Title: Traumatic Stress and International Christian Workers: Assessment and Intervention
1Traumatic Stress and International Christian
Workers Assessment and Intervention
This presentation can be downloaded from
www.careandcounselasmission.org
- AACC- September 29, 2011
- Heather Davediuk Gingrich, Ph.D.
- Denver Seminary
- Care and Counsel International (CCI)
2Which of these experiences did I find the most
traumatic? Why?
- Visiting missionary friends who lived in a
dangerous part of the country - Hearing of a bus bombing within a block of the
seminary - Hearing of a mall bombing in a mall we were in
weekly - Our 10-year old diagnosed with potentially fatal
dengue fever - Forced out of taxi when streets were flooded
(within 3 months of arrival) - Stopped by traffic police when alone with a 3 and
4-year old - Seeing blood stains on roadway in front of our
house where 2 people were murdered in the night - Sudden onset of urinary tract infection
- Family pet dog hit by car
- Finding out mall closing early because of coup
attempt several miles away - Berating by a Filipino-Canadian for content of my
presentation on the Philippines during first home
assignment - Hearing of the Burnhams kidnapping
3Answer
- Sudden onset of urinary tract infection
- Family pet dog hit by car
- Forced out of taxi when streets were flooded
(within 3 months of arrival)
4Common Elements
- Feeling of helplessness
- Cultural aspects
- Not knowing where vet clinic was
- Being turned away at first one
- Not knowing what to expect at hospital/vet clinic
- Fear of not being able to communicate
sufficiently - Dealing with emotional reactions of
children/house helper - Feeling of isolation
- husband unavailable
- Teaching
- Sick
- Best friends on home assignment
- Other friends too far away (traffic) to help
-
5Experiences of Fellow Missionaries
- Single woman kidnapped and raped (she had been a
virgin) while visiting friends held for a week - Married man long-time missionary kidnapped
held for 3 months in a bamboo cage - Husband killed by suitcase bomb while picking up
his wife at the airport - Woman came very close to death from dengue fever
while husband was out of the country - Traveling companion/friend murdered 3 feet from
her - Death threats
- Driving a car that killed a national in an
accident - Kidnapping by insurgents - marched through jungle
at night for many months caught in cross-fire
of numerous gun battles horrendous living
conditions - Mental illness or serious physical illness on
field (e.g., bi-polar, suicidology, cancer) of
self or spouse - Ferry sinking hanging onto dead bodies
overnight to keep afloat until help came
6Experiences of Other Missionaries
- Evacuation because of war
- Witnessing war-related atrocities
- In jeep that flipped over into water with only a
small airspace in which to breathe
7Although particular objective events are often
defined as traumatic
- Subjective components actually most important in
symptom development - No trauma is so severe that almost everyone
exposed to the experience develops PTSD
(McFarlane Gerolama, 1996, p. 148) - Only 25-35 of people who are exposed to a
traumatic experience develop PTSD (Carlson, 1997,
p. 4)
8Pragmatic Definition of Trauma
- Trauma is anything that exceeds ones capacity to
cope
9Stress and Trauma are Related
- Definition of Stress any force of nature or
experience that disrupts physiological
equilibrium (Scaer, 2005) - We need a certain amount of stress to get going
but stress can build to the point of being
unhealthy - Most missionaries live at stress levels that are
beyond the average person in their home culture
This could mean greater resilience or greater
risk - (From Boecker, 2007)
10Types of Stressors
- 3 categories of stressors
- Cataclysmic events- have a sudden, powerful
impact and universally elicit a stress response,
e.g., war, natural disaster, nuclear accident - Personal stressors - strong and unexpected
- Background stressors - daily hassles, e.g.
