumatic stress among substance abuse counselors. Traumatology, 15(2), 96–105. Cherniss, C. (1980). Professional burnout in human service organizations. New York, NY: Praeger. Erikson, E. H. (1950). Childhood and society. New York: Norton. Evans, Y. A., & Payne, M. A. (2008). Support and self-care: Professional reflections of six New Zealand high school counsellors. British Journal of Guidance and Counseling, 36(3), 317–330. Farrenkopf, T. (1992).What happens to therapists who work with sex offenders? Journal of Offender Rehabilitation, 18 (3–4), 217–224. Figley, C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner/Mazel. Freud, S. (1933). Fragment of an analysis of a case in hysteria. In Collected papers of Sigmund Freud (Vol. 3). London: Hogarth. (Original work published 1905). Freud, S. (1955). Beyond the pleasure principle. In J. Strachey (Ed. & Trans.). Standard edition of the complete psychological works of Sigmund Freud (Vol. 18, pp. 1–65). London, United Kingdom: Hogarth Press. (Original work published 1920)

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Freud, S. (1959). Further recommendations in the treatment of psychoanalysis: On beginning the treatment. In Collected papers of Sigmund Freud (Vol. 2). New York: Basic Books Freud, S. (1964). Analysis terminable and interminable. In J. Strachey (Ed. & Trans.), Standard edition of the complete psychological works of Sigmund Freud (Vol. 23, pp. 209–253). London, United Kingdom: Hogarth Press. (Original work published 1937) Hettler, B. (1984). Wellness: Encouraging a lifetime pursuit of excellence. Health Values: Achieving high level wellness, 8 (4), 13–17. Johansen, K. H. (1993). Countertransference and divorce of the therapist. In J. H. Gold & J. C. Nemiah (Eds.), Beyond transference: When the therapist’s real life intrudes (pp. 87–108). Washington, D. C.: American Psychiatric Press. Jung, C. (1961). Memories, dreams, reflections. New York, NY: Random House. Jung, C. (1985). The psychology of the transference. In The practice of psychotherapy: Collected works (Vol. 16, pp. 163–22). Princeton, NJ: Princeton University Press. (Original work published 1954) Lawson, G., & Venart, B. (2005). Preventing counselor impairment: Vulnerability, wellness, and resilience. In G. R. Walz & R. Yep (Eds.), Vistas: Perspectives on counseling 2005 (pp. 243–246). Alexandria, VA: American Counseling Association. Lee, S. M., Cho, S. H., Kissinger, D., & Ogle, N. (2010). A typology of burnout in professional counselors. Journal of Counseling and Development, 88 (2), 131–138. Mahoney, M. (1997). Psychotherapists’ personal problems and self-care patterns. Professional Psychology: Research and Practice, Vol. 28. Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52, 397–422. McAdams, C. R., & Keener, H. J. (2008). Preparation, action, recovery: A conceptual framework for counselor preparation and response in client crises. Journal of Counseling and Development, 86(4), 388–398. Myers, J. E., & Sweeney, T. J. (2008). Wellness counseling: The evidence base for practice. Journal of Counseling and Development, 86(4), 482–493. Myers, J. E., Sweeney, T. J., & Witmer, J. M. (2000). The wheel of wellness counseling: A holistic model for treatment planning. Journal of Counseling and Development, 78 (3), 251–266. Newsome, S., Christopher, J. C., Dahlen, P., & Christopher, S. (2006). Teaching counseling self-care through mindfulness practices. Teacher’s College Record, 108 (9), 1881–1900. Norcross, J. C., & Brown, R. A. (2000). Psychotherapist self-care: Practitioner tested, research informed strategies. Professional Psychology: Research and Practice, 31(6), 710–713. Norcross, J. C., & Guy, J. D. (2005). The prevalence and parameters of personal therapy in the United States. In J. D. Geller, J. C. Norcross, & D. E. Orlinshy (Eds.), The psychotherapists’ own psychotherapy. New York, NY: Oxford University Press. O’Halloran, T. M., & Linton, J. M. (2000). Stress on the job: Self-care resources for counselors. Journal of Mental Health Counseling, 22(4), 354–364. Osborn, C. J. (2004). Seven salutary suggestions for counselor stamina. Journal of Counseling and Development, 8 (3), 319–328. Rogers, C. (1995). A way of being. Boston, MA: Houghton-Mifflin. Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80 (1), 1–28. Saakvitne, K. W., Pearlman, L. A., & Staff of TSI/CAAP. (1996). Transforming the pain: A workbook on vicarious traumatization. New York, NY: Norton. Savicki, V., & Cooley, E. (1982). Implications of burnout research and theory for counselor educators. Personnel and Guidance Journal, 60 (7), 415–417. Schwarzbaum, S. (2010, February). Counselors don’t necessarily make good clients. Counseling Today, 48–49. Siegel, D. (2010, January/February). The complexity choir: The eight domains of self-integration. Psychotherapy Networker, 46–61. Skovholt, T. M., Grier, T. L., & Hanson, M. R. (2001). Career counseling for longevity: Self-care and burn-out prevention strategies for counselor resilience. Journal of Career Development, 27(3), 167–176. Smith, C. D. (1990). A study of the relationship between selected personality attributes and allergic symptomatology. Unpublished doctoral dissertation, University of Akron.

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Stebnicki, M. (2008). Empathy fatigue: Healing the mind, body and spirit of professional counselors. New York, NY: Springer Publishing. Substance Abuse and Mental Health Services Administration. (2008). National survey on drug use and health. Retrieved from http://www.oas.samhsa.gov/2k8/SPDtx/SPDtx.htm U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General— executive summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. Retrieved from http://www. surgeongeneral.gov/library/mentalhealth/home.html Witmer, J. M., & Sweeney, T. J. (1992). A holistic model for wellness prevention over the lifespan. Journal of Counseling and Development, 71(2), 140–148.

CHAPTER 33

Trauma and Supervision DEMOND E. BLEDSOE

INTRODUCTION The area of trauma continues to be ignored, largely, in the preservice curricula of the helping professions. The issue of supervision is typically addressed, in preservice practicum and internship experiences, as an important function of professional training. Unfortunately, there is not as much instructional emphasis on how to provide quality (or even adequate) clinical supervision. These two gaps, taken together, create an unacceptable situation concerning the clinical supervision of therapists who are treating the survivors of trauma. The purpose of this chapter is to elucidate how trauma is processed within the supervisory dyad and to provide intervention strategies aimed at mitigating the effects of trauma on clinicians so that they may increase the effectiveness of the treatment services provided. These aims are accomplished through discussions in the following sections: (a) trauma and supervision and (b) implications for counseling. These major sections are followed by a summary of the chapter and a list of resources intended to be of assistance to students, clinicians, and instructors.

TRAUMA AND SUPERVISION Supervision has been accepted for some time as an integral part of development for trainees and professionals alike. The increasing demands of a changing work environment have provided new and constantly changing needs within the supervisory relationship. Of primary concern today is the increasing volume of clients who have suffered severe and pervasive traumatic experiences throughout their lives. Drs. Anda and Felitti (2003) found, upon conducting their Adverse Childhood Experiences Study, that nearly two thirds of respondents reported having childhood experiences that are considered to be traumatic. They also found a positive relationship between the number of adverse childhood experiences and behaviors such as smoking, suicide attempts, and illicit drug use. This landmark study was significant for many reasons, including the exceptionally large sample of more than 17,000 people. With increasingly high rates of turnover in the counseling professions, the need for supervisors to attend to the vicarious trauma present in their supervisees is an essential function that often is overlooked or avoided altogether. In this section, I offer discussions of relevant issues associated with clinical supervision, trauma-sensitive supervision, and the relevance of a personal trauma history.

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Clinical Supervision Defining clinical supervision can be challenging, due to the various dynamics of the supervisory process. Definitions may include processes that are designed to facilitate growth or development of clinical competence, shape clinical understanding, enhance professional functioning, and ensure the quality of the services being provided (Bernard & Goodyear, 2004). Furthermore, the role of the clinical supervisor is to provide coaching and modeling, be encouraging and supportive, and provide feedback that is both evaluative and constructive (Pearson, 2004). The ultimate goal of clinical supervision is to provide the most ethically sound and clinically competent service to the client in order to facilitate the achievement of client goals (Kilminster & Jolly, 2000). Clinical supervision often is viewed as its own distinct specialty within the counseling profession and has been gaining ground as an important facet of the overall counseling process. Viewed as a career-long process, clinical supervision has the potential to create immediate change and also to create change that has lasting effects for the supervisee and clients alike (Falender et al., 2004). Many clinicians identify clinical supervision as an integral component to their self-perceived efficacy as a counselor and also as critical to their ability to mitigate the effects of emotional and job stress, thereby lowering the rate of burnout (Bransford, 2009). A potential peril in the supervisory relationship is the tendency for the relationship to be authoritarian, with the supervisor regarded as the expert and the supervisee relegated to the role of novice, or somehow lesser, in terms of clinical skill, knowledge, and ability. This very hierarchy can lead to a therapist’s perceptions of the client changing without regard to the previous view or dynamics of the counseling relationship (Miehls, 2010). As this change occurs, a therapist may repress feelings associated with the client due to a shift in focus or understanding of the case. This repression may increase the stress and force the therapist not only to contain but also to cast aside these feelings without the ability to process or resolve the therapist’s concerns or residual feelings. This is even more critical for a therapist who is encountering secondary stress reactions, as there seems to be an increased likelihood that the clinical viewpoint is less defined (Everall & Paulson, 2004) than in clinicians exhibiting a lower level of traumatic stress. Clinical supervision may be thought of as a reflective process by which issues discussed between the therapist and the client are recreated within the context of clinical supervision (Miehls, 2010). This reflective process is necessary in developing a supervisory dyad that is supportive and allows the clinician to manage personal feelings and emotions that may be brought up during the process of providing therapy to clients. In effective clinical supervisory relationships, authenticity and concepts of mutuality within the dyad can influence the counselor’s relationships with clients in a parallel fashion (Miehls, 2010). To this end, so that clinical supervisors can support, challenge, assess, and nurture their therapists effectively, there must be a clear understanding of the impact of trauma on the therapist and within the supervisory relationship alike. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000), stress responses may affect not only a victim but also others who learn of the incident(s). The knowledge of these events can create traumatic stress-related responses in family members, friends, and clinicians who regularly hear details of the incidents, coupled with the results of the traumatic experiences on the client (Ennis & Horne, 2003; Sommer, 2008).

