UNDERSTANDING METHODS OF CRISIS INTERVENTION.
Aim Identify what constitutes a crisis and to discuss methods of crisis intervention.
A crisis is a period of transition in the life of the individual, family or group, presenting individuals with a turning point in their lives, which may be seen as a challenge or a threat, a “make or break” new possibility or risk, a gain or a loss, or both simultaneously. Most crises are part of the normal range of life experiences that most people can expect, and most people will recover from crisis without professional intervention. However, there are crises outside the bounds of a person’s everyday experience or coping resources which may require expert help to achieve recovery. A crisis can refer to any situation in which the individual perceives a sudden loss in their ability to problem solve and to cope. These may include natural disasters, sexual assault, criminal victimisation, mental illness, suicidal thoughts, homicide, a drastic change in relationships and so on.
Therefore, in terms of mental health, a crisis does not necessarily refer to a traumatic situation or event. It is the person’s reaction to an event. One person may be deeply affected by an event, whilst another does not suffer. The Chinese word for crisis presents a good depiction of the components of a crisis, both the positive opportunity for growth or decline and the negative idea of danger. We often think of a crisis as an unexpected disaster, such as car loss and so on, but crisis can vary in their type and severity.
Crises in the Life Cycle – Sometimes a crisis is predicted in terms of a predictable part of the life cycle. An example of this is Erikson’s Stages of Psychosocial Development. (We will look at Erikson in more detail in lesson 4).
Situational Crises – Such as natural disasters, accidents etc.
Existential Crises – Inner conflicts relating to the way we want to live our life, our purpose, spirituality and so on.
There are many different definitions of crisis –
“an upset in equilibrium at the failure of one’s traditional problem solving approach which results in disorganization, hopelessness, sadness, confusion and panic” (Lillibridge and Klukken, 1978)
“People are in a state of crisis when they face an obstacle to important life goals – and obstacle that is, for a time, insurmountable by the use of customary methods of problemsolving” (Caplan, 1961)
“..crisis is a perception or experience of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms” (James and Gilliland, 2001)
“Crisis. An acute emotional reaction to a powerful stimulus or demand. A state of emotional turmoil. Three characteristics of crisis: The usual balance between thinking and emotions is disturbed; the usual coping mechanisms fail; there is evidence of impairment in the individual or group involved in the crisis” (Jeffrey T. Mitchell, PhD)
Activity Think about crises and write down as many as you can think of. Use your own life, newspapers, internet, media, friend’s and so on. You do not need to submit this to your tutor, but by the end of this exercise, you should find that you have quite a list, ranging from severe to relatively minor crises. However, as we said earlier, it is not the actual
event that causes the problem, but the person’s reaction to that problem. As you work through the course, you may find other crises to add to this list.
Responses to Crisis Response to crisis is very individual, and people’s reaction to crisis can be influenced by many factors, including: The type and severity of the crisis
Previous experience in personal crisis
Availability of emotional support
Ability to do self-care activities.
A person’s reaction to a stress, traumatic event or crisis can take many forms.
Typical responses can include:
Physical Mental Emotional Behavioural
Nausea
Upset stomach
Tremor
Feeling
Profuse sweating
Chills
Diarrhoea
Dizziness
Difficulty falling asleep or staying awake
Headaches
Rapid breathing
Slowed thinking
Fearful thoughts
Disorientation
Memory problems
Distressing
Blaming
Illogical thinking
Flashbacks of previous traumas
Intrusive thoughts
Poor judgement
Difficulty making decisions
Feeling lost or abandoned
Numbness
Feeling isolated
Anger/irritability
Hopelessness and/or helplessness
Anxiousness
Guilt
Fear
Grief
Denial
Depression/sadness
Feeling lost or abandoned
Numbness
Feeling isolated
Anger/irritability
Hopelessness and/or irritability
Crying spells
Extreme hyperactivity
Change in activity level
Withdrawal
Increase or decrease in smoking, drug or alcohol use
Startle easily
Conflicts with others
Change in hygiene and/or self care
Change in social patterns and/or communication
Significant decrease or increase in productivity.
All of these responses are normal and are how we process a traumatic event or stressful situation. When a child experiences stress and trauma, he or she may also manifest many of these reactions. Many of these reactions are short-term, where feelings and thoughts run the gamut of emotions, from shock to denial, rage, anger, terror, shame, suicidal thoughts and so on. Flashbacks and mental images of the traumatic events, startle responses and so on can be observed also. Again, these are quite normal and expected, also they can assist the survivor. However, other symptoms can occur gradually.
These long term crisis reactions can occur, such as excessive alcohol, drug or tobacco use, strained interpersonal relations, work related absenteeism, depressive illnesses or neurotic anxiety.
Crisis Intervention Crisis intervention refers to the methods used to offer short term immediate help to individuals who have experienced an event that produces mental, physical, emotional and behavioural distress.
“Crisis Intervention: TEMPORARY, but ACTIVE and SUPPORTIVE entry into the life of individuals or groups during a period of extreme distress. “Emotional First Aid.” Different interventions tools are used for individuals vs. groups.” (Jeffrey H. Mitchell, PhD)
Crises happens to everyone, and intervention can take many forms, from family helping and support strategies to professional counseling strategies aimed at helping the individual cope with crisis in ways that reduce the negative psychological, physiological and behavioural effects of trauma on that person and his or her environment.
The purpose of crisis counseling is to deal with the person’s current status by dealing with a crisis. Chronic exposure to stress or trauma can lead to mental illness. Therefore, it is important that counselors have the skills and knowledge to help clients cope with their current stressors and trauma. Crisis counseling is not intended to provide psychotherapy or similar, but offers a short-term intervention to helps clients receive assistance, resources, stabilization and support. Crisis intervention differs from other counseling interventions in that it focuses on short term strategies to prevent damage during and immediately after the experience of trauma. Crisis counseling is often followed by counseling for long term improvement of the client’s mental health and personal well being. These will be discussed in more detail later in this lesson. Crisis intervention has several purposes. It aims to reduce the intensity of the person’s physical, mental, emotional and behavioural reactions to a crisis. It also helps the individual return to the level of functioning they were at before the incident.
There is also an educational component to crisis intervention. The individual will be advised of the normal reactions to an abnormal situation. The individual will be told that their responses are temporary and that there is not a specific time that the person can expect to recover from the crisis. “Principles of Crisis Intervention: Simplicity – People respond to simple not complex in a crisis Brevity – Minutes up to 1 hour in most cases (3-5 contacts typical) Innovation – Providers must be creative to manage new situations Pragmatism – Suggestions must be practical if they are to work Proximity – Most effective contacts are closer to operational zones Immediacy – A state of crisis demands rapid intervention Expectancy – The crisis intervener works to set up expectations of a reasonable positive outcome” (Jeffrey H. Mitchell, PhD)
Who Provides Crisis Intervention? We will discuss in detail later the skills required for professionals working in crisis intervention, but in the initial stages, a range of professionals may be involved. They may include: psychiatrists psychologists counsellors fire fighters emergency medical staff search and rescue staff police officers doctors
nurses soldiers clergy communications personnel community members hospital workers and so on. Responding to a Crisis – Urgent or Routine? The Goals of Crisis intervention are to: Mitigate the impact of an event Facilitate a normal recovery process, where normal people are having normal reactions to abnormal events. Restore adaptive functioning.
However, many societal factors will affect how a society responds to a crisis. They include:
Religion Warfare Medicine Disasters Law enforcement Psychiatry and psychology Emergency medical services
When responding to a crisis, the emergency services will deal with a wide range of psychological and social problems. Problems can occur slowly over time or suddenly. When people face a crisis, they can experience a range of psychological and physical symptoms, as well as changes in their relationship and routines. Some problems are emergencies and require urgent intervention and stabilisation, whilst others are not emergencies. Many may be urgent and require attention within three days. A qualified emergency and crisis intervention specialist can evaluate a crisis and give advise on the necessary steps to take.
Emergency Problems These require immediate assistance and include situations which are dangerous, threatening, violent or where the person is potentially self-harming, destructive or suicidal. There may a significant risk of suicide or violence. There may be abuse, especially of a child or the elderly. Any emotional or mental problems may not have been evaluated and may be caused by a medical problem. The person may show strange, unusual or bizarre symptoms or behaviours that have not been evaluated or treated. Conditions in which the person has failed to take required medication, thereby cause themselves significant mental, physical or emotional harm are also included.
Crisis Problems These are problems that require assistance within 24 hours. They are emergency problems that have been evaluated by a suitably qualified professional, who has decided that their evaluation cannot wait for 24 hours. This includes – potentially dangerous, threatening, violent, self-harming, destructive or suicidal behaviour, but the professional feels that the person can wait for an appointment within a 24 hour time frame. Domestic abuse or abuse where there is no immediate risk of violence may also be defined as being able to wait 24 hours.
Urgent Problems These usually require support within 3 days and include symptoms of psychological and social problems that disrupt important activities. There is behaviour of symptoms that may lead to a crisis in the near future. There is exposure to/involvement in a traumatic life
experience, such as – serious injury, loss of life, life threatening experience, physical assault.
Routine Routine problems are usually dealt with within one week and include – symptoms of psychological and social problems that disrupt activities. The behaviour or pattern of symptoms may lead to additional problems, become harder to change or may create urgent problems in the future (but not the immediate future). The person is knowledgeable about the problem and able to wait for a convenient appointment.
Useful Definitions Critical Incident – A critical incident is often called a crisis event which has an impact sufficient enough to overwhelm the usually effective coping skills of either an individual or group. What is a critical incident? The term covers a variety of situations such as – Death Serious injury Psychological or physical threat
Events faced by emergency staff Global events eg. Explosions, tsunami, terrorist attacks, abuse, rape, stalking victims, earthquakes, workplace violence, industrial disasters.
Critical Incident Stress Management – CISM is a comprehensive, organized approach for the reduction and control of the harmful aspects of stress in the emergency services. It is a comprehensive, integrated, systematic intervention containing multiple tactics to dealing with the crisis after traumatic events. CISM is a coordinated programme of tactics, linked together to alleviate reactions to traumatic events.
Critical Incident Stress Debriefing – CISD is a seven step, group psychological process developed as a method for mitigating the harmful effects of work-related trauma and mitigating post-traumatic stress disorder.
Jeffrey H Mitchell, PhD, lists the following organizations as having used multi-tactic CISM when responding to incidents.
They include –
American / International Red Cross Austrian Red Cross Japanese Red Cross Canadian Red Cross Critical Incident Stress Management Foundation of Australia National Organization of Victims Assistance Salvation Army Church of the Brethren Community Crisis Centres Crisis Hot Lines Hospitals Clergy Motorola Communications United Auto Workers Amtrak Martin Marietta Corporation Delta Airlines Lufthansa Airlines German Air Traffic controllers American Airlines US Airways Aer Lingus United Airlines Association of Traumatic Stress Specialists American Academy of Experts in Traumatic Stress International Critical Incident Stress Foundation National and International Disaster Relief Agencies Police Departments Fire Services
Emergency Medical Services Organizations throughout the world School systems United States Army; United States Air Force United States Navy; United State Marine Corps United States Coast Guard National Health Trust of the United Kingdom Federal Aviation Administration United States Department of Agriculture Environmental Protection Agency The United Nations Federal Bureau of Investigation Secret Service US Marshals Service Bureau of Alcohol, Tobacco, and Firearms Federal Emergency Management Agency Homeland Security (many branches) Swedish National Police Finish Police German Air Force, Navy and Army Numerous other organizations, agencies and private practitioners
Medical Crisis Counselling – This is a brief intervention used to address psychological and social problems related to chronic illness in a health care setting. It uses coping techniques and builds social supports for the patient to cope with the stress of the diagnosis and their responses to the stressful circumstances.
Psychological Debriefing Psychological debriefing is a structured group meeting where participants are able to review traumatic events that they have experience and how they have responded to it.
What is debriefing? Debriefing is a specific technique that is used to help others deal with the physical and psychological symptoms associated with exposure to a trauma. Debriefing allows those involved to process the event and reflect on the impact of it. Debriefing should usually occur near the site of the event.
There are many different models and it has several phases, usually – Introduction Narrative phase Reaction phase Education phase
Psychological debriefing aims to – Promote cognitive organization Decrease the sense of uniqueness that the participant may feel – for example – “I’m the only one this has happened to”, “No one else will understand how I feel.” Mobilising group resources – making use of the other members of the group, so that they help each other, make the participants aware that other people have experienced similar events and feel the same way they do. Preparation for reactions that may arise – make the participants aware that they may experience side effects, physical effects, depression and so on, so they should be aware of this. Reduction of unnecessary side effects – by helping people to understand that they may experience certain reactions, this may reduce the anxiety that can attend these feelings. For example, earlier we looked at reactions to trauma. Say a person was
experiencing problems with their memory. If they knew that these may be part of the side effects of experiencing a crisis, they may accept these memory problems.
Whereas, if they did not know it was a possible side effect, they may also worry about the memory problems. So by knowing about the side effects, they hopefully reduce the anxiety they feel. Identification of other avenues for help – the participants can be made aware of other support groups, counselling groups and so on they can go to for extra help in the future.
Direct help can also be given – known as Critical Incident Stress Management.
Critical Incident Stress Debriefing In the wake of critical incidents, communities and individuals may be ill-equipped to cope with the aftermath of a catastrophic situation. So survivors may struggle to regain control of their lives, when friends or family may be injured, dying or dead or missing. Others may be traumatised by events and need support and personal care for months and years to come. The true extent of a traumatic situation may never be fully known. Psychological reactions are common and fairly predictable and CISD can be a useful tool following a traumatic event. Critical Incident Stress debriefing (CISD) is highly significant to the fields of traumatic stress and emergency responses throughout the world. It has been used by emergency response personnel, disaster counsellors, American Red Cross workers, mental health workers, and so on.
CISD was originally developed to mitigate stress responses among people who were the first to respond to emergency situations. CISD can help disaster victims.
CISD is a label applied to a range of protocols used in a variety of settings with different groups and often carried out by people trained in CISD. A CISD is a group process, usually led by a facilitator. It is usually conducted soon after a traumatic event when individuals are considered to be under stress due to exposure to trauma.
Most CISD approaches use a seven part model. In this process, individuals are encouraged to describe their experience followed by a didactic presentation on common reactions to stress and stress management. This early intervention is thought to encourage people to verbalise, offer peer and group support for therapeutic factors to add recovery.
CISD is increasingly used in settings outside the normal emergency response sites, such as emergency rooms, police stations and is now used in a wide range of settings eg. Schools.
Introduction – The team leader introduces the CISD process, encourages participation by the group, and sets the ground rules by which the debriefing will operate. These guidelines usually involve confidentiality, attending the full duration of the group, non-forced participation and non-critical atmosphere. Assessment – the impact of the critical incident on survivors or personnel is assessed. The debriefer or facilitator assesses the individual’s involvement in the crisis situation, their age, level of development, exposure to the critical incident. The age of the individual and their developmental level may affect how they respond to an event and how they understand an event.
Fact Phase – During this phase, the group are asked to describe their incident from their own perspective. Immediate issues are identified, surrounding security and safety, particularly with children. Feeling safe and secure are important. When suddenly these feelings are lost, without warning, individual’s lives can be shattered by tragedy and loss.
Thought Phase – The group are asked to discuss their first thoughts during the critical incident. Defusing is used to allow for the ventilation of thoughts, experiences and emotions associated with the event and validation of possible reactions. This ventilation and validation are important as individuals need to express their feelings,
exposure to the event, sensory experiences, thoughts and feelings. They give the individual the opportunity to express their emotions.
Defusing is another component of CISD that allows for the ventilation of emotions and thoughts associated with the crisis event. Debriefing and defusing should be provided within the first 24 to 72 hours after the initial impact on the event. The longer the time after the event until CISD occurs, the less effective CISD becomes. People who experience CISD 24 – 72 hours after the initial incident experience less shortterm and long-term crisis reactions or psychological trauma. People who do not receive CISD are at greater risk of developing clinical symptoms described above.
Reaction Phase – This phase is where the participants move from the cognitive level of intellectual processing to the emotional processing level. Events and reactions to come after the event are predicted. The debriefer will assist survivors and support personnel to predict future events. This involves discussing their emotions, reactions and possible problems they may experience due to the traumatic exposure. By predicting, preparing and planning for the psychological and physical reactions that might occur after the critical incident, the debriefer can help the survivor prepare and plan for the short and long term future. This can help avert long term negative reactions to the event.
Symptom Phase – This phase moves back from the emotional processing level to the cognitive level again. The participants are asked to consider their emotional, cognitive and behavioural signs of distress – within 24 hours of the incident, a few days after the incident and those that are still being experienced. A systematic review of the incident is conducted, considering the impact – emotionally, cognitively and physically – on the survivors. The debriefer should conduct a thorough systematic review of the emotional, psychological and physical impact of the critical incident on the individual. The debriefer should listen, evaluate the thoughts, mood, choice of words and perceptions of the individual and look for clues as to how they are coping with the event or might experience future problems.
Education Phase – Information is exchanged on the nature of the stress response and the psychological and physiological reactions to critical incidents. This helps them to normalise the stress experience and the coping response. Closure of the incident – encouraging people to start rebuilding after the event – emotionally and physically, such as encouraging the review of positive events. A sense of closure is needed. Support services and resources information should be given to survivors and assistance to plan for future action to anchor the person in times of high stress.
Re-entry phase – This is where the sessions are wrapped up, referrals made for individual follow ups and how they can get help from others in the group and other resources. Debriefing assists the “re-entry” process back into the workplace or community. Debriefing can be done in small groups, one to one or large groups, depending on the situation. It is a systematic review of events leading up to, during and after the crisis occurs.
CASE STUDY – Law Enforcement Personnel and CISD When we phone the emergency services, we expect to be taken seriously and our call handled competently. We expect the police to rush to our burgled home, the fire service to rush to put out the fire the ambulance to save our loved one and so on. We take these services for granted, because of the workers who perform these services. However, these emergency service staff are routinely exposure to traumatic events and daily pressures that require them to have a certain attitude, temperament and training. Without this, they couldn’t do their jobs effectively. Sometimes the stress may become too much and the toughness they need to do their jobs can impede them seeking help for themselves.
Police officers are often reluctant to talk to outsiders and may not wish to show “weakness” to their peers or other emergency service staff or the public. Police officers may typically work alone or with a single partner, whereas the fire service or paramedics may have more of a team mentality.
Police officers deal frequently with the most violent and predatory members of society. Their job requires them to put their lives on the line and face things that the rest of us only see on our televisions or in our newspapers. They are also frequently criticised by the media, the public, judicial system and so on.
Sometimes the stresses become too much. They may experience a traumatic event, such as a homicide, violent crime against a child, brush with death, death of a partner, death of an innocent civilian, a large scale crime or so on. This can result in PTSD (post traumatic stress disorder). The symptoms of this will be discussed in a later lesson.
For others, there may be no single trauma, but the cumulative effect of routine stresses. In America, two-thirds of officers involved in shootings suffer moderate or severe problems. About 70% leave the force within seven years of the incident. Police are more likely to be admitted to hospital than the general population. Twice as many officers die by suicide than those killed in the line of duty.
CISD is used within the law enforcement service. The structure usually consists of one or more mental health professionals and one or more peer debriefers (fellow officers who have trained in CISD themselves). A typical debriefing will usually take place 24 – 72 hours after a critical incident and may involve a single meeting lasting two to three hours.
Criticisms of Psychological Debriefing and CISD Psychological debriefing is meant to be an ongoing therapy. One off sessions where events are relived and emotions stimulated can make the person more upset. This is not surprising as psychological debriefing should not involve reliving the event or its attendant emotion. The idea that a series of interventions are more helpful is common sense. There has been concern expressed about the effectiveness of CISD. As long as the provider of CISD is properly trained, it should be helpful to individuals who are distressed. If untrained personnel conduct CISD, it can result in harm to the participants. CISD is not psychotherapy or a substitute for any form of counselling. It is not designed to solve all problems in the meeting, sometimes follow up referrals for other treatment or assessment is required.
SET READING
Resick, P.A (2001) Stress and Trauma, Psychology press LTD U.K. p 1 – 28
SET TASK
Carry out a library or internet search on CISD. Write notes.
ASSIGNMENT
1. Bill is the sole survivor in a train crash. You are called in to conduct a critical incident debriefing.
a) What sort of emotional and physical responses do you think Bill may display in response to this stressful situation? b) Define CISD. c) Describe how you will conduct the CISD. d) How can Bill recognize that he is in a crisis situation and may require counselling? e) What would be the desired outcomes of this CISD?
Lesson 2
ETHICAL, PROFESSIONAL AND LEGAL ISSUES
Aim Discuss current ethical, professional and legal implications of crisis intervention.
Counsellors’ Professional Responsibilities Counsellors maintain high standards of professional competence and ethical behaviour, and recognize the need for continuing education and personal care in order to meet this responsibility.
Counsellors participate in only those practices which are respectful of the legal, civic, and moral rights of others, and act to safeguard the dignity and rights of their clients, students, and research participants.
Counsellors limit their counselling services and practices to those which are within their professional competence by virtue of their education and professional experience, and consistent with any requirements for provincial and national credentials. They refer to other professionals when the counselling needs of clients exceed their level of competence.
Counsellors take reasonable steps to obtain supervision and/or consultation with respect to their counselling practices and, particularly, with respect to doubts or uncertainties which may arise during their professional work.
Counsellors claim or imply only those professional qualifications which they possess, and are responsible for correcting any known misrepresentation of their qualifications by others.