commuting, job dissatisfaction, type of job -
short-term not as much of a problem, but
long-term make require more adaptive responses - Lazarus and Cohen as cited in Gatchel, 1994
11Common Stressors From World Vision Survey
- Interpersonal
- Separation from family due to work
responsibilities - Conflicts between team members
- Physical Environment
- Travel difficulties, threatening checkpoints,
rough roads - Excessive heat cold or noise
- Shortages of resources
- Housing/Privacy Issues
- Vehicle Mechanical Problems
- Organizational
- Lack of direction from management
- Lack of recognition for work
- Being asked to perform duties that are outside
ones professional training - Criticism of work by agency authorities
- Community/Host Country
- Feeling hostility from the host
country/environment - Being watched or under surveillance
- Oppressive leadership in the community
- Criticisms of work by media or community members
12Impact of Traumatic Stress
13Traumatic stress in a missionary population
Dimensions and impact (Irvine, Armentrout
Miner, 2006)
- N173
- 80.1 reported traumatic stress
- 35 reported their symptoms have continued
- 38 reported some form of permanent negative
change - Non catastrophic events had greater total impact
than catastrophic ones - no differences of impact on acute or gradual
onset - Support failure (SF i.e., interpersonal and
organizational) most frequent - 75 of those reporting SF had a permanent
negative change - We had a hurricane and not one of the leaders
called or wrote. No one really reached out to me
or was even sensitive or seemed to care about
what I was going through I felt completely alone
and rejected (p. 333) - Younger missionaries more likely to experience
permanent negative change - 2/3 of population reported a positive sequel to
their stressful experiences (i.e., mixed)
14Hans Selyes Research (1950s)
- Non-specific stress responses
- regardless of the stressor, there is a
predictable triad of responses - 1) enlargement of adrenal glands ( 2) shrinkage
of thymus gland and 3) bleeding ulcers - stressor excites hypothalamus?, pituitary
stimulated to produce ACTH (adreno-corticotrophic
hormone) ?,adrenal stimulated to secrete
corticoids,? shrinkage of thymus (which is
involved in immune defense) - General adaptation syndrome (G.A.S.)
- 1) alarm reaction (initial decrease in resistance
2) stage of resistance (adaptation to continued
stressor alarm reaction disappears) 3) stage of
exhaustion - following long-term exposure alarm reaction
disappears, but are irreversible effects - diseases of adaptation occur, e.g., kidney
disease, arthritis, cardiovascular disease
(Gatchel) - Specific effects that specific stressors have
in addition to the non-specific or G.A.S.
15Response to Acute Stressor (Schubert, 1987)
- Normal Response
- E.g., G.A.S. (hg)
- Adjustment Disorder Response (DSM-IV)
- Clinically significant symptoms develop within 3
months of onset of stressor, and do not last
longer than 6 months after termination of
stressor or its consequences - Can be acute or chronic, with depressed mood,
anxiety, mixed anxiety and depressed mood, with
disturbance of conduct, with mixed disturbance of
emotions and conduct, unspecified - Brief Psychotic Response
- Brief Psychotic Disorder with marked stressor(s)
or Brief reactive psychosis (DSM-IV) - Post Traumatic Disorder Response
16Symptoms Related to Posttraumatic Stress Disorder
(PTSD) and Dissociative Disorders
17 18DSM-IV Criteria for PTSD
- Exposure to traumatic event (specific criteria)
- 1 or more re-experiencing symptom
- 3 or more avoidant
- 2 or more hyperarousal
- Duration of more than 1 month (less than 1 month
see Acute Stress Disorder)
19Reexperiencing
- Reexperiencing involves intrusive and
distressing - memories
- thoughts
- mental images
- dreams
- flashbacks
- Additional reexperiencing symptoms for children
- traumatic play
- dreams without recognizable content
- trauma-specific reenactments
20Avoidant/Numbing
- Attempts to avoid exposure to reminders of the
trauma, including - thought stopping
- social withdrawal
- amnesia for the trauma
- constriction of affect
- Avoidant symptoms for children include
- constriction of play
- social withdrawal
- decreased range of affect
-
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22Hyperarousal
- Hyperarousal symptoms include
- irritability
- explosive anger
- hypervigilance
- problems with concentration
- difficulty falling and staying asleep
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24Additional Symptoms for Children
- behavioral regressions (e.g., language, toilet
training) - new fears or aggression
- loss of social, academic and self-care skills
- inappropriate sexual behavior (if sexually
abused) - somatic symptoms (as traumatic reenactments)
25Definition of Dissociation
Disruption in the usually integrated functions of
consciousness, memory, identity, or perception of
the environment (DSM-IV-TR), sensation and motor
function.