Transference, Countertransference, Parallel Process, and Isomorphism Bernard and Goodyear (2004, p. 170) define transference as “a phenomenon in which a person transfers to someone in the present, the responses and feelings that he or she has had to someone in the past.” Furthermore, they go on to indicate that supervisees may

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exhibit transference toward their supervisors, a process that is analogous to the one by which clients exhibit transference toward their therapists (Bernard & Goodyear, 2004). Within the context of the supervisory relationship, transference relates to the process of the therapist assigning feelings elicited from the relationship with the client onto the supervisor. This process has sometimes been referred to as parallel process. When parallel process occurs, the therapist typically is unconscious of the dynamic; it may be triggered either by the therapist’s client or by the relationship with the client, and it is often a function of the manner in which the therapist interacts with the supervisor (Bernard & Goodyear, 2004). Countertransference relates to the emotional reaction of the therapist to the client within the realm of treatment (Shubs, 2008). It stems from unresolved issues with the therapist or supervisor, in the context of the supervisory dyad, which are projected onto the client or the supervisor (Bransford, 2009). Countertransference also may be present within the context of the supervisory dyad (Bernard & Goodyear, 2004). Supervisors may not be aware of their own unconscious feelings that are brought up during a supervision session. Akin to the countertransference that often is discussed in regard to therapy sessions, unacknowledged countertransference can shape the supervisory relationship; it may affect interventions and have an impact on the clinician’s understanding or the supervisor’s perception. Parallel process occurs in supervision when the manner in which a client’s behaviors and attitudes that are present during therapy are reenacted by the clinician during the course of supervision, and then, subsequently, when the same clinician replicates the behaviors and attitudes of the supervisor with the client in the course of therapy (Bernard & Goodyear, 2008). Outside the realm of consciousness, the clinician’s identification with the client is a driving factor in the occurrence of the parallel process and may be brought about by resistance experienced during early stages of treatment (Bernard & Goodyear, 2008). The resistance created in therapy then manifests itself as some sort of resistance in supervision. The bidirectional nature of parallel process assumes that when the resistance is presented in supervision and the clinical supervisor is able to address and move past the resistance, the supervisee then is able to address and move past the resistance in the client (Bernard & Goodyear, 2008). The supervisee then becomes the gatekeeper, so to speak, of the parallel process and the most important factor in the potential for change as well as for progress to occur in treatment. Isomorphism, although similar to parallel process, refers more to the presence of systems in therapy that are similar to those in supervision (Bernard & Goodyear, 2008). The focus of isomorphism is the recursive patterns that occur in systems, for example, the “boundaries, hierarchies, and subsystems, each with its own distinct characteristics,” (Bernard & Goodyear, 2008, p. 154) that are replicated in therapy and supervision.

Vicarious Trauma and Secondary Traumatic Stress It is essential for clinical supervisors to have a clear understanding of theories related to trauma therapy (Etherington, 2000; Sommer, 2008; Sommer & Cox, 2005). The processes and treatment interventions for trauma-related concerns often are specific and encompass emotional, cognitive, and behavioral elements aimed at reducing the level of arousal, thereby allowing for more appropriate responses to stressful stimuli and situations. The recognition of traumatic stress symptoms in clinicians is an essential responsibility for clinical supervisors (Etherington, 2000). Early recognition of potential traumatic stress reactions or vicarious traumatization (VT) on the part of the therapist can lead to supervisory interventions that focus on providing the necessary support and guidance to assist the therapist in identifying issues that are emotionally taxing.

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Such acknowledgment can assist in identifying support systems and ways to reduce the negative aspects of the traumatic stress reaction; it also can ensure that treatment is being delivered to the client in an ethical and effective manner. Within the domain of counseling, the terms secondary traumatic stress (STS) disorder and VT are used frequently and interchangeably; however, there are some distinct differences between these two concepts. STS is the result of a therapist’s exposure to another individual’s traumatic incidents on an empathic level (Hahn, 2010). Primarily based in the expression of thoughts and behaviors, STS can have a rapid onset, and therapists experiencing STS may have symptoms often resembling those that meet the criteria for posttraumatic stress disorder (Etherington, 2000; Hahn, 2010; Sommer, 2008). VT describes the cumulative effect of working with the trauma experienced by others (Hahn, 2010). It is primarily identified as affecting therapists in the cognitive realm. Trust, safety, control, esteem, and intimacy have been key areas associated with therapists’ reactions to hearing the traumatic life stories of their clients (Jenkins & Baird, 2002). The therapist’s view of self as well as his or her worldview may be altered (Bober & Regehr, 2006) as a result of indirectly experiencing the trauma and resulting emotional responses described by clients. It is essential to remember that both VT and STS are occupational hazards and do not indicate pathology on the part of the therapist (Pearlman & Maclan, 1995). Although VT and STS are recognized as possible outcomes of repeated exposures to the traumatic experiences of the clients, there seems to be a discrepancy in the anecdotal reports of the prevalence of the reactions in therapists and the actual presence of the conditions supported by empirical data (Elwood, Mott, Lohr, & Galovski, 2011; Kadambi & Truscott, 2004). Research has not substantiated the presence of STS or VT in clinicians who primarily treat clients with severe trauma histories at a higher incidence than clinicians who do not work primarily with trauma (Elwood et al., 2011). Research does, however, suggest that clinicians who work extensively with clients experiencing severe traumas tend to score higher on scales measuring VT and STS, although there is no increase in the scores reaching a clinically significant level (Bober & Regehr, 2006). Often thought to affect large numbers of clinicians, the instances of VT or STS may be overreported or may seem more prevalent, because the supervision of therapists encountering these symptoms may be intensive and frequent. Another factor that cannot be ignored is the tendency for the presence of VT or STS in clinicians who themselves have a history of sexual or physical abuse or other psychological traumas that may yet be unresolved. Pearlman and Maclan (1995) found that therapists with personal trauma histories tended to score higher on scales designed to measure VT and STS than did therapists without personal trauma histories.

Trauma-Sensitive Supervision The concept of clinical supervision is one that increasingly has become accepted, even mandated, in the field of counseling over the past two decades and has developed into a distinct discipline. As the discipline continues to evolve, an iterative process has occurred, and distinct modalities or orientations have begun to appear. Trauma-sensitive supervision is one such modality and has gained ground in recent years due to the prevalence of trauma in the population seeking counseling services. The integration of trauma theory with standard supervision theories, in a deliberate attempt to provide effective supervision specifically related to managing the effects of psychological trauma, provides direct support for clinicians and indirect support for clients. Although the need for clinical supervision is increasingly more apparent in the various mental health fields, a gap remains between the number of supervisors

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who have received formal training and the number of supervisees who require clinical supervision (Pearson, 2004). Supervision for counselors working with clients who have experienced severe, persistent, and pervasive trauma is an ongoing dilemma for supervisors. The emotional toll that clinicians experience often becomes a central theme in the supervisory process. Currently, there is no uniform documented process for providing supervision that fully supports clinicians as they work to improve the lives of clients with trauma histories. There are, however, some common factors and approaches that have been documented to provide supervisors with the tools necessary to support the clinicians they supervise. The most critical of these factors is the supervisor’s own knowledge of trauma theory (Sommer, 2008). Miehls (2010) states that there are specific enactments or interactions that can occur between a client with a trauma history and a therapist; these same interactions then may occur between the clinician and the supervisor. A supervisor’s understanding of trauma theory allows for an acceptance of the clinician’s reactions and also an appropriate response that supports the clinician in professional development and working with the client. Trauma-sensitive supervision is based on understanding the constructs of parallel process and isomorphism, then pairing those constructs with trauma theory and applying interventions in a way that supports clinician development and client growth. The most primary concern when considering effective supervision for clinicians who work with trauma is ensuring that clinical supervision takes place frequently and consistently in a manner that adequately provides support for the therapists. Sommer and Cox (2005) noted in their study that counselors expressed concern over not receiving what they perceived as an adequate amount of supervision in order to feel competent and supported in their efforts to work with traumatized populations. Hanson, Hesselbrock, Tworkoski, and Swan (2002) found that less than 33% of the sampled organizations provided supervision specifically designed to address concerns related to trauma in either the client or the clinician. The development of a strong supervisory relationship is a critical component for trauma-sensitive supervision (Sommer, 2008). This is highlighted by considering the importance of trust in the therapeutic relationship between client and clinician; it is trust that enables clients to expose their most difficult feelings, concerns, inadequacies, and life events that have created psychological stress and anxiety. Without the presence of trust and respect, the process is inhibited, partially due to the emotional toll that may follow. An isomorphic process occurs in supervision (Bernard & Goodyear, 2008) in which the clinician must make a decision not only to share similar information but must also be willing to accept critical feedback and assessment. Bernard and Goodyear (2008) relate the processes of therapy such as joining, goal setting, challenging client realities, and possessing sensitivity to the same isomorphic principles in supervision. Furthermore, supervisors should use the same level of intentionality, which occurs in therapy, throughout the supervisory process (Bernard and Goodyear, 2008). According to Miehls (2010), clinicians and supervisees tend to recreate enactments similar to those that occur in the course of the counseling relationship. Miehls states that in the supervisory relationship, these enactments are parallel to those that occur between the clinician and the client during the course of the treatment, in which the client attempts to get the therapist to act in a manner similar to that of the abuser. Repeated and ongoing traumas may culminate in traumatic responses being less specific to the given situation and more ingrained and patterned, based on previous experiences (Hodas, 2006). These traumatic responses lead to spontaneous enactments that pose unique opportunities for the clinician to reshape client expectations by providing positive, respectful, and nurturing responses—the kind of responses that the client

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could never expect from the abuser. Analogous to the reshaping that occurs within the counseling relationship, supervisors have a similar opportunity to sculpt supervisee expectations by providing nurturing and supportive feedback. Just as the worldview of a client can be altered over the course of time, given a patterned set of responses that occur consistently within the confines of a relationship, the processes that occur within the supervisory relationship are parallel and provide a similar opportunity to change the clinician’s worldview. Thus, the relationship between the supervisor and the supervisee becomes a critical factor in the process of change and growth for the supervisee. When this process occurs, the worldview of the clinician or the client, respectively, is reinforced and more likely to develop further in the future in response to the positive and caring interactions. The subjective experience of the relationship between the supervisor and supervisee can provide the experience necessary to create a relationship that is both genuine and authentic (Etherington, 2000) and that is able to foster growth and independence. Bennett (2008) suggests that when supervisors are more attuned to the attachment style and needs of the supervisee, a more secure bond is formed, and this bond then leads to a greater ability to repair any damage to the relationship that was done during therapy or supervision. Without the development of a secure relationship, the efforts of a therapist to assist a client may be viewed as threatening or overwhelming. The resulting use of defense mechanisms to ensure safety may hinder the therapeutic process (Pearlman & Courtois, 2005). A parallel process occurs during supervision when a supervisor attempts to address a clinical need; this triggers a response of resistance (Bennett, 2008), and the resulting support that either is present or absent depends on the quality of the relationship in the supervisory dyad. Another process likely to play out within the context of the supervisory dyad is dissociation, which is a typical response to traumatic situations (Hodas, 2006; Miehls, 2010). For clinicians working with clients who are survivors of trauma, dissociative symptoms may manifest themselves as reports of intrusive imagery and may be present during supervision or counseling sessions (Sommer, 2008). Clinicians may notice disruptions outside of the workplace in their interpersonal relationships with family and friends (Etherington, 2000). There also may be changes in behavior that only can be noticed if the supervisor has a solid understanding of and relationship with the clinician (Miehls, 2010). Supervisory assessment for potential VT or STS reactions is crucial in clinician development and support. Frequent and ongoing assessment, specifically aimed at targeting changes in clinician behavior or the clinician’s ability to process client concerns, can alert the supervisor to subtle changes outside the consciousness of the clinician. For many supervisors and clinicians alike, assessment is narrowly viewed as an administrative task for measuring competency and work performance, when in reality, it should encompass multiple domains, including wellness and any other factor that helps or hinders the clinician’s ability to provide treatment. Addressing the dissociation that clinicians experience during the counseling or supervisory process must occur within the context of a supervisory relationship that is built on mutual respect and trust. Furthermore, clinicians must be provided a space and opportunity to discuss personal feelings freely, which may, on the surface, appear to be inappropriate for discussion in the professional arena. These discussions should include increasing the supervisee’s self-awareness of the sensations that he or she experiences during therapy sessions, imagery that is present, somatic feelings (Miehls, 2010), or feelings of anxiety that arise during specific conversations. Etherington (2009) suggests that supervisors help therapists to find meaning in their experiences. Similar to the processes of therapy, supervisors can encourage clinicians to explore their own personal or professional stories in hopes that they can better understand their responses to client

