Mitchell R. Morrissey
Denver District Attorney
 
Unit 2:
 
 
Trauma
 

Rationale
: Provide an overview of post-traumatic stress disorder, traumatic grief, and community criminal disasters.

Format:

Video:
Victim Care: Issues for Clergy and Faith-Based Counselors
The Impact of Trauma – Lesson Three
Access via http://FCPEI.denverda.org/index.htm or
Contact Steve Siegel – 720/913-9022

Video:
Victim Care: Issues for Clergy and Faith-Based Counselors
High Profile Mass Tragedy – Lesson Four
Access via http://FCPEI.denverda.org/index.htm or
Contact Steve Siegel – 720/913-9022

Reading: Hope Gets the Last Word: Stories That Heal – Finegan & Flannigan
Chapter 1: “Human Connection”
Chapter 2: “Understanding”

Suggested Reading: Trauma and Recovery – Judith Lewis Herman
Chapter 3: “Disconnection”
Chapter 7: “A Healing Relationship”
Chapter 8: “Safety”
Chapter 9: “Remembrance and Mourning”

Instructors may wish to order the document, Mental Health Response to Mass Violence and Terrorism, from the U.S. Department of Justice; Office for Victims of Crime and the U.S. Department of Health and Human Services; Substance Abuse and Mental Health Services Administration. Contact 1-800-627-6872 and order DOJ Publication No. NCJ 205451.

Assignments:
After completing the readings, write a 2-page paper addressing these questions.
  • Why is it difficult to listen to other people talk about their pain?
  • Why are we inclined to give answers to questions that have not yet been asked?

Lecture:
Historical Perspective on Trauma Terminology

The Greek word for trauma, ‘traumata,’ from which our English word derives, simply meant “wound or injury.” The impact of trauma on one’s emotional and mental framework went largely ignored throughout history, other than use of the term hysteria, which was generally applied to women who had strange and unexplainable symptoms that were believed to somehow be related to the uterus.

Not until the late 1800’s did Sigmund Freud and his colleagues recognize that hysteria was the result of psychological trauma, and that if given the opportunity to recover traumatic memory, ventilate the feelings surrounding it, and put the traumatic experience into words, symptoms decreased. This process was called psychoanalysis, and Freud became convinced for a period of time that premature sexual experience was the cause of most hysteria in women. He later recanted this theory after he had heard so many such stories from his patients that he had to conclude that “perverted acts against children” were endemic, particularly among his esteemed colleagues in Vienna.

Just prior to Freud’s work, writings from the Civil War had described an ailment among soldiers called “irritable heart.” Likewise, writings from World War I in the early 1900’s reveal stories of soldiers huddled down in the trenches under attack, shells screaming overhead, exploding, and causing extraordinary displays of light and contusions in the ground. As a result of these types of prolonged, life- threatening experiences, many soldiers began to act like “hysterical women,” screaming and crying uncontrollably. Some froze; some became mute. Terms like “combat neurosis” and “shell shock” became common to describe these combat reactions.

Following the Vietnam War, significant psychological inquiry into the combat-related symptoms of veterans led to the recognition of a group of symptoms called Acute Stress Disorder and Post-traumatic Stress Disorder (PTSD).

Clinical Definitions
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, commonly called the DSM-IV and published by the American Psychiatric Association, is the book from which mental health practitioners currently diagnose. Trauma is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 2000) as an experience in which both of the following is present:

  • 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; and
  • The person’s response involved intense fear, helplessness, or horror.

DSM-IV criteria for Posttraumatic Stress Disorder are as follows:

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) 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; and,
(2) the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

(1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are experienced.
(2) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and disassociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma specific reenactment may occur.
(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event;
(5) Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

(1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
(2) Efforts to avoid activities, places, or people that arouse recollections of the trauma.
(3) Inability to recall an important aspect of the trauma.
(4) Markedly diminished interest or participation in significant activities
(5) Feelings of detachment or estrangement from others.
(6) Restricted range of affect (e.g., unable to have loving feelings).
(7) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

(1) Difficulty falling or staying asleep;
(2) Irritability or outbursts of anger;
(3) Difficulty concentrating;
(4) Hypervigilance;
(5) Exaggerated startle response.