Counsellors have a primary responsibility to respect the integrity and promote the welfare of their clients. They work collaboratively with clients to devise integrated, individual counselling plans that offer reasonable promise of success and are consistent with the abilities and circumstances of clients.
Counsellors understand that ethical behaviour among themselves and with other professionals is expected at all times.
Counselling services and products provided by counsellors through classroom instruction, public lectures, demonstrations, publications, radio and television programs, computer technology and other media must meet the appropriate ethical standards of this Code of Ethics.
Conflicts of Interest If, after entering a counselling relationship, a counsellor discovers the client is already in a counselling relationship, then the counsellor is responsible for discussing the issues related to continuing or terminating counselling with the client. It may be necessary, with client consent, to discuss these issues with the other helper.
Duty of Care Counsellors do not condone or engage in sexual harassment, which is defined as deliberate or repeated verbal or written comments, gestures, or physical contacts of a sexual nature.
Counsellors strive to understand and respect the diversity of their clients, including differences related to age, ethnicity, culture, gender, disability, religion, sexual orientation, and socio-economic status.
Counselling relationships and information resulting there from are kept confidential. However, there are the following exceptions to confidentiality: (i) when disclosure is required to prevent clear and imminent danger to the client or others; (ii) when legal requirements demand that confidential material be revealed; (iii) when a child is in need of protection. When counsellors become aware of their clients’ intent or potential to place others in clear or imminent danger, they use reasonable care to give threatened persons such warnings as are essential to avert foreseeable dangers.
When counselling is initiated, and throughout the counselling process as necessary, counsellors inform clients of the purposes, goals, techniques, procedures, limitations, potential risks and benefits of services to be performed, and other such pertinent information.
Counsellors make sure that clients understand the implications of diagnosis, fees and fee-collection arrangements, record keeping, and limits to confidentiality. Clients have the right to participate in the ongoing counselling plans, to refuse any recommended services, and to be advised of the consequences of such refusal.
Sexual Exploitation Counsellors avoid any type of sexual intimacies with clients and they do not counsel persons with whom they have had a sexual relationship. Counsellors do not engage in sexual intimacies with former clients within a minimum of three years after terminating the counselling relationship. This prohibition is not limited to the three-year period but extends indefinitely if the client is clearly vulnerable, by reason of emotional or cognitive disorder, to exploitative influence by the counsellor. Counsellors, in all such circumstances, clearly bear the burden to ensure that no such exploitative influence has occurred, and to seek consultative assistance.
Group Counselling When counsellors agree to provide counselling to two or more persons who have a relationship (such as husband and wife, or parents and children), counsellors clarify at the outset which person or persons are clients and the nature of the relationship they will have with each person. If conflicting roles emerge for counsellors, they must clarify, adjust, or withdraw from roles appropriately.
Counsellors have the responsibility to screen prospective group members, especially when group goals focus on self-understanding and growth through self-disclosure. They take reasonable precautions to protect group members from physical and/or psychological harm resulting from interaction within the group, both during and following the group experience.
Children and Persons with Diminished Capacity Counsellors conduct the informed consent process with those legally appropriate to give consent when counselling, assessing, and having as research subjects, children and/or persons with diminished capacity. These clients also give consent to such services or involvement commensurate with their capacity to do so.
Multicultural Issues and Respect Counsellors actively work to understand the diverse cultural background of the clients with whom they work, and do not condone or engage in discrimination based on age, colour, culture, ethnicity, disability, gender, religion, sexual orientation, marital, or socioeconomic status.
Client Records and Confidentiality Counsellors maintain records in sufficient detail to track the sequence and nature of professional services rendered and consistent with any legal, regulatory, agency, or
institutional requirement. They secure the safety of such records and create, maintain, transfer, and dispose of them in a manner compliant with the requirements of confidentiality. Counsellors understand that clients have a right of access to their counselling records, and that disclosure to others of information from these records only occurs with the written consent of the client and/or when required by law.
Dual Relationships Counsellors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. Examples of dual relationships include, but are not limited to, familial, social, financial, business, or close personal relationships. When a dual relationship cannot be avoided, counsellors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs.
Counsellors remain accountable for any relationships established with former clients. Those relationships could include, but are not limited to, those of a friendship, social, financial and business nature. Counsellors exercise caution about entering any such relationships and take into account whether or not the issues and relational dynamics present during the counselling have been fully resolved and properly terminated. In any case, counsellors seek consultation on such decisions.
Professional Consultation Counsellors may consult with other professionally competent persons about the client. However, if the identity of the client is to be revealed, it is done with the written consent of the client. Counsellors choose professional consultants in a manner which will avoid placing the consultant in a conflict-of-interest situation.
The Skills Required to be a Competent Crisis and Emergency Intervention Professional Emergency and crisis intervention requires professionals with specialist skills and experience in dealing with crises. Many professionals will lack this experience. The ability to assess and intervene in emergencies is not a routine skill. Many doctors, counsellors or psychotherapists may have good intentions, but may not realise how critical, unstable and demanding a crisis can become. An incorrect assessment, missed opportunities or unskilled behaviour can prolong a crisis, create new problems or turn an urgent problem into a dangerous emergency. The field of crisis intervention is the field within mental health that has the highest incidence of negligence and malpractice that results in significant harm.
It can be difficult to find competent and caring crisis intervention professionals. Very few practitioners will identify themselves as that. Some people working in crisis intervention may not be suitably qualified or experience.
So what background and characteristics should a competent crisis intervention professional have? Can be reached 24 hours a day, 7 days week. Has training in emergency psychological services and/or crisis intervention. Can arrange appoints for up to 3 hours or as frequently as three times a week. Be available for daily phone contact if required. Has experience of routine as well as crisis services. Knows about medication use, side effects, risks and benefits. Experience of working with patients in a psychiatric hospital setting. Qualified in medicine, social work, counselling or psychology.
Practical Ways to Support People Who Are Grieving Practical ways to support these individuals may include: Provide them with support when the funeral is held.
Provide them with opportunities for ventilation of emotions. Use active and empathic listening. Provide the individual with opportunities to reminisce and reflect on the person they have lost. Encourage them to take care of themselves and eat well. Educate the individual on the ways in which the experience may affect them – such as, sleep difficulties, physical effects and so on. Be aware of signs that the individual is not coping.
Suicide Supporting suicidal people creates a lot of ethical dilemmas, we will consider suicide and ethical support in the next lesson.
Dealing with Anger in Others People who have experienced a crisis will experience a range of symptoms and emotions. Anger may be one of them. When dealing with anger in others, we should: Acknowledge and affirm the other person’s feelings. o It is OK to be angry. Accept it. Help the other person to talk about anger in order to diffuse it. o Drain their physical energy! Do not explain, interrupt, contradict, and give reasons, until the anger is depleted (if at any stage you feel their anger could become physical, then immediately stop the counselling session and either use your immediacy skills to bring the situation into awareness, or terminate the session and suggest to the client that they may wish to go out into a field where no-one will see or hear them and scream the anger out, or run the anger out etc.). Send caring and valuing messages, understanding or empathetic statements, before, during, and after the expression of anger. Adopt a calm style yourself and if you feel yourself becoming afraid of someone’s anger, terminate the counselling session. o Avoid getting hooked into an angry response (see below). o Try to personalise the situation. The angry person had those feelings before you came on the scene. You may be just a convenient target or sounding board.
Of course, responses to dealing with angry people must be matched with the stage of anger the person is exhibiting. For instance, it would not be appropriate to try to help a person deal with their anger through talking it out, when they look like they are on the verge of becoming physical/aggressive. It would also not be appropriate to send caring or valuing messages to someone who is in the middle of explaining what another has done to stir their anger. In the first example, the only option one would have is either the flight or fight response, as there is usually no point in talking reason to a person who has been hijacked by their angry feelings (hence they are not thinking, just acting). In the second example, it would be best to acknowledge and affirm the other person’s feelings, rather than jumping in too soon and giving them caring and valuing messages.
Although some previous research has suggested it may be beneficial to encourage a person who is angry to express their anger via punching or screaming into a pillow or hitting a punching bag, more recent research has in fact provided evidence that encouraging an angry person to express their anger in this manner, merely increases their feelings of frustration and their desire to take out their anger on an object or person. As this could prove dangerous, it is not recommended that any person be encouraged to do this, but rather to explore the deeper feelings or beliefs that anger might be covering so that the person has an opportunity to take control by exploring the cause of the emotion, and redirecting the feeling into a positive self-awareness and growth experience.
Ultimately, there is value in the energy that anger creates. Anger can signal to us that we need to take a look at our deeper or underlying feelings and use it as an opportunity for
self-empowerment by allowing ourselves to consciously choose the most constructive/positive way of responding, without falling into the trap of being reactive.
Termination and Referral When counsellors determine their inability to be of professional assistance to clients, they avoid initiating a counselling relationship, or immediately terminate it. In either event, members suggest appropriate alternatives, including making a referral to resources about which they are knowledgeable. Should clients decline the suggested referral, counsellors are not obligated to continue the relationship.
Counsellors terminate counselling relationships with client agreement when possible, when it is reasonably clear that: the goals of counselling have been met, the client is no longer benefiting from counselling, when clients do not pay fees charged, when previously disclosed agency or institutional limits do not allow for the provision of further counselling services.
However, counsellors make reasonable efforts to facilitate the continuation of counselling services when services are interrupted by such factors as counsellor illness, client or counsellor relocation, client financial difficulties, and so forth.
Further Meetings If you have reached a point with a client where you feel that they have resolved their issues, you may not consider that they need to come back. If this is the case, it is always best to inform the client that they would be welcome to come back should they feel the need, but that in your professional opinion they do not need to at the moment.
If you are unsure about asking them back for further appointments because you yourself feel anxious about them not taking up your offer, then it is probably better to ask. At worst they will decline. It is also harder for the client to make an appointment than break one. Where you feel the need for ongoing sessions, it is important to give the client an idea of the possible duration of the counselling relationship. This should help to counter the client’s insecurities about future sessions.
Dependency On occasion the counsellor may wish to terminate sessions before the client wishes. This can raise issues of dependency. Dependency will perhaps inevitably occur during the counselling relationship. There are several reasons for this occurring. A meaningful relationship will emerge, especially if the counsellor is warm and compassionate (some clients may even wish the relationship to continue after the sessions have ended, though obviously this is encroaching on ethical boundaries). Clients may perceive that sharing their most intimate thoughts and feelings with the counsellor will result in an ongoing relationship. A number of the clients who seek the help of a counsellor may not have many close friends or family members, and so will naturally strive for closeness and affection through the counselling relationship leading to dependency.
Dependency may also evolve out of the counselling process itself. It is possible that some clients once they have worked through the most difficult issues will then turn their attention to less troublesome issues. The counsellor needs to recognize this as the whole point of the counselling is to help the client to return to society and resolve their own issues. Working through minor issues that do not directly interfere with the client’s quality of life is self-defeating. Dependency of Counsellors Similarly, it is possible for the counsellor to become dependent on the client. Once again the intimacy of the sharing relationship can lead the counsellor to become dependent on
the client. It is therefore essential that the counsellor remains vigilant to prevent them from continuing with the counselling relationship merely to satisfy their own needs. Dependency is bound to occur from time to time and one of the purposes of ongoing supervision is to identify when this may be occurring.
Ending the Counselling Process It is often clear to both counsellor and client when it is time to end the whole counselling process. In some instances, particularly where dependency has occurred, it might not be so obvious. It is therefore necessary for the counsellor to frequently review the progress that is being made in the sessions and update the goals that are being achieved.
If progress is not being made and goals are not being achieved, then it may be necessary for the counsellor to address this issue with their supervisor. It is of course possible that the counsellor’s own unresolved issues are interfering. It could also be that the counsellor does not have the necessary skills in their repertoire to deal with the issues that the client has raised. Supervision may help the counsellor to deal with a client who seems unable to change.
Another option is to suggest to the client that they are referred on to someone else who may be better able to help them. Of course it is important too, to note that some clients will not change.
Ending the process may be similar to ending other relationships, and it may be necessary for the counsellor to use questions to challenge the client. They may ask the client how it feels to end the relationship and other similar questions.
Confronting Dependency If it is necessary to inform the client that dependency has emerged in the counselling relationship, then obviously this has to be dealt with by exercising a great deal of sensitivity. If the dependency is reframed in a positive manner then it will help to lead the process toward termination.
The end of the counselling process will also inevitably lead to a sense of loss. This can be resolved by arranging meetings with the client in the future at longer intervals than the sessions were being held at. For example, if the counsellor was meeting clients on a weekly basis, they might arrange a couple of appointments on a monthly basis.
It can also be useful to have a follow up session say 3 months down the track. This enables the client to have a period to adjust to their independence and it also provides a gentle transition away from dependence. Finally, it is a good way of assessing whether there are any loose ends that need to be tied up.
OTHER SERVICES As mentioned in the case study above, the end of counselling may not mean the end of services the client requires. If you or they feel they may benefit from other services, you should recommend them. Such as support groups, online chat rooms specifically for other people with their difficulties, workshops and so on. As you gain more experience within counselling, you will become more aware of the services available within your area.
SET TASK
Read information on what counselling organisations and associations include in their code of conduct.
ASSIGNMENT
1. Sylvia is an employee of the company you work for. She suffers a traumatic incident. You are called to provide a CISD debriefing and ongoing counselling. Sylvia finally agrees to continue with the therapy. After a few more sessions, she begins to make it plain that she finds you physically attractive. She begins to make suggestive remarks. Bearing in mind the information from the lesson and appropriate professional codes of conduct, how would you handle this situation?
2. CASE STUDY – Supporting Victims of Hurricanes Survivors of hurricanes, such as Rita and Katrina, may have lost relatives, friends and acquaintances, possessions and their homes. Counsellors may be required to help them to overcome their feelings of grief and loss in the wake of such events.
Write around 500 to 750 words on how you would support clients who had experienced a traumatic event, such as a hurricane or tsunami. Consider what you have learned in the first two lessons when answering this question.
Lesson 3
DANGERS DURING CRISES AND EFFECTIVE INTERVENTION
Aim Explain the dangers posed by crises to the individual, the counsellor and those around them during crisis intervention, and to determine effective modes of intervention.
Experiencing a crisis is obviously a traumatic time for the person concerned. They may or may not seek help. The counsellor will need to be highly skilled and experienced to ensure that the crisis is well-managed. Poorly managed interventions can prolong the problem and even make them worse.
Transference and Counter-Transference Transference and counter-transference are natural projective behaviours and are to be expected in the counselling relationship. “Transference” refers to certain unconsciously redirected feelings, fears, or emotions from a client towards the counsellor that actually stems from past feelings and interactions with others. These are transferred into the current counselling relationship. “Counter-transference” refers to the projection into the counselling situation of a counsellor’s experiences, values and repressed emotions that are awakened by identification with the client’s experiences, feelings and situation. The counsellor’s projected emotions will affect the dynamics of a counselling relationship.
When counselling, it is important to be aware of some of the dangers inherent in transference /counter-transference, for example, when they are denied or labelled as wrong or imaginary. The key is for the counsellor to acknowledge the existence and significance of transference for the client and counter-transference on his or her own part. The counsellor must accept the client’s transference, and/or recognise his or her projections while keeping the boundaries and objectives of the counselling relationship clear and firm. Only then can a safe environment be established, one where the client can express all of their feelings, secure that the counsellor will not act out against them.
Such a relationship can give the client the opportunity to observe their own feelings and their associations to problematic relationships and/or behaviours, without risking negative consequences. This safe environment makes it possible for the client to filter-out past issues from present situations and to deconstruct negative past experiences, which permits the counsellor to empower the client to reconstruct those experiences, events and outcomes in a new and positive light.
Working with teenagers through crises will be covered more in lesson 4, but here we will look at the problems that can be encountered due to misdiagnosis of a teenager’s problems.
Teenage Crises Teenagers can experience crises. Adolescence is a traumatic time. Parents may feel confused and frustrated in their interactions with the teenager. The parents may disagree and argue about what should be done, thus losing them credibility. However, sometimes parents may feel the need to seek help from mental health professionals. Schools may try to help, but may blame the student, who will eventually drop out if they feel school is boring, unsupervised or humiliating for them. Some children may only go to school to be with friends who have access to drugs, cars, cigarettes and so on.
The possibility of drug or alcohol use may be overlooked by doctors, counsellors or parents, as they are afraid or reluctant to give their child a drugs screen. They may take the child’s word that they are not using alcohol or drugs. Also, a teenager may admit to drinking, but not to taking drugs. Drugs and a negative peer or social group can seriously affect a teenager’s life and put them on a negative pathway.
Many health care and education models today do not adequately address the unique needs of teenagers in crisis. A diagnosis is often made based on a few interviews and an impression. Thorough evaluations are often not completed. Family, teachers, friends and siblings are often not interviewed in an open and cooperative manner. The underlying cause for the crisis may not be understood or addressed, because the real issue often requires more effort than providing “symptom relief.”
It can take a great deal of time for a mental health professional to earn a teenager’s trust. After a few sessions, many teenagers do not want to go back to the “therapy” as it “isn’t helping”. Or they may simply refuse to stop doing what they are currently doing. Sometimes the symptoms the teenager is showing may go away when they first start to see a counsellor, but eventually they may resurface, such as failing school, missing classes, staying out late, sleeping all day, running off, being expelled, coming into contact with law enforcement and so on.
Teenagers are learning to hide their behaviour and symptoms to manipulate doctors, counsellors, teachers and their parents. They may often seek advice and support from other teenagers who feel the same way they do. However, teenagers may lack the experience and support to support another adequately and may simply give ways on how to avoid the consequences of their actions and manipulate others.
A teenager may not understand that antidepressants may help, even if they have unpleasant side effects, or why they should avoid doing things that make them feel good. This is a real dilemma for parents and counsellors alike. It is a real challenge to help a teenager in crisis to see this. They may often focus on feeling better immediately and not be concerned about the long term impact on how they will feel. For example, illegal drugs may instantly make them feel better, but psychiatric medications may not. Although of course, prescription drugs are not necessarily the best option for a child or teenager in distress. Teenagers may be sorry when they get in trouble, but they may feel they are invulnerable, so defy law enforcement and their parents. They may not learn from their mistakes, but try to learn ways to avoid and escape the consequences of their actions. Teenagers will often act like victims and become victims, or they become abusive and victimise others. This can cause problems for the teenager, ending up abused, assaulted, threatened or worse.
Even more difficult, is that a teenager may suffer from an undiagnosed physical, mental or neurological disorder. For example, children with diabetes and hypothyroid may be placed on antidepressants. Some children with a mental disorder may be placed on the wrong medication and suffer toxic side effects that require other medication to treat.
Fear and depression are natural symptoms in some situations, for example, when a teenager breaks up with a girlfriend or boyfriend, if they are expelled, in trouble with the law etc. By failing to gain a clear understanding of a teenager with problems, this problems can escalate and lead to more serious long term harm. If the mental health professional is able to diagnose any condition properly, effective solutions can hopefully be put in place in time.
This clearly shows the importance of effective diagnosis and counselling, ensuring the counselling has sufficient experience and expertise to support teenagers well through any crisis situation. This will be covered more in lesson 4.
CASE STUDY – SUICIDE We will now consider interventions when a person is suicidal. In 1997, there were more adolescent deaths from suicide than from AIDS, cancer, birth defects, heart disease and lung disease. Suicide claims more adolescents than any disease or natural cause. Suicidal behaviour can be due to complex social, familial and psychiatric factors. There are far more suicide attempts than actual suicides (Carol Watkins, MD).
Types of Suicide There are three distinct forms of suicide – unassisted, facilitated and assisted. The form the suicide takes depends on the involvement of a clinician.
Unassisted Suicide – There are two types. The first applies when a victim commits suicide when they are not currently or recently in the care of a counsellor/mental health professional. The second applies where the victim is currently under the care of a professional, but not for suicidality. The clinician may not suspect the risk. The victim will not have confided their plan or threaten or acknowledge such behaviour if queried.
Facilitated Suicide – This applies when the victim is currently or recently under the care of a professional and the clinical knew there was a risk and the means of prevention or intervention were available. A suicide in this context suggests a breach of duty. This could include ignoring the risk or not providing the resources that could have reduced the risk. This suggests that the suicide has been facilitated. This does not mean that the professional has caused the suicide, just ethically failed to do anything or acted passively.
Assisted suicide – This is when the professional knows the client’s wishes and enables the person to commit suicide by providing lethal means or guidance as to how to use the lethal means. This assumes the person has done this rationally. However, many victims of assisted suicide appear to be driven by extreme stress and/or great pain which can impair rationality. Enabling suicides is unethical and illegal in many countries.
Suicide Intervention Suicidal behaviour is the most frequent mental health emergency. The goal of crisis intervention in this case is to keep the individual alive, so that they can reach a stable state and explore alternatives to suicide. In other words, help the individual reduce their distress and survive the crisis. Assessment The suicide intervention will begin with an assessment of how likely the individual is to kill him/herself in the immediate future. The assessment will have various components. The professional will assess – Does the individual have a plan for how the act should be committed? How deadly is the method? Overdosing? Shooting? Do they have the means e.g. Access to a gun? Is the plan detailed or vague? Their emotional state – depression, hostility, anxiety and so on. Past suicide attempts. Completed suicides amongst their family and friends. Current crisis events such as illness, accident, unemployment.