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narratives. This process permits the exploration of cognitive, behavioral, and emotional responses. It also may bring to light some of the unconscious responses present in the therapy sessions that are replicated during supervision. Group clinical supervision may be an effective way to help therapists mitigate the effects of prolonged exposure to working with traumatized populations. As discussed previously, clinicians who score high on scales for VT or STS share a given set of responses to their experiences. Using group clinical supervision allows clinicians to normalize some of the feelings they may be experiencing, takes the focus away from specific and individual difficulties, and allows for the discussion of common themes or experiences (Kitchiner, Phillips, Roberts, & Bisson, 2006). The normalization that occurs in groups, when clinicians share their feelings and experiences—those that result from dealing with the traumatic experiences of clients—allows clinicians to perceive their group-based supervision as perhaps more validating and supportive than in individual supervision. (Trippany, White Kress, & Wilcoxon, 2004). Furthermore, Trippany et al. (2004) state that other constructs such as isolation, objectivity, and even compassion and empathy can be influenced by the support a clinician experiences from peers through informal supervision; however, this also can be applied to more formal group clinical supervision.

Personal Trauma History Based on the rates of trauma in the general population, we can presume that significant portions of the population of clinicians practicing mental health counseling, at any given time, have a history of trauma. This personal history may provide some unique challenges to the supervisory process. A supervisor may become aware of recurrent images or a theme presented by a clinician or a pattern in the content of cases where a clinician has a difficult time managing (Etherington, 2000). The lack of a clinician’s ability to manage the feelings associated with particular cases may represent unresolved trauma or even trauma that was thought to be reconciled. This phenomenon known as the “wounded healer” is frequently present in counseling environments and has been explored and documented in counseling literature. Although a discussion of the wounded healer phenomenon is germane to this chapter, this and associated constructs are explored in detail in Chapters 31 and 32 of this book. Although it has yet to be substantiated empirically, it has been hypothesized that the severity of a clinician’s own personal trauma history may relate to the clinician’s own experience of VT or STS (Sabin-Farrell & Turpin, 2003).

COUNSELING IMPLICATIONS The prevalence of trauma in the population underlies the need for the counseling profession to adopt more rigorous standards and expectations in order to address trauma more efficaciously. Changes in credentialing by the organizations that develop and approve standards for curricula of counselor preparatory programs, that include trauma as a distinct discipline or area of counseling, are necessary to prepare students to work more effectively with a greater number of clients. Changes in the standards for practicum and internship supervision would ensure that students have the support necessary to manage situations related to trauma during their field placement experience. The addition of continuing education related to supervision and trauma is warranted, in light of the complexities of the relational difficulties that can arise when clinicians are tasked with treating survivors of trauma. The requirement of a portion of the

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already required continuing education units (CEUs) by state and national credentialing and licensing bodies, to be focused in the areas of trauma and supervision, ensures a growing knowledge base in the field of professional counseling. For example, Ohio’s counselor licensure board has established a supervision endorsement to the clinical license; only those who qualify receive the endorsement, which carries with it a prescribed CEU requirement for each licensure renewal period. The addition of ongoing training assumes that a minimum knowledge base of trauma-related principles and skills is developed within the professional counseling community. The transfer of knowledge and skills to the clinician, during the supervisory process, creates the opportunity for alternate treatment options and improved services for the clients. Finally, counseling supervisors and counselor educators have the responsibility to identify and address supervisees’ personal trauma histories as they may relate to the counseling or educational work being done. As discussed, the prevalence of personal trauma histories among students and professionals cannot be overlooked. Although it is unethical for supervisors and educators to provide treatment services to their supervisees and students, it is ethically responsible to encourage self-exploration and personal therapy when needed.

CONCLUSION The process of supervision offers unique opportunities for learning and growth, both personally and professionally. This process can, however, be interrupted due to the presence of trauma-related symptoms in the supervisory dyad. The ability for clinical supervisors to develop a rapport and openness with their supervisees is paramount, as their ability to encourage growth and change is based on the establishment and presence of a trusting relationship. Developing a strong knowledge of trauma-related principles and techniques permits the supervisors to support the expansion of their supervisees’ ability to feel confident in treating clients with trauma histories and also allows supervisors to address VT and STS reactions in the clinicians. Although the areas of trauma and supervision have developed over the past few years, their lack of formally acknowledged interconnectedness has left a gap for the counseling profession. The integration of knowledge and skills from both areas is necessary to continue to support clinicians effectively as they strive to provide quality services.

RESOURCES Websites Briere, J. (2011). Inventory of altered self-capacities. (http://www4.parinc.com/Products/Product.aspx? ProductID = IASC) International Society for Traumatic Stress Studies (http://www.istss.org/Home.htm) National Center for Trauma-Informed Care (http://www.samhsa.gov/nctic/) Publications Elwood, L. S., Mott, J., Lohr, J. M., & Galovski, T. E. (2011). Secondary trauma symptoms in clinicians: A critical review of the construct, specificity, and implications for trauma-focused treatment. Clinical Psychology Review, 31(1), 25–36. Etherington, K. (2009). Supervising helpers who work with the trauma of sexual abuse. British Journal of Guidance & Counselling, 37(2), 179–194.

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Figley, C. R. (Ed.) (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner/Mazel. Figley, C. R. (2002). Treating compassion fatigue. New York, NY: Psychology Press.

REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Vol. ed., Rev. ed.). Washington, DC: Author. Anda, R., & Felitti, V. (2003). Origins and essence of the study. In C. Redding (Ed.), ACE Reporter (1st ed., Vol. 1, pp. 1–4). Retrieved from http://www.acestudy.org/files/ARV1N1.pdf Bennett, C. S. (2008). The interface of attachment, transference, and countertransference: Implications for the clinical supervisory relationship. Smith College Studies in Social Work, 78 (2), 301–320. Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision (3rd ed.). Boston, MA: Pearson Education. Bernard, J. M., & Goodyear, R. K. (2008). Fundamentals of clinical supervision (4th ed.). Upper Saddle River, NJ: Pearson Education. Bober, T., & Regehr, C. (2006). Strategies for reducing secondary or vicarious trauma: Do they work? Brief Treatment and Crisis Intervention, 6(1), 1–9. Bransford, C. L. (2009). Process-centered group supervision. Clinical Social Work Journal, 37(2), 119–127. Elwood, L. S., Mott, J., Lohr, J. M., & Galovski, T. E. (2011). Secondary trauma symptoms in clinicians: A critical review of the construct, specificity, and implications for trauma-focused treatment. Clinical Psychology Review, 31(1), 25–36. Ennis, L., & Horne, S. (2003). Predicting psychological distress in sex offender therapists. Sexual Abuse: a Journal of Research and Treatment, 15(2), 149–157. Etherington, K. (2000). Supervising counsellors who work with survivors of childhood sexual abuse. Counselling Psychology Quarterly, 13 (4), 377–389. Etherington, K. (2009). Supervising helpers who work with the trauma of sexual abuse. British Journal of Guidance & Counselling, 37(2), 179–194. Everall, R. D., & Paulson, B. L. (2004). Burnout and secondary traumatic stress: Impact on ethical behaviour. Canadian Journal of Counselling, 38 (1), 25–35. Falender, C. A., Cornish, J. A., Goodyear, R., Hatcher, R., Kaslow, N. J., Leventhal, G., . . . Grus, C. (2004). Defining competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60 (7), 771–785. Hahn, K. (2010). Considering the power of context: Racism, sexism, and belonging in the vicarious traumatization of counselors. Unpublished master’s thesis, University of Kentucky, Lexington. Hanson, T. C., Hesselbrock, M., Tworkoski, S. H., & Swan, S. (2002). The prevalance and management of trauma in the public domain: An agency and clinician perspective. The Journal of Behavioral Health Services & Research, 29 (4), 365–380. Hodas, G. R. (2006). Responding to childhood trauma: The promise and practice of trauma informed care (pp. 1–77). Harrisburg, PA: Pennsylvania Office of Mental Health and Substance Abuse Services. Jenkins, S. R., & Baird, S. (2002). Secondary traumatic stress and vicarious trauma: A validation study. Journal of Traumatic Stress, 15(5), 423–432. Kadambi, M. A., & Truscott, D. (2004). Vicarious trauma among therapists working with sexual violence, cancer, and general practice. Canadian Journal of Counselling, 38 (4), 260–276. Kilminster, S. M., & Jolly, B. C. (2000). Effective supervision in clinical practice settings: A literature review. Medical Education, 34 (10), 827–840. Kitchiner, N. J., Phillips, B., Roberts, N., & Bisson, J. (2006). Increasing access to trauma focused cognitive behavioural therapy for post traumatic stress disorder through a pilot feasibility study of a group clinical supervision model. Behavioural and Cognitive Psychotherapy, 35(2), 251–254. Miehls, D. (2010). Contemporary trends in supervision theory: A shift from parallel process to relational and trauma theory. Clinical Social Work Journal, 38 (4), 370–378. Pearlman, L. A., & Courtois, C. A. (2005). Clinical applications of the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress, 18 (5), 449–459.