Normal versus Pathological Dissociation
26BASK MODEL OF DISSOCIATION
- Behavior
- Affect (emotions)
- Sensation (physical)
- Knowledge
- Full, integrated memory includes all four
re-associated components. -
- Braun, 1988
27BASK - KNOWLEDGE
- Trauma survivor has full or partial cognitive
knowledge of traumatic event - Cognitive knowledge of the trauma is dissociated
from behavior, affect and sensation - Generally what people mean when they say I
remember
28BASK - BEHAVIOR
- Behavior is dissociated from other aspects of
memory - Individual acts in a certain manner without
knowing why - Examples
- -avoiding contact with particular nationals
- -avoiding certain types of travel
- (e.g., refusing to ride in a jeep)
- -nausea at specific foods
29BASK - AFFECT
- Affect is dissociated from other aspects of
memory - Example feeling of fear for no apparent reason
30BASK AFFECT (contd)
- There are no feelings attached to the cognitive
knowledge of the memory - -flat affect
- -matter-of-fact tone of voice
- e.g., can talk about atrocities as though
discussing the heat of the coming summer
31BASK - SENSATION
- Physical sensation is dissociated from other
aspects of memory - Individual may have cognitive knowledge of the
traumatic event, be aware of related affect, and
understand some behavior, but not remember the
pain or pleasure associated with the trauma - Examples
- -body memories physical symptoms such as
bleeding or severe pain occur in the present but
are unexplained -
32Integration
- Any, or all 4 BASK components can be dissociated
from each other - All 4 BASK components of an experience need to be
integrated for full integration of an experience
33DSM-IV Dissociative Symptoms
- Amnesia - A specific and significant block of
time that has passed but that cannot be accounted
for by memory - A total cognitive avoidance response
- The K component of BASK
- Depersonalization - Sense of detachment from
ones self, e.g., a sense of looking at ones
self as if one is an outsider - A cognitive/affective avoidance response
- The A, S, and K components of BASK
- Derealization - A feeling that ones surroundings
are strange or unreal. - Either avoidance (e.g., distancing from actual
surroundings) or re-experiencing (e.g., a full
flashback where one is not in touch with current
reality but is reliving the traumatic event) - The K component of BASK
34Dissociative Symptoms (contd)
- Identity Alteration - Objective behavior
indicating the assumption of different identities
or ego states, much more distinct than different
roles - Avoidance (another part of self takes on the
traumatic memory) or re-experiencing (another
part of self internally relives the event) - B, A, S, and K components of BASK
- Identity Confusion - Subjective feelings of
uncertainty, puzzlement, or conflict about ones
identity
35Secondary and Associated Symptoms
- Developed in response to the core trauma symptoms
- Include depression, aggression, low self-esteem,
disturbances in identity, interpersonal
relationships, guilt and shame - Example of secondary symptom
- Person shows aggressive behavior after a
traumatic experience, then receives negative
feedback from the social environment - Could result in low self-esteem or depression
- Carlson, 1997
36Factors Affecting Symptomatology
37General Factors Affecting Symptomatology
(Carlson, 1997)
- Three defining features of traumatic events that
are necessary although not sufficient for
developing PTSD symptoms - Perception of the Event as Negative
- Suddenness (although study by Irvine et al.,
2006, calls this into question) - Lack of Controllability
-
38Factors of Individuals (Carlson, 1997 subpoints
hg)
- Biological
- Developmental Level at Time of Trauma
- Severity of Trauma
- Although subjective sense of impact more
important - Social Context
- Fits with Irvine et al.s study re System
Failure (SF), i.e., in SF, not only is the social
context not supportive, but can be a source of TS
in itself - Prior and Subsequent Life Events
- Innoculation against the effects of a
subsequent stressor - Reduction of an individuals coping resources
- E.g., child abuse associated with PTSD in war
vets - Growing up in a traumatic environment makes one a
prime candidate to unwittingly seek out traumatic
situations in adult life (Grant, 1995). - Unresolved issues may be driving people into
service abuse, survivor guilt, unresolved grief
39Other Factors
- Choice of Psychological Defense
- E.g. peritraumatic dissociation
- Dissociation at the moment of trauma appears to
be the single most important predictor for the