Treatment Plan The professional and client will devise a safekeeping contract that is signed by both of them. This confirms that the individual agrees not to commit suicide, will complete various actions and will contact family/friends/emergency personnel/the counsellor if they have thoughts of suicide again. The contract may include coping strategies to enable the client to reduce their distress. If the individual feels they are not able to do this, they may think that medical treatment is required or voluntary/involuntary psychiatric hospitalisation may be required. Educating family and friends is also an important part of suicide intervention. Family therapy, individual therapy, substance abuse treatment or psychiatric medication may be recommended. This will depend on the other problems that the person is experiencing.
Professional Ethics and Suicide We covered ethics in lesson two, but suicide is a tricky area, as the person has “chosen” to end their life, so counselling and supporting a person at that time can be difficult. The conduct of clinicians should be guided by ethical codes that provide protection to suicidal clients. The code will be drawn on the principles of – Autonomy – respect for the individual’s right to self-determination. This includes respect for the person and their rights, telling the truth and giving all the facts (disclosure) and fidelity (being there for the client) and confidentiality. Beneficence – doing the greatest possible good. This means acting in the best interests of the client. Non-maleficence – preventing or minimizing harm. Justice – fair and equal access to care. So treating clients fairly.
Suicide and Autonomy This principal affects the professional response to suicidal individuals. It calls for dignity, respect and choice. Suicide is the result of psychological dehabilitation. By extending
autonomy to people who have experienced that, we may be facilitating their suicide. So it is important to respect the client, but realise that it may be important to recognise their vulnerability and potential risk to them. Client also deserve the truth. Some mental health professionals will have strong views on suicide, they may not feel able to support a client because of this. If this is the case, they may have to refer them to another counsellor/mental health professional.
Confidentiality can also be a real dilemma, as it can be fatal for the counsellor to maintain secrecy for a suicidal person, but if they tell another, they may breach their confidentiality.
Mental health professionals should also be faithful to their clients (fidelity) so ensure that the risk of suicide is taken seriously. Fidelity also means that counsellors/mental health professionals should update their knowledge and skills as outdated views of suicide can put the person at risk.
Risks to the Professional We have covered risks to the patient, but there are also potential risks to the professionals dealing with crisis situations. There is obviously a physical risk, such as dealing with natural disasters, violence and so on. But there are other risks. In 1996, Western Management Consultants, carried out research on 582 nurses in Canada. They found that :
65% of nurses had had at least one critical incident per year in the work place. 37% had experienced the death of a child 28% had been the victim of an attempted or actual physical assault. 25% had experienced a break in 52% had been verbally threatened or verbally assaulted. 44% had experienced a suicide attempt or completion by a patient.
The Federal Government of Canada used a CISM as a way of reduced critical incident stress in their nurses. They found that 99% of the nurses using the CISM programme reported reduced sick days using CISM. It also significantly reduced turnover amongst the nurses.
Case Study – Supporting Crisis Intervention Staff After the South Asian Tsunami There was massive destruction and loss of life after the Tsunami. The recovery may take years or even decades, if not generations. It will affect the national for potentially centuries. The emotional recovery of the people concerned will proceed at a different pace to the rebuilding of buildings. The true impact of the loss the person has experienced may not be fully realised until the security and personal safety of the victim has been stabilised.
Initially victims may focus on survival, finding out what happened to any missing loved ones, dealing with the recovery of bodies, coping with dehydration, illness and starvation. At this stage, the assistance is in meeting the physical and safety needs of the person. They may require a compassionate presence to help them cope with their losses. Preexisting physical and mental conditions should also be dealt with.
Victims may experience multiple layers of trauma. They may become victims, rescuers, bereaved, homeless and so on, within a very short space of time. Each of these roles has a traumatic impact, leading to psychological reactions at various times in the future. Trying to resolve this issues too quickly or too soon can cause further distress. Also, as we have already discussed, if the support is not appropriate and given by a suitably qualified professional, it can create even more problems in the future.
Crisis responders should only attend when part of an official organized support team. They should not attend the emergency without being asked, as it can be difficult to manage a large number of spontaneous volunteers. Bearing in mind they may have little water or food and many additional volunteers can cause additional stress on these resources.
The organization also needs to support their personnel. Dealing with the loss of live and destruction in a community can cause emotional problems for the professionals involved. This can affect their functionality at the time and for years to come. The organization needs to ensure that every member of the teach is educated as to the potential impact their involvement has on them, and encourage them to take advantage of the support offered to them.
All personnel should be screen after their deployment and be involved in post-deployment support programmes, involving debriefing, defusing and other post-trauma support.
Debriefing the Debriefer When sending professionals out to respond after a crisis, there are some ways that the organization needs to respond. Usually the most experienced personnel are the ones who will deal with the situation. Because they are the most experienced, it can be easy to think that they will not need as much support as others. This is not the case. The debriefer is the person who supports the victims after a disaster.
Before a team leaves, they should be briefed with as much information as possible about what they will be doing and what they might experience. If you are working with people who are dealing with a crisis for the first time, they must be made aware that it will be like nothing they have dealt with before. The experience for debriefers can be overwhelming. They will hear terrible stories, see heart breaking scenes and experience a seemingly never-ending trail of emotional trauma. A disaster lasts much longer on the scene, as there is the visual devastation and trauma, than most of us will see in a lifetime.
This may be a life changing event for many debriefers, especially if they are debriefing people after a particularly intense disaster. Professionals should not work for more than a week at the disaster site. The trauma to the team will increase daily. At the end of each day, the team should meet together to do a mini-debrief of themselves. This helps prepare them for the next day’s work and remind them to do some things for themselves that they may have been teaching victims to do. The professionals need to take care of themselves.
Before the team leaves, each member should agree to attend a debriefing of the debriefers immediately after they return home. This is very important. Many volunteers returning from a disaster just want to go home, and may think they are handling things fine. For some people this may appear true, but generally it isn’t.
The debriefing of the debriefers should be completed by a team with at least one mental health professional. Some debriefers may need more of a mental health follow up than others. The team should not have been on the site, so will not have direct trauma of the event, so are able to support the debriefers who have attended the disaster. The debriefing debriefers team should be highly experienced and trusted by other members of their team. So basically, the person responding to the disaster, “on site” so to speak, is the debriefer. The debriefer comes home and is also debriefed to enable them to get rid of any emotional or stress related problems from supporting people in the crisis. These people are known as the debriefing the debriefers team.
So how do we debrief a debriefer?
The process consists of three phases – review, response and remind.
Review Phase This phase is a combination of introduction, facts and thoughts. It uses questions designed to encourage people to think about and discuss the debriefing and how they participated in it. The following questions are examples of what might be used – How do you think you did? Did any themes emerge? Is there anything you are worried about? Is there anything you think you could have done better? The leader will guide the discussion into teaching about how debriefings can go well and ways to handle some of the problems they experienced. Constant positive feedback should be given on their work, as much as possible. The debriefing the debriefers personnel should be validating their experience and providing guidance to the debriefers.
The Response Phase Looks at the self-perception of team members and any reactions they may have. It looks at things such as – Is there anything you said you wish you hadn’t? What was the hardest part of the experience for you? How has it affected you?
The leader will guide the group into discussion on their self-impressions, if they are worried about something, blaming themselves for something and so on. The other team members and leader will usually reassure each other that they handled the situation well and discuss alternative methods for handling a similar situation in the future. This is a time to learn new techniques or reinforce what the team actually did.
The Remind Phase In this phase, the team members are asked to do the same things that they ask the victims of the disaster to do. For example – What are you going to do to take care of yourself in the next 24 – 48 hours? What will you do to “let go” of this experience?
There are also other activities that the debriefing the debriefers team may use after a crisis, such as
Follow up phone calls Journaling what they have done Opportunities to talk to each other about what happened in a structured way. Opportunities to report to others about their experiences and what they learned.
This type of structured approach can help minimize the effects of disaster experience on team members. Having them recover as quickly as possible and helping prevent long term effects should be the natural goal of anyone doing CISM work. IT helps the person to be able to take care of themselves and able to support victims again after a crisis.
SET READING
Resick, P.A (2001) Stress and Trauma, Psychology press LTD U.K. p 29 – 54
SET TASK
Carry out a library/internet search on supporting clients who are suicidal.
ASSIGNMENT
1. Continuing with the example of Sylvia from the previous lesson. Sylvia states that she is feeling suicidal. How would you support her in this?
2. When supporting clients who have experienced a crisis, there are potential dangers to the counsellor. Write about 500 words on what these crises may be and how the counsellor could deal with them.
Lesson 4
DEVELOPMENTAL CRISES
Aim Identify and explain crises evolving from a developmental perspective.
Developmental Crises These are the transitions between the stages of life that we all go through. These major times of transition are often marked by “rites of passage” at clearly defined moments (e.g., those surrounding being born, becoming adult, getting married, having children, becoming an elder, or dying). They are crises because they can be periods of severe and prolonged stress, particularly if there is insufficient guidance and support to prevent getting stuck while in transit. In small-scale cultures, there is a sense of continuity and retained value in transiting from before birth to beyond death (e.g., becoming an ancestral resource). In Western societies, rites of passage between these stages have become blurred, the extended kinship networks they depend upon for clear expression have become scattered, the cultural value ascribed to such transitions varies with occupational and economic status, and events surrounding birth and death tend to be experienced as clinical termini.
Situational Crises Sometimes called “accidental crises”, these are more culture- and situation-specific (e.g., loss of job, income and/or home, accident or burglary, or loss through separation or divorce).
Complex Crises These are not part of our everyday experience or shared accumulated knowledge, so we find them harder to cope with. They include:
Severe trauma, such as violent personal assault, natural or man-made disasters, often directly involving and affecting both individuals and their immediate and extended support network, observers and helpers. In modern society, we are increasingly faced with violence, substance abuse, suicide, serious injuries and death within schools. There is also the violence from terrorist attacks, hostagetakers, snipers, murders, graffiti and bomb scares.
Crises associated with severe mental illness, which can increase both the number of crises a person experiences and sensitivity to a crisis. Reciprocally, the stress of crises can precipitate episodes of mental illness in those who are already vulnerable. Post-traumatic stress syndromes similar to those resulting from a disaster have been reported in some individuals after emergency treatment of acute episodes of mental illness. Developmental, situational and complex crises may overlap, and one may lead to the other (e.g., a train driver distracted by being in crisis may make an error, causing a disaster).
Erikson’s Psychosocial Stages of Development Model As mentioned earlier, crises can occur within the development of a person’s life. Erikson’s model looks at the crises that occur during development. Erik Erikson was born in Germany in 1902. He is a post-Freudian or Freudian ego-psychologist. This means that he accepts Freud’s ideas as basically correct and other ideas on the ego added by other Freudians e.g. Anna Freud and Heinz Hartmann. However, Erikson is more culture and society oriented than most Freudians. He based his theory on the recognition that we are social beings, so our psychological attributes cannot be treated as isolated phenomena.
Erikson is most famous for refining and expanding Freud’s theory of stages. He argued that development functioned by the epigenetic principle.
This principle is that we developed through a predetermined unfolding of our personalities in eight stages. We progress from each stage depending on our success or lack of it in previous stages. We develop at a certain time in a certain order which is determined through genetics. If we interfere with this natural order of development, we will ruin our development. Imagine our development as a flower – genetically, the flower will develop at a certain time in a certain order. But imagine that we try to make the flower grow a petal before it is ready, the flower may be ruined. The same can be said of our personalities and development. Try and make a baby walk before they are ready and we could cause physical harm.
In his view, therefore, each stage of a person’s psychological development involves an aspect of relating to others, and the way in which we cope with each theme has a profound effect on our general social being for the rest of our lives. Unlike Piaget’s and Freud’s stages, Erikson’s eight stages extend from the cradle to the grave. For each of Erikson’s stages, there is a dominant social theme or psycho-social crisis which the individual is challenged to resolve, before continuing a healthy pattern of development.
Each stage involves developmental tasks that are psychosocial in nature. Erikson calls these tasks crises. For example, a child at senior school has to learn to be industrious and this industriousness is learned through the social interactions of the family and school. The tasks are usually referred to by two terms. For example, infants have a task called “trust-mistrust”. They must learn trust and not trust. This is a balance we must learn.
At each stage there is an optimal time. It is useless to try to rush children towards adulthood, which can happen. Also, it is not advisable to slow down their progress to protect them from the demands of life. There is a time when each task is optimal. If a stage is well managed, we will carry away from that stage a virtue or social strength. If we do not do so well, we may develop malignancies or maladaptations, which can endanger our future development. A malignancy is the worst of the two and involves too little positive and more of the negative of the task, for example, a person who can’t trust others. A maladaptation involves too much positive and too little negative, for example a person who trusts too much.
Freud argued that a child’s parents influence his/her development dramatically. Erikson also felt that there was an interaction between generations, which he called mutuality. Erikson argued that children can influence their parents’ development as well. When children arrive, this will change a couple/person’s life quite considerable and moves the parent(s) along their developmental path. Also, we may be influenced by grandparents and great-grandparents and they can be influenced by new additions to the family also.
An Example of Mutuality A teenage mother is still an adolescent. She may cope well with having a child, but she is still finding out who she is and how she fits into society at large. She may have a relationship with the father, who may also be a teenager, so is again struggling with how HE fits into society. The baby will have straight forward needs that infants have. One of these is that his parent(s) will be mature enough to look after him/her and that the mother will have the social support she needs. The mother’s parents may help. They may then be influenced on their developmental tracks, as they are suddenly back caring for a baby, when they had thought they had moved beyond that stage, but were not yet ready to become grandparents. So they may find the role demanding. So their lives are all intertwined in a complex way. But to ignore the way they mesh together can be to ignore vitally important changes in a person’s personality and development.
Therefore, Erikson’s potentially greatest innovation was to have eight stages which start from birth through three stages of adulthood. We do not stop developing, so it seems right to extend theories of development to cover our later ages.
Briefly, the first stages relate to ages prior to adolescence and are:
Stage 1 – Oral-Sensory Stage (lasting to around 12 – 18 months)
Psycho-Social Crisis Basic trust versus mistrust Significant Social Relationship Mother or mother substitute Favourable Outcome Trust and optimism Unfavourable outcome Mistrust, fear & pessimism
Stage 2 – The Anal-Muscular Stage (lasts from around 18 months to 3 – 4 years) Psycho-Social Crisis Autonomy versus shame and doubt Significant Social Relationship Parent Favourable Outcome Sense of self control and self sufficiency Unfavourable Outcome Over dependency and lack of self control
Stage 3 – Genital-Locomotor Stage or Play Age (lasting from 3 – 4 years to 5 – 6 years) Psycho-Social Crisis Initiative versus guilt Significant Social Relationship Basic family Favourable Outcome Purpose & direction: Ability to initiate ones own activities Unfavourable Outcome Lack of purpose & objectives, guilt about self assertion, tendency to jump on the bandwagon.
Stage 4 – Latency Stage (lasts from around 6 – 12 years)
Psycho-Social Crisis Industry versus inferiority Significant Social Relationship Neighbourhood, school Favourable Outcome Competence in intellectual, social and physical skills Unfavourable Outcome Sense of social inferiority, lack of intellectual and social resourcefulness.
Stage 5 – Adolescence (lasting from puberty to around 18-20 years) Stage 5 is the stage that begins when a child approaches adolescence.
Psycho-Social Crisis Identify versus role confusion Significant Social Relationship Peer groups and models of leadership Favourable Outcome An integrated image of oneself as a unique individual Unfavourable Outcome A confused identity, easily influenced by others, conflicting behavioural roles.
The adolescent task is to achieve ego identity and avoid role confusion. Ego identity means you know who you are and how you fit into the rest of society. You mould yourself into a unified self-image that is meaningful to your community also. Good adult role models, open lines of communication and a mainstream adult culture that the adolescent respects are important for this.
A society should also provide rights of passage, accomplishments and rituals that allow us to distinguish between a child and an adult. For example, in more traditional societies, an adolescent boy may be required to leave his village for a whole or seek an inspirational vision.
In other societies, there may be symbolic ceremonies or educational events e.g. leaving school. Without this, a child can have role confusion about their place in society and the world.
Too much ego identity can mean that a person is so involved with a particular role that there is no room left for tolerance. Erikson calls this the maladaptive tendency of fanaticism. A fanatic will think their way is the only way. A lack of identity may be even more difficult. Erikson called this the malignant tendency repudiation. The adolescent will repudiate their membership in the adult world or the need for an identity. They may join groups that are eager to provide details of your identity, for example, religious cults, militaristic organizations, groups founded on hate and so on. The adolescent may become involved in destructive activities, such as taking drugs or alcohol or withdraw into psychotic fantasies.
Successful negotiation of this stage gives people the virtue of fidelity. This means the ability to live by the standards set by society and loyalty. This doesn’t mean blind loyalty, but loving the community you live in and wanting it to be the best it can be. Fidelity also means you have found a place in the community and will contribute towards that community.
Erikson also has further stages which relate to the transition to adulthood. Briefly, they are: Stage 6 – Young Adulthood (18 – around 30 years)
Psycho-Social Crisis Intimacy versus isolation Significant Social Relationship Partners in friendship and sexual relationships Favourable Outcome Ability to form close and lasting relationships, to co-operate and share resources, also to make career commitments Unfavourable Outcome Social and personal isolation, fear of intimacy & sharing
Stage 7 – Middle Adulthood Psycho-Social Crisis Generativity versus self absorption Significant Social Relationship Divided labour and shared household Favourable Outcome Concern for family, society and future generations Unfavourable Outcome Negative self absorption, lack of social awareness
Stage 8 – Late Adulthood Psycho-Social Crisis Integrity versus despair Significant Social Relationship Mankind or My Kind Favourable Outcome A sense of fulfilment and satisfaction with ones life, a willingness to face death Unfavourable Outcome A sense of emptiness and meaninglessness
Teenagers in Crisis Earlier, we considered the problems of misdiagnosis in teenagers. We are now going to look at critical warning signs of a crisis. They may be subtle, but they can show that a teenager needs help.
Warning Signs Critical Signs Deception, lying, keeping activities secret. New friends are unacceptable to parents. Changes in routines. Changes in sleeping habits. Refusing to contribute to household tasks. Dramatic drop in school work, attendance and grades. Possession of weapons. Dramatic disregard for appearance, hygiene and self-care. Drugs or drugs paraphernalia. Abrupt change in personality, attitude and emotional stability. Destructive, reckless and threatening behaviour. Violence, self-harming or suicidal behaviour/statements.
Causes of Teenage Crises A crisis will usually take some time to become critical or life threatening. A pattern of crises has usually taken place before a crisis becomes dangerous. At some point, a counsellor should be able to trace one or more factors that have led to the current serious crisis. Identifying the factors can help the counsellor or mental health professional to characterise the evolution of the crisis, which in turn helps them to find the appropriate response and duration of any required intervention.
Previous potential crises may include: Drugs Alcohol Peer and social pressure Parental alcoholism, drug abuse or mental disorder that is untreated. Failure by the parents to provide rules, discipline and a bonded relationship with the child.
Family conflict and discord. A traumatic experience A fragile emotional state Parental separation or divorce Interventions Once we understand the potential cause of the crisis, this can lead us to think of potential, comprehensive interventions. There are a range of potential interventions, which should be tailored to the unique needs of the individual. Interventions may include: Education and training for parents Education and training for teenagers Self help Group counselling/therapy Individual counselling/therapy Family counselling/therapy Change schools Outdoor adventure programmes Wilderness therapy programmes Increased parental supervision and involvement Move to a new area Move in with other family members Foster care Private school Boarding school Day treatment programme Therapeutic boarding school Residential treatment programme Psychiatric hospitalisation Police or law enforcement response
The duration and choice of intervention and the competence of the professionals involved are crucial to the success of any intervention. The intervention must also be appropriate to the level of risk and responsive to the underlying problem or potential cause. The level of risk needs to be determined and the likelihood of the problem escalating or continuing considered.
The Adolescent Clinical Screening Questionnaire is one of the most systematic and reliable methods for assessing risk with teenagers. When a crisis first occurs, it is important to stabilise the teenager and provide any symptom relief. But after that, there must be sufficient structure and follow-up to prevent further crises or relapse. Parents and family members must keep it in mind that an inappropriate intervention can make matters worse and can undermine their relationship with their child, and create another crisis.
An inadequate response can prolong a problem and reduce the likelihood of future interventions succeeding. There is often a cycle to the crisis that teenagers experience. The crisis tends to grow, escalate, subside and resurface in a pattern of increasing emotional, psychological and behavioural problems. Typically, with teenagers, there may be brief periods of normalcy between crises. At those times, the teenager may be cautious, reflective and remorseful. Whether a crisis represents a turning point or not will depend on whether an appropriate intervention is designed and followed through.
Teenage Crises Teenagers can experience crises. Adolescence is a traumatic time. Parents may feel confused and frustrated in their interactions with the teenager. The parents may disagree and argue about what should be done, thus losing them credibility. However, sometimes parents may feel the need to seek help from mental health professionals. Schools may try to help, but may blame the student, who will eventually drop out if they feel school is boring, unsupervised or humiliating for them. Some children may only go to school to be with friends who have access to drugs, cars, cigarettes and so on.
The possibility of drug or alcohol use may be overlooked by doctors, counsellors or parents, as they are afraid or reluctant to give their child a drugs screen. They may take the child’s word that they are not using alcohol or drugs. Also, a teenager may admit to drinking, but not to taking drugs. Drugs and a negative peer or social group can seriously affect a teenager’s life and put them on a negative pathway.
Many health care and education models today do not adequately address the unique needs of teenagers in crisis. A diagnosis is often made based on a few interviews and an impression. Thorough evaluations are often not completed. Family, teachers, friends and siblings are often not interviewed in an open and cooperative manner. The underlying cause for the crisis may not be understood or addressed, because the real issue often requires more effort than providing “symptom relief.”