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Pearlman, L., & Maclan, P. S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research and Practice, 26(6), 558–565. Pearson, Q. M. (2004). Getting the most out of clinical supervision: Strategies for mental health counseling students. Journal of Mental Health Counseling, 26(4), 361–373. Sabin-Farrell, R., & Turpin, G. (2003). Vicarious traumatization: Implications for the mental health of health workers? Clinical Psychology Review, 23 (3), 449–480. Shubs, C. H. (2008). Countertransference issues in the assessment and treatment of trauma recovery with victims of violent crime. Psychoanalytic Psychology, 25(1), 156–180. Sommer, C. A. (2008). Vicarious traumatization, trauma-sensitive supervision, and counselor preparation. Counselor Education & Supervision, 48, 61–71. Sommer, C., & Cox, J. (2005). Elements of supervision in sexual violence counselors’ narratives: A qualitative analysis. Counselor Education & Supervision, 45(2), 119–134. Trippany, R. L., White Kress, V. E., & Wilcoxon, S. A. (2004). Preventing vicarious trauma: What counselors should know when working with trauma survivors. Journal of Counseling & Development, 82(1), 31–37.

CHAPTER 34

Conclusion: An Integrative Systemic Approach to Trauma LISA LOPEZ LEVERS

INTRODUCTION Until relatively recently, many mental health-related educators and therapists seemingly have avoided intentionally engaging trauma issues, perhaps daunted by the horrors experienced by many victims of trauma. However, in this age of high-technology immediacy, just as ordinary citizens of the planet, we no longer can deny the sometimes unspeakable lived experiences of some trauma victims. Throughout this textbook, the authors of various chapters have repeated that, to date, many single-theory clinical responses to client issues surrounding trauma have not been adequate. As students, instructors, and clinicians, with our growing understanding of the multifaceted effects of trauma, we no longer can deny the reality of trauma-induced distress or the need for multimodal systemic and integrative approaches to helping survivors of trauma. As I have reread and reexamined the preceding 33 chapters of this textbook, I have noted many of the authors echoing what I consider to be relevant themes associated with counseling survivors of trauma. These themes offer some level of congruency among the various topics related to trauma and to categories of traumatic events. The purpose of this chapter is to recap and explicate some of the most salient implications for counseling, drawn from the chapters of this book, and to emphasize the need for an integrative systemic approach to trauma.

IMPLICATIONS FOR COUNSELING SURVIVORS OF TRAUMA Perhaps the most essential consideration in interventions that help survivors of trauma in their healing processes is the quality of the relationship between the therapist and the client. This seems so obvious, and yet it sometimes becomes woefully lost within treatment delivery systems that are not intentionally trauma informed. But paradoxically, although the relationship is paramount, the therapeutic alliance is not solely applicable to the client; it also extends to the counselor’s colleagues and the service delivery system. The therapeutic dyad is nested within larger-but-still-relevant social units or systems; multiple influences, across any or all of these systems, may or may not be interlinked. Considering this as a parallel to the bioecological framework, the client and therapist are central, but their relationship is affected by perhaps countless other individuals and systems across multiple environments, some of which the clinician and the client may have relative little control over. This is illustrated, very simplistically, in Figure 34.1.

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Figure 34.1 Integrative Systemic Approach to Trauma 1. Clinical Relationship

2. Nexus of Personal and Treatment Issues

3. Broader Systemic and Cultural Influences

1. The clinical relationship, of course, includes the client–clinician dyad, but it also includes any other more-or-less formal healing modalities in which the survivor may be involved, such as group therapy, a 12-step program, spiritual activities, and so forth. The emphasis of this dimension is on the traumatized client’s ability to reestablish trusting relationships. However, relationship implies more than one person. Although the client is facing the aftermath of a traumatic event, recognizing and treating trauma constitutes an ecological transition for the therapist as well. 2. The nexus of personal and treatment issues includes matters associated with all of the actors who are involved in trauma treatment, as well as significant persons in the client’s life, who may affect treatment outcomes, and colleagues of the clinician, which may have an effect on treatment (e.g., clinical supervisor, agency administrator). The aspects of this dimension are too numerous to detail here but include personal characteristics of the client and personal and professional characteristics and qualifications of the counselor, the treatment milieu, client triggers, informal client support systems, clinical supervision, other clinician support mechanisms, and so forth. 3. The broader systemic and cultural influences include the overall treatment system, funding mechanisms, and the mental health and other regulatory policies that exist at local, state, regional, national, and even global levels and that may have an ultimate effect on treatment outcome. These elements represent an ecological perspective of counseling survivors of trauma, or what I am terming the integrative systemic approach to trauma (ISAT) model, which offers a conceptual framework for aligning multiple levels of trauma response with what appear to be best-practice and best-milieu approaches. The model assumes an overall bioecological and systemic approach to counseling survivors of trauma, continually constructing integrative best-practice methods to assist clients’ healing

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processes in trauma-informed environments. Integral to this model is the attention paid to the lived experiences of trauma survivors, to the trauma-specific training needs and the trauma-specific supervisory/support needs of therapists who work with traumatized clients, and to the degree to which the service-delivery system is sensitive to trauma issues. Many of these features are identified and described in the various chapters of this textbook, and the work of refi ning this model is ongoing. The remaining parts of this section highlight the following themes that arise from the implications for counseling identified in the previous 33 chapters: (a) How We Understand and Approach Trauma, (b) Social View and Systemic/Ecological Perspectives of Trauma, (c) Clinical Preparation, (d) Clinician-Related Characteristics/Attributes, (e) Client-Related Characteristics/Attributes, and (f) Research-Related Issues.

How We Understand and Approach Trauma Many of the authors of this textbook have emphasized the importance of an interdisciplinary approach to trauma treatment. Not exclusively viewed as the sole province of any one set of medical or social science professionals—including psychiatrists and other physicians, counselors, psychologists, social workers, teachers, nurses, pharmacists, and emergency first responders—the work of trauma recovery has been seen here as extending to additional professionals like anthropologists, sociologists, attorneys, judges, police officers, firemen, religious leaders, public health workers, and journalists who also may be intricately involved with issues of trauma. However, regardless of discipline, the quality of the relationship between the trauma survivor and the therapist has been regarded as contributive to the success or failure of treatment. Throughout this book, experiences of trauma have been framed as persistent across all levels of contemporary societies. In the various chapters of this book, authors have described best and promising practices associated with trauma counseling. A frequently expressed view has been that interventions need to incorporate multimodal, integrative, and systemic methods aimed at empowering survivors; as Peck aptly asserted in Chapter 10, “One size does not fit all.” In most of the chapters, the relevance of attending to contextual factors and cultural influences has been prioritized. Issues of prevention, multicultural considerations, historical or transgenerational trauma, and the comorbidity of posttraumatic stress disorder (PTSD) with so many other conditions have been discussed variably across chapters. I was particularly taken by Ventura’s citation of Pearlman and Saakvatine (1995) that the work of trauma therapy “. . . is subversive work; we name and address society’s shame” (p. 2) Indeed, acknowledging, facilitating expression of, and bearing witness to the lived experiences of trauma survivors often forces us to engage with the darkest dimensions of humanity, and this notion has been articulated, respectfully and humbly, throughout many of the chapters. Because the focus of this textbook has been on counseling survivors of trauma, it was beyond the scope of the book to address the situation and needs of perpetrators. However, a number of authors have noted that many perpetrators are victims of violence; thus, if we are going to have a public-health impact on interrupting and diminishing the cycle of violence, we need to develop effective treatment and prevention interventions for batterers, perpetrators, and other culprits of interpersonal and mass violence.

Social View and Systemic/Ecological Perspectives of Trauma In several of the chapters in this textbook, authors have noted the lingering societal stigma, even today, regarding mental health treatment. The psychosocial needs of some groups, for example older adults, often are missed or undertreated. Primarily because

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of issues of inequity, mental health services are neither readily available nor realistically accessible to many groups of people. This includes clinical treatment for the effects of traumatic experiences, thereby constituting one facet of why issues of trauma extend to the arena of human rights and social justice. Along with discussions regarding both the clinical and phenomenological features of trauma, several of the authors have commented on the notion of trauma as a socially constructed concept that has differing meanings in varying contexts. Some of the authors have noted the importance of counselors’ worldviews when apprehending the effects of others’ traumatic experiences. Several of the authors have discussed the impact of historical or transgenerational trauma on survivors. An ecological conceptualization of trauma has been embraced throughout the chapters in this textbook, emphasizing the impact of traumatic events on individuals, families, and broader communities. Many of the authors have written about trauma from bioecological and transactional perspectives, signifying the importance of a systemic understanding of the impact of trauma. The various authors in this text have articulated the relevance of a range of counseling modalities, including integrative and trauma-informed approaches to trauma treatment.

Clinical Preparation A major reason for developing this textbook was the lack of an effective tool for teaching an introductory graduate-level human service course that addresses the various issues concerning trauma, crisis, and disaster events. Endemic to this need is the reality that interest in such graduate training is a relatively recent phenomenon. Many of the authors here have asserted the unquestionable importance of adequate training in trauma-related issues and the need for advanced learning around adequate clinical supervision and other therapist-centered systemic support mechanisms—this includes preparing entry-level students to be receptive to supervision as well as preparing advanced students to provide competent trauma-sensitive supervision. Most of the authors have advocated that preservice training concerning trauma, crisis, and disaster events be incorporated into master’s-level social service academic programs; they also have highlighted the need for continuing education and in-service training in these areas. A number of the authors have espoused the idea that clinicians be trained in an integrated approach to trauma care. Several authors have suggested that preservice training is not sufficient, urging therapists to remain current with diagnostic and treatment issues by staying abreast of the most recent literature, reading peer-reviewed journals, and attending trainings and conferences concerning trauma. Across the chapters in this textbook, authors have reiterated the absolute necessity of adequate clinical supervision and support for therapists involved with trauma treatment. In the discussion surrounding the co-occurrence of trauma and addiction in Chapter 13, Burke and Carruth have suggested that a treatment team or traumasensitive supervision group share in the responsibility of caring for complex and challenging clients. In Chapter 31, Jankoski has pointed to the need for supervisors working with trauma counselors to be knowledgeable about and sensitive to issues of trauma; she also has affirmed the supervisory duty of being actively aware of the content and severity of supervisees’ caseloads. Finally, in Chapter 33, Bledsoe has called for adoption by the social service professions of more rigorous standards for and expectations of care and supervision, so that issues of trauma can be addressed more efficaciously and in a systemic fashion.