Duration of the disturbances in criteria B, C, and D is more than one month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more

Specify:
With Delayed Onset: if onset of symptoms is at least six months after the stressor

Acute Stress Disorder is very similar, but is diagnosed during the first month before a diagnosis for PTSD may be applied.

Research continues to explore why, among persons exposed to the same traumatic events, some individuals develop enough symptoms for the PTSD diagnosis, some develop some symptoms but not enough for the diagnosis, and a small percentage develop no symptoms at all. In addition to the type of trauma, Brian W. Flynn, Ed.D.i outlines factors that may influence an individual’s unique response to trauma:

  • Degree of threat to physical well being;
  • Seriousness of threat to personal safety;
  • Exposure to grotesque situations;
  • Diminished health status;
  • Magnitude of loss;
  • Trauma history;
  • Gender and age;
  • Socioeconomic status;
  • Marital status;
  • Pre-disaster functioning;
  • Interaction among factors.

Most people who are exposed to a traumatic, life threatening event experience at least a few symptoms associated with PTSD in the days and weeks following the incident. Data suggests that about 8% of men and 20% of women go on to develop PTSD, and roughly 40% of these individuals develop a chronic form that persists throughout their lifetimes.

The traumatic events most often associated with PTSD for men are rape, combat exposure, childhood neglect, and childhood physical abuse.ii The most traumatic events for women are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse. Chronic PTSD may be experienced as occasional intense symptomatic periods followed by a decrease or non-symptomatic periods.

Who is most likely to develop PTSD? According to the National Center for Post-traumatic Stress Disorder the following factors influence the likelihood of developing PTSD:

1. Those who experience greater stressor magnitude and intensity, unpredictability, uncontrollability, sexual (as opposed to nonsexual) victimization, real or perceived responsibility, and betrayal;
2. Those with prior vulnerability factors such as genetics, early age of onset and longer-lasting childhood trauma, lack of functional social support, and concurrent stressful life events;
3. Those who report greater perceived threat or danger, suffering, upset, terror, and horror or fear;
4. Those with a social environment that produces shame, guilt, stigmatization, or self-hatred.
(Note to Instructors: For more information go to: http://www.ncptsd.va.gov/facts/general/fs_what_is_ptsd.html


Flynniii identifies characteristics of trauma, regardless of the type, that influence trauma reactions:

  • Duration of traumatic event;
  • Scope of event;
  • Human error;
  • Malicious intent;
  • Lack of warning.

According to Charles Figley, this is both bad news and good news.

“The bad news is that since each person is unique, there is no way to measure or understand a person adequately. The good news, however, is that we are not totally ‘at sea’…the person forms habits, styles, patterns, and ways of being that persist and are recordable. They are tinkered with, struggled, over, and often resolved. But at the level of traits, at least some measure of consistency exists. Traits represent then, the substance from which to understand a person and although limited, we can know something of them.”iv

Trauma Symptoms
Trauma is the experience of an inescapable stressful event that overwhelms one's coping mechanisms. There are common symptoms associated with traumatic stress:

Behavioral:

  • Suspicious/Caution
  • Obsessive Retelling of Story
  • Rapid Intense Mood Changes
  • Antisocial Acts
  • Intense Startle Reflex
  • Alcohol/Drug Abuse

Cognitive

  • Time Expansion Slowed Thinking
  • Difficulty Making Decisions
  • Dissociation Memory Problems Tunnel Vision
  • Confused
  • Disoriented
  • Replays Event Over and Over
  • Distressing Dreams

Spiritual

  • Where is God?
  • Is it God’s Will?
  • Is God Trying to Punish Me?
  • Is God Testing My Faith
  • What Kind of God Would Allow This to Happen?