It can take a great deal of time for a mental health professional to earn a teenager’s trust. After a few sessions, many teenagers do not want to go back to the “therapy” as it “isn’t helping”. Or they may simply refuse to stop doing what they are currently doing. Sometimes the symptoms the teenager is showing may go away when they first start to see a counsellor, but eventually they may resurface, such as failing school, missing classes, staying out late, sleeping all day, running off, being expelled, coming into contact with law enforcement and so on.
Teenagers are learning to hide their behaviour and symptoms to manipulate doctors, counsellors, teachers and their parents. They may often seek advice and support fro other teenagers who feel the same way they do. However, teenagers may lack the experience and support to support another adequately and may simply give ways on how to avoid the consequences of their actions and manipulate others.
A teenager may not understand that antidepressants may help, even if they have unpleasant side effects, or why they should avoid doing things that make them feel good. This is a real dilemma for parents and counsellors alike. It is a real challenge to help a teenager in crisis to see this. They may often focus on feeling better immediately and not be concerned about the long term impact on how they will feel. For example, illegal drugs may instantly make them feel better, but psychiatric medications may not. Although of course, prescription drugs are not necessarily the best option for a child or teenager in distress.
Teenagers may be sorry when they get in trouble, but they may feel they are invulnerable, so defy law enforcement and their parents. They may not learn from their mistakes, but try to learn ways to avoid and escape the consequences of their actions. Teenagers will often act like victims and become victims, or they become abusive and victimise others. This can cause problems for the teenager, ending up abused, assaulted, threatened or worse. Even more difficult, is that a teenager may suffer from an undiagnosed physical, mental or neurological disorder. For example, children with diabetes and hypothyroid may be placed on antidepressants. Some children with a mental disorder may be placed on the wrong medication and suffer toxic side effects that require other medication to treat.
Fear and depression are natural symptoms in some situations, for example, when a teenager breaks up with a girlfriend or boyfriend, if they are expelled, in trouble with the law etc. By failing to gain a clear understanding of a teenager with problems, this problems can escalate and lead to more serious long term harm. If the mental health professional is able to diagnose any condition properly, effective solutions can hopefully be put in place in time.
Case Study – Children Coping With The Experience of Hurricane Katrina Hurricane Katrina occurred in 2006. Many people lost their lives and homes. Even a year or more later, some children may still be experience distress following this crisis. Signs of the child experiencing problems may include:
Young Children (1 – 6 years) School children (6 – 11 years) Adolescents (12 – 18 years) Feelings of helplessness. Lack of usual responsiveness Difficulty talking about the event Nightmares and sleep disturbances Separation fears/clinging to caregivers Bedwetting Anxieties about death Complaints of stomach aches, headaches etc. Their body freezing or becoming immobile suddenly. Loss of motor and speech skills Feelings of guilt or responsibility Nightmares and sleep disturbances Repetitious traumatic play and retelling Preoccupation with danger and safety Behavioural changes Aches and pains with no obvious physical cause Withdrawal Fear of being alone Listlessness Disinterest in everyday activities Lack of understanding re hurricane Abrupt shift in relationships Rebellion at school or home Social withdrawal Depression Declining performance at school Revenge seeking behaviours Eating disturbances Sleep disturbances
Grief and Children Children respond to grief differently to adults and as such, they should be treated differently. The following notes are summarised notes taken from our Grief Counselling course.
Preschool children usually see death as temporary and reversible, a belief reinforced by cartoon characters that “die” and “come to life” again. Children may not understand the meaning of death until they are around three or four years old. Children between five and nine begin to think more like adults about death, yet they still believe it will never happen to them or anyone they know. However, they will still feel the loss and shock of close relatives in the same way as adults. Infants and children can grieve and feel great distress.
However, they may have a different experience of time to that of adults, so may go through their stages of mourning more rapidly. In their early school years, children may feel responsible for the death of a close relative and may need to be reassured. They may not speak of their grief because they think they might be adding an extra burden to the adults around them. The grief of children and adolescents should not be overlooked when a member of the family dies. They should, if appropriate, be included in the funeral arrangements.
Developmental Stages Birth to 3 years – A child may view death as a loss, abandonment or separation. They may be less disturbed at losing someone than an older child, because of their difficulty understanding the whole concept. The most important element is the response of the living parent or significant others around them. If their routines and security remain intact and as normal as possible, they will eventually come to terms with the situation. They will take their clues from their security or lack of it. It’s not that they will not grieve or pretend it has not happened, it’s that they gain security from the living parent’s response to grief.
3 – 6 years – At this stage, the child will see things as temporary or reversible. They may believe in “magical thinking” – their thoughts can cause things to happen. This can work against them, as they may believe that if they are good enough their parent will return. They may have nightmares, confusion or regress to an earlier stage of development, or even seem unaffected by the death.
7 – 8 years – The child will begin to see death as final. They may have lost a pet, but don’t think about it happening to them. They may see it as something that occurs in an accident or old age.
They may show an unusual interest in knowing the details around death, what happens after death or act as if nothing has happened. Social development is occurring during this stage, so they will watch the response of others to know how to respond.
9 and upwards – The child now knows that death is final and irreversible. They know it could happen to themselves and anyone else. They may exhibit feelings such as shock, anxiety, denial, anger and fear, depression and withdrawal. They may be the same as an adult, except they may “act out” their grief by showing behavioural changes at home or at school.
Preparing a Child for a Death It is hard for anyone to be totally prepared for someone to die. But things around us can help us to understand that loss and death are part of everyday life and part of everyone’s growing up.
Some ways that a child can be prepared for death is having pets. Pets like hamsters and guinea pigs do not live very long. When they die, the child may be upset, perhaps want to bury them or have a funeral. This allows them to experience grief and focus their feelings. If a child sees a dead animal, it can be useful for an adult to explain to them what this means. For example, if they see a dead bird, the parent could explain that it means the bird will not breathe, be hungry, thirsty, fly, feel hot and cold and so on again.
Sometimes a family member may be dying, it is important to be honest with the child. They may not want to visit the person in hospital, but then feel guilty about it. If they truly understood how seriously ill a person was, it might make them more willing to visit or more forgiving of themselves if they didn’t. They may want to be with the person when they die. They may feel that they are being “left out” if everyone else is at the hospital and they are not.
It can be helpful if a person is in hospital for a nurse or doctor to talk to the children to explain that they may not come home again. Telling them the truth means that they are able to trust and rely in you.
Sudden Deaths Sometimes there is no time to prepare and the death shocks everyone. Children may feel anger at not saying goodbye to the dead person or because they cannot see the body, they may not believe they are dead. The child needs to be encouraged to find way to realise that the death is real. Perhaps by creating scrap books, holding little rituals and so on – this will be covered later in this lesson.
After a Death Adding to a child’s shock and confusion at the death of a brother, sister, or parent is the unavailability of other family members, who may be so shaken by grief that they are not able to cope with the normal responsibility of child care.
However, death is not the only loss of a family member is not the only loss that children may face today. There may also be the death of friends of the same age, divorce, jail. Children will see on the television and via the internet, all the violent and terrible things that go on in the world. This will make them aware of death in a way that may not have been experienced by previous generations.
Children may feel that adults may not be able to protect them. This may cause them to “act out” inappropriate behaviour, be self-destructive with drugs, sex or drinking etc. Not all children will respond in this way. Children naturally assume that the world is safe and full of kindness. They will try to answer questions, such as who am I? Why am I here? This safety can disappear if a child begins to feel that the world is not a nice place.
Parents should be aware of normal childhood responses to a death in the family, as well as signs when a child is having difficulty coping with grief. According to child and adolescent psychiatrists, it is normal during the weeks following the death for some
children to feel immediate grief or persist in the belief that the family member is still alive. However, long-term denial of the death or avoidance of grief can be emotionally unhealthy and can later lead to more severe problems.
Once children accept the death, they are likely to display their feelings of sadness on and off over a long period of time, and often at unexpected moments. The surviving relatives should spend as much time as possible with the child, making it clear that the child has permission to show his or her feelings openly or freely. The person who has died was essential to the stability of the child’s world, and anger is a natural reaction. The anger may be revealed in boisterous play, nightmares, irritability, or a variety of other behaviours. Often the child will show anger towards the surviving family members.
After a parent dies, many children will act younger than they are. The child may temporarily become more infantile; demand food, attention and cuddling; and talk “baby talk.” Younger children frequently believe they are the cause of what happens around them. A young child may believe a parent, grandparent, brother, or sister died because he or she had once “wished” the person dead when they were angry. The child feels guilty or blames him or herself because the wish “came true.”
Typical Childhood Responses to Grief Numbness Feeling nothing after someone has died can seem scary to a child, particularly if everyone else is so upset. A child may take a while, perhaps weeks or months, to begin to feel upset, then their grief will come out. Gradually, the child may calm down. It can be hard for them to realise that death is permanent, that you have to live the rest of your life without that person.
Worry It is normal to worry about the future and who will look after them. They may find themselves talking to the person who has died or thinking that they are seeing them – adults can also do this when they are grieving.
Anger Some children may feel angry or cross without knowing why. Sometimes adults may respond by getting angry back with the child, which can make things worse. It is natural to feel like this when someone close has died. Feeling angry for no particular reason is normal. There may not be a reason or it may be that the child feels it is unfair that someone has died and left them. They may blame the doctors and nurses who cared for the person, thinking they did not do enough. They may blame the person themselves, for example, if they died due to a smoking related illness, or crashed their car etc. They may feel angry because no one explained to them what has happened. They may be too afraid to ask or scared about what has happened to their loved one when they have died.
Confusion Sometimes adults can confuse children by talking about a dead person being “lost”. A child may feel that if they are “lost”, that they can go and find them. This can create confusion and make their feelings even more muddled up. They may have different people looking after them, different ways of doing things and so on. So it is normal for them to feeling different emotions, including confusion and anger.
At times, a child may feel like laughing or giggling and then feeling bad because they do. They may want to go back to school, but find it hard to concentrate and get told off. They may then come home to a family who is sad and everyone is thinking about the person who has died. They may find they are not missing the person who has died as much as everyone else, which can make them feel bad. Then they can experience intensely the pain of losing the person.
Sometimes a child may just want to go and play with their friends as if nothing has happened. This is natural and perfectly ok for them to do.
Loneliness Children may feel very lonely if a parent dies. They may have been used to their mum there at breakfast time or their dad there to read them a bedtime story and suddenly they are gone. They may miss siblings who die. Even if they argue and fight with them, they may miss their company and someone else to play with.
One way to deal with this is to ensure that the child has other people/friends to play with, rather than spending time alone at home. They may feel they are being disloyal doing this, but it is helping them to get used to carrying on with their lives without the person being there. Friends may help to fill in some of the gaps in their time. Trying to pretend the dead person never existed will not help though.
Supporting a Grieving Child Children should be allowed to grief and grow through their grief. Adults have a responsibility for their care, this may include parents, but also the wider family, teachers, youth group leaders, religious ministers and so on.
Many studies have shown that after the death or departure of a parent, that children tend to suffer from loss of self esteem, as can adults who lose a spouse. The child’s sense of personal worth may be damaged and needs to be balanced by other significant adults. When a child dies in the family, the remaining brothers and sisters may feel neglected, as the emotions are focussed on the child who has died. A grieving parent may find it hard to meet the needs of their other children due to their own grief. They may need support themselves to be able to do so.
It is important to listen to children and teenagers who are grieving, so they can tell us what their needs are. 1. They may need adults who they can turn to and trust. 2. They should be able to express their feelings without judgement or criticism. They may already feel vulnerable, so disapproval or indifference will not help. 3. Tears should be allowed and encouraged. It is not helpful for adults to say things such as “come on, be brave, you’re the man/woman of the house now.” 4. Accept that they may not cry easily. 5. Offer them a secure setting and safe ways to let their anger and feelings be expressed. 6. It can sometimes be helpful for children to talk to adults outside the family. For example, teachers. They may not feel able to talk about a lost parent, for example, to the other parent, when they can see that the parent is upset. 7. Encourage the child to spend time with things that belonged to the dead person e.g. Books, photos, and so on. If the person liked a particular piece of music, encourage the child to listen to it, rather than avoiding it. Encourage them to choose a memento to keep to remind them. These will help them to remember the person who has died and help them feel close to them. 8. Pets can be important to children when they are grieving, something to love and cuddle and take for walks. Soft toys can also be comforting. Touch is important and the child may like to cuddle the animal or toy when an adult or sibling is not around. 9. If possible, a child may contact a child bereavement group. This can help them see that they are not the only one who is grieving. Unfortunately, there are not always suitable groups around. 10. A child may like to draw a picture about how they are feeling, especially if they are too young to write about their thoughts and feelings yet. Other ideas are to get the child to tie their picture or words to a balloon and send it into the sky to say good bye to the person who has died. They may want to plant a tree or flower in the garden to help them remember. They may like to start a scrap book or memory box of things that remind them of the person who has died. 11. Little rituals in families can change when one of a family dies. Children may find this difficult.
12. It can be important to remember “special days”, such as the birthday of the dead person, or mother’s day or father’s day. Other adults may encourage the child to remember the person, for example, plant a new flower in the garden, put flowers on the grave, or so on. 13. As the child grows, they may need to look at the death of the person again. How we experience death as a six year old will be very different to a 15 year old. A 15 year old girl may suddenly strongly feel the loss of her mother, for example, when she is developing and starting relationships. She may wish her mother was there for support and advice. This is not unresolved grief, it is a simply a reassessment of something that has occurred and that the child may need to come to terms with as they grow and develop.
Therefore, it helps for children and teenagers to:
Be told what has happened simply and honestly Be reassured they are still loved and cared for Be allowed to say good Participate in simple rituals Understand that however they feel – it is alright to feel it Express emotions Be allowed to enjoy themselves Be encouraged to look forward to a time when their grief will get less, but that doesn’t mean that they will forget the person.
Guidelines for Letting Children Know What is and is not OK It is important that children are aware of what is and is not OK when a person has died.
It is OK to…. It is not OK to …….
Cry
Feel depressed and low
Feel angry
Not want to talk about your feelings
Copy some activities that your brother or sister did before they died
Live in the past for a while – thinking about the person who died
Have fun and enjoy life. It is OK to forget for a while.
Forgive yourself for saying nasty things or having arguments with the person who has died.
Carry on living!
Use alcohol and drugs to dull your feelings. This is only an escape and will not resolve your feelings of pain.
Act recklessly due to frustration.
Skip school
Experiment with casual sex as a way to get close to someone
Do things in anger to hurt others because you are hurting yourself
Avoid talking to your parents in case talking about the dead person hurts them.
Try to appear tough
Children with Serious Problems with Loss and Grief Children who are having serious problems with grief and loss may show one or more of these signs:
an extended period of depression in which the child loses interest in daily activities and events
inability to sleep, loss of appetite, prolonged fear of being alone
acting much younger for an extended period
excessively imitating the dead person
repeated statements of wanting to join the dead person
withdrawal from friends, or
sharp drop in school performance or refusal to attend school
These warning signs indicate that professional help may be needed. A child and adolescent psychiatrist can help the child accept the death and assist the survivors in helping the child through the mourning process. (Based on American Psychiatric Association Fact Sheet 2003)
They may also show signs of reduced self esteem, dropping activities they used to love, show risk taking behaviour or have a deteriorating relationship with other members of their family.
GRIEF AS A UNIQUE ADOLESCENT EXPERIENCE Adolescents often believe that their grief is unique and incomprehensible to anyone else. Some may find themselves reacting in a new or unusual way which frightens them and may cause them to think that their reactions are abnormal. Others may limit their expressions of grief to brief outbursts because they are very concerned about how they are perceived by others, and they worry about losing emotional control.
Adults may have a tendency to dismiss the suffering of teenagers. But they may suffer intensely. They may be skilled at hiding the intensity of their grief, as they tend to hide their grief, which may develop into behaviour problems at a later date. As these may not appear to be “linked” to their grief by adults, adults may not be aware that it is a grief reaction.
Unfortunately, the needs of bereaved teenagers have been overlooked in the past. There are often grief support services available for adults and younger children, but teenagers have not always been provided with services. Teenagers can give mixed messages. They tell us what they need and expect our help, for example, providing them with food, but they also think that they can run their own lives. Because of this, people do not always know how to respond to teenagers. This can result in the teenager feeling alone with limited support.
During the period of adolescence, adolescents are attempting to define themselves. They test their limits and experiment with roles. For some teenagers, the idea of their own death or that of those close to them becomes a fairly important concern. For other teenagers, death may seem remote and they show little awareness or acknowledgement of it. .
Implications A death may affect a teenager in a number of ways. If it is a parent who has died, this may affect the career possibilities that the teenager had been considering. For example, there may not be sufficient money to go to university.
The teenager might become defensive about death, using denial and attempts to distance themselves from the possibility of death in the future.
The teenager’s goals might be affected by grief and death.
Universality – Death affects us all. It is a natural phenomenon affecting all living organisms. Some teenagers will become obsessed with making contributions to the world by which they will be remembered. Others will an interest in religion, including cults and alternative religions. The acceptance of the universality of death seems to result when the teenager is more able to engage in abstract thought. The death of someone their age will affirm the possibility that they could also die. A response that may occur to this is to glorify death or the deceased person.
Remoteness of Death – Many teenagers will consider that death is something that happens to older people and feel that death will not affect them in the near future. So, they may seem blasé and almost callous when hearing that someone who is not close to them has died. However, if someone close to them dies, this will affect how remote they feel death is to them. Accepting the death of another young person is particularly difficult for them.
Tears – Tears are a natural part of the grieving process. If a teenager doesn’t cry, it doesn’t mean that the grief is not there. By crying or showing emotion, the teenager may feel that they are standing out or different to their peers, so may try to conceal their emotions. They may be grieving in private. Even though a teenager may be striving for independence, they will still need support and to be able to cry.
Immortality – They may move between understanding death and also believing in immortality.
Anger – We already discussed briefly above that teenagers may show behaviour problems that are not recognised by adults as part of the grief process. Teenagers may have a tendency to “strike out” in anger. They may not understand the grief process or have a safe place to let out their feelings, so violent or reckless behaviour can occur. Research has shown that over 95% of teenagers incarcerated in juvenile facilities had experienced a death of someone close to them. Society teaches us that anger is an emotion we should suppress, thereby teaching us that anger is not a “normal” emotion.
Substance Abuse – Teenagers may also turn to substance abuse as part of the grieving process – to heal their pain and hurt. When teenagers are grieving, they may naturally want to numb the pain, get drunk or high so they do not have to feel. Bereaved teenagers are at high risk of involving themselves in self-destructive behaviour. The drugs may temporarily numb the pain, but this will complicate and prolong the grieving process.
Egocentrism – When hearing news of a death, adolescents’ will initially be mainly concerned about how it will affect them. How they will appear in other people’s eyes, how it will affect their routine and so on. They may feel ill at ease about offering sympathy and condolences to others.
Sexual Activity – It is not unusual for a teenager to become sexually active during the grief process. If they have lost a family member, they may feel that other family members are not there for them as they are also in pain. They may want someone close to them, physically and emotionally, so sexual activity can serve as a distraction from pain.
How to Help Every teenager needs to grieve in their own time and in their own way. It is no good trying to speed up the recovery process as this could be harmful. However, there are ways of helping a bereaved adolescent.
Check things out. Direct Approach – Ask the teenager what they need. Indirect Approach – watch for their reaction to offers of support. Be careful of physical contact.
Grieving people often have difficulty asking for help. They are preoccupied with mourning and may be afraid to be seen as weak or a burden. They may not be aware that talking will help them. So invite them to talk to you.
Be clear about the type of help you are offering and set your limits. It is no good offering to be there 24 hours a day if they need you, if you know that you have to go to work or have your own family to look after, for example.
Simply listen. Let them tell you about their experience of the death, where they were when it happened, what happened after and what they are experiencing now. Adults may avoid the subject or put on a front that can create an atmosphere of confusion or isolation. This can cause the teenager to think that others didn’t really love the deceased as they don’t seem to be grieving in the same way that they are. This can be frightening for them.
Facilitate Communication – Adults may suggest creative ways to facilitate communication about the loss, memorializing the deceased, encouraging expression of grief, and achieving a sense of closure for the adolescents. Suggestions include: creating a memory book, cards, or collages; displaying a memorial plaque; or planting a memorial tree or garden in the person’s name.
Research has shown that the bereaved are offended and hurt by some support attempts. Behaviours that are considered unhelpful include: saying, “I know how you feel,” encouraging a speedy recovery, giving advice, minimizing the loss/forcing cheerfulness, and intentionally avoiding the use of the deceased’s name. Failing to acknowledge that the death has occurred can also be offensive and hurtful.
Encourage rituals – Writing a letter to the deceased can be a way for the teenager to say goodbye. It may be painful but can provide relief and a safe expression of feelings. They may also want to write a letter to someone they love who is still alive. They may have distanced themselves from those they love to avoid being hurt, so a letter can be a way to reconnect with their loved ones. Encourage them to build a collage as a way of healing. They may cut out words and photos from magazines or of the deceased person. They may put it in a visible place, so encouraging people to ask them questions about how they feel about the dead person. Relationship Transformation – Encourage the adolescent to maintain an attachment to the deceased. Some of the ways in which adolescents can preserve the bond between the deceased and themselves include: visiting the cemetery, believing in a spiritual realm, praying or talking with the deceased, keeping possessions that the deceased valued, and/or placing items representing things the deceased valued (pictures, notes, sports equipment, favourite hat, class ring, etc.) in the casket. Telling the adolescent that the person has gone forever, or will not be able to hear them or that their actions are useless, is not a positive approach.