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Clinician-Related Characteristics/Attributes Across the various chapters, authors have noted that the cost of caring is high in the trauma-, crisis-, and disaster-related situations described in this textbook; trauma counselors are at high risk for vicarious trauma and secondary traumatization. Therefore, most of the authors have emphasized strongly the importance of trauma therapists possessing keen self-reflection and self-care abilities. An underlying presumption, as highlighted by Tarvydas and Ng in Chapter 30, has been that trauma counselors need to be ethical practitioners, taking seriously their ethical responsibility to self, to clients, and to constituent communities. Some of the authors here have indicated that counselors need to be in touch with their own histories of grief, loss, and trauma, as well as to be aware of the parallel process of feeling overwhelmed by client concerns. A number of the authors have stated that if a clinician has a history of trauma, this should be addressed in clinical supervision. Throughout this text, the authors have expressed concern about the potential for therapists, who are not adequately trained in trauma issues, to harm their traumatized clients, emphasizing that, regardless of any other interaction, therapists must ensure that they do no harm to clients. Authors have asserted that trauma therapists need to have an adequate baseline of knowledge, including but not limited to the following: ■ ■ ■ ■ ■

Knowledge of PTSD and other trauma-related symptoms, An understanding of clients’ triggers, Knowledge of assessment techniques, Knowledge of best-practice treatments, and Knowledge of medication side effects and adverse drug reactions.

Authors consistently have identified and accentuated the following competencies of trauma counselors: ■ ■ ■ ■ ■

Having empathy, Maintaining appropriate boundaries, Recognizing the potential for countertransference, Being able to formulate intentional treatment strategies, and Having a multisystemic understanding of trauma issues.

In several of the chapters, the authors have underscored the need for counselors to be aware of their own worldviews, so that they are not imposing their own values onto clients. Many of the authors have recommended that clinicians be sensitive to clients’ contextual factors as well as to their unique experiences and backgrounds. In Chapter 17, Mosley has argued that practitioners need to take the cultural backgrounds of trauma survivors into consideration when designing intervention techniques. Several authors have noted that therapists need to be aware of hate-motivated violence and to be prepared to address issues of aggression. In fact, Fallon and Seem, in Chapter 18, have described the issue of hate crimes as an opportunity for service providers to act as agents of systemic change by advocating for social justice and human rights. The contemporary service delivery system is more aware of trauma issues than in the past; therefore, some of the authors have suggested that asking about a client’s history of trauma now should be considered a standard line of inquiry and part of the routine intake process. Various authors have identified the importance of clinicians listening to clients’ narratives, rather than operating solely on canonical diagnostic

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tenets. Likewise, authors have advised that therapists need to take care not to use leading language with clients concerning their trauma experiences so as to ensure against potential iatrogenic effects. In Chapter 22, relative to disaster work, Tracy has raised the importance of counselors knowing how to work, in tandem, with emergency service providers. Especially in situations of disaster and crisis, therapists may need to adapt and treatment orientations may need to be adapted to a rapidly changing environment; in addition, the environmental situation may require mobile services. In Chapter 26, Smith and Jankoski have pointed out that when responding to a disaster, therapists need to be prepared for the details associated with the specific disaster and to be affiliated with an organization that is part of an official response structure—a disaster clearly is not the time for “lone ranger” tactics, no matter how well intended. Finally, counselors need to understand the circumstances under which addressing immediate needs is essential, and thus psychotherapy is not appropriate.

Client-Related Characteristics/Attributes One of the major implications for counseling, as expressed by the authors of this textbook, has been the necessity for therapists to help traumatized clients to feel safe and secure. When individuals experience traumatic events, their ability to trust in the world may shatter, life may feel fragmented and disconnected, and victims of trauma may feel a sense of powerlessness. Although our diagnostic codes and treatment models may be based on objective criteria, we need to remember that our clients’ responses to their lived experiences of traumatic events may be highly subjective. Although the lives of people affected by traumatic events may be changed permanently as a result of their traumatic experiences, they do not have to feel damaged permanently by these events. The core experiences of traumatic events affect victims on multiple personal and systemic levels; therefore, several of the authors have advocated employing a holistic perspective, engaging situations of trauma across the client’s multiple dimensions of being, including physiological, psychosocial, cognitive, affective, and spiritual or existential. A common therapeutic aim expressed by many of the authors has emphasized the importance of therapists assisting clients to reconnect and to regain or develop a sense of empowerment.

Research-Related Issues In many of the chapters in this textbook, authors have identified the need for more data-driven research in a variety of trauma-related areas. In general, authors have noted that additional research is needed to refine current best-practice treatment modalities and to explicate the interactions between individual client needs and sociocultural context. Authors also have articulated several specific research needs. For example, in Chapter 1, Levers has identified the need for more research concerning pedagogical aspects of designing an adequate preservice trauma curriculum for academic programs. In Chapter 7, Choate has asserted that future research should prioritize a multisystemic approach to the conceptualization of sexual violence. In Chapter 12, Falk has identified the compelling need for more research about elder abuse. In Chapter 19, Levers and Buck have suggested more rigorous research concerning efficacious responses to community-based trauma, crisis, and disaster situations. In Chapter 20, Daniels and Haist have addressed the need for more extensive applied research regarding school violence. In Chapter 27, Evans has asserted the need for more research that is specific to careful trauma-related psychological assessment practices.

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THE NEED FOR AN INTEGRATIVE SYSTEMIC APPROACH TO TRAUMA This textbook has been organized from the emerging perspective of an ISAT. Like others in the field, I believe that it not only is important to acknowledge the necessity of approaching trauma treatment from multimodal and integrative perspectives, but that we also must be acutely aware of all systemic aspects of trauma care. In this case, systemic applies to individual trauma victims as well as to the practitioners from whom they seek help and the organizations to which they go in an effort to heal. The ISAT approach affirms a bioecological and transactional perspective of the individual’s position within a family, community, society, and culture; it also presumes, much as with trauma-informed care, that the trauma care system needs to be much more aligned with client needs than ever before. Beyond system-of-care implications, ISAT views adequate trauma-related education and competent trauma-sensitive clinical supervision as essential aspects of a fluid system of trauma care. The ISAT model promotes a keen and holistic understanding of the complexities of trauma counseling and supervision; it further emphasizes the systemic and reciprocal interrelationships among preservice training, counseling practice, in-service training, and supervision. This approach draws from the research, theory, and practice literatures, defining relevant constructs and offering a comprehensive and integrative conceptual model. Although addressing the pertinent diagnostic and treatment issues of trauma, the ISAT model has the potential for illuminating how various systems and multiple environments require an integrative and systemic approach when dealing with the complexities of trauma. This ecological model incorporates client, clinical, supervisory, consultative, administrative, organizational, societal, and cultural facets of service delivery; it offers a useful framework for conceptualizing a wholly integrative and systemic approach for helping the victims of trauma to make meaning of their traumatic experiences and to heal.

CONCLUSION In this chapter, I have examined the content of the previous 33 chapters of this textbook and have offered an analysis and synthesis of the trauma-related implications for counseling as these have been identified by the various authors. I have discussed the implications according to themes related to client- and profession-based issues. This discussion has illuminated the need for continued development of systemic approaches to trauma as well as the need for a metasystemic framework for conceptualizing all aspects of trauma care, which I have advanced as the ISAT model.

Index

Abandonment, elders, 201 Abnormal events, normal reactions to, 321 Abusers, 179 characteristics, 204 Abusive Behavior Observation Checklist (ABOC), 481 Abusive supervision, workplace, 352 Acceptance, 82–83 Access, for people with disabilities, 99 Accommodation phase, 84 Acquired disability, courtesy trauma and, 105 Acquisition of new roles/reorganization, 83 Acute situational maladjustment, 31 Acute stress disorder (ASD), 2, 9–10, 466 Adaptive information processing (AIP), 172 Addiction, 214–230 counseling strategies in early stages, 220–222 integrative approach to trauma treatment, 506–507 PTSD and, 215–216 recovery support groups, 222–224 spirituality in treatment, 224–226 staging the treatment, 219–220 treating symptom versus treating problem, 218–219 Adolescence age- and stage-appropriate considerations, 149–150 family issues, 151–152 multiple diagnostic categories, 150–151 promising counseling practices, 153 stages of development, 147 trauma experienced in, 146–160 typical stages of trauma, 148 Adrenocorticotropic hormone (ACTH), 90

Adult Protective Services (APS), 199, 206 Adults, survival of trauma, 161–177 Aetiology of Hysteria (Freud), 48 Africans, colonial oppression, 285–286 Africans (South Africa), colonial oppression, 290–291 Ageism, 199 Alcoholic Anonymous (AA), 221 Ambiguous loss, 89 American Red Cross (ARC), 466 model, 327–328 Antidepressants as adjunct medications, 67–70 use in PTSD, 63–64 Antihypertensive agents, in PTSD, 71 Anti-LGBT hate violence, 299 Antipsychotics atypical, 70–71 use in PTSD, 65 Anxiety, management in survivors of sexual trauma, 126 Anxiety disorders, brain structures affected, 61 Apparently normal personality (ANP), 171 Appreciation of life, domain of PTG, 37 Armed robbery, 233 ARNG Leader’s Guide: Soldier Resilience, 447 Asians, colonial oppression, 286 Assault and battery, 233 Assault characteristics level, sexual trauma, 118 Assessment, context for, 471–475 Assimilation, 280–283 Association for Counselor-Education and Supervision (ACES) Guidelines, 531 Attachment, 133–134 Attitudes, for people with disabilities, 99

587

588 Attitudinal discrimination, 100–101 Australian Aborigines, colonial oppression, 287–288 Authority, role in evil, 275 Autonomy, 523–524 in SDT, 51–52 Avoidance phase, 84

Banality of evil, 272–273 Basic psychological needs, in SDT, 51 Beck Anxiety Inventory, 472 Beck Depression Inventory, 472 Behavioral symptoms, 324 Beneficence, 525 Benzodiazepines, in PTSD, 71 Bereavement work, in political violence, 404–405 Beyond the Pleasure Principle (Freud), 375 Bias crimes, 299 attending to perpetrators, 308–309 community and systemic implications, 311–312 experience of, 302–307 responding to, 307–312 Bibliotherapy, 516–517 early childhood trauma, 140 Bilateral stimulation (BLS), 172 Bioecological model of human development, 6, 7 Bioecological perspective, 322–323 Biological/ecological disasters, 373–374 Biomedical model, IPV, 187 Biopsychosocial approach, grief, 90–91 Bisexual, 298 Borderline personality disorder (BPD), autonomy and, 52–53 Brain anxiety disorder effects, 61 physiologic impact of trauma, 60–62 Briere’s self-trauma model, 500–501 Broader systemic and cultural influences, 580 Bronfenbrenner, Uri, bioecological model of human development, 6, 7 Brutality, LGBT hate crime violence, 305–306 Bullying, 352 Bupropion, in PTSD, 70 Burglaries, 232 Burnout, 543

Campus violence, 355–368 developmental issues, 360–361 enabling factors, 359 environmental factors, 360