establishment of chronic PTSD. (Van der Kolk,
Weisaeth, van der Hart, 1996, p. 66) - Gender, Race and Culture
- Temporal Stability or Instability of Symptoms
- Discrete vs. Chronic Traumatic Experiences
- (Carlson, 1997 van der Kolk and McFarlane, 1996
van der Kolk, Weisaeth, and van der Hart, 1996
deVries, 1996) - Significant disruption to the individual, to the
family, property, or community as a result of the
trauma - (Schubert, 1987 as cited by Boecker, 2007)
-
40Factors that impact Trauma and Stress Reactions
Organizational Support
Background
Level of Traumatic Response
Traumatic Event
Resilience Factors
Occupational Environment
Fawcett (2003), as cited by Boecker (2007)
41Resilience
- Coping Styles
- Active vs. Avoidant
- Spirituality
- Positive health behaviors
- Social Support
- Commitment
- Engagement with all aspects of life social, work
and family - Activities experienced as enjoyable and
interesting - Belief in importance and value of self
- Control
- Perception that one can influence outcomes
- Opposite of seeing self as passive recipient of
circumstances - Challenge
- Belief that change is normal and anticipated
Adaptation of Fawcett (2003), as cited by Boecker
(2007)
42Intervention
43Peer Debriefing Critical Incident Stress
Debriefing (CISD)
- Definition The CISD is a structure small group
or individual crisis intervention process. It is
an active temporary and supportive small group or
individual process that focuses on building a
groups resilience and the ability to bounce back
from a traumatic exposure. - (pg. 126 CISD manual, as cited by Boecker,
2007)
44Peer debriefing Critical Incident Stress
Debriefing (CISD) (contd)
- What it is not
- Psychotherapy (counseling) or a substitute for
psychotherapy - A treatment for PTSD or any mental or physical
disease or disorder - A cure for PTSD or any mental or physical disease
or disorder - An organizational problem solving process for
administrative problems - (pg. 126 CISD manual, as cited by Boecker,
2007)
45Peer debriefing Critical Incident Stress
Debriefing (CISD) (contd)
- Goals
- Lower tension and mitigate a small group or
individuals reaction to a traumatic event - Facilitation of normal recovery processes of
normal people with in a small group or one on one
who are having normal reactions to an abnormal
event. - Identification of people who may need additional
support or in some cases a referral to
professional counseling. - Best applied within 24-72 hours after a
traumatic event. Providers must assess for
psychological readiness for assistance. - Providers must be trained and follow the standard
procedures
(pg. 126 CISD manual, as cited by Boecker, 2007)
46CISD Model bathtub
Cognitive
Re-entry Phase
Introduction
Teaching Phase
Fact Phase
Symptom Phase
Thought Phase
Reaction Phase
Affective
47Cautions
- Never view peer debriefing as a definitive
solving of peoples needs - Assess for long term issues (cumulative stress or
trigger trauma that is brought to the surface) - ALWAYS know your limitations
- Know when people need to get longer term help
48CISD/CISM Training
- AACC accredited Critical Incident Stress
Management (CISM) training - http//aacc.net/conferences/cism-07/
- ICISF (International Critical Incident Stress
Foundation) Listing of trainings - http//www.icisf.org/training/calendarOfTrain.asp
49Psychological First Aid (PFA)(Fromhttp//www.ncp
tsd.va.gov)
- Immediate response in disaster/terrorist
situations (within first few days or weeks) - For children, adolescents, parents, families, and
adults - Developmentally and culturally adaptive
- Flexible based on needs of individuals
- Recognize that not everyone will respond the same
way - Different than debriefing (which is not allowed)
- Free info and manuals available at above website
50Objectives of PFA
- Establish human connection
- Enhance safety and provide ongoing physical and
emotional comfort - Calm and orient distressed survivors
- Help survivors talk about immediate
concerns/needs - Offer practical information and assistance to
address immediate needs - Connect survivors to social supports
- Support adaptive coping (e.g., acknowledge coping
efforts and strengths) - Provide info to enhance coping
- Be clear about your availability and link them to
other support services - It is NOT to elicit details of trauma
51Preparing to Deliver PFA
- Preparation
- Do you have adequate training for this particular
population/setting? - Do you know who is in charge/the command
structure? - Entering the setting
- Do you know what special needs there may be?