Provide them with information – They may ask why the person has died. They may ask for religious reasons about why death has happened, e.g. Why does God let people die and so on.
Ask to see a picture of the person who has died. Let them tell you about the person and why they were special. Let them share some special memories with you.
Let them tell you about any dreams they have had about the dead person. Dreams can be powerful and they may need support.
A teenager who understands the grief process, including anger and fear will have a better chance of coping with their feelings of loss and be able to cope with their losses more during their lives.
What makes Adolescent Grief Different to That Experienced by an Adult?
We’ve already discussed some reasons that adolescent grief is different to adult grief, but there are also other things to consider beyond bereavement itself. There are other forms of loss that a teenager might experience.
A teenager might experience loss when their siblings move out of home to go to university, get married or so on. They will have to adjust to life without their sibling. They will spend less time with them, meal times will be different and so on. This will also affect the dynamic within the family. Some teenagers or younger child may experience a divorce or separation within their family, which will again lead to a grieving process. Some children/teenagers may have experience abuse, sexually, physically or mentally, which results in a loss of their innocence and control over their own bodies.
As teenagers grow, they may begin to have relationships with others. This process is a natural adolescent process – they will start relationships and probably end relationships. Again, this will lead to them developing and grieving. Along with the relationships, they may develop sexual relationships. This can lead to another type of loss if a girl becomes pregnant. If she keeps the child, she potentially loses her future career (even if only in the short term), her innocence, her freedom and so on. The father of the baby will also be affected as he may support the girl. If they choose not to keep the baby, the mother and father then have to live with the emotional consequences of abortion or adoption, which can affect them later in life, for example, if they have future pregnancies. Children and teenagers may also experience the death of a pet, which can affect them profoundly. These are only examples of the type of losses that teenagers can experience, as well as bereavements – loss of parents/siblings/grandparents/friends and so on.
SET READING
Resick, P.A (2001) Stress and Trauma, Psychology press LTD U.K. p 57 – 76
SET TASK
1. Interview three individuals and ask them what developmental crises they have experienced in their lives. If possible, ensure that you have at least one male and one female interviewee. Write brief notes.
2. If possible view the movie “K-pax” with Kevin Spacey and Geoff Bridges.
ASSIGNMENT
1. Write a brief report on your findings from set task 1. Were there any differences in the crises experienced by the male and female interviewees?
2. Write a short essay on crisis evolving from a developmental perspective. In your discussion consider, age, gender, family environment, childhood influences and life events. (Between 500 and 700 words).
3. Using the notes from this lesson, prepare a leaflet for family and friends on how to support a teenager who is experiencing a crisis.
Lesson 5
POST TRAUMATIC STRESS DISORDER (PTSD)
Aim Explain the symptoms, treatment options and possible outcomes of PTSD.
Post-traumatic Stress Disorder Post-traumatic stress disorder (PTSD) is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Sufferers of PTSD may experience emotional numbness and sleep disturbances, depression, anxiety, and irritability or outbursts of anger. Feelings of intense guilt are also common. PTSD is diagnosed when symptoms last more than 1 month.
PTSD is a normal response to an abnormal situation. Tsunami, terrorist attacks, rape, assault, murder, accidents and so on are not normal situations. After a tragic event, you may experience different symptoms and emotions, known as PTSD. But some of these symptoms may not appear for weeks or months after the event itself. Traumatic events that can trigger PTSD include violent personal assaults such as rape or mugging, natural or human-caused disasters, accidents, or military combat. PTSD can be extremely disabling. Military troops who served in the Vietnam and Gulf Wars; rescue workers involved in the aftermath of disasters like the terrorist attacks on New York City and Washington, D.C.; survivors of accidents, rape, physical and sexual abuse, and other crimes; immigrants fleeing violence in their countries; and people who witness traumatic events are among those at risk for developing PTSD. Families of victims can also develop the disorder.
About 3.6 percent of adults ages 18 to 54 have PTSD during the course of a given year. About 30 percent of the men and women who have spent time in war zones experience PTSD.PTSD can develop at any age, including in childhood. Symptoms typically begin within 3 months of a traumatic event, although occasionally they do not begin until years later. Once PTSD occurs, the severity and duration of the illness varies. Some people recover within 6 months, while others suffer much longer.
Common symptoms of PTSD Re-experiencing Trauma Most people with PTSD try to avoid any reminders or thoughts of the ordeal, many people repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms.
Re-experiencing means that the survivor continues to have the same mental, emotional, and physical experiences that occurred during or just after the trauma. This includes thinking about the trauma, seeing images of the event, feeling agitated, and having physical sensations like those that occurred during the trauma.
To re-experience the trauma is to feel and act as if the trauma were happening again. Sufferers feel as if they are in danger and may experience panic sensations, want to escape, become angry, or want to attack or harm someone else. Because they are anxious and physically agitated, they may have trouble sleeping and trouble concentrating. These experiences are not usually voluntary; the survivor usually can’t control them or stop them from happening.
Mental effects of re-experiencing trauma can include: Upsetting memories such as images or other thoughts about the trauma Feeling as if it the trauma is happening again (“Flashbacks”) Bad dreams and nightmares
Getting upset when reminded about the trauma (by something the person sees, hears, feels, smells, or tastes) Anxiety or fear – feeling in danger again Anger or aggressive feelings and feeling the need to defend oneself Trouble controlling emotions because reminders lead to sudden anxiety, anger, or upset Trouble concentrating or thinking clearly.
Physical effects of re-experiencing trauma can include: Trouble falling or staying asleep Feeling agitated and constantly on the lookout for danger Getting very startled by loud noises or something or someone coming up on you from behind when you don’t expect it Feeling shaky and sweaty Having your heart pound or having trouble breathing.
Avoidance Because thinking about the trauma and feeling as if you are in danger is so upsetting, people who have been through traumas want to avoid reminders of trauma. Sometimes they are aware of this and avoid trauma reminders on purpose and sometimes they do it without realizing what they are doing.
Avoidance strategies may include: Actively avoiding trauma-related thoughts and memories Avoiding conversations and staying away from places, activities, or people that might remind you of trauma Trouble remembering important parts of what happened during the trauma “Shutting down” emotionally or feeling emotionally numb Trouble having loving feelings or feeling any strong emotions Finding that things around you seem strange or unreal Feeling strange or “not yourself” Feeling disconnected from the world around you and things that happen to you Avoiding situations that might make you have a strong emotional reaction Feeling weird physical sensations Feeling physically numb Not feeling pain or other sensations Losing interest in things you used to enjoy doing.
There are 10 suggested ways to recognise if you or another person is suffering from PTSD.
1. Re-experiencing the event through vivid memories or flash backs
2. Feeling “emotionally numb”
3. Feeling overwhelmed by what would normally be considered everyday situations and diminished interest in performing normal tasks or pursuing usual interests
4. Crying uncontrollably
5. Isolating oneself from family and friends and avoiding social situations
6. Relying increasingly on alcohol or drugs to get through the day
7. Feeling extremely moody, irritable, angry, suspicious or frightened
8. Having difficulty falling or staying asleep, sleeping too much and experiencing nightmares
9. Feeling guilty about surviving the event or being unable to solve the problem, change the event or prevent the disaster
10. Feeling fears and sense of doom about the future
Treatment of PTSD Research has demonstrated the effectiveness of cognitive-behavioural therapy, group therapy, and exposure therapy, in which the patient gradually and repeatedly relives the frightening experience under controlled conditions to help him or her work through the trauma. Studies have also shown that medications help ease associated symptoms of depression and anxiety and help promote sleep. Scientists are attempting to determine which treatments work best for which type of trauma.
Some studies show that giving people an opportunity to talk about their experiences very soon after a catastrophic event may reduce some of the symptoms of PTSD. A study of 12,000 schoolchildren who lived through a hurricane in Hawaii found that those who got counselling early on were doing much better 2 years later than those who did not.
Treatment of PTSD – A National Center for PTSD Fact Sheet (This leaflet is reproduced with the kind permission of the National Center for PTSD Website www.ncptsd.va.gov.) This fact sheet describes elements common to many treatment modalities for PTSD, including education, exposure, exploration of feelings and beliefs, and coping-skills training. Additionally, the most common treatment modalities are discussed, including cognitive-behavioural therapy, pharmacotherapy, EMDR, group treatment, and psychodynamic treatment.
Common Components of PTSD Treatment Treatment for PTSD typically begins with a detailed evaluation and the development of a treatment plan that meets the unique needs of the survivor. Generally, PTSD-specific treatment is begun only after the survivor has been safely removed from a crisis situation. If a survivor is still being exposed to trauma (such as ongoing domestic or community violence, abuse, or homelessness), is severely depressed or suicidal, is experiencing extreme panic or disorganized thinking, or is in need of drug or alcohol detoxification, it is important to address these crisis problems as a part of the first phase of treatment. It is important that the first phase of treatment include educating trauma survivors and their families about how persons get PTSD, how PTSD affects survivors and their loved ones, and other problems that commonly come along with PTSD symptoms. Understanding that PTSD is a medically recognized anxiety disorder that occurs in normal individuals under extremely stressful conditions is essential for effective treatment. Exposure to the event via imagery allows the survivor to re-experience the event in a safe, controlled environment, while also carefully examining his or her reactions and beliefs in relation to that event. One aspect of the first treatment phase is to have the survivor examine and resolve strong feelings such as anger, shame, or guilt, which are common among survivors of trauma. Another step in the first phase is to teach the survivor to cope with posttraumatic memories, reminders, reactions, and feelings without becoming overwhelmed or
emotionally numb. Trauma memories usually do not go away entirely as a result of therapy but become manageable with the mastery of new coping skills.
Therapeutic Approaches Commonly Used to Treat PTSD: Cognitive-behavioural therapy (CBT) involves working with cognitions to change emotions, thoughts, and behaviours. Exposure therapy is one form of CBT that is unique to trauma treatment. It uses careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context to help the survivor face and gain control of the fear and distress that was overwhelming during the trauma. In some cases, trauma memories or reminders can be confronted all at once (“flooding”). For other individuals or traumas, it is preferable to work up to the most severe trauma gradually by using relaxation techniques and by starting with less upsetting life stresses or by taking the trauma one piece at a time (“desensitization”).
Along with exposure, CBT for trauma includes: · learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts (“cognitive restructuring”), · managing anger, · preparing for stress reactions (“stress inoculation”), · handling future trauma symptoms, · addressing urges to use alcohol or drugs when trauma symptoms occur (“relapse prevention”), and · communicating and relating effectively with people (social skills or marital therapy). Pharmacotherapy (medication) can reduce the anxiety, depression, and insomnia often experienced with PTSD, and in some cases, it may help relieve the distress and emotional numbness caused by trauma memories. Several kinds of antidepressant drugs have contributed to patient improvement in most (but not all) clinical trials, and some other classes of drugs have shown promise. At this time, no particular drug has emerged as a definitive treatment for PTSD. However, medication is clearly useful for symptom relief, which makes it possible for survivors to participate in psychotherapy. Eye Movement Desensitization and Reprocessing (EMDR) is a relatively new treatment for traumatic memories that involves elements of exposure therapy and cognitive-behavioural therapy combined with techniques (eye movements, hand taps, sounds) that create an alternation of attention back and forth across the person’s midline. While the theory and research are still evolving for this form of treatment, there is some evidence that the therapeutic element unique to EMDR, attentional alternation, may facilitate the accessing and processing of traumatic material.
Group treatment is often an ideal therapeutic setting because trauma survivors are able to share traumatic material within the safety, cohesion, and empathy provided by other survivors. As group members achieve greater understanding and resolution of their trauma, they often feel more confident and able to trust. As they discuss and share how they cope with trauma-related shame, guilt, rage, fear, doubt, and selfcondemnation, they prepare themselves to focus on the present rather than the past. Telling one’s story (the “trauma narrative”) and directly facing the grief, anxiety, and guilt related to trauma enables many survivors to cope with their symptoms, memories, and other aspects of their lives. Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event, particularly as they relate to early life experiences. Through the retelling of the traumatic event to a calm, empathic, compassionate, and nonjudgmental therapist, the survivor achieves a greater sense of self-esteem, develops effective ways of thinking and coping, and learns to deal more successfully with intense emotions. The therapist helps the survivor identify current life situations that set off traumatic memories and worsen PTSD symptoms.
Psychiatric disorders that commonly co-occur with PTSD
Psychiatric disorders that commonly co-occur with PTSD include depression, alcohol/substance abuse, panic disorder, and other anxiety disorders. Although crises that threaten the safety of the survivor or others must be addressed first, the best treatment results are achieved when both PTSD and the other disorder(s) are treated together rather than one after the other. This is especially true for PTSD and alcohol/substance abuse.
Complex PTSD
Complex PTSD (sometimes called “Disorder of Extreme Stress”) is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. Developmental research is revealing that many brain and hormonal changes may occur as a result of early, prolonged trauma, and these changes contribute to difficulties with memory, learning, and regulating impulses and emotions. Combined with a disruptive, abusive home environment that does not foster healthy interaction, these brain and hormonal changes may contribute to severe behavioral difficulties (such as impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse, and self-destructive actions), emotional regulation difficulties (such as intense rage, depression, or panic), and mental difficulties (such as extremely scattered thoughts, dissociation, and amnesia). As adults, these individuals often are diagnosed with depressive disorders, personality disorders, or dissociative disorders. Treatment often takes much longer than with regular PTSD, may progress at a much slower rate, and requires a sensitive and structured treatment program delivered by a trauma specialist.
As PTSD can occur regularly after a major crisis, we will continue to look at some aspects of PTSD throughout the rest of the course, for example, PTSD and drug abuse.
SET READING Resick, P.A (2001) Stress and Trauma, Psychology press LTD U.K. p 79-93
SET TASK Carry out a library or internet search on PTSD. Write notes.
ASSIGNMENT
1. Simon comes to you with post-traumatic stress disorder (PTSD).
a) Briefly describe PTSD and the symptoms that Simon might display.
b) Describe a possible treatment plan for Simon (no more than 500 words)
c) What impact is PTSD likely to have on Simon’s family? (No more than 500 words)
Lesson 6
VIOLENCE AND SEXUAL ASSAULT
Aim Describe the effect of violence and sexual assault on the individual and possible modes of intervention.
Responses to Assault Sexual assault is an act of violence initiated without the consent of the victim. The victim will usually experience terror, helplessness and fear during the assault, which will tend to put the victim into crisis. This crisis will overtake the person’s traditional psychological resources and problem solving skills. His/her belief system about the world being a safe place will be shattered and their positive view of themselves potentially destroyed. The victim may face alienation from society due to the damaging myths about sexual assault and there may be a lack of family, social and institutional support. This is a revictimization by the medical, legal and social interventions and may lead to powerlessness and lack of control over the victim’s own life. Post-traumatic stress syndrome related to sexual assault is a violation of the private aspects of a person’s self, committed on the physical and emotional integrity of the person. It has become known as Sexual Assault Trauma Syndrome and is specific to victims of sexual assault.
Phases of Sexual Assault Trauma Syndrome There are three stages to the syndrome:
Acute Phase Assault is traumatic, not only for the person assaulted, but for her or his family and friends as well. The following are common initial reactions to learning of the sexual assault:
Every victim responds to trauma in her or his unique way. The following are things which assault victims have reported experiencing after sexual assault. Sexual assault typically affects victims on four levels – physical, emotional, cognitive, and social.
Physical reactions: o soreness/physical injuries o sleep disturbance o appetite disturbance/eating disorder o muscular tension o nightmares o somatic illness (headache, back pain, diarrhoea, ulcer, etc.). Emotional reactions: o fear o shock o numbness o anxiety o depression o shame/humiliation o powerlessness o guilt o anger o irritability o mood swings o sadness o feeling vulnerable o decreased self-esteem.
Cognitive (Thought): o what will people think? o will they believe me? o will they blame me? o why did this happen to me? o what if I had done . . . ? o what if I hadn’t . . . ? o will others hate me? o if I forget about it, maybe it will go away o I deserved it because . . . o difficulty concentrating-confusion o loss of memory for part of the assault-flashbacks o reliving the experience, triggered by sights, sounds, smells tastes, sensations, or experiences.
Impact on Social Behaviour: o withdrawal o afraid to be alone o uncomfortable around other people o difficulty trusting others o afraid to leave home o difficulty relaxing o disruption in sexual relations o hypersensitivity in relating to others o difficulty/apprehension around men, especially if they resemble the assailant.
Anger There is sometimes a tendency to blame the victim for the assault. This may be due to a belief in myths, such as women “ask for it” or that rape is primarily a sexual act rather than a violent crime. A friend or family member may express anger although they know intellectually that it was not the victim’s fault. Anger may also be directed at the assailant. Men who are close to the victim may feel it is their duty to seek revenge. They may be so tied up in anger that they are not able to be supportive to the victim. This may be because it is easier for some men to express anger than to express sadness.
Guilt Some people close to the victim may blame themselves, thinking they could have done something to protect the victim. This is particularly true of husbands, wives, or parents. Even young children have expressed some guilt. Children close to the victim may understand more than people think. Not telling them doesn’t mean they aren’t aware.
Fear Someone close to the victim may suddenly feel very vulnerable; they are facing the fact that this could happen to them also . Embarrassment It may be embarrassing for them to have to explain and to answer questions from acquaintances. It may even be embarrassing for them to have to hear about the assault.
Confusion They may not know how to help. They may not have a clear idea of what rape is and how it affects people.
Rejection
You may not be able to handle close relationships. Intimate relationships, particularly, may scare the victim or be difficult. Boyfriend/girlfriend, husband/wife, or friends may feel shut out.
Most significant others, after their initial shock and anger, become supportive of the victim. As the reality of the assault begins to sink in, most family and friends are able to shift their focus from their own pain, to that of their loved one who has been sexually assaulted. They can be a tremendous source of support and encouragement for the sexual assault victim.
Other practical problems may occur such as vaginal/anal bleeding, discharge, itchiness, sore throats and so on.
Outward Adjustment The victim may appear to be coping with the emotional turmoil, the immediate anxiety will subside and the victim will return to their normal pursuits.
Integration Phase This phase is usually precipitated by a specific event, e.g. the victim sees a person who looks similar to their assailant, they may receive a court summons, find out they are pregnant etc. The person will feel depressed and wish to talk to a counsellor or someone who can support them.
Grief A sexual assault is a loss and as such the person who experiences the assault will grieve.
There is no single way to grieve. Everyone is different and each person grieves in his or her own way. However, some stages of grief are commonly experienced by people. Feeling emotionally numb is usually the first reaction to a loss, and perhaps lasts for a few hours or days. The person may feel agitated or angry, and find it difficult to concentrate, relax or sleep. They may also feel guilty, thinking the assault was their fault, that they could have done something different. This period of strong, often volatile emotions usually gives way to bouts of depression, sadness, silence and withdrawal from family and friends. Over time, the pain, sadness and depression begins to lessen. The person begins to see their life in a more positive light again, although, the event will probably remain a traumatic memory for them. The final phase of grieving is to let go of the feelings of pain about the assault, but this may take some time.
Male Survivors of Sexual Abuse There are misconceptions about male sexual abuse. The fact that a male may ejaculate during an assault is a physiological response and does not imply consent. There may be misconceptions that the assault was a “rite of passage” or sexual initiation but the victim will still experience the same Traumatic Sexual Assault Syndrome. Ways for supporting male victims include – Help him to find somewhere he feels safe. Believe him. Listen to him. *Do not minimize his experience. Respect his decisions. Reassure him the assault is not his fault. Be aware of your own misconceptions regarding males who have been sexually assaulted. Encourage him to seek professional support.
Remind him abuse is abnormal, his feelings and responses are normal. Make him aware you know how difficult it was for him to disclose his abuse.
Stalking Stalking is often a very misunderstood thing by the general public, courts and law enforcement. Stalking can obviously be very distressing for the person being stalked. Women stalk men as much as men stalk women. Also men and women tend to stalk in similar ways. However, there are some differences in the way men and women stalk each other :
Women More likely to sneak around during the day More likely to stalk in public May turn up unexpectedly “to talk”. Men More likely to sneak around at night More likely to stalk at night May sneak around to see if their ex-partner is with someone else.
Around 1 in 1000 people believe that they are being stalked. A true stalker does not want to be ignored. They may believe that if they can’t have a person’s love, that they will have their anger or hatred. The worst think the victim can do is respond or interact with the person stalking them.
There are three types of stalking:
Relationship Stalking Occurs when a couple breaks up. It is not stalking in a legal sense, but it looks and feels like stalking to the victim. Obsessional Stalking Develops because of the way a couple interacted and broke up. It is a psychological obsession. It can be caused as a result of an on/off relationship, where the couple fear loss and separation from the other. The childhood of one of the partners is usually emotionally abusive or barren. Delusional Stalking This occurs when a mental disorder causes a person to become fixated on people like film stars, public figures, fellow workers or even a former partner.
Pursuit Behaviour Stalking often involves unwanted pursuit behaviour, which includes: Writing notes Giving gifts Contacting friends Following the person Making phone calls Intruding into their lives.
The important word here is obviously “unwanted”. There is a line which is acceptable and not and for some pursuit behaviour may be normal and wanted. When a relationship breaks down, it is normal for one partner to pursue the other, as a means of restoring the relationship. This is called “relationship repair mechanism”. Sometimes this is mistakenly seen as stalking.
Wanted pursuit behaviour may include: Returning phone calls Leaving messages Writing back
Talking to the person Giving them hugs Encouraging them Having sex with them Almost “rewarding” them for their pursuit.