Index hate crimes, 357 hazing, 358 predisposing factors, 359 reinforcing factors, 359 sexual/relationship, 357 suicide and murder, 357–358 Center for Mental Health Services (CMHS), 467 Centering, 237 Centers for Disease Control and Prevention (CDC), 457, 466 disaster phases, 462–464 impact pyramid, 461 primary and secondary prevention of IPV, 192 Central nervous system, response to trauma, 60–62 Character, 49–50 Childhood, early, 132–145 attachment as a developmental competency, 133–134 development, 132–135 developmental competencies, 134–135 PTSD in, 137–138 trauma and, 135–136 trauma effects, 137–138 Childhood sexual abuse (CSA), 151 Child maltreatment, 136 Child-parent psychotherapy, 138 Child protective movement, historical context, 30 Children capacity for reconciliation, 419–420 effects of war, 418–421 Child soldiers, 420–421 Chronosystem, 6 Chronosystem level, sexual trauma, 119 Civil defense, 375 Civilian populations, effects of war, 412–433 Classical grief theory, 79–84 implications of stage-oriented grief theory, 81–84 implications of task-based grief theory, 79–81 Clery Act, 356 Clinical interviews, 472, 475–476 complex PTSD and dissociation, 477–478 dimensional, scale-based structured, 476–477 disorders of extreme stress, 477 Clinical relationship, 580 Clinical supervision, trauma professionals, 570–572 Closure, crime victims, 242 Coconsciousness, 172

Index Code of Ethics (ACA), 527 Cognitive behavioral therapy (CBT), 62, 496–499 SUDS, 222 survivors of sexual trauma, 123–124 trauma-focused, 139, 401, 508 trauma survivors, 173 Cognitive impairment/dementia counselors working with, 208 elder abuse and, 202 Cognitive restructuring (CR), survivors of sexual trauma, 124–125 Cognitive symptoms, 324 Collaborative and therapeutic assessment, 486 Collaborative care (CC) pilot intervention, in PTSD, 108 Collective trauma, definition, 460 Colonial oppression, 283–291 Combat Exposure Scale (CES), 479 Combat fatigue, 28 Communities effects of war, 421–422 implications of homicide and suicide trauma, 258 Community-based violence, 317–334 chronic, 318 Community crises, 317–321 implementing services community wide, 321 Community Emergency Response Team (CERT), 467 Community Service Foundation Buxmont Academy (CSF Buxmont), 153 Compassion fatigue, 542–543 in counselors, 528–530 Confrontation phase, 84 Congenital disability, courtesy trauma and, 105 Constructivist self-development theory, 543–546 Contemporary trauma theory, 47 Context of trauma, 1–22 Co-occurring conditions addiction and psychological trauma, 216–218 treatment outcomes, 108 Core experience of trauma, 10–11 Corticotropin-releasing hormone (CRH), PTSD changes, 61 Council for the Accreditation of Counseling and Related Education Programs (CACREP), 14 Counseling, 15–16 adolescent trauma, 152–154 adult trauma survivors, 174

589 campus violence, 361–362 clinical supervision of, 531 community-based crises, 330 co-occurring trauma and SUDs, 226 crime victims, 238–244 culturally sensitive approaches, 425–426 disaster behavioral health, 464–465 early childhood trauma, 138–140 effects of war, 425–426 ethical implications, 535 grief and loss, 93 homicide and suicide, 256–259 impact of war on military veterans, 448–449 implication of traumatic events, 38–39 integrative approaches to therapy, 500–501 medications and, 72 multicultural sensitivity, 531–532 natural disasters, 385–386 older victims of abuse, 207–210 political violence, 405 PPV, 190–193 psychological assessment, 487 psychology of evil, 276–277 racial and ethnic intolerance, 292–293 school violence and trauma, 345 sexual trauma, 126 stigma in older adults, 208 strategies and techniques, 517–518 theory-based perspectives, 47–53 therapist self-care, 564 trauma-sensitive supervisors, 531 trauma survivorship and disability, 109–110 vicarious traumatization, 547–549 Counseling professionals role in healing process, 556 self-care, 554–568 stigma of therapy work, 555–556 wellness self-assessment, 561 as wounded healers, 558 Countertransference (CT), 542, 570–571 Courtesy trauma, 104–106 Creative therapies, use in political violence, 404 Crime Awareness and Campus Security Act, 356 Crime in the community, PTSD and, 233 Criminal assault, 231–232 Criminal victimization, 231–248 psychology of, 233–234 symptom management and short-term mental health stabilization, 236–238 therapeutic and counseling guidelines, 234–236

590 Crisis basic intervention and management, 318–320 institutional settings, 317–334 sex-step model of intervention, 320 three-stage integrative intervention model, 320 training, 320–321 trauma and, 14–15 Crisis- and disaster-focused models, 499 Crisis Counseling Assistance and Training Program (CCP), 467 Crisis counseling (CC), 467 Crisis intervention programs, 122 Crisis response, models of, 326–330 Critical incident stress debriefing (CISD), 467 Critical Incident Stress Management (CISM) model, 328, 467 Cued relaxation, 237 Cultural genograms, use in political violence, 403 Culturally supported heterosexism, 300–302 Cultural racism, 283 Culture sensitivity in counseling, 425–426 trauma experiences and, 12 Cyberaggression, 353 Cycle of violence, 183–184

Dance and movement therapy, 513 Dart Society, 17–18 Debriefing, children exposed to violence, 341–342 Deep therapies, 236 Defense mechanisms, cognitive, 241 Defense of Marriage Act (DOMA, 1996), 301 Dehumanization, 270–271 Denial, 81–82 crime victims, 241 Department of Homeland Security (DHS), 467 Depersonalization, 164 Deployment, 467 Derealization, 164 Despair and disorganization, 83 Detailed Assessment of Posttraumatic Stress (DAPS), 472, 480 Development, impaired and delayed, 165 Developmental trauma disorder (DTD), 165 Diagnoses of disorders of extreme stress not otherwise specified (DESNOS), 165 Diagnostic and Statistical Manual of Mental Disorders, 8 development of, 31–33

Index Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), 9 addiction, 214 PTSD and crime in the community, 233 trauma definition, 102, 474 Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) psychological effects of disaster, 375–376 structured clinical interviews for, 472 trauma definition, 102 Dialectical behavior therapy (DBT), 53, 153, 172–173, 498–499, 509–511 Disability, 98–115 congenital and acquired, courtesy trauma and, 105 discrimination, 99 relevant terms and concepts, 99–100 research on, 106–107 Disability models, 99 Disability service delivery, 109 Disabled persons organizations (DPOs), 99–100 Disaster behavioral health, 454–470 institutional settings, 317–334 mental health interventions, 379–382 phases, 462–464 phases of, 378–379 process, 459–460 psychological effects, 375–379 responder self-preparation, 465 trauma and, 14–15 Disaster Action Team (DAT), 467 Disaster Application Center (DAC), 467 Disaster Crisis Outreach and Referral Team (DCORT), 467 Disaster field office (DFO), 467 Disaster mental health, 468 eligibility criteria, 460 versus traditional mental health, 456–459 Disaster plan, school violence, 337–338 Disaster relief operations (DRO), 468 Disaster response system, 375–385 Disaster worker reactions, 529 Disciplining of grief, 84 Discrimination, 269 people with disabilities, 99, 100–102 trauma linked to, 101–102 Disenfranchised grief, 88–89 Disorders of extreme stress not otherwise specified (DENOS), 34, 474 Disorders of extreme stress (SIDES), structured interviews for, 477 Displacement/projection, crime victims, 241

Index Dispositional factors, evil, 270–275 Dissociation, 50–51, 164 complex PTSD and, 477–478 SCID-D-R and, 477 Dissociative amnesia, 164 Dissociative Experience Scale II, 481 Distributive injustice, 354 Domestic violence/abuse. See also Intimate partner violence (IPV) young children and, 136 Domestic violence by proxy, 180 Drama therapy, 513 Drug and alcohol use, in workplace aggression, 355 Dual process theory, 86–87

Earth movement-related disasters, 372–374 Eating disorders (EDs), 150-151 Ecological development and attachment models, IPV, 187–188 Ecosystem theory, 318 Education, IPV trauma, 192 Ego state therapy, 171 Eichmann in Jerusalem: A Report on the Banality of Evil (Arendt), 272 Elder abuse, 199–213 abuser characteristics, 204–205 common red flags for, 206 counseling, 207–211 definition, 199–213199 effects, 205 extent of, 200 identification and reporting, 205–207 risk factors, 200–201 role of long-term care ombudsman, 207 types, 201 Emergency manager (EM), 468 Emergency Medical Services (EMS), 468 Emergency Operation Center (EOC), 468 Emergency providers. See also First responders working with, 382–385 Emotional abuse, 352 Emotional personality (EP), 171–172 Emotional symptoms, 324 Employment Non-Discrimination Acts, 301 Empowerment, 100 Engagement with the community, 336–337 Environmental affordances, in SDT, 51 Environmental conditions in campus violence, 360 in workplace aggression, 355 Environmental discrimination, 101 Environmental trauma, young children and, 136–137

591 Erikson, comparison of theories, 4–6 Esteem, 3–4 Ethics, 521–539 Ethnic cleansing, 390–391 Ethnocentrism, 281 Ethnomedicine, 12 Eugenics, 269 Evil, 264–279 banality of, 272–273 inaction, 274–275 psychology of, 270–275 Existential issues, crime victims, 242 Existential perspectives, evil, 266–268 Exosystem, 6 Exosystem level, sexual trauma, 120 Expected student behaviors, 336–337 Exposure therapy (ET), 497–498 survivors of sexual trauma, 123–124 Expressive arts therapy, trauma survivors, 512–517 Externalizing (acting-out), 148 Eye movement desensitization and reprocessing (EMDR), 152, 172, 401, 498, 511–512

Family issues adolescent trauma and, 151–152 effects of war, 417–418 Family systems model, IPV, 186–187 Family Violence Project, San Francisco District Attorney, 181 Fantasy theory, 48–49 Federal Emergency Management Agency (FEMA), 375, 468 history of, 455–456 Feeling rules, 88 Femicide, Botswana, 259–261 Feminist theory, IPV, 186 Fetish burglaries, 232–233 Fidelity, 526–527 Fight-or-flight response, 60–61, 165 Financial exploitation, elders, 201 First responders. See also Emergency providers mental health in natural disasters, 369–388 on-scene crisis intervention, 234–236 Five Vs, 92 Flashback, 440 Freeze response, 165 Freud, Sigmund, 2, 47–53 comparison of theories, 4–6 repression, 48–49 Frustration, in workplace aggression, 355 Functional impairment, elder abuse and, 202

592 Gay men, 298 Gender differences adolescent trauma, 148–149 elder abuse, 202 in workplace aggression, 353 Gender identity and expression definitions, 298 Gender prejudice and victimization, 297–316 Genocide, 390 Grief and loss ambiguous, 89 biopsychosocial effects, 90–91 continuing bonds and, 87–88 disenfranchised, 88–89 interventions, 91–93 mean-making and, 86 Group psychotherapy, survivors of trauma, 508–509

