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Title: Traumatic Stress and International Christian Workers: Assessment and Intervention

Traumatic Stress and International Christian
Workers Assessment and Intervention
This presentation can be downloaded from
  • AACC- September 29, 2011
  • Heather Davediuk Gingrich, Ph.D.
  • Denver Seminary
  • Care and Counsel International (CCI)

Which 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
  • Hearing of a mall bombing in a mall we were in
  • 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
  • Hearing of the Burnhams kidnapping

  • 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)

Common 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
  • 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

Experiences 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
  • Death threats
  • Driving a car that killed a national in an
  • Kidnapping by insurgents - marched through jungle
    at night for many months caught in cross-fire
    of numerous gun battles horrendous living
  • 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

Experiences 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

Although 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)

Pragmatic Definition of Trauma
  • Trauma is anything that exceeds ones capacity to

Stress 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
  • Most missionaries live at stress levels that are
    beyond the average person in their home culture
    This could mean greater resilience or greater
  • (From Boecker, 2007)

Types 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

Common Stressors From World Vision Survey
  • Interpersonal
  • Separation from family due to work
  • 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
  • Being watched or under surveillance
  • Oppressive leadership in the community
  • Criticisms of work by media or community members

Impact of Traumatic Stress
Traumatic 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
  • Non catastrophic events had greater total impact
    than catastrophic ones
  • no differences of impact on acute or gradual
  • 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)

Hans 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
  • following long-term exposure alarm reaction
    disappears, but are irreversible effects
  • diseases of adaptation occur, e.g., kidney
    disease, arthritis, cardiovascular disease
  • Specific effects that specific stressors have
    in addition to the non-specific or G.A.S.

Response 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

Symptoms Related to Posttraumatic Stress Disorder
(PTSD) and Dissociative Disorders
  • Posttraumatic Symptoms

DSM-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)

  • Reexperiencing involves intrusive and
  • memories
  • thoughts
  • mental images
  • dreams
  • flashbacks
  • Additional reexperiencing symptoms for children
  • traumatic play
  • dreams without recognizable content
  • trauma-specific reenactments

  • 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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  • Hyperarousal symptoms include
  • irritability
  • explosive anger
  • hypervigilance
  • problems with concentration
  • difficulty falling and staying asleep

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Additional Symptoms for Children
  • behavioral regressions (e.g., language, toilet
  • new fears or aggression
  • loss of social, academic and self-care skills
  • inappropriate sexual behavior (if sexually
  • somatic symptoms (as traumatic reenactments)

Definition of Dissociation
Disruption in the usually integrated functions of
consciousness, memory, identity, or perception of
the environment (DSM-IV-TR), sensation and motor
Normal versus Pathological Dissociation
  • Behavior
  • Affect (emotions)
  • Sensation (physical)
  • Knowledge
  • Full, integrated memory includes all four
    re-associated components.
  • Braun, 1988

  • 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

  • Behavior is dissociated from other aspects of
  • 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

  • Affect is dissociated from other aspects of
  • Example feeling of fear for no apparent reason

  • 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

  • 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

  • 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

DSM-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

Dissociative Symptoms (contd)
  • Identity Alteration - Objective behavior
    indicating the assumption of different identities
    or ego states, much more distinct than different
  • 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

Secondary 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

Factors Affecting Symptomatology
General 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

Factors of Individuals (Carlson, 1997 subpoints
  • Biological
  • Developmental Level at Time of Trauma
  • Severity of Trauma
  • Although subjective sense of impact more
  • 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
  • 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

Other 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
  • (Schubert, 1987 as cited by Boecker, 2007)

Factors that impact Trauma and Stress Reactions
Organizational Support
Level of Traumatic Response
Traumatic Event
Resilience Factors
Occupational Environment
Fawcett (2003), as cited by Boecker (2007)
  • 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
  • Belief in importance and value of self
  • Control
  • Perception that one can influence outcomes
  • Opposite of seeing self as passive recipient of
  • Challenge
  • Belief that change is normal and anticipated

Adaptation of Fawcett (2003), as cited by Boecker
Peer 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,

Peer debriefing Critical Incident Stress
Debriefing (CISD) (contd)
  • What it is not
  • Psychotherapy (counseling) or a substitute for
  • 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,

Peer 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
  • 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

(pg. 126 CISD manual, as cited by Boecker, 2007)

CISD Model bathtub
Re-entry Phase
Teaching Phase
Fact Phase
Symptom Phase
Thought Phase
Reaction Phase
  • 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

CISD/CISM Training
  • AACC accredited Critical Incident Stress
    Management (CISM) training
  • http//
  • ICISF (International Critical Incident Stress
    Foundation) Listing of trainings
  • http//