This is where it becomes difficult for the law and counsellors. If a person has had sex with a person they claim is stalking them, they cannot really say one day they are having sex and the next day the person is stalking them.
It can be hard for some people to move from a deep emotional and sexual bond to friendship. Especially people with traumatic childhoods that have involved the death or loss of a loved one. The person who is being “dumped” will usually have the hardest time coping, as they are hurt, surprised and so on. Human beings may find ways that are not healthy to cope with these feelings. They may act in ways that feel better in the moment, but disregard the consequences and impact of their behaviour on others. Drugs and alcohol are not solutions and may make matters worse.
Obsessional pursuit becomes stalking when it is scary and not a mutual pursuit (that is, doesn’t involve wanted pursuit behaviour). Obsessional intrusions can scare and alarm people. They also suggest that the stalker is obsessed and delusional. They may take objects or mementos, for example, stealing someone’s underwear.
False Stalking Syndrome It is estimated that around 1/24 people who are convinced they are being stalked, actually aren’t. About 1/49 people who ARE being stalked don’t believe they are. Some people who claim they are being stalked suffer from “false stalking syndrome.” This is a pattern of behaviour that can confuse the courts, law enforcement and friends of the “victim”. False stalking syndrome is similar to Munchausen’s Syndrome. This is a disorder where people go to the doctor for attention, sympathy and support from others. Women with false stalking syndrome will go to police, friends and so on, to establish support, gain friendships and escape other problems in their lives. It has not been established whether men have this syndrome.
Women with this condition typically are: Dramatic Sexually provocative Live chaotic lives Have financial problems Dysfunctional histories, probably involving drug or alcohol abuse. Have a history of failed relationships History of being stalked or know people who have been stalked
The woman may present herself as though her life is being ruined by the stalking, but engage in a relationship with the man, follow him to his workplace, home, church etc.
Coping with Being Stalked Obviously stalking can cause a crisis for the victim. If a person believes they are being stalked, they should contact a mental health professional. They may suggest some ways to support people who are being stalked: End the relationship with the help of a counsellor. Talk to a counsellor and ensure that you are not sending mixed messages. Agree with the victim a period of time when you will have no contact with the stalker. Do not talk to the friends or family of the stalker about the behaviour. Get caller id. Change your mobile phone number Document all contact Do not get into a pattern of being angry and nice to the person. Say “no” and nothing else. Do not explain or justify yourself.
A CASE STUDY OF SEXUAL ABUSE COUNSELLING If a person has been sexually abused, good counselling can help them to overcome problems that have arisen due to the abuse. Counselling should be thought of as having three stages: The beginning The middle And the end.
The beginning stage will begin with disclosure. The client may feel issues of trust, doubt and shame. When they disclose to the counsellor, they may feel a rush of emotions, which can trigger a range of defence mechanisms. They may have vivid recollections of their abuse. They may experience these consciously or whilst dreaming. As the sessions progress, the client may be more willing to share their experiences.
The middle stage is a continuation of the first. There may still be issues of trust, security and safety, particularly if they have had unsuccessful counselling in the past. The counsellor will have to come up to the shortcomings of the previous counsellor as well as helping the client themselves. As the person becomes more comfortable with you as a counsellor, they may relax and share more personal details. They may still find this
overwhelming. The role of the counsellor is to normalize these reactions and help them to pace their disclosure, to help them gain control of their own emotions and reactions. The client may experience relief or an exacerbation of symptoms in the middle stage. They may go up and down. This is normal and to be expected. The client should be encouraged to discuss these ups and downs with the counsellor. At the end of the middle stage the client should feel some relief of symptoms and an improved psychosocial functioning.
The end stage – at this stage, the client may feel reluctant for the counselling to end. Their relationship with the counsellor may be the healthiest interpersonal experience they have had. This can lead to feelings of attachment. The counsellor can help this by gradual reducing meetings, perhaps from weekly to fortnightly then monthly and so on. Or reducing the times of the sessions from an hour to half an hour. The counsellor may also offer the possibility of the occasional session in the future if the client feels the need for it. The end of counselling can be the beginning of other services, such as support groups, educational opportunities, a new job or lifestyle.
CASE STUDY – TERRORIST ATTACK Over recent years, there have been terrorist attacks in many countries, 9/11 in America, the tube bombings in London and more. Governments are working to develop plans to address the different types of attacks that can disable communities, such as biological, nuclear, chemical and radiological attack. The primary goal of this is to preserve live and stabilise injuries that may occur.
The physical safety of the population is the priority. However, whilst physical trauma can destroy lives, but there is a hidden trauma, traumatic stress, that can ultimately destroy many more lives. Traumatic stress is the emotional, cognitive, behaviour and physiological experience of individuals who are exposed to or witness events that overwhelm their ability to cope. A terrorist attack will have direct and indirect victims. Individuals who are at the scene may experience traumatic stress. However, there will also be an impact on others, such as family and friends of victims, emergency service responders, health care providers and so on. We must also acknowledge the effect the media has on the general population in reporting these events. We do not know how stressful people find experiencing these events on the television.
Traumatic stress that results from a terrorist attack can disable people, cause disease, lead to mental disorders, substance abuse, destroy families and relationships. In some organizations, traumatic stress can lead to breakdowns in communication, decreasing morale and reduced group cohesiveness. Also, excessive absenteeism, employee sabotage, increased disability claims, inability to maintain personnel and so on. In the past, people may have experienced problems for months and years after the event. Today, techniques have been developed to defuse and debrief people soon after the traumatic event, such as CISD.
During traumatic incidents, people will experience sensations (smells, touch, tastes, sounds and sights) that become etched on their minds. They will run through those experiences again and again in their mind. This can cause traumatic stress disorders.
A terrorist attack can compromise our ability to think clearly, leaving us feeling out of control. A traumatic Stress Response Protocol will help people to be in control and know what they need to do. Those who help others after a terrorist attack need to know how people react in the face of tragedy. They need to know what traumatic stress is, how it affects others and themselves. They need to recognised the emotional, behavioural, cognitive and physiological reactions of people who experience traumatic trauma. This awareness will usually come from having relevant training prior to a crisis. Acute Traumatic Stress Management (ATSM) is a ten stage module for providing structure in a crisis. The first four stages of ATSM are of main importance for emergency personnel, the latter stages can be implemented by all caregivers at the scenes of traumatic events. It is
important to remember that in this sort of crisis situation, events will not necessarily follow a neat linear pattern.
1. Assess Danger/Safety for others and yourself – it is important for staff to determine whether the situation is safe. They cannot help others if they become injured themselves, so they need to assess the equipment, clothing and so on that is required to protect themselves.
2. The Mechanism of Injury – They must assess the nature of the individual’s exposure, for example, are they unconscious. The staff also need to consider the impact that the event has on people, for example, if they have seen people killed and mutilated by the terrorist attack.
3. Evaluate the level of responsiveness – The emergency personnel will need to determine if the individual is alert and able to respond to verbal comments. Are they in pain? Aware of what has happened? Are they in psychological shock? This is not an unusual response, the person may stare blankly or not respond when people try to engage them in conversation. People will experience a wide range of emotional responses when being involved in traumatic events.
4. Address Medical Needs – Emergency personnel will know how to respond to injuries, people who have stopped breathing and so on. Medical intervention should be provided by trained medical staff. Untrained staff may cause injuries that are worse that the actual initial trauma, for example, moving some one with a spinal injury. Life threatening injuries should be addressed before psychological needs.
5. Observe and Identify – Victims should be observed and identified. They may not be direct victims, that is they may be witnesses (secondary or hidden victims). Witnesses may show signs of traumatic stress as well as the actual victims.
6. Connect with the individual – In a crisis situation, the emergency staff should try to connect with the victim e.g. “I’m Bill, I’m a paramedic” etc. They should try to establish a rapport. They may ask a simple question e.g. “How are you doing?”
7. Ground the individual – When the staff have connected with the individual, they can initiate the ground stage. This is where the staff acknowledge the traumatic event on a factual level and try to orient the person by discussing the facts around the event. They should address the situation on a cognitive/thinking level, helping the individual to focus on the here and now, the reality of the situation, rather than the emotional expression. As we said earlier, people may be replaying events over and over in their minds. This is known as negative cognitive rehearsal and encouraging people to discuss the actual facts of the event, can break this replaying of events and help them deal with the hear and now.
8. Provide Support – Discussing the event factually can stimulate thoughts and feelings. This is the time that individuals exposed to an attack may need the most support. Many people may find it hard to cope with the painful feelings of others. They may be scared to say the “wrong thing”. It is important to try to understand the individual and the thoughts and feelings they are experiencing. They may feel alone and withdrawn in their own world. The staff supporting them should try to understand and enter “their world”.
9. Normalise the response – After a traumatic event, a person may begin to experience a range of emotions, they may feel they are going “mad”. Helping them to understand that they are not going crazy, that their experiences are normal responses to abnormal events is important. The staff should not be too sympathetic or make statements such as “I know how you feel” or “when I was…”. No one knows how the victim feels, so this can appear patronising.
10. Prepare For the Future – The final stage is aimed at helping the person prepare for the future. They may – a. review the nature of the incident, b. bring the person into the present, c. describe events that are likely to occur in the future.
ATSM is not counselling or psychotherapy, but a way to guide individuals through times of crisis, keep them functioning and try to avoid long term emotional consequences.
SET READING Resick, P.A (2001) Stress and Trauma Psychology press LTD U.K. (117-165)
SET TASK
Either
If possible view the film “The Accused” starring Jodie Foster.
OR
Read or listen to a story about one person’s experience with sexual assault, violence, or torture.
ASSIGNMENT
Mrs K. experiences a serious sexual assault.
1. List some of the initial cognitive and emotional reactions she might experience.
2. What physiological reactions is she likely to experience?
3. Describe how Mrs K’s husband might react to this situation.
4. How might the reactions of Mrs K. be similar to victims of violent assault?
5. What do you think the essential intervention modes are for support of victims of violence & sexual assault?
6. Briefly describe ways that the assault or torture victim in your story or film coped with the trauma. (E.g. withdrawal, hostility, counselling, amnesia etc).
Lesson 7
CRISES AND DRUG ADDICTION
Aim Explain the relationship between crises and drug dependence.
In 1999, nearly 15 million people in America admitted using illicit drugs in the prior month. Drug use is widespread, from the person who uses coffee and tea to get up in morning, to cigarettes and soft drinks to stay alert during the day, to using alcohol as a way to relax. The opportunity for drug abuse is there. People who abuse drugs risk their close personal relationships and their work performance. The pathological use of substances falls into two categories – substance dependence and substance abuse.
Substance use disorders are conditions that arise from misuse of alcohol, psychoactive drugs and other chemicals. This if also people who report symptoms attributed to the effects of drug abuse, the side effects of medications, or exposure to toxic materials
Substance use disorders are usually classified further as follows: abuse (harmful use) dependence intoxication withdrawal states psychotic disorders amnestic syndromes
The term abuse refers to maladaptive patterns of substance use that harms health in a broader sense. It is possible for an individual to show signs of misuse without being dependent. However, wherever dependence is present then it replaces abuse in the diagnosis. Most people can drink alcohol in moderation. They can have one or two drinks and not encounter problems. Others develop alcohol related disorders, such as alcohol abuse or alcohol dependence. These individuals drink to excess and become a danger to themselves and others.
Although addiction begins when an individual makes a conscious choice to drink or use other drugs, most individuals who experiment with addictive substances do not become addicted. Addiction develops over time and, once established, is a chronic and relapsing illness. Substance use can be associated with impulsive, aggressive or violent behaviour, which can result in criminal activity and injury to the person or others. This can also vary greatly depending on the substance that is being abused.
Substance-related disorders affect every segment of the population, regardless of age, race, ethnicity, socioeconomic status, gender or sexual orientation. People who also have substance related disorders usually find that their general health deteriorates.
Many people who use drugs use more than one at any given time. Polydrug abuse poses a serious health problem as the effects of the drugs taken together can produce a stronger reaction than individually.
Traumatic Effects That May Lead to Drug Use Our community accepts, and in some cases values, drug use. Alcohol is a central part of many people’s lives. Medicinal drugs are widely used and vital to the health of our community. They are sometimes misused. Illicit drugs are currently used for their psychoactive properties, but potentially some could be used for medicinal purposes (for example, cannabis and heroin).
Defining some drugs as ‘illegal’ and ‘demonising’ the users has not eliminated their use. Some users suffer serious health or other problems as a result of their drug use.
Psychoactive drugs will cause changes to consciousness by changing the biochemistry of the body. Though psychoactive drugs are considered a problem in many societies, they are used in almost every society, though not necessarily in a way that causes harm or distress.
Many societies intentionally use drugs in rituals or for recreation, yes such drugs are so much a part of our lives that many of us use them without realising that we are altering our biochemistry and affecting our consciousness. Tobacco and caffeine are stimulants that heighten out alertness, energy and mood. Tobacco is also a major cause of death, and caffeine increases can lead to anxiety, panic attacks, and high blood pressure. Alcohol and many widely prescribed tranquillisers are depressants, reducing our anxiety but also slowing our reactions and leading to possible psychological problems, as well as some potentially fatal physical reactions.
There is some evidence that problematic and harmful drug use most often occurs where people are vulnerable or lack self-esteem, such as at times when they are experiencing a crisis or traumatic event. The illegal status of the drugs and the stigma attached to users further entrenches their marginalisation. Provision of information, support and treatment is made more difficult in these circumstances. There are potentially serious health consequences that arise from misuse of illicit drugs. The level and nature of the consequences varies between drugs and is, to some degree, dependent upon the circumstances of their use. Many people who use illicit drugs will be polydrug users/abusers – that is, using more than one drug at any given time. Polydrug abuse poses serious health problems as the effects of drugs are sometimes synergistic, that is, the effects of each interact to produce an especially strong reaction.
People who go through traumatic experiences often have symptoms and problems afterwards. How serious the symptoms and problems are depends on many things, including a person’s life experiences before the trauma, a person’s own natural ability to cope with stress, how serious the trauma was, and what kinds of help and support a person gets from family, friends, and professionals immediately following the trauma.
Because most trauma survivors don’t know how trauma usually affects people, they often have trouble understanding what is happening to them. They may think it is their fault that the trauma happened, that they are going crazy, or that there is something wrong with them because other people who were there don’t seem to have the same problems. They may turn to drugs or alcohol to make them feel better. They may turn away from friends and family who don’t seem to understand. They may not know what they can do to get better.
Why Do People Use Drugs? Wired for Health (www.wiredforhealth.gov.uk) argues that many young people may be attracted to drugs for the following reasons –
“They are curious about the effects
The drugs are easily available
They want the same kind of experience that they get from drinking a lot of alcohol (and illegal highs may be cheaper than an evening of drinking)
They enjoy the short-term effects
Their friends use them
‘Dance drugs’ are a part of their music scene
Use seems part of the local youth culture
As part of growing up, they might want to ‘break the rules’
There is not much attractive recreational provision locally”. www.wiredforhealth.gov.uk
Experiencing a traumatic event may lead some adults or younger people to turn to drugs and alcohol to enable them to cope. In lesson 5, we discussed the most common symptoms of Post Traumatic Stress Syndrome which can arise in response to trauma. Some of these responses, re-experiencing the trauma and avoiding memory of the trauma, can be complicated by the development of secondary or associated trauma symptoms. (Review lesson 5 notes).
The DSM-IV-TR criteria for Substance abuse and substance dependence are different:
DSM-IV-TR Criteria for –
Substance Dependence Substance Abuse
Three or more of the following must be shown:
Withdrawal
Tolerance
Substance taken for longer or in greater amount than intended
Much time spent in activities to obtain the substance
Desire or efforts to reduce or control use
Social, occupational or recreational activities given up or reduced
Continued, despite knowing that psychological and physical problems are worsened by it
Maladaptive use of the substance shown by one of the following :
Repeated use in situations where it is physically dangerous
Repeated substance-related legal problems
Continued use despite problems caused by substance
Failure to meet obligations
Secondary Symptoms These are problems that come about because of having post-traumatic re-experiencing and avoidance symptoms. For example, because a person wants to avoid talking about a traumatic event that happened, she might cut herself off from friends and begin to feel lonely and depressed. As time passes after a traumatic experience, more and more secondary symptoms may develop. Over time, secondary symptoms can become more troubling and disabling than the original re-experiencing and avoidance symptoms.
Associated Symptoms These are problems that don’t come directly from being overwhelmed with fear, but happen because of other things that were going on at the time of the trauma. For example, a person who gets psychologically traumatized in a car accident might also get physically injured and then get depressed because he can’t work or leave the house. Common secondary and associated symptoms of PTSD are:
Depression: can happen when a person has losses connected with the trauma situation or when a person avoids other people and becomes isolated.
Despair and hopelessness: can happen when a person is afraid that he or she will never feel better again.
Loss of important beliefs: can happen when a traumatic event makes a person lose faith that the world is a good and safe place.
Aggressive behaviour toward oneself or others: can happen due to frustration over the inability to control PTSD symptoms (feeling that PTSD symptoms “run your life”). It can also happen when other things that happened at the time of trauma made the person angry (the unfairness of the situation). Some people are aggressive because they
grew up with people who lashed out when they were angry and never taught them how to cope with angry feelings. Because angry feelings keep people away, they also stop a person from having positive connections and getting help. Anger and aggression can cause job problems, marital and relationship problems, and loss of friendships.
Self-blame, guilt, and shame: can happen when PTSD symptoms make it hard to fulfil current responsibilities. It can also happen when people fall into the common trap of second-guessing what they did or didn’t do at the time of a trauma. Many people, in trying to make sense of their experience, blame themselves. This is usually completely unfair. At best, it fails to take into account the other reasons why the events occurred. Self-blame causes a lot of distress and can prevent a person from reaching out for help. Society sometimes takes a “blame-the-victim” attitude, and this is wrong.
Problems in relationships with people: can happen because people who have been through traumas often have a hard time feeling close to people or trusting people. This may be especially likely to happen when the trauma was caused or worsened by other people (as opposed to an accident or natural disaster).
Feeling detached or disconnected from others: can happen when a person has difficulty in feeling or expressing positive feelings. After traumas, people can get wrapped up in their problems or get numb and then stop putting energy into their relationships with friends and family.
Getting into arguments and fights with people: can happen because of the angry or aggressive feelings that are common after a trauma. Also, a person’s constant avoidance of social situations (such as family gatherings) may annoy family members.
Less interest or participation in things the person used to like to do: can happen because of depression following a trauma. Spending less time doing fun things and being with people means a person has less of a chance to feel good and have pleasant interactions.
Social isolation: can happen because of social withdrawal and a lack of trust in others. This often leads to loss of support, friendship, and intimacy, and grows fears and worries.
Problems with identity: can happen when PTSD symptoms change important things in a person’s life, like relationships or whether a person can do your work well. It can also happen when other things that happened at the time of trauma make a person confused about their own identity. For instance a person who thinks of himself as unselfish might think he acted selfishly by saving himself during a disaster. This might make him question whether he is really who he thought he was.
Feeling permanently damaged: can happen when trauma symptoms don’t go away and a person doesn’t think they will get better.
Problems with self-esteem: can happen because PTSD symptoms make it hard for a person to feel good about him or herself. Sometimes, because of things they did or didn’t do at the time of trauma, survivors feel that they are bad, worthless, stupid, incompetent, evil, and so on.
Physical health symptoms and problems: can happen because of long periods of physical agitation or arousal from anxiety. Trauma survivors may also avoid medical care because it reminds them of their trauma and causes anxiety, and this may lead to poorer health. Habits used to cope with post-traumatic stress, like alcohol use, can also cause health problems. Also, other things that happened at the time of trauma may cause health problems (for example, an injury).
A combination of any of these symptoms which are often compounded with feelings of guilt, helplessness and/or emotional isolation, can create such intense and continuous psychological distress that sufferers seek other ways to cope with or avoid suffering, such
as drugs. Therefore, alcohol and drug abuse are closely associated with PTSD, and can be seen not only as a way of coping with trauma but as a symptom that eventually leads to more even more problems.
Men, Depression and Substance Abuse Depression can go unrecognised, men in particular may be unlikely to admit to depressive symptoms and to seek help. Depression in men is not uncommon. In America, around 7% (six million people) have depression. Men and women can both develop the standard symptoms of depression, but experience it differently and have different ways of coping. Men may be more willing to report irritability, loss of interest in work or hobbies, sleep problems and irritability than sadness, guilt or worthlessness. However, men are more likely to report alcohol or drug abuse or dependence in their life. This may be a symptom of an underlying depression.
Men may turn to alcohol or street drugs to help with their depression, rather than seeking professional help. Some may throw themselves into their work, hide their depression from themselves and family and friends, indulge in reckless behaviour and so on. Men are four times as likely to die by suicide than men. More research is needed to determine the differences in depression in men and women.
Disasters and Substance Abuse or Dependence – A National Center for PTSD fact sheet – www.ncptsd.va.gov): What are the rates of substance use following disasters? The following findings from empirical disaster research summarize the issue of disasters and substance abuse or dependence.
Rates of new onset alcohol dependence disorders after a disaster, assessed according to DSM criteria, range from 0% to 2%.
Virtually no cases of new onset drug abuse emerged in any of the studies.
Although there are rarely new onsets, the total current prevalence of diagnosed alcohol dependence disorders is approximately 8%.
Individuals in select groups who had significant problems with alcohol before a disaster are likely to have problems with alcohol use after a disaster.
Rates of self-reported problematic alcohol use are similar to the total prevalence (7% – 9%).