Hate crimes, 292 attending to perpetrators, 308–309 campus, 357 community and systemic implications, 311–312 consequences relevant to victims, 305–306 definitions, 299 experience of, 302–307 linking heterosexism to, 302 responding to, 307–312 Hate Crimes Sentencing Enhancement Act (1995), 357 Hate speech, 299 Hawaiians, colonial oppression, 288–289 Hazard, 468 Hazardous materials (HAZMAT), 468 Hazing, campus violence, 358 Heart of Darkness (Conrad), 264 Helibase, 468 Helispots, 468 Herman’s Recovery-focused model, 500 Heterosexism, 298 culturally supported, 300–302 linking to prejudice and hate crimes, 302 Historical contexts, 23–27 Historical trauma, 13–14 Historical trauma theory, 26–27 History, early, trauma survivors, 162 Home invasion, 233 Homicide background, 251 counseling implications, 256–259 emotional and psychological experiences, 253 family survivors, 252–253

Index implications for policy and law makers, 258 implications for researchers, 259 multiple losses, 255–256 physical experiences, 255 social experiences, 254 trauma of, 252 WHO definition, 250 Homophobia, 299 internalized, 302 Homosexual (homosexuality), 298 Hostage situations Hostile attributional bias, in workplace aggression, 354 Human development, 3–7 bioecological perspective, 6, 7 Human nature, historical context, 268–270

Identity threat, workplace, 352 Imaginal exposure, use in exposure therapy, 124 Immediate response, 468 Impact pyramid (CDC), 461 Inaction, evil of, 274–275 Incident commander (IC), 468 Incident command post (ICP), 468 Incident command system (ICS), 468 Indians (India), colonial oppression, 289–290 Individual level effects of war, 415–417 sexual trauma, 118 Individual/personal aspects, 322 Individual racism, 282–283 Individual trauma, definition, 460 Injustice or unfair treatment in political violence, 397–398 in workplace aggression, 354 Inner child therapy, 171 Inquisition, 25–26 Institutional discrimination, 101 Institutional racism, 283 Integrated therapy treatment, addiction and psychological trauma, 216–218 Integration, after trauma, 169–170 Integrative systemic approach to trauma (ISAT) model, 580 Intensive combat, stresses from, 442 Interaction therapy, parent-child, 138–139 Internalized homophobia (IH), 122, 302 Internalizing, 148 International Classification of Diseases, Tenth Revision (ICD-10), trauma definition, 474 International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD-6), 31

Index Interpersonal conflict, in workplace aggression, 355 Interpreters, use in political violence, 399–400 Interpretive counseling, crime victims, 240 Interventions grief, 91–93 for institutional crisis, 329–330 models for, 493–503 school-based, 340–345 stage-appropriate, 152 Intimate partner violence (IPV), 178–198. See also Domestic violence consequences on society, 183–185 definition, 179, 180 multicountry study, 181 physical effects, 182 prevalence in the U. S., 180 psychological effects, 182–183 recognition of perpetrator’s behavior, 183 risk factors, 188–190 in sexual minorities, 181 social costs and multiple losses, 184–185 theoretical contexts, 185–190 trauma of, 181–185 Intolerance, racial and ethnic, 280–297 Intrapsychic trauma, 415 Introductory Lectures on Psychoanalysis (Freud), 28 Introjets, 52 In vivo exposure, use in exposure therapy, 124 Iraq War Clinician Guide (NCPTSD & WRAMC, 2004), 441 Isomorphism, 570–571

Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, 356 Jewish people, historical persecution, 25 Job dissatisfaction, in workplace aggression, 355 Justice, 524–525

Leadership Council on Child Abuse and Interpersonal Violence, 180 Lesbian, gay, bisexual, and transgender (LGBT), 297 attending to perpetrators, 308–309 community and systemic implications, 311–312 consequences of hate crime violence, 305–306 responding to survivors, 307–308 Lesbian women, 298

593 Liberal racism, 283 Life span development, 3–6 Life storybooks, use in political violence, 403 Living conditions, elder abuse and, 203 Longer-term counseling, children exposed to violence, 342–345 Long-term care facilities, providing counseling services in, 208–209 Long-term care ombudsman, role in elder abuse, 207 Losing a job, in workplace aggression, 355 Loss and grief, 77–97 phenomenology of, 78–89 Love and belonging, 3–4 Low-intensity combat, stresses from, 442

Macrosystem level, sexual trauma, 121 Madness and Civilization: A History of Insanity in the Age of Reason (Foucault), 24 Magic circle of everyday life, 392–394 Malingering, 484 Malleus Maleficarum (The Hammer of Witches), 25 Man’s Search for Meaning, 86 The Manufacture of Madness (Szasz), 25–26 Maslow’s Hierarchy of Needs, 3–4 Mean-making and grief, 86 Mean world syndrome, 233 Medications. See also specific drug or drug type use in PTSD treatment, 63–72 Melting pot theory, 281 Mental asylum, history of, 24–25 Mental health conditions, elder abuse and, 203 Mental illness, history of, 25 Mesosystem, 6 Microsystem, 6 Microsystem level, sexual trauma, 121 Military sexual trauma, 443–444 Military veterans healing through meaning, 449 impact of war, 434–453 recovery, 445–447 trauma-related triggers, 448 treatment modalities, 444–448 Miller Children’s Abuse and Violence Intervention Center (MCAVIC), 153 Mindfulness, 237–238 Mindfulness-based parenting programs, early childhood trauma, 140 Minnesota Multiphasic Personality Inventory-2 (MMPI-2), 472, 482–483 Mirtazapine, in PTSD, 67–68

594 Mississippi Scale for Combat-Related PTSD (M-PTSD), 479 Mobbing, 352 Monoamine oxidase (MAO) inhibitors, in PTSD, 69 Multicultural perspectives, in trauma counseling, 531–532 Multiple diagnoses in adolescent trauma, 150–151 adult trauma survivors, 164–165 categories, trauma interface, 34–35 Multiple losses, 395 Multiple personality disorder, 477 Murder, campus violence, 357–358

Narcotics Anonymous (NA), 221–222 Narrative therapy, use in political violence, 402 National Adult Protective Services Association (NAPSA), 199, 206 National Board for Certified Counselors (NBCC) Code of Ethics for Approved Clinical Supervisors, 531 National Center for Trauma-Informed Care (NCTIC), 494–496 National Center on Elder Abuse (NCEA), 199 National Incidence Study, 200 National Clearinghouse on Abuse in Later Life (NCALL), 209 National Crime Victimization Survey (NCVS), 179 National Incident Management System (NIMS), 468 National Long-Term Care Ombudsman Resource Center (NORC), 207 National Organization for Victims Assistance (NOVA) model, 328 National Response Framework (NRF), 469 National Sexual Assault Online Hotline (NSAOH), 123 National Voluntary Organizations Active in Disaster (NVOAD), 469 Native Americans, colonial oppression, 284–285 Natural disasters first responder mental health, 369–388 types, 369–374 Nefazodone, in PTSD, 68–69 Negative affectivity, in workplace aggression, 354 Neglect, elders, 201 Neurobiology PTSD, 59–76 trauma and, 165

Index Neurotransmitters, role in mental and physical health, 90 New possibilities, domain of PTG, 36 Nexus of personal and treatment issues, 580 Nonmaleficence, 525–526 Norepinephrine, 90 Normal reactions, abnormal events, 321 Numbness, 83

Observed and Experiential Integration model, 499 Ohio Cares, 449–450 Ohio model, 328 Older Americans Act, 207 On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families (Kübler-Ross), 81–83 On Killing (Grossman), 439 On-scene crisis intervention, 234–236 Organismic growth processes, in SDT, 51 The Origins of Totalitarianism (Arendt), 273 Othering, definition, 281 Overeaters Anonymous (OA), 222

Parallel process, 570–571 Parallel treatment, addiction and psychological trauma, 216–218 Parent-child interaction therapy, 138–139 Passive complicity, victims, 275–276 Pedagogical dimensions, trauma training, 14 People with disabilities (PWD), 98 Performance-based tests, 472, 483–484 Personal characteristics, responses to trauma and, 436–437 Personality assessment instruments, 472, 481–484 Personality Assessment Inventory, 472 Petty tyrant, workplace, 352 Phenomenology of trauma, 10–12 Physical abuse, elders, 201 Physical symptoms, 324 Physiological needs, 3–4 Piaget, comparison of theories, 4–6 Play therapy, early childhood trauma, 139 Political violence, 391, 397–398 Poor whites, colonial oppression, 286–287 Positive adult interactions, 336–337 Postmodern grief theory, 84–89 Posttraumatic growth (PTG), 35–38 controversy involving, 38 domains of, 36 theoretical foundation of, 37–38

595

Index Posttraumatic Stress Diagnostic Scale (PDS), 479 Posttraumatic stress disorder (PTSD), 2, 8–10 addiction and, 215–216 adjunctive agents in, 65 in adolescence, 147–151 alternative and complementary interventions, 108–109 antidepressant use in, 64 antipsychotics use in, 65 brain structures affected, 61 checklist, 478 children, 418–421 clinician-administered scale for DSM-IV, 476 complex, 474–475, 477–478 complex trauma effects, 33–34 co-occurring conditions, 108 diagnosis in children, 30 diagnostic scale, 479 drug therapy duration, 71–72 DSMs and, 30–35 in early childhood, 137–138 genocide, ethnic conflict, and political violence, 389–411 growing awareness of, 29 intimate partner violence and, 182–183 malingering and, 484 more severe or complex symptoms, 324 need for medication, 63 neurobiology and psychopharmacology, 59–76 post medication recovery, 72 psychological assessment for, 472–473 refugees, 413 sexual violence and, 117 SUDs and, 215 in survivors of hate crimes, 310–311 symptom clusters, 376 symptom development, 323–326 symptom scale, 476 talk therapy and, 62–63 trauma-focused therapies, 108 trauma-specific scales, 478–481 Power and control, survivors of sexual trauma, 125 Predictable responses, crisis- and traumaevoking events, 321–326 Preflight and flight stress, 423–424 Prejudice, linking heterosexism to, 302 Premorbid personality, 107 Presidentially Declared Disaster (PPD), 469 Prevention programs, IPV, 192 Primary traumatization, 375

Procedural injustice, 354 Processing of trauma, 168–169 Progressive muscle relaxation, 236–237 Project MATCH, 222 Property crime, 233 Proximate intent, 350 Psychiatric interviews, 472–478 Psychodrama, 515–516 Psychodynamic approach, treatment of trauma survivors, 173–174 Psychoeducation, survivors of sexual trauma, 123 Psychological abuse, elders, 201 Psychological assessment, 471 best practices, 484–485 combat-related trauma, 479 for PTSD, 472–473 Psychological First Aid Manual model, 329 Psychological first aid (PFA), 381, 469 curriculum, 469 Psychological trauma addiction and, 214–230 precise definition, 474 Psychological triage, 464–465 The Psychology of War (LeShan), 437 Psychopharmacology, PTSD, 59–76 Psycho-physiological and other somatic factors, 440 Psychophysiological studies, 321 Psychosocial context, impact of war on veterans, 435–436 Psychotherapy child-parent, 138 crime victims, 238–244 Psychotraumatology, 541 PTSD Checklist-Military, 479 Public health, trauma and, 13