Psychological First Aid (PFA)(Fromhttp//www.ncp
  • Immediate response in disaster/terrorist
    situations (within first few days or weeks)
  • For children, adolescents, parents, families, and
  • Developmentally and culturally adaptive
  • Flexible based on needs of individuals
  • Recognize that not everyone will respond the same
  • Different than debriefing (which is not allowed)
  • Free info and manuals available at above website

Objectives of PFA
  • Establish human connection
  • Enhance safety and provide ongoing physical and
    emotional comfort
  • Calm and orient distressed survivors
  • Help survivors talk about immediate
  • 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

Preparing to Deliver PFA
  • Preparation
  • Do you have adequate training for this particular
  • Do you know who is in charge/the command
  • 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

Core 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
  • 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
  • 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

Core 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
  • 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

Core 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
  • Linkage with collaborative services
  • Immediate or future

  • Gingrich, H. D. (2002). Stalked by Death
    Cross-cultural trauma work with a tribal
    missionary. Journal of Psychology and
    Christianity, 21, 262-265.

Phase-oriented Treatment
  • Safety
  • Assessment
  • Trauma Work
  • Integration
  • (Adapted from Herman, 1992/97)

  • Physical/emotional/spiritual
  • Within and outside of the therapeutic
  • Symptom management
  • Journaling, talking, prayer, meditation,
    bibliotherapy, normalizing
  • Agreements with self
  • Ideomotor signalling

Assessment Instruments
Categories of Trauma Assessment Instruments
  • Those that measure exposure to potentially
    traumatic events
  • E.g., Trauma History Questionnaire
  • PTSD scales that closely follow DSM symptom
  • 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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Assessment 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)

Trauma Work
Trauma 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
  • 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

EMDR Eye Movement Desensitization and
  • EMDR uses specific psychotherapeutic procedures
  • 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

The 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.

Copies of this presentation can be downloaded
  • American Psychiatric Association (2000).
    Diagnostic and statistical manual of mental
    disorders (text revision). Washington, DC
  • Boecker, B. (2007). Trauma and the missionary An
    education project. Unpublished manual for Denver
    Seminary Class, CO 646 Counseling for Trauma and
  • Braun (1988). The BASK model of dissociation
    Clinical applications. Dissociation, 1(2), 16-23.
  • Carlson, E. (1997). Trauma assessments A
    clinicians guide. New York Guilford Press.
  • EMDR International Association, EMDRIAS
    definition of eye movement desensitization and
    reproecessing. Retrieved April 23, 2007
  • http//
  • Fawcett, J. (Ed.). 2003. Stress and trauma
    handbook Strategies for flourishing in demanding
    environments. Monrovia CA World Vision
  • Gatchel, R. J. (1994). Stress and coping. In B.
    Parkinson A. M. Colman (Eds.), Emotion and
    motivation. London Longman.
  • Grant, R. (1995). Trauma in missionary life.
    Missiology An International Review, 23, 71-83.
  • Gingrich, H. D. (2002). Stalked by Death
    Cross-cultural trauma work with a tribal
    missionary. Journal of Psychology and
    Christianity, 21, 262-265.
  • Herman, J. (1992/97). Trauma and recovery The
    aftermath of violence-from domestic abuse to
    political terror. New York Basic Books.
  • Irvine, J., Armentrout, D. P. Miner, L. A.
    (2006). Traumatic stress in a missionary
    population Dimensions and impact. Journal of
    Psychology and Theology,34, 327-336.
  • Mitchell, J. Everly, G. (1992). Critical
    Incident Stress Debriefing An operations manual
    for the prevention of traumatic stress among
    emergency services and disaster workers.
    Maryland Chevron Publishing Corporation.

  • McFarlane, A. Girolamo, G. (1996). The nature
    of traumatic stressors and the epidemiology of
    posttraumatic reactions. In B. A. van der Kolk,
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    stress The effects of overwhelming experience on
    mind, body, and society. New York Guilford
  • Nijenhuis, E. R. S. (1999). Somatoform
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    theoretical issues. Assen, The Netherlands Van
  • Putnam, F. W. (1997). Dissociation in children
    and adolescents A developmental perspective. New
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  • Shapiro, R. (2002). EMDR treatment Overview and
    integration. In EMDR as an integrative
    psychotherapy approach Experts of diverse
    orientations explore the paradigm prism.
    Washington, D. C. American Psychological
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    wounds and human resiliency. New York Norton.
  • Selye, H. (1974). Stress without distress How to
    use stress as a positive force to achieve a
    rewarding lifestyle. New York New American
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    society. New York Guilford Press.
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