Using alcohol occasionally as a way of coping is more common, about 15% on average. These rates range from 6% – 40%. The high rates occur among survivors with other psychological diagnoses.
Unlike rates of most other diagnoses and problems, rates of alcohol abuse or dependence appear to be no higher in survivors of mass violence than in survivors of natural disasters.
What has research shown about substance use following disasters?
Four studies on the aftermath of the bombing of the Murrah Federal Building in Oklahoma City found only minimal increases in alcohol use, abuse, or dependence.
North et al. conducted diagnostic interviews with 192 highly exposed survivors and found no new onset substance use (alcohol or drug) disorders. This finding is striking in light of the high prevalence of other psychological disorders in the sample. For example, 34% had disaster-specific PTSD and 13% had new onsets of Major Depressive Disorder.
Most of the survivors who used alcohol as a way of coping to a significant degree were those who were suffering from some other psychological disorder. That is, only 6% of respondents who did not meet criteria for a psychiatric disorder used alcohol to cope compared to 13% – 40% of persons who had one or more psychiatric diagnoses.
Shariat et al. surveyed 494 victims directly involved in a traumatic event about various medical problems. At a rate of 7%, alcohol use was among the least frequent problems. The most prevalent new medical conditions were auditory problems (32%), anxiety (28%), and depression (27%).
Smith et al. conducted a population survey of the Oklahoma City metropolitan area using Indianapolis as a control community. The rates of increased use of alcohol were approximately 2% and 1% in the two communities, respectively.
In a study that has not yet been published, North found a high lifetime rate (50%) of alcohol abuse/dependence among the firefighters who worked in Oklahoma City.
Although none of these disorders began after the disaster, 25% continued to abuse alcohol after the disaster. Other studies of incidents of mass violence yielded similar results.
After a shooting spree in a Texas cafeteria, North et al. detected new onset alcohol use or dependence disorders in 4% of the men and 0% of the women. In contrast, the rates for new onset PTSD were 21% for men and 29% for women, and the rates for new onset depression were 5% for men and 8% for women. Fifteen percent of the sample said they sometimes used alcohol to cope with stress.
North and her colleagues have studied a total of 10 disasters (including the two mentioned above) using the same methods and instruments. The remaining disasters spanned the range of mass violence (shooting sprees), technological disasters (plane crash), and natural disasters (tornado, firestorm, flood, earthquakes). Tallied across all studies, 8% of 811 adults met criteria for post disaster alcohol dependence, but the rate of new onset alcohol use disorders was only 1%. There were no new onset drug problems in any of the studies.
Although few researchers have data as directly relevant, other researchers have corroborated the findings that alcohol abuse is not a common reaction to disaster.
After Hurricane Andrew, David et al. assessed a sample of area residents. New onsets of PTSD (36%) and depression (30%) were common but alcohol dependence (2%) was not.
Norris et al. reported that 9% of their sample of victims of Hurricane Andrew “used alcohol or drugs to forget” at least sometimes, but of the 25 symptoms that were assessed, only one symptom was less prevalent.
Bravo et al. studied a large sample of victims of floods and mudslides in Puerto Rico and found no increase in symptoms of alcohol use, even within the most severely exposed group (pre-disaster = 0.9; post disaster = 1.1).
In a regression analysis that controlled for a number of important variables, exposure was correlated with depressive, somatic, and posttraumatic stress symptoms but not with alcohol use symptoms.
PTSD and Problems with Alcohol Use (Reproduced from www.ncptsd.va.gov) PTSD does not automatically cause problems with alcohol use; there are many people with PTSD who do not have problems with alcohol. However, PTSD and alcohol together can be serious trouble for the trauma survivor and his or her family.
How do PTSD and alcohol use affect each other and make problems worse? PTSD and alcohol problems often occur together.
People with PTSD are more likely than others with similar backgrounds to have alcohol use disorders both before and after being diagnosed with PTSD, and people with alcohol use disorders often also have PTSD. Being diagnosed with PTSD increases the risk of developing an alcohol use disorder.
Women exposed to trauma show an increased risk for an alcohol use disorder even if they are not experiencing PTSD. Women with problematic alcohol use are more likely than other women to have been sexually abused at some point in their lives.
Men and women reporting sexual abuse have higher rates of alcohol and drug use disorders than other men and women.
Twenty-five to seventy-five percent of those who have survived abusive or violent trauma also report problems with alcohol use. Ten to thirty-three percent of survivors of accidental, illness, or disaster trauma report problematic alcohol use, especially if they are troubled by persistent health problems or pain.
Sixty to eighty percent of Vietnam veterans seeking PTSD treatment have alcohol use disorders. Veterans over the age of 65 with PTSD are at increased risk for attempted suicide if they also experience problematic alcohol use or depression. War veterans diagnosed with PTSD and alcohol use tend to be binge drinkers. Binges may be in reaction to memories or reminders of trauma.
Alcohol problems often lead to trauma and disrupt relationships.
Persons with alcohol use disorders are more likely than others with similar backgrounds to experience psychological trauma. They also experience problems with conflict and intimacy in relationships.
Problematic alcohol use is associated with a chaotic lifestyle, which reduces family emotional closeness, increases family conflict, and reduces parenting abilities.
PTSD symptoms often are worsened by alcohol use.
Although alcohol can provide a temporary feeling of distraction and relief, it also reduces the ability to concentrate, enjoy life, and be productive.
Excessive alcohol use can impair one’s ability to sleep restfully and to cope with trauma memories and stress. Alcohol use and intoxication also increase emotional numbing, social isolation, anger and irritability, depression, and the feeling of needing to be on guard (hyper-vigilance).
Alcohol use disorders reduce the effectiveness of PTSD treatment. Many individuals with PTSD experience sleep disturbances (trouble falling asleep or problems with waking up
frequently after falling asleep). When a person with PTSD experiences sleep disturbances, using alcohol as a way to self-medicate becomes a double-edged sword. Alcohol use may appear to help symptoms of PTSD because the alcohol may decrease the severity and number of frightening nightmares commonly experienced in PTSD. However, alcohol use may, on the other hand, continue the cycle of avoidance found in PTSD, making it ultimately much more difficult to treat PTSD because the client’s avoidance behavior prolongs the problems being addressed in treatment. Also, when a person withdraws from alcohol, nightmares often increase.
Additional Mental Health Issues
Individuals with a combination of PTSD and alcohol use problems often have additional mental or physical health problems. As many as 10-50% of adults with alcohol use disorders and PTSD also have one or more of the following serious disorders:
Anxiety disorders (such as panic attacks, phobias, incapacitating worry, or compulsions)
Mood disorders (such as major depression or a dysthymic disorder)
Disruptive behavior disorders (such as attention deficit or antisocial personality disorder)
Addictive disorders (such as addiction to or abuse of street or prescription drugs)
Chronic physical illness (such as diabetes, heart disease, or liver disease)
Chronic physical pain due to physical injury/illness or due to no clear physical cause
What are the most effective treatment patterns?
Because the existence of both PTSD and an alcohol use disorder in an individual makes both problems worse, alcohol use problems often must be addressed in PTSD treatment. When alcohol use is (or has been) a problem in addition to PTSD, it is best to seek treatment from a PTSD specialist who also has expertise in treating alcohol (addictive) disorders. In any PTSD treatment, several precautions related to alcohol use and alcohol disorders are advised:
The initial interview and questionnaire assessment should include questions that sensitively and thoroughly identify patterns of past and current alcohol and drug use.
Treatment planning should include a discussion between the professional and the client about the possible effects of alcohol use problems on PTSD, sleep, anger and irritability, anxiety, depression, and work or relationship difficulties. Treatment should include education, therapy, and support groups that help the client address alcohol use problems in a manner acceptable to the client.
Treatment for PTSD and alcohol use problems should be designed as a single consistent plan that addresses both sources of difficulty together. Although there may be separate meetings or clinicians devoted primarily to PTSD or to alcohol problems, PTSD issues should be included in alcohol treatment, and alcohol use (“addiction” or “sobriety”) issues should be included in PTSD treatment.
Relapse prevention must prepare the newly sober individual to cope with PTSD symptoms, which often seem to worsen or become more pronounced with abstinence.
Where can you get help?
For a listing of professionals in the USA and Canada who treat alcohol disorders and PTSD, we suggest consulting the membership directories of the International Society for Traumatic Stress Studies or the Association of Traumatic Stress Specialists. For veterans experiencing problems with PTSD and alcohol use, the Department of Veterans Affairs has a network of specialized PTSD and substance use treatment programs. For information on these programs, contact the local VA Vet Center or the Psychiatry Service at a VA Medical Center. (For addresses and telephone numbers, look under the “United States Government” listings in the telephone directory.) (www.ncptsd.va.gov)
SET READING
Resick, P.A (2001) Stress and Trauma, Psychology press LTD U.K. p 117 – 165
SET TASK
Carry out a library or internet search on drug abuse/misuse in either: a. people suffering from PTSD. b. people who have experience a sexual assault.
Particularly consider explanations for the high use of drugs by people who have PTSD or have experienced a sexual assault.
ASSIGNMENT
1. Write a brief report on your findings from the set task. Explain the high use of drugs by persons suffering PTSD or victims of sexual assault. (no more than 500 words).
2. Give a case example to illustrate the association between PTSD and alcohol or drug abuse. You might use a real life example, or one taken from films like the 4th of July.
3. How might you apply your understanding of the relationship between drugs or alcohol and trauma to help a client suffering from trauma? (There is not one correct answer to this question. Use your own judgement and what you have read).
Lesson 8
FAMILY CRISES
Aim Discuss the major issues that arise in family crises and appropriate methods of intervention.
Families are exposed to a number of stressors on a daily basis, including time, financial, relationship, illness etc. Some of the more extreme outcomes of these stressors can include divorce of domestic violence. A consequence of parental break-ups is often a change of residence, as well as school, for the children, possibly several times.
A Western Australian study of 144 highly mobile children aged between four and eight showed there was only a small difference between these children and their peers at the early ages. However, as their grade level increased so did the margin between the two groups, with the mobile children being left behind academically.
A more severe form of family crisis is domestic violence. If children do not bear the physical scars of domestic violence they are often not acknowledged as victims. The effects on children who have been abused or have witnessed their mother being abused include: nervous and withdrawn demeanour; increased levels of anxiety; psychosomatic illnesses; increased internalised problems such as depression; adjustment problems; lower rating in social competence; decreased cognitive abilities and poor school performance; bed-wetting; restlessness; running away from home.
Another outcome of family violence is homelessness, as families often become homeless when trying to escape domestic violence. Recent Australian studies are showing a similarity with overseas studies in that families are the fastest growing groups applying to shelters for the homeless and to welfare agencies.
EXAMPLES OF PARTICULAR CRISES WITHIN A FAMILY Personal Events Personal crisis include a variety of things, such as hardship (poverty, unemployment, bad working conditions), exploitative relationships, catastrophes (floods, tsunami, fire), significant personal loss, addictive behaviours (alcoholism, drug addiction), affairs/infidelity, marriage break ups, birth of a child, children leaving home, mental illness, physical illness. Caplan (1970) argues that when a personal crisis occurs, the individual is suddenly confronted with a problem that their typical way of responding to the world is not sufficient for. The individual may be thrown into an acute crisis, where everything they thought they knew or believed is turned upside down. This response can contribute to the crisis as much as the actual event itself.
An acute personal crisis can be very frightening, as the world will tend to lose its elements of safety and predictability. Crisis can be turning points in our lives. Caplan argued that an acute crisis is usually time limited, so support is often required quickly or immediately.
Some people may deal with the crisis by avoiding situations. This avoidance can be due to the fear of loss of control, however, it can lead to other psychological states, such as depression, chronic anxiety and obsessive reactions.
CHILD ABUSE The following section on child abuse is taken from our Child Psychology course as it is also relevant to crisis counselling as useful information. Child abuse is one of the crises that a
family may face. They may find caring for their children so stressful, that the parents themselves may be the abusers. Or their children may be abused by others.
What is Child Abuse The term child abuse covers a wide range of behaviours: Neglect – not feeding a child properly, not providing them with adequate clothing or shelter, failing to provide a clean and safe environment and so on Physical Abuse – hitting, smacking, thumping, whipping etc. Sexual Abuse – rape, forcing a child to complete sexual acts e.g. oral sex, child pornography etc. Mental Abuse – shouting, insulting, degrading, not allowing them to go out, not allowing them to make friends etc. The list of possible abuses is potentially endless.
Who Gets Abused Research has found that some children are more likely to be abused than others. Ross and Lewis (1981) – parents who rely on physically coercive methods to deal with defiance are at serious risk of becoming child abusers, particularly if their children are defiant. So it may be that the child is defiant, even after a smack say, pushing the parent to go farther.
Eagland and Sroufe (1981) found that babies who are emotionally unresponsive, irritable, hyperactive or ill are at far more risk of being abuse than healthy, quiet babies who are easy to care for. Klein and Stern (1971) found that premature babies who are more likely to have the characteristics suggested by Eagland and Sroufe represented 25% of the abused children they studied, but only 8% of babies in the general population were born prematurely. This doesn’t mean 25% of premature babies will be abused; it means that in the group studied by Klein and Stern they were, and that premature babies are more likely to have the characteristics that “trigger” abusive responses in some caregivers – not all!
Who Are the Abusers Unfortunately, there are still situations where children are physically, mentally and sexually abused by their parents, caregivers, family members, family friends, teachers etc. etc. You can not say “Who is an abuser?” – anyone could be an abuser. This is to not scaremonger, but you can not recognize abusers. However, not everyone is an abuser. In the modern age, it is very difficult for parents and carers of children to strike a balance between protecting a child from danger and overprotecting them so that they fear everyone and everything. It is one thing to say to a child something like “All men are nasty, so stay away from them” – What damaging impact would that have on their future life? Would girls fear men as they grow older, refrain from relationships with men, be unable to talk to men” or would boys hate themselves because they are men and therefore nasty! It is very difficult. This section intends to discuss what child abuse is, and the effects it can have on the child. It is not intended to scare or overemphasize the issue of child abuse – but to inform.
People who are child abusers come from all social groups, all races, both sexes, all ethnic groups and many may appear as typical loving parents – but they may have a tendency to become extremely irritated with their children, leading them to abuse their children. Only 1 in 10 abusers has a serious mental illness that would be difficult to treat (Kempe and Kempe, 1978). Frodi and Lamb (1980) showed videotapes of children crying and children smiling to a group of abusive and non-abusive mothers. In the abusive mothers, they were more likely to experience strong physiological changes to the crying than the non-abusive mothers. They were less willing to respond or react to smiling infants either, so a smile might be enough to trigger an abusive parent.
Some abusers have been abused themselves and may never have learned how to give or receive affection. They may have only learned a certain type of parenting and continue in that way. That is not to say that all victims of abuse become abusers themselves – this is not the case. The suggestion from research is that some caregivers are almost primed to become abusive if their children annoy or irritate them. However, the child is never to blame for their abuse!
Triggers of Abuse
Socialization Experiences Situational Stresses of Abuser Was abused or neglected as a child. Marital problems. Has learned how to administer Loss of job Discipline from a physically Social isolation coercive caregiver. Poverty
Psychotic States Child-produced Stress Character disorders Unwanted child Poor parenting Large number of children Poor self discipline “Problem child” Active Irritable Emotionally unresponsive Defiant Ill Physical or mental disability
Cultural influences Attitudes about violence and Behaviour control Attitudes about children’s rights
Precipitating Events Child cries, misbehaves, Has an accident, Irritates the parent
CHILD ABUSE OR NEGLECT Physical abuse Emotional abuse Sexual Abuse Withdrawal or ignoring the child (e.g. refusing to feed, cloth, care for their needs)
Diagram adapted from Gelles (1973)
Stranger Abusers In some situations, the abuser is an opportunist who will try to find a child in a public situation. There are some basic rules we can try to teach children to protect them from stranger-abusers. These are: If a child is approached by a stranger – it would be best to say something like, “You should never talk to strangers – men or women – unless your mother/father/grandmother/child minder etc. speaks to them first”. If a stranger asks them to go somewhere with them, get into a car or so on – they should refuse and say they can only go if their mother/father etc. comes with them. If a stranger tries to grab them – encourage your child to run screaming as loudly as they can for help. If a stranger does grab them – encourage them to scream as loudly as they can and fight as much as they can to attract attention. Many parents now take children to self-defence classes, where they are taught to do just this – scream, run, fight, and some other methods of defending themselves and attacking an attacker – such as always hit them in the stomach or genitals. This will hurt the attacker more than you. If you hit someone in the head – there is bone in a person’s head and this could potentially injure the child, perhaps breaking
their hand. If this happened, they would find it even harder to fight back – so go for the stomach or genitals. In some countries, you can now buy bracelets to put on your child’s wrist stating their name and who to contact if lost. Some people will put stickers on their children saying things such as – “If I’m lost, phone “mobile phone no””. This type of things may help a lost child to find their parents and hopefully prevent them meeting an abuser if one were to be there at the same time.
In recent years, there has been a growing awareness of child abuse. It is reported more in the media and reported more by victims of abuse. Most of us are aware that the issue exists. Child abuse has always existed, but it has not been so widely reported and children were often not encouraged to tell anyone that they were being abused. Even today, children may not report their abuse, but hopefully organizations such as the NSPCC and Child line in the U.K. are encouraging more victims to come forward.
Any child is at risk of abuse, but environmental and social triggers, coupled with the parent’s upbringing and attitude to discipline and the child’s personality can join together and unfortunately lead to the abuse of a child.
Divorce Divorce or parental separation is another crisis that can occur within a family. There are numerous factors, which affect how children are able to cope with divorce. Some of those factors parents can influence through our own actions, others we may have no control over. Researchers have estimated that the period of adjustment for families can range anywhere from one to three years, and sometimes even as long as five, depending on the circumstances surrounding the divorce. It is important for parents to realize children will have different types of reactions. Some may be short-term reactions that are in response to the crisis nature of divorce. Others may be long-term reactions that could be either positive or negative depending again on how parents are able to help their children. Some factors that may affect adjustment are: Level of conflict between parents How parents adjust to divorce Information children are given regarding the divorce Level of support available to child Child’s personality Child’s ability to deal with stress Age and developmental level of children
TRANSITIONS Transitions are also difficult times within a family. For example, when a child becomes an adult, a child starts school, a parent retires etc.
Early adulthood is a period that many of us reach our peak in physical performance. It is said that early adulthood starts at about eighteen years of age and ends at about thirty or forty years of age. For many people the early adulthood phase is or was a time of developing a sense of self and identity, learning to become independent of the parents, choosing a career, and having a family and kids of your own. During the later years of early adulthood and the beginning years of middle age, people seem to change from a more self indulgent way of life to a generous lifestyle. They start looking at things as “What’s best for the family?” As people get older they start seeing the meaning of life as they know it. An understanding of what is important and what is not is define again and again as the individual lives with it’s family. Many times people start looking at their lives differently and do not like what they see as they get older thus sudden changes often occur.
During the transition from early adulthood to mid-life we see many physical changes. The changes that occur during this stage take place rather gradual compared to the changes during adolescence. Most people start to gain weight and shrink in height about a halfinch. Loss of vision is the greatest during this transition and many middle age adults have to get glasses if they do not already have them. Cognitive development during the transition of early adulthood to middle adulthood seems to get slower but many people make use of education methods to handle problems better. The memory is thought to be better when younger but not all kinds of memory can be applied to age. People become less creative and start maintaining stability with things. Although the brain may slow down as it gets older it also may become more efficient. The retrieval of memories is one of the things that older people have a hard time with. As we get older we might have a great memory but can retrieve the memory thus limiting the memories we can remember. There is a higher level of thought done by adults, which leads to better use of time. Intelligence decreases and increases as we make the transition from early to middle adulthood. Intelligence is more likely to incline when tested more often and intelligence is more likely to decrease when required to be abstract. As we get older we keep developing until we die. Development is not always positive but some information we acquire as we go makes life easier and better.
GRANDPARENTHOOD – Another Crisis Living longer means that most people now lead three lives: first as children, second as adults with careers and most likely as parents, and third as retirees from careers – and for most of us as grandparents. During each of these lives we continually discover and learn new things. We find sides of ourselves that we did not know existed.
Our third life is a time for discovering new talents and creative possibilities in our inner worlds. It is a time for applying the wisdom of the ages to ourselves. It is a time for discovering the full meaning of life and for preparing for the future, whatever that may be. Being a grandparent means different things. Although grand parenting is not the dominant aspect of most of our lives, it is an aspect that is more important than most of us realize.
We have covered PTSD in earlier chapters, but having a victim of PTSD within the family can also affect the rest of the family. The following is a useful article from the National Center for PTSD.
PTSD AND THE FAMILY – Reproduced from National Centre for PTSD (www.ncptsd.va.gov) Eve B. Carlson, Ph.D. and Joseph Ruzek, Ph.D.
How does PTSD affect family members? Because the symptoms of PTSD and other trauma reactions change how a trauma survivor feels and acts, traumatic experiences that happen to one member of a family can affect everyone else in the family. When trauma reactions are severe and go on for some time without treatment, they can cause major problems in a family. This fact sheet will describe family members’ reactions to the traumatic event and to the survivor’s symptoms and behaviors.
It’s no wonder that family members react to the fact that their loved one has gone through a trauma. It’s upsetting when someone you care about goes through a terrible ordeal. And it’s no wonder that people react to the way a traumatized family member feels and
acts. Trauma symptoms can make a family member hard to get along with or cause him or her to withdraw from the rest of the family. It can be very difficult for everyone when these changes occur. Just as people have different reactions to traumatic experiences, families also react differently when a loved one is traumatized.