Racial and ethnic intolerance, 280–297 experts, 294 Racism, 281–283 Radiating impact of violent victimization, 232 Rape, Abuse and Incest National Network (RAINN), 123 Rape crisis movement, historical context, 29–30 Rape Trauma Syndrome, 30 Rationalization, crime victims, 241 Reconnection, after trauma, 169–170 Recovery, 445–447 variables, 446–447 Recovery Service Center (RSC), 469 Recovery support groups, 222–224 Refocusing, crime victims, 241

596 Refugees life as, 424 PTSD in, 413 resettled, counseling for, 426–427 Reintegration, variables, 447–448 Relationships, domain of PTG, 36–37 Reminiscences, 48 Reporting barriers, LGBT hate crime violence, 306 Repression, 48–49 Research, homicide and suicide, 259 Resettlement stress, 424–425 Resiliency, variables, 447 Resources, elder abuse and, 203 Response styles, 480 Retraumatization, in self-help groups, 224 Richter Scale, 373 Risk factors elder abuse, 200–201 IPV, 188–190 Roman Catholic Church, historical persecution, 25–26 Rorschach Inkblot Method, 472, 483–484 R processes, 84

Safety, in treatment of trauma survivors, 167–168 Safety needs, 3–4 Salvation Army, 469 Sanctuary Model, 495–496 Sanctuary Model of Trauma-Informed Organizational Change, 153 Sand tray therapy, 513–515 School violence, 335–348 disaster plan, 337–338 internal and external factors affecting students, 340 physical building, 336 school-based interventions, 340–345 social-emotional climate, 336–337 treatment of students, 339–345 weapons, 337 Secondary traumatic stress, 311, 542–543, 571–572 Secondary traumatization, 378 Secondary victimization, 120 Secular Organizations for Sobriety (SOS), 222 Selective serotonin reuptake inhibitors (SSRI) brain structures affected, 61 use in PTSD, 66 Self-actualization, 3–4 Self-blame and guilt, survivors of sexual trauma, 125 Self-care, in counselors, 530, 554–568

Index Self-concept discrepancies, 55–56 Self-determination theory (SDT), 47, 51–53 Self-esteem, survivors of sexual trauma, 125 Self-Management and Recovery Training (SMART), 222 Self-monitoring behavior, in workplace aggression, 354 Self-reflection, IPV trauma, 192 Self-report tests, 472, 482–483 Sensory/mobility deficits, accommodating in older adults, 207–209 Separation anxiety, 83 Sequential treatment, addiction and psychological trauma, 216–218 Serotonin-norepinephrine reuptake inhibitors (SNRI), in PTSD, 67 Sexual abuse, elders, 201 Sexual and gender prejudice definitions, 298–299 Sexual assault, 232 Sexual Assault Nurse Examiner (SANE), 122 Sexual minorities, IPV in, 181 Sexual orientation definitions, 297–298 Sexual prejudice and victimization, 297–316 Sexual violence, 116–131 counseling treatment model, 123 cultural values and myths in reporting of, 121–122 ecological model for conceptualization, 117–122 military, 443–444 treatment for, 122–126 Shell shock, 389 Situational factors, evil, 270–275 Skills instruction, 336–337 Social factors, 322 Social justice, trauma and, 13–14 Social scapegoat as victim, 24–25 Social support elder abuse and, 203 trauma recovery, 441 Social trauma, 414–422 Social undermining or obstructionism, workplace, 352 Societal trauma, 121 homicide and suicide, 258 Spiritual/existential symptoms, 324 Spirituality in addiction treatment, 224–226 domain of PTG, 37 in trauma treatment, 224–226 Stabilization, in treatment of trauma survivors, 167–168 Stage-appropriate interventions, adolescent trauma, 152

Index Staging areas, 469 Standards for Education and Training in Psychological Assessment, 484 Stanford Prison Experiment, 271–272 Stockholm syndrome, 178 Storytelling tests, 472 Strength, domain of PTG, 36 Stress preflight and flight, 423–424 resettlement, 424–425 trauma and, 14–15 The Stress of Life (Selye), 14 Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R), 477 Student self/other awareness, 336–337 Substance abuse, 214 Substance abuse-focused models, 499–500 Substance dependence, 214 Substance use disorder (SUD), 214 counseling strategies in early stages, 220–222 PTSD and, 215 recovery support groups, 222–224 staging the treatment, 219–220 treating symptom versus treating problem, 218–219 Suffering, core experience of trauma, 10–11 Suicide background, 251 Botswana, 259–261 campus violence, 357–358 counseling implications, 256–259 emotional and psychological experiences, 253 family survivors, 253 implications for policy and law makers, 258 implications for researchers, 259 physical experiences, 255 social experiences, 254 trauma of, 252 traumatic aftermath, 249–263 WHO definition, 250 Superficial therapies, 236 Supervision counseling, 531 personal trauma history, 575 trauma professionals, 569–578 trauma-sensitive, 572–575 Supportive counseling, crime victims, 240 Survivors of trauma. See also Trauma survivorship and disability clinical complexity, 164–165 as consumers of services, 532–533

597 hate and bias crimes, 307–308 input to therapy and recovery, 534 knowing the client, 162–164 levels of impaired and delayed development, 165 mission, 534–535 multiple diagnosis, 164 strategies and techniques for counseling, 504–521 transformation from victim to survivor, 533–534 treatment, 166–174 Symptom development, 323–326 Symptoms, trauma survivors, 163–164 Symptom-specific tests, 472

Talk therapy, PTSD and, 62–63 Terrorism counselors responding to, 454–470 disaster behavioral health and, 460–464 Terrorist activities/guerilla warfare, 443 Testimonial psychotherapy, use in political violence, 403–404 Theft, 232 Thematic Apperception Test (TAT), 472, 483–484 Therapeutic assessment, 471 Therapeutic integration, crime victims, 242 Therapeutic strategy, crime victims, 238–244 Therapeutic technique, crime victims, 238–244 Together We Play (Nuzzo), 139–140 Trait factors, in workplace aggression, 353 Transference, 570–571 Transgender, 298 Transient Situational Personality Disturbance, 31 Transsexual, 298 Trauma, 8–15 adolescence, 146–160 adult survivors, 161–177 aftermath of homicide and suicide, 249–263 characteristics of the events, 441–442 clinical assessment, 471–492 as a clinical issue, 9–10 combat related, 479 complex, 33–34 complex nature of responses to, 436–444 constructs related to, 14–15 core experience of, 10–11 counseling implications, 15–16 courtesy, 104–106 cultural aspects, 12

598 Trauma (cont.) defining relevant issues, 98 early childhood, 132–145 ethical perspectives, 521–539 growing awareness of impact, 29 historical contexts, 23–46 individuals affected by an event, 461 integrative systemic approach, 579–585 interface with multiple diagnostic categories, 34–35 linked to disability discrimination, 101–102 loss and grief with, 78 modern study of, 27–30 neurobiologic effects, 165 pedagogical dimensions of, 14 phenomenology of, 10–12 physical response to, 59–60 psycho-physiological and other somatic factors, 440 public health dimensions of, 13 racial and ethnic intolerance, 280–297 research on, 106–107 school violence, 335–348 severe and prolonged, 161–166 sexual, 116–131 social factors, 441 social justice dimensions, 13–14 suffering as a component of, 11–12 as a systemic issue, 12–14 unfathomable, 391–392 Trauma and Recovery (Herman), 10 Trauma centrality, 106–107 Trauma Content Index (TCI), 483 Trauma counseling. See also Counseling definition, 1 supervision, 569–578 Trauma-focused therapies, 108 Trauma-informed care, 494–496 Trauma journalism, 17–18 Trauma literature review, 321–322 Trauma portfolio, 13 Trauma-related triggers, 448 Trauma-sensitive supervisors, 531 Trauma-specific care, 494–496 Trauma-specific characteristics, 322 Trauma-specific scales, 478–481 Trauma survivorship and disability, 98–115 current practices and treatment, 107–109 referral and level-of-care considerations, 330 varying perspectives, 102–104 Trauma Symptom Inventory (TSI), 472, 480 The Traumatic Neuroses of War (Kardiner), 29 Trazodone, in PTSD, 68–69

Index Treatment approaches present- and past-focused approaches, 505–506 selected best-practices, 508–517 students exposed to violence, 339–345 therapeutic alliance in, 506 trauma survivors, 172 Treatment phases, trauma survivors, 166–167 Treatment principles, trauma survivors, 170–171 Treatment research, 322 Tree of life technique, use in political violence, 402–403 Tricyclic antidepressants (TCA), in PTSD, 68 Triggers, trauma-related, 448 Trust, trauma survivors, 162–163 Trust and intimacy, survivors of sexual trauma, 126 Type A behavioral pattern, in workplace aggression, 354

UCLA Trauma Psychiatry Program, 153

Validating, 92 Valuing, 92 Ventilation, 92 Verifying, 92 Vicarious traumatization, 540–553, 571–572 Victim blaming, LGBT hate crime violence, 306 Victims, 179 passive complicity, 275–276 Viet Nam, combat effects on human psyche, 29 Violence campus, 349–368 experience by family survivors, 252–253 racial and ethnic intolerance, 280–297 WHO definition, 249 workplace, 349–368 Violence against children historical context, 30 treatment, 339–345 Violence against women, historical context, 29–30 Violence Against Women Act (1994), 357 Visionary, 92

War, 412–433 conceptualization of, 437–439 effects on children, 418–421 effects on communities, 421–422 effects on families, 417–418

599

Index effects on individual, 415–417 fleeing the combat zone, 422–425 hysteria, 28 impact on veterans, 434–453 intensive combat, 442 lived experience of, 414–422 low-intensity combat, 442 phases of adjustment, 436 psychology of warfare, 437 psychosocial responses to, 435–436 resistance to killing, 439 Ways of Seeing (Tortora), 140 Weapons, school violence, 337 Weather-related disasters, 370–372 White privilege, 291–292 Whole person, in trauma counseling, 1 Wife beating. See Intimate partner violence Witches, historical persecution, 25 Women for Recovery, 222 Women’s Recovery Program (WRP), model for women’s treatment, 227–228

Workplace aggression, 351–352 etiology of, 353–354 harassment, 352 incivility, 352 victimization, 352 Workplace victimization, 352 Workplace violence, 349–368 World Health Organization (WHO) definition of homicide, 250 definition of suicide, 250 definition of violence, 249 multicountry study on IPV, 181 World Report on Violence and Health (WHO), 116 World War I and II, study of trauma, 28–29 Wound healer, counselor as, 527–528

Youth and Family Consensus Statement on Resiliency and Children’s Mental Health, 447