Traumatic Grief
Judith Lewis Herman in Trauma and Recovery identifies three crucial steps in helping a traumatized individual. The first is to establish physical and emotional safety. The second is to allow the emergence and telling of the traumatic story, including mourning for all that was lost. The third is reconnecting with ordinary life, even as a changed person.v

Too many caregivers fail to recognize the significance of grief and mourning for all that was lost during victimization. These losses can range from loss of actual body parts or functioning to loss of naiveté and everything in between. Victims of crime grieve over the loss of their former carefree life, the loss of a familiar part of themselves, the loss of safety and confidence, the loss of trust in God. They also grieve over “secondary losses.” Secondary losses refer to possessions or mental health characteristics due to a crime – but not necessarily directly related to the criminal act. For example, following the Oklahoma City bombing, families could not return to the apartment building damaged by the Murrah Building bombing. Children grieved over the loss of important stuffed animals, toys, clothes and other familiar items.

While all these losses are forms of traumatic grief, the most common use of the phrase is related to deaths due to homicide, vehicular crashes and other sudden, unexpected, usually violent, deaths. Grief is complicated due to the violence and negligent behavior of another person.

Trauma Care and Intervention
Trauma care is more than crisis counseling, although it often begins with crisis intervention.

Crisis Intervention is offered at a crucial time or turning point in reaction to real or perceived events that place a person in a position beyond their normal ability to cope. It focuses on response to an internal reaction. While such events are perceived as negative when the person enters pastoral counseling, they may, in time, become perceived as positive growth experiences.vi Crisis counseling is short-term in nature, generally no more than six weeks. Some limit the time frame of crisis counseling to the first 72 hours.vii

Trauma Counseling is offered to a person who is reacting to an event (as distinguished from a “perception”) that is intensely negative with the potential of shattering the body, mind, soul, and/or basic beliefs of the survivor.viii

While most crime victims achieve significant recovery sometime between one and three months after the crime, Dean Kilpatrick, Director of the National Crime Victims’ Research and Treatment Center at the Medical University of South Carolina, points out that for many crime victims, total elimination of crime-related psychological injuries is not a realistic goal. Rather, helping victims learn to cope with the ways their life has changed is the primary objective. Some victims suffer long-term consequences including panic attacks, general anxiety, depression, and post-traumatic stress disorder. While pastoral counselors may need to refer traumatized persons for specialized trauma-related psychological treatment when they realize that they are not adequately trained to help them, they also can offer crucial long-term supplemental support. Each victim's time frame for recovery is different. Patience and availability of faith leaders and members of the faith community may continue to be important even after professional treatment concludes.

Terrorism and Large-Scale Disasters
Terrorism and other large-scale community disasters include the full range of trauma and grief experiences. The first large-scale disaster in Oklahoma City, the numerous and continuing school shootings, the tragic events of September 11, murders of court officials, military disasters, and other high profile tragedies capture our attention.

The inner circles of those who have been traumatized include the family members of those killed and injured. The next group includes those who where involved, but not actually hurt. These are witnesses and crisis responders such as police, firefighters, and paramedics who may suffer significant emotional damage. Trauma can take a toll on emergency care physicians and medical examiners. Another group affected by a large-scale event is the media, clergy, and others with particular roles involved in a disaster.

Large community disasters affect all of us. The horrific sights and the injured people become part of our lives. These events change all of us, not just a select few at the epicenter of the tragedy, but all who now must reevaluate our sense of safety, live under new security restrictions, adjust our behaviors, and rehearse emergency plans.ix

The unremitting and ever present threat of calamity forces each of us to draw upon resources normally reserved for managing everyday stress brought on by the normal juggling act of work and family demands in an increasingly fast paced world. This unprecedented and relentless stress can have severe consequences, if left untended. The symptoms brought on by unmanaged stress can lead to paralyzing mental health issues, debilitating physical conditions, as well as organizational chaos. These consequences affect individuals, families, and organizational systems.