(e.g., children, those with disabilities etc.) - Establish communication with organization/people
in charge of operation - Providing services for those who are
- Disoriented, confused, panicky, agitated/frantic,
worried, angry, shut-down/withdrawn - Group settings
- Some principles can be used with groups (e.g.,
families, children, adolescents) - Maintain a calm presence
- Be sensitive to culture and diversity
- Be aware of at-risk populations
- Children, risk-taking adolescents, pregnant
women, injured, socially disadvantaged
52Core Actions for PFA
- Contact and Engagement
- Introduce yourself/ask about immediate needs
- Confidentiality
- Safety and Comfort
- Ensure immediate physical safety
- Provide information about disaster response
activities and services - Attend to physical comfort
- Promote social engagement
- Attend to children who are separated from their
parents/caregivers - Protect from additional traumatic experiences and
trauma reminders - Help survivors who have a missing family member
- Help survivors when a family member or close
friend has died - Attend to grief and spiritual issues
- Provide information about casket and funeral
issues - Attend to issues related to traumatic grief
- Support survivors who receive death notification
- Support survivors involved in body identification
- Help caregivers confirm body identification to a
child or adolescent
53Core Actions for PFA (contd)
- Stabilization
- Stabilize emotionally-overwhelmed survivors
- Orient emotionally-overwhelmed survivors
- The role of medications in stabilization
- Information Gathering Current Needs and Concerns
- Nature and severity of experiences during the
disaster - Death of a loved one
- Concerns about immediate post-disaster
circumstances and ongoing threat - Separations from or concern about the safety of
loved ones - Physical illness, mental health conditions, and
need for medications - Losses (home, school, neighborhood, business,
personal property, and pets) - Extreme feelings of guilt or shame
- Thoughts about causing harm to self or others
- Availability of social support
- Prior alcohol or drug use
- Prior exposure to trauma and death of loved ones
- Specific youth, adult, and family concerns over
developmental impact
54Core Actions for PFA (contd)
- Practical assistance
- For immediate needs/concerns
- Connection with social supports
- Family, friends, community resources
- Information on coping
- Provide info on stress reactions and coping to
help reduce distress and promote adaptive
functioning - Linkage with collaborative services
- Immediate or future
55Counseling
56- Gingrich, H. D. (2002). Stalked by Death
Cross-cultural trauma work with a tribal
missionary. Journal of Psychology and
Christianity, 21, 262-265.
57Phase-oriented Treatment
- Safety
- Assessment
- Trauma Work
- Integration
- (Adapted from Herman, 1992/97)
58Safety
- Physical/emotional/spiritual
- Within and outside of the therapeutic
relationship - Symptom management
- Journaling, talking, prayer, meditation,
bibliotherapy, normalizing - Agreements with self
- Ideomotor signalling
59Assessment Instruments
60Categories of Trauma Assessment Instruments
- Those that measure exposure to potentially
traumatic events - E.g., Trauma History Questionnaire
- PTSD scales that closely follow DSM symptom
criteria - Symptom checklists
- E.g., Revised Civilian Mississippi Scale for PTSD
and Traumatic Stress Schedule - Impact of Event Scale
- Combinations of measures of exposure and symptoms
- E.g., Traumatic Experiences Checklist
- PTSD scales from larger inventories
- E.g., MMPI-PTSD (PK) Scale
- Scales developed for culturally specific, or
cross-cultural research - Structured Interviews
- E.g., Clinician-Administered PTSD Scale
- Protocols
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64Assessment Instruments for Dissociation/Dissociati
ve Disorders
- Somataform Dissociation Questionnaire (SDQ-5 or
SDQ-20) (Nijenhuis, 1999) - Dissociative Experiences Scale-II (DES-II),
Adolescent Dissociative Experiences Scale, and
Child Dissociative Checklist (Putnam, 1997) - Structured Clinical Interview for DSM-IV
Dissociative Disorders-Revised (SCID-D-R)
(Steinberg, 1993)
65Trauma Work
66Trauma Work
- Talking, writing about details of trauma
- Exposure Therapy (Taylor, 2006)
- Generally refers to specific cognitive-behavioral
techniques involving some type of exposure to
traumatic memories - E.g., taping client recounting details of
traumatic event, then having them listen to tape
for 60 minutes every day - Integration of BASK components
- My experience has been that if a memory is
recounted, with all BASK components accessed, the
memory will be integrated, and further exposure
is not necessary - May involve several recountings of event (i.e.,
facts, then including affect etc.), or one
recounting, with all BASK components
re-experienced - Importance not only of catharsis, but of
integrating experience into over-all
understanding of life, beliefs, and calling - EMDR
- A specific technique for processing/integrating
traumatic experience
67EMDR Eye Movement Desensitization and
Reprocessing
- EMDR uses specific psychotherapeutic procedures
to - access existing information
- introduce new information
- facilitate information processing and
- inhibit accessing of information
- EMDR is used within an 8-phase approach to trauma
treatment in order to insure sufficient client
stabilization and reevaluation before, during and
after the processing of distressing and traumatic
memories and associated stimuli
http//emdria.org/displaycommon.cfm?an1subarticl
enbr3
68The Challenge
- To be aware of the situations that can lead to
traumatic stress - Have appropriate procedures in place
- Intervene appropriately
- so that by entering into the depths of others
suffering, we can see them restored to effective
service for the Kingdom of God.
69Copies of this presentation can be downloaded
from www.careandcounselasmission.org
70References/Bibliography
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