In the section below, many different types of reactions are described. A family may experience many of these reactions, or only a few. All of the reactions described, however, are common in families who have had to deal with trauma.
Sympathy One of the first reactions many family members have is sympathy for their loved one. People feel very sorry that someone they care about has had to suffer through a terrifying experience. And they feel sorry when the person continues to suffer from symptoms of PTSD and other trauma responses. It can be helpful for the person who has experienced the trauma to know that his or her family members sympathize with him or her, especially just after the traumatic event occurs.
Sympathy from family members can have a negative effect, though. When family members’ sympathy leads them to “baby” a trauma survivor and have low expectations of him or her, it may send a message that the family doesn’t believe the trauma survivor is strong enough to overcome the ordeal. For example, if a wife has so much sympathy for her husband that she doesn’t expect him to work after a traumatic experience, the husband may think that she doesn’t have any confidence in his ability to recover and go back to work.
Depression One source of depression for family members can be the traumatic event itself. All traumas involve events where people suddenly find themselves in danger. When this happens in a situation or place where people are used to feeling safe, just knowing the event happened could cause a person to lose faith in the safety and predictability of life. For example, if a woman gets mugged in the parking lot of a neighbourhood shopping center, her family may find they feel depressed by the idea that they are not really as safe as they thought they were, even in their own neighbourhood.
It can also be very depressing when a traumatic event threatens a person’s ideals about the world. For instance, if a man gets traumatized in combat by seeing someone tortured, it can be very depressing to know that people are capable of doing such cruel things to each other. Before the man was faced with that event, he may have been able to believe that people are basically good and kind.
Depression is also common among family members when the traumatized person acts in a way that causes feelings of pain or loss. There may be changes in family life when a member has PTSD or other symptoms after trauma. The traumatized person may feel too anxious to go out on family outings as he or she did in the past. The traumatized person may not be able to work because of PTSD symptoms. As a result, the family income may decrease and the family may be unable to buy things and do things the way they did
before the traumatic event. A husband may feel unloved or abandoned when-because of her depression-his traumatized wife withdraws emotionally and avoids being intimate or sexual. Children whose father can’t be in crowds because of combat trauma may feel hurt that their father won’t come to see them play sports. When PTSD lasts for a long time, family members can begin to lose hope that their loved one or their family will ever get “back to normal.”
Fear and Worry Knowing that something terrible can happen “out of the blue” can make people very fearful. This is especially true when a family member feels unsafe and often reminds others about possible dangers. Very often, trauma survivors feel “on edge” and become preoccupied with trying to stay safe. They may want to get a guard dog, or put up security lights, or have weapons in the house in order to protect themselves and their family members. When one person in a family is very worried about safety, it can make everyone else feel unsafe too. However, something that helps one person feel safe-like a loaded weapon under the bed-may make another person feel unsafe.
Family members can also experience fear when the trauma survivor is angry or aggressive. As described above, trauma survivors can become angry and aggressive automatically if they feel they are in danger. Trauma survivors may also become angry and aggressive because they are frustrated that they have trauma symptoms, or because they learned to be aggressive as a way to protect themselves in the trauma situation. No matter what the reason for the anger and aggression, it naturally makes family members fearful.
Many trauma symptoms can cause family members to worry. A wife might worry that her traumatized husband who becomes angry and violent at the least provocation will be injured in a fight or get in trouble with the police. A daughter may worry that her mother will make herself ill by drinking heavily as a result of a traumatic event. A man’s inability to keep a job because of trauma-related problems may cause his family to worry constantly about money and the future.
Avoidance Just as trauma survivors are often afraid to address what happened to them, family members are frequently fearful of examining the traumatic event as well. Family members may want to avoid talking about the trauma or trauma-related problems, even with friends. People who have experienced trauma hope that if they don’t talk about the problem, it will go away. People also don’t wish to talk about the trauma with others because they are afraid that others won’t understand or will judge them. Sometimes, if the traumatic event is one associated with shame, such as rape, family members may avoid talking about the event and its effects because of social “rules” that tell us it is inappropriate to talk about such things. Family members may also not discuss the trauma with others because they fear it will bring their loved one more shame.
Family members may avoid the things that the trauma survivor avoids because they want to spare the survivor further pain, or because they are afraid of his or her reaction. For
example, the wife of a combat veteran who is anxious about going out in public may not make plans for family outings or vacations because she is afraid to upset her husband. Though she doesn’t know what she can do to “fix” the problem, she does know that if the family goes to a public event, the husband will be anxious and irritable the whole time.
Guilt and Shame Family members can feel guilt or shame after a traumatic event for a number of reasons. A family member may experience these feelings if he or she feels responsible for the trauma. For instance, a husband whose wife is assaulted may feel guilt or shame because he was unable to protect her from the attack. A wife may feel responsible for her husband’s car accident if she thinks she could have prevented it if she had gotten the car’s brakes fixed. A family member may feel guilt and shame if he or she feels responsible for the trauma survivor’s happiness or general well-being, but sees no improvement no matter how hard he or she tries to help. Sometimes, after years of trauma-related problems in a family, a family member may learn about posttraumatic stress disorder and realize that this is the source of their family problems. The family member may then feel guilty that he or she was unsupportive during the years.
Anger Anger is a very common problem in families that have survived a trauma. Family members may feel angry about the trauma and its effect on their lives. They may be angry at whomever they believe is responsible for the traumatic event (this includes being angry at God). They can also feel anger toward the trauma survivor. Family members may feel that the survivor should just “forget about it” and get on with life. They may be angry when their loved one continues to “dwell” on the trauma. A wife may be mad because her husband can’t keep a job or because he drinks too much or won’t go with her to social events or avoids being intimate with her or doesn’t take care of the kids. Family members may also feel angry and irritable in response to the anger and irritability the trauma survivor directs at them.
Negative Feelings Sometimes family members have surprisingly negative feelings about the traumatized family member. They may believe the trauma survivor no longer exhibits the qualities that they loved and admired. A person who was outgoing before a trauma may become withdrawn. A person who was fun loving and easy-going before a trauma may become ill tempered. It may be hard to feel good toward a person who seems to have changed in many ways. Family members may also respond negatively to behaviors that develop following a trauma. For instance, family members may be disgusted by a woman’s overdrinking in response to a trauma.
Family members may also have negative feelings about the survivor that are directly related to the traumatic event. For example, a wife may no longer respect her husband if she feels he didn’t behave bravely during a traumatic event. A husband whose wife was raped may feel disgusted about what happened and wonder if she could have done
something to prevent the assault. A son may feel ashamed that his father didn’t fight back when he was beaten during a robbery. Sometimes people have these negative feelings even when they know that their assessment of the situation is unfair.
Drug and Alcohol Abuse Drug and alcohol abuse can become a problem for the families of trauma survivors. Family members may try to escape from bad feelings by using drugs or drinking. A child or spouse may spend time drinking with friends to avoid having to go home and face an angry parent or spouse. On the other hand, spouses sometimes abuse drugs or alcohol to keep their loved ones “company” when they’re drinking or using drugs to avoid traumarelated feelings. Sleep Problems Sleep can become a problem for family members, especially when it is a problem for the trauma survivor. When the trauma survivor stays up late to avoid going to sleep, can’t get to sleep, tosses and turns in his or her sleep, or has nightmares, it is difficult for family members to sleep well. Often family members are also unable to sleep well because they are depressed and/or they are worried about the survivor. Health Problems Family members of trauma survivors can develop health problems for a number of reasons. Bad habits, such as drinking, smoking, and not exercising may worsen as a result of coping with a loved one’s trauma responses. In addition, many illnesses can be caused by trauma-related stress if it goes on for an extended period of time. When family members constantly feel anxious, worried, angry, or depressed, they are more likely to develop stomach problems, bowel problems, headaches, muscle pain, and other health problems.
What can families do to care for themselves and the survivor? Trauma survivors and their families often don’t know what to do to care for themselves. First, it is important to continue to learn more about trauma and its effects. Some books are listed below that may be helpful. For veterans, educational classes may be available through a local VA Medical Center or VA Readjustment Counseling Service Vet Center (see below).
Treatment for PTSD is available in most communities through psychologists and social workers in private practice. Insurance may help pay for this treatment. Community mental-health centers and private mental-health clinics (such as those run by charitable or church organizations) may also provide treatment, sometimes at low or reduced fees. To find phone numbers for mental-health professionals, you can look in the yellow pages of your local phone book under “Mental Health Services” and “Therapists.”
Family members of a traumatized person should find out as much as they can about PTSD and get help for themselves, even if their loved one doesn’t seek treatment. Family members can encourage the survivor to inquire about education and counseling, but they should not pressure or try to force their loved one to get help. Classes or treatment may
also be useful for stress and anger management, addiction, couples communication, or parenting.
While in the process of getting help, if family members feel comfortable, they should let their loved one know that they are willing to listen if the survivor would like to talk about his or her trauma. But the family should stop if anyone gets too upset or overwhelmed. If everyone is able, it is also important to talk about how the trauma is affecting the family and what can be done about it.
www.ncptsd.va.gov
Responding to Family Crisis In the past, in response to crisis, therapists and counsellors have responded and supported individuals, rather than focussing on the needs of the entire family. Family therapy evolved as a response to this. To support families through crisis, they will need good quality counselling and therapy to encourage the family to develop and remain as a family unit.
However, many counsellors may find the task of supporting a family daunting. Interventions are difficult. There is little hard research evidence showing the value of the family approach. There are often too many variables that need to be taken into account.
There are issues that the counsellor has to consider such as – confidentiality, who is the client, how do they assess the family’s level of functioning, etc. Traditional counselling will tend to focus on the individual and how many problems may originate in family functioning.
Salvador Minuchin is one of the best known early family therapists. He developed a theory known as “Structural Family Therapy”. His theory was radical. It presented the possibility of working with individuals in the family and with structures and spaces between them. Also, Minuchin made no assumptions about developmental blocks, faulty learning or pathology within the family. Symptomatic behaviour was seen as a sign that the family had reached an impasse. By working within the structure and space, the system could make readjustments without anyone being blamed. This was a significant departure from the focus on the individual, but it still retained much of traditional medical style interventions. However, since Minuchin’s work in the 1960s, family therapy has continued to develop. Family structures are changing, but evidence shows that most of us continue to wish to live our lives in committed relationships. Caplan and others have shown that at times of crisis, a good quality intervention at the right time can have a critical impact on future functioning within the family.
SET TASK
Carry out an internet/library search on different methods/therapies used in response to family crisis and the problems that can occur within these different methods.
ASSIGNMENT
1. You are to support a family through a major crisis (this can be of your choosing). Using your notes from your set task, write as much as you can about the actual crisis e.g. suicide, illness, abuse and the effects that it may have on the family.
2. Using the notes from the set task, consider which method/therapy you consider most useful for the crisis in question 1 and write notes on how you would respond to the particular crisis.
3. Using the same method/therapy as you used in question 2, what potential problems occur when using this particular therapy?
Lesson 9
CRISES AND CULTURAL ISSUES
Aim Discuss cultural influences on crisis situations.
Different people will experience and respond to crises in different ways, each of which can be quite valid. These variations can become even more important in cases affected by cultural differences. Imagine the following scenario: A young Malaysian woman who is suffering from domestic violence approaches the counsellor at her workplace, and asks if she can talk to her privately. They arrange a counselling session. The young woman explains that she has unsuccessfully tried to change her husband’s violent behaviour by talking, by trying to be more agreeable, by having his mother talk to him and a range of other steps. She explains that he is angry because she deals with men in her workplace, and dresses in what he considers immodest modern clothing. She tells the counsellor that her domestic problems are affecting her work, and that she is seriously considering giving up her position, even though they badly need her income.
The counsellor suggests that the husband should participate in the counselling. However, he refuses, and after the counsellor writes several letters persuading him to come, he becomes quite angry with his wife. At the next session, the young woman is very distressed and admits that she is ready to quit her job. The counsellor decides that the client must develop her self esteem and assertiveness skill. “If that doesn’t help”, she tells her client, “you might consider the option of leaving your husband”.
After the first assertiveness-training session, however, the woman does not return to counselling. Later, she confides to a workmate that she felt pressured by the counsellor, and found her direct statements and personal questions threatening. She also admitted that she thought the assertiveness training encouraged her to be rude and selfish. Furthermore, the young woman was upset because the counsellor did not understand that she did not want to end her marriage. She would rather try to pacify her husband.
This true story illustrates how different cultural values and expectations can and will affect the perceptions of both counsellor and client. When they hold different beliefs and expectations, counselling can be quite ineffective, or even damaging.
Just a few of the areas in which cultural perceptions may vary considerably are: the allocation and uses of power gender rights and responsibilities family roles and responsibilities expressions of authority and appropriate responses to authority interpersonal behaviours such as touching, eye contact, disclosure acceptable and unacceptable questions, topics of discussion, behaviour responsibility to care for, give to, or share with family and/or community privacy and or personal space saying No or expressing disagreement or displeasure self-expression in public or private places the nature and role of marriage.
Also, sub-cultures exist within any society, and these often have their own formal or unspoken rules. A sub-culture can be described as a culture operating within the wider culture. Most of us function quite well within at least one sub-culture, and usually, within a few. Some sub-cultures are:
minority groups within a larger society, such as Chinese Australians, or AfroAmericans age groups, such as ‘the aged’, teenagers, pre-schoolers, or the middle aged gangs, such as youth or street gangs who are often in conflict with other gangs occupational groups such as blue collar workers, academics, doctors, environmental activists religious or value groups such as Seventh Day Adventists, Mormons, Sikhs, pacifists.
Are Counselling and Therapy Culture Bound? Some theorists argue that current theories of counselling and psychotherapy fail to account for the complexity of multicultural or pluralistic societies, which have rapidly grown in numbers within the last 100 years. Most theories, they explain, make assumptions about the nature of mental health problems and intervention through counselling or other means that are based on Western cultural values and expectations. Because of this, counselling theories are seen by some critics to be culture bound (i.e. limited by cultural assumptions), and cannot be easily adapted to the counselling needs of people from other cultural backgrounds.
Moreover, as demonstrated in first part of the lesson notes, assumptions made by culturally different counsellors and clients have resulted in culturally biased counselling and reluctance of people from other cultures to use existing mental health services (D.W. sue & Sue, 1999; Pederson, 2000). Multicultural specialists have asserted that the theories of counselling and psychotherapy represent different world views, each with its own values, biases, and assumptions about human behaviour.
Some counsellors have criticised traditional therapeutic practices as irrelevant for people of colour and other special populations such as the elderly. Most Western models of counselling originated in Euro-European culture and are grounded in the beliefs and values of the white middle or upper classes that made up the initial clientele for psychotherapists or counsellors. However, as these treatments have become much more accessible to people from all walks of life and different cultural backgrounds, the danger of imposing white middle class European-American values on clients is very real, and can have major repercussions.
For instance, implicit in contemporary counselling theories is an emphasis on individualism and on individuation (psychological and emotional separation from the mother or primary caregiver) as the foundation for maturity. In modern Indian society, however, attachment to the mother remains quite deep and persistent, and is, in fact, considered a hallmark of good character. One can see that an emphasis on individuation, which may be expressed as “think for yourself”, during counselling can be meaningless at best, and at worst, may result in profound inner conflict for a client from a more group-focused (or reciprocal) culture. Counsellors who assume that individuality and self-assertion are highly desirable goals might actually be working against the mental health of the client.
The problem also relates to sub-cultures such as the elderly, urban and rural Australian Aborigines, or Afro-Americans. Although they operate within, and are part of the wider culture, their particular needs, values and goals may be different, and they may require a more flexible counselling approach that considers their variation from the dominant culture. For instance, depression might take quite different forms among the elderly or among black youth than among young or middle-classed Europeans, Australians or Americans, and might not respond to standard intervention.
What is needed is a “theory of multicultural counselling and therapy” that takes into account the different values, attitudes and perceptions of clients form different backgrounds. More inclusive theories are needed to: a) make counsellors more aware of their own cultural “values, biases and assumptions about human behaviour” and how they can affect their ability to understand and assist their clients b) prepare counsellors to deal with clients whose world view and perception of their situation is different to their own, and who may be seeking different outcomes than expected.
Therefore, the counsellor’s primary task is to listen carefully to clients to find out what they want and need, what outcomes they desire, and how best to deliver appropriate assistance. To do this, the counsellor must be prepared to continually monitor his or her thoughts, words and actions for existing cultural biases and assumptions and learn to keep an open mind.
(Source: Corey, Gerald., Theory and Practice of Counselling and Psychotherapy, 6th edition, Brooks/Cole, United States, pp. 50-51).
Culture Shock Another aspect of culture that might affect the counsellor’s interactions with clients is culture shock. Culture shock is the term used to describe a collection of responses to either very rapid cultural change within a society, or the trauma that may be experienced by individuals who have moved from one cultural milieu to another. Culture shock is the interaction of affect (emotional) responses, behavioural responses (what people do), and cognitive (thought) responses.
The Affective Component – can be experienced as a “buzzing confusion… anxiety, disorientation, suspicion, bewilderment, perplexity and an intense desire to be elsewhere”. These responses are associated with feelings of being overwhelmed, and may arise in individuals who do not have, or feel they do not have, the social, family, or personal resources to cope effectively with the new situation. Traditional counselling interventions that assist in the development of effective coping skills can be useful in dealing with these symptoms.
The Behavioural Component – can be experienced as confusion about how to deal with people and situations in the new culture, unwillingness to initiate or maintain relationships with others, easily giving or taking offence, difficulty in the workplace, underachieving, anxiety, low self esteem, and difficulty in achieving goals. Intervention methods generally focus on “acquiring relevant basic social skills through behavioural culture training, mentoring and learning about the historical, philosophical and socio-political foundations of the host society.”
The Cognitive Component – can be experienced as inflexibility, unwillingness to change, judgementalism, abandonment of or even hostility to the mother culture or conversely, an inflexible, stricter adherence to the mother culture. These responses arise from internal anxiety that is strongest when the values of the new culture conflict with the values of the mother culture. When the established ‘truths’ and ‘certainties’ by which an individual has lived are either rejected by the new society or not valued within it, the individual’s belief system comes under threat. Hence, the traumatised individual either retreats into his/her own culture, becoming increasingly hostile or unreceptive to the surrounding culture, or rejects the mother culture, effectively cutting him or herself off from traditional social, cultural and often, family support systems.
While the majority of people seem to adapt without trauma to their new cultural milieu, some experience culture shock, a form of trauma that can be alleviated with sensitive counselling. It is important, however, not to confuse cultural difference and variation of values, behaviours and responses to crises with culture shock, which is merely one form of crisis that may be experienced. (Source: Ward, Bochner, Furnham, 2001, The Psychology of Culture Shock, Routledge, Sussex, pp.271-274).
Methods of Training to Deal with Cultural Change The following methods are widely used to: (i) train counsellors and others to deal with people from other cultures, and to (ii) develop client’s awareness and skills to prevent or alleviate the trauma of culture shock. While the most effective way to help clients cope with cultural change, of course, is to prepare them for it prior to the event, these methods can be used by the counsellor to help develop the coping skills of clients already traumatised by cultural change.
Cultural Sensitisation – sensitising clients not only to the new culture, but to their own biases and assumptions in regard to that culture. The aim is to increase awareness of ethnocentricity (judging other cultures against the values and standards of one’s own culture), and to encourage the client to understand that beliefs and behaviours are not necessarily universal, but are mostly specific to a culture. Cultural sensitisation also
involves increasing awareness of values and attitudes typically held in the client’s culture that may be rejected by other societies, including their new cultural milieu.
Simulations or Role Playing – can help clients by allowing them to practise for effective participation in their adopted society. This method is widely used by business and government organisations whose personnel must deal with other cultures, or stay in different countries, but it can be effective one-to-one, as long as the client sees the relevance of the exercise.
Critical Incident Technique – consists of exploring “series of brief descriptions of social episodes where there is a misunderstanding or conflict arising from cultural differences between actors [individuals]”. The exercises include analysing different perceptions of the situation, and exploring each person’s feelings and thought about the situation, as well as their responses. “The purpose is to increase the participant’s awareness of their own culturally determined attitudes and their interpretations of the behaviour of other people”. (Source: Ward, Bochner, Furnham, 2001, The Psychology of Culture Shock, Routledge, Sussex, pp.256-261)
Crisis Intervention – Cultural Implications Crises affect everyone, no matter what their culture. Some crises are fairly universal, such as bereavement, domestic violence, change in marital status, loss of job and so on.
However, crisis has a strong impact on how the victim responds to it and how the professional responds to it. Culture can affect how we respond to a crisis, to provocation and so on. For example, if you live in a culture that rejects certain types of crises, you may not receive the support you require. For example, if you lived in an imaginary culture where it was thought that rape was not possible. Then you were raped, you would not receive the support you required. The response should therefore take account of the culture where the person lives, the counsellor should also be, if possible, from the same culture or experienced in supporting people within that culture. We are now drawing to the end of this course and at ways we can cope after a crisis. The following article from the National Center for PTSD (www.ncptsd.va.gov) offers valid and useful advise on coping with traumatic stress reactions.
Coping with Traumatic Stress Reactions The Importance of Active Coping When veterans take direct action to cope with their stress reactions and trauma-related problems, they put themselves in a position of power. Active coping makes you begin to feel less helpless.
Active coping means recognizing and accepting the impact of trauma on your life and taking direct action to improve things.
Active coping occurs even when there is no crisis; coping is an attitude and a habit that must be strengthened.