While the role of the faith community is not traditionally addressed in community crisis response, it, nonetheless, plays a significant role. George Everly writes:

“Given the apparent natural affinity that many individuals show for faith-based support, guidance, and/or reassurance, it is interesting, indeed, to note the conspicuous omission of faith-based resources as part of a formalized community-wide crisis intervention and disaster response. Such services have traditionally been supplied within the context of chaplaincy services to well-circumscribed groups, but have usually lacked breadth in large-scale community crisis. Pastoral counseling services have certainly been used in the wake of community crises and disasters, but these are, by definition, counseling services and not crisis intervention.”x

Crisis responders must consider both the individual impact as well as the community impact in large-scale disasters. Most of the factors that contribute to the severity of traumatic stress reactions are exacerbated in an incident of mass violence. The role of pastoral counseling in a large-scale, community disaster is significant. Faith-based, trained counselors should coordinate with other community disaster responders to provide a comprehensive response to a community’s emotional distress. Religious facilities are used as family gathering centers, emergency operations centers and sites for community memorial services.

Robin Finegan and Krista Flannigan (2003) have identified established factors common in mass disaster:

  • Multiple victims;
  • Intense media coverage;
  • Political atmosphere;
  • Multiple agency response;
  • Public vicarious trauma;
  • Public outpouring of money;
  • Normal agency resources overwhelmed.

According to Finegan and Flannigan, large-scale disasters and mass fatality events have factors that complicate and exacerbate a victim’s reactions:

  • Number and age of victims;
  • Emergency responders as targets of terrorism;
  • Extent of suffering, damage, injury and death;
  • Suddenness of event;
  • Length of time to recover and identify bodies;
  • How families learn of death or injury;
  • Family reunification;
  • Intense media coverage;
  • Emergency management resources overwhelmed;
  • Difficulty and delays in obtaining information;
  • Decontamination;
  • Delayed onset;
  • Widespread impact beyond primary victims;
  • Bodies not recovered or extensively damaged.

Finegan and Flannigan write in Hope Gets the Last Word,

“Mass tragedy presents some very unique opportunities for healing and recovery from the resulting grief and trauma, which are not as accessible to victims who suffer through a tragic experience alone. As we came to know and understand many “communities” of survivors – groups of people brought together around a common tragedy or circumstance – it became very clear that there was one element of recovery unique to survivors of a mass-fatality, mass-injury tragedy. They can heal each other.”xi

Discussion: Given the information that has been presented thus far in this lecture, what are some questions you would want to ask a person who had been trapped in one of the towers on September 11, 2001, and came to you for pastoral care?

Discussion: As you consider a pastoral call to a family following the murder of a family member, what might you expect that is different from a family in which a loved one has died from a lengthy illness? What are some ways you might encourage a person to talk about what they experienced?

____________________
iFlynn, B. (2005). Conference: Addressing Disaster and Emergency Stress Beyond First Responders.
iiUnited States Department of Veterans Affairs. Retrieved from: http://www.ncptsd.va.gov/facts/general/fs_what_is_ptsd.html
iiiFlynn, B. (2005). Conference: Addressing Disaster and Emergency Stress Beyond First Responders.
ivFigley, C. (1985). Trauma and it’s wake. New York: Brunner/Mazel. (p. 17).
vHerman, J. (1992). Trauma and Recovery. New York: Basic Books. (p. 155).
viStone, H. (1993 ). Crisis Counseling (Rev). Minneapolis: Fortress Press. (pp. 13ff).
viiWright, H. (1999). Crisis counseling: What to do and say the first 72 hours: A practical guide for pastoral counselors and friends. New York: Regal Books.
viiiHerman, J. (1992). Trauma and Recovery. New York: Basic Books p. 51.
ixFinegan, R. (2004). All Hazards Plan CISM Annex
xEverly, G., Jr. Ph.D. Role of Pastoral Crisis Intervention in Disasters, Terrorism, Violence, and other Community Crises. International Journal of Emergency Mental Health.
xiFinegan, R. & Flannigan, K. (2004). Hope Gets the Last Word: Stories That Heal. Colorado: Continuing Legal Education in Colorado, Inc.