Trauma and Missionary Families How Can We Help
- Slides: 71
Trauma and Missionary Families: How Can We Help? Midwest Conference on Missionary Care February 21, 2015 Heather Davediuk Gingrich, Ph. D. Denver Seminary
Individual vs Family Trauma n Whatever happens to an individual has a spill-over affect on other relationships ¨ Marriage ¨ Parenting ¨ Mission family Friendships n Co-workers n
Although particular objective events are often defined as traumatic: n Subjective components actually most important in symptom development ¨“No trauma is so severe that almost everyone exposed to the experience develops PTSD” (Mc. Farlane & 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 n Trauma is anything that exceeds one’s capacity to cope
Stress and Trauma are Related n n n 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)
Types of Stressors n 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 n Interpersonal ¨ ¨ n Physical Environment ¨ ¨ ¨ n 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 ¨ ¨ n Travel difficulties, threatening checkpoints, rough roads Excessive heat cold or noise Shortages of resources Housing/Privacy Issues Vehicle Mechanical Problems Organizational ¨ ¨ n Separation from family due to work responsibilities Conflicts between team members 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 Existential ¨ Feeling powerless to change the external situation Fawcett (2003) as cited by Boecker (2007)
Impact of Traumatic Stress
Traumatic stress in a missionary population: Dimensions and impact (Irvine, Armentrout & Miner, 2006) n n n n N=173 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 ¨ ¨ n n 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 Selye’s Research n “Non-specific” stress responses (1950’s) regardless of the stressor, there is a predictable triad of responses: 1) enlargement of adrenal glands ( 2) shrinkage of thymus gland 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) ¨ n “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) ¨ n “Specific effects” that specific stressors have in addition to the non-specific or G. A. S.
Response to Acute Stressor n (adapted from Schubert, 1987) Normal Response ¨ E. g. , G. A. S. (hg) n Acute Stress Disorder ¨ Similar to PTSD but of shorter duration (3 days-1 month) n Adjustment Disorder Response (DSM-5) ¨ 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 with depressed mood, anxiety, mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, unspecified n Brief Psychotic Response ¨ Brief Psychotic Disorder with marked stressor(s) n Post Traumatic Disorder Response
Posttraumatic Symptoms
Posttraumatic Stress Disorder: DSM-V Criteria n n n n Exposure to traumatic event Intrusive Symptoms (at least 1) Avoidance Symptoms (at least 1) Negative Alterations in Cognitions and Mood (2 or more) Alterations in arousal and reactivity (2 or more) Symptom duration of more than 1 month Specifiers ¨ With dissociative symptoms (depersonalization or derealization ¨ With delayed expression American Psychiatric Association, 2013
Intrusive Posttraumatic Symptoms Memories n Dreams n Dissociative reactions (e. g. flashbacks) n Distress at exposure to internal or external trauma cues n Physiological reactions to internal or external trauma cues n
Intrusive Symptoms for Children Memories n Dreams with content related to the event or unrecognizable content n Dissociative reactions (e. g. , flashbacks, reenactments in play) n Distress at exposure to internal or external cues n
Avoidance n Attempts to avoid exposure to reminders of the trauma, including avoiding: ¨ Distressing memories, thoughts or feelings ¨ External reminders (e. g. , people, places etc. ) n Symptoms for children include avoiding or efforts to avoid: ¨ Activities, places or physical reminders ¨ People, conversations or interpersonal situations
Posttraumatic Symptoms: Negative Alterations in Cognitions and Mood n n n Amnesia Persistent and exaggerated negative beliefs or expectations about onesself, others, or the world (e. g. , “I am bad”) Persistent, distorted cognitions about cause or consequences of traumatic event leading to selfblame or blaming others Persistent negative emotional state Diminished interest in significant activities Feelings of detachment from others Persistent inability to experience positive emotions
Posttraumatic Symptoms: Negative Alterations in Cognitions and Mood ¨ Amnesia ¨ Persistent and exaggerated negative beliefs or expectations about onesself, others, or the world (e. g. , “I am bad”) ¨ Persistent, distorted cognitions about cause or consequences of traumatic event leading to selfblame or blaming others ¨ Persistent negative emotional state ¨ Diminished interest in significant activities ¨ Feelings of detachment from others ¨ Persistent inability to experience positive emotions
Posttraumatic Symptoms: Negative Alterations in Cognitions for Children Increased frequency of negative emotional states n Diminished interest in significant activities, including constriction of play n Social withdrawal n Reduction in expression of positive emotions n
Alterations in Arousal and Reactivity (for both adults and children) Irritability (e. g. , verbal or physical aggression) n Reckless or self-destructive behavior n Hypervigilance n Exaggerated startle response n Problems with concentration n Sleep disturbance n
DSM-5 -Definition of Dissociation Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Simply put: Dissociation is compartmentalization, or disconnection among aspects of self and experience Normal versus Pathological Dissociation
BASK MODEL OF DISSOCIATION n Behavior n Affect (emotions) n Sensation (physical) n Knowledge Full, integrated memory includes all four reassociated components. Braun, 1988
BASK - KNOWLEDGE Trauma survivor has full or partial cognitive knowledge of traumatic event n Cognitive knowledge of the trauma is dissociated from behavior, affect and sensation n Generally what people mean when they say “I remember” n
BASK - BEHAVIOR n n n 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
BASK - AFFECT n Affect is dissociated from other aspects of memory n Example: feeling of fear for no apparent reason
BASK – AFFECT (cont’d) n 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
BASK - SENSATION n n n 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
Integration Any, or all 4 BASK components can be dissociated from each other n All 4 BASK components of an experience need to be integrated for full integration of an experience n
BASK Model Behavior Affect Sensation Knowledge Gingrich, H. D. , 2013, p. 107
Secondary and Associated Symptoms n n n 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: n Perception of the Event as Negative n Suddenness (although study by Irvine et al. , 2006, calls this into question) n Lack of Controllability
Factors of Individuals n n n Biological Developmental Level at Time of Trauma Severity of Trauma ¨ n Although subjective sense of impact more important Social Context ¨ n (Carlson, 1997; subpoints hg) 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 individual’s coping resources ¨ n ¨ 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). n Unresolved issues may be driving people into service – abuse, survivor guilt, unresolved grief
Other Factors n 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) n n n Gender, Race and Culture Temporal Stability or Instability of Symptoms Discrete vs. Chronic Traumatic Experiences (Carlson, 1997; van der Kolk and Mc. Farlane, 1996; van der Kolk, Weisaeth, and van der Hart, 1996; de. Vries, 1996) n Significant disruption to the individual, to the family, property, or community as a result of the trauma (Schubert, 1987 as cited by Boecker, 2007)
Factors that Impact Trauma and Stress Reactions Background Organizational Support Level of Traumatic Response Traumatic Event Occupational Environment Fawcett (2003), as cited by Boecker (2007) Resilience Factors
Resilience n Coping Styles ¨ n n Spirituality Positive health behaviors Social Support Commitment ¨ ¨ ¨ n Engagement with all aspects of life: social, work and family Activities experienced as enjoyable and interesting Belief in importance and value of self Control ¨ ¨ n Active vs. Avoidant 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)
Family Resilience “the ability to stretch (like elastic) or flex (like a suspension bridge) in response to pressures and strains of life” n n n Includes: ¨ Normative stress from everyday hassles ¨ Expected family transitions of entries and exits (including births and deaths) across the lifespan ¨ Stress and trauma from unexpected crises and catastrophes The ability to bounce back to previous, or higher, levels of functioning Living relatively comfortably with ambiguity/uncertainty Boss, P. G. (2005)
The Bridge Analogy n n n Stress = the Stress bridge has weight (pressure) on it Strain = the Strain bridge is shaking but holding for now Crisis = the Crisis bridge is beginning to collapse Resilience = the bridge is bending from the weight without negative effects and can continue to absorb pressure without harm to the bridge Boss, P. G. (2005), as cited by F. Gingrich, 2009.
Keys to family resilience Family belief systems • Making meaning of adversity • Positive outlook • Transcendence and spirituality Organizational patterns • Flexibility • Connectedness • Social and economic resources • Clarity Communication • Open emotional expression processes • Collaborative problem solving Walsh, 2006, p. 131, as cited by F. Gingrich, 2009.
Score Card on Missionary Family Resilience Resiliency Processes Missionary families on average: 1 (low)-10 (hi) Family belief systems Making meaning of adversity Positive outlook Transcendence and spirituality Organizational patterns Flexibility Connectedness Social and economic resources Communication processes Clarity Open emotional expression Collaborative problem solving Unique issues for missionary families
Intervention
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 group’s resilience and the ability to bounce back from a traumatic exposure. (pg. 126 CISD manual, as cited by Boecker, 2007) n
Peer debriefing – Critical Incident Stress Debriefing (CISD) (cont’d) n 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)
Peer debriefing – Critical Incident Stress Debriefing (CISD) (cont’d) n Goals ¨ ¨ ¨ n n Lower tension and mitigate a small group or individual’s 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)
CISD Model – bathtub Cognitive Re-entry Phase Introduction Teaching Phase Fact Phase Thought Phase Symptom Phase Reaction Phase Affective
Cautions n n 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 n AACC accredited Critical Incident Stress Management (CISM) training ¨ http: //aacc. net/conferences/cism-07/ n ICISF (International Critical Incident Stress Foundation) Listing of trainings ¨ http: //www. icisf. org/training/calendar. Of. Train. asp
Psychological First Aid (PFA) (From: http: //www. ncptsd. va. gov) n n n n 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
Objectives of PFA n n n n n 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
Preparing to Deliver PFA n Preparation ¨ ¨ n 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 ¨ n Providing services for those who are ¨ n Group settings ¨ n n n Disoriented, confused, panicky, agitated/frantic, worried, angry, “shutdown”/withdrawn 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 n Contact and Engagement ¨ ¨ n 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
Core Actions for PFA (cont’d) n Stabilization ¨ ¨ ¨ n 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
Core Actions for PFA (cont’d) n Practical assistance ¨ For immediate needs/concerns n Connection with social supports ¨ Family, friends, community resources n Information on coping ¨ Provide info on stress reactions and coping to help reduce distress and promote adaptive functioning n Linkage with collaborative services ¨ Immediate or future
Counseling
Gingrich, H. D. (2002). Stalked by Death: Cross-cultural trauma work with a tribal missionary. Journal of Psychology and Christianity, 21, 262265.
Trauma Field n Posttraumatic Stress Disorder - even single exposure - natural disasters - rape incident - witnessing violence - combat veterans - primarily cognitivebehavioral treatments n Complex Traumatic Stress Disorder (Disorders of Extreme Stress) - multiple exposures - incest survivors - child abuse and rape - multi-faceted treatment approaches
Determine whether: n PTSD or Posttraumatic symptoms only ¨ i. e. , single incident or multiple but discrete incidents n Complex Traumatic Stress Disorder ¨ Chronic ¨ Relational
PTSD or Posttraumatic Symptoms Cognitive-behavioral treatments n EMDR n
Complex Trauma n Three-Phase Treatment Process ¨ Phase I – Safety and Stabilization ¨ Phase II – Processing of Traumatic Memories ¨ Phase III – Consolidation and Restoration
Rationale for Phase-Oriented Model n Premature trauma processing can lead to destabilization ¨ Hospitalization ¨ Inability to function in job ¨ Difficulty parenting ¨ Basic coping capacities can be overwhelmed
What Missionary Care Personnel Can Do to Help
The Challenge To be aware of the situations that can lead to trauma responses n Have appropriate procedures in place n 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. n
Do’s and Don’ts n Do ¨ Assess and help build family resilience BEFORE a crisis happens ¨ Reach out ¨ Listen ¨ Be empathic ¨ Seek to understand n Don’t ¨ Problem-solve before understanding ¨ Judge ¨ Compare one family to another ¨ Make assumptions
Assess (informally) each family member for posttraumatic symptoms ¨ Nightmares? ¨ Flashbacks? ¨ Avoidance of trauma reminders ¨ Hypervigilance? ¨ Mood changes? ¨ Sleep difficulties?
Assess (informally) each family member for dissociative symptoms ¨ BASK Unexplainable Behavior n Intense “out-of-the blue” Affect (emotion) or flat, emotionless presentation n Physical pain or symptoms that have no known cause (Sensation) n Amnesia (partial or no Knowledge of traumatic event) n
Assess (informally) family relationships Is there marital distress? n Parenting distress? n Rigidity n Denial of obvious problems? n Are children acting out? n How are relationships with broader missionary family/team members? n
For single-incident trauma or build-up of traumatic stress n Determine if CISD and/or Psychological First Aid is warranted Within several days of incident ¨ Who can provide the service? ¨ n Assess current level of support On field ¨ At home ¨ n Determine if/what kind of counseling is needed Individual, Couple, Family, Short-term, Longer-term? ¨ EMDR? ¨ Accessibility? n On field or within region n “Parachuted in” n Home country ¨
For complex trauma How severe are symptoms? n Can counseling be put on hold until scheduled home assignment? n ¨ Support system ¨ Containment of symptoms On-field resources? n Regional resources? n Intensive therapy options? n
n n n n References/Bibliography American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5 th ed. ). Washington, DC: Author. Boecker, B. (2007). Trauma and the missionary: An education project. Unpublished manual for Denver Seminary Class, CO 646 Counseling for Trauma and Abuse. Boss, P. G. (2005). Loss, trauma, and resilience: Therapeutic work with ambiguous loss. New York: Norton. Braun (1988). The BASK model of dissociation: Clinical applications. Dissociation, 1(2), 16 -23. Carlson, E. (1997). Trauma assessments: A clinician’s guide. New York: Guilford Press. EMDR International Association, EMDRIA’S definition of eye movement desensitization and reproecessing. Retrieved April 23, 2007 http: //emdria. org/displaycommon. cfm? an=1&subarticlenbr=3 Fawcett, J. (Ed. ). 2003. Stress and trauma handbook: Strategies for flourishing in demanding environments. Monrovia CA: World Vision International. 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, F. C. (Nov. 20, 2009). Strengthening resilience in missionary families. Seminar presented at the Mental Health and Missions Conference, Angola, IN. 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.
n n n n n Mc. Farlane, A. & Girolamo, G. (1996). The nature of traumatic stressors and the epidemiology of posttraumatic reactions. In B. A. van der Kolk, A. C. Mc. Farlane, & L. Weisaeth (Eds. ), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press. Nijenhuis, E. R. S. (1999). Somatoform dissociation: Phenomena, measurement, and theoretical issues. Assen, The Netherlands: Van Gorcum. Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York: Guilford Press. 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 Association. Schubert, E. (2005). The trauma spectrum: Hidden 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 Library. Steinberg, M. (1993). Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Washington, DC: American Psychiatric Press. Taylor, S. (2006). Clinician’s guide to PTSD: A cognitive-behavioral approach. New York: Guildford Press. van der Kolk, B. A. , Weisaeth, L. , & van der Hart, O. (1996). History of trauma in psychiatry. In B. A. vander Kolk, A. C. Mc. Farlane, & L. Weisaeth (Eds. ), Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press. Walsh, F. (2006). Strengthening family resilience (2 nd ed. ). New York: Guilford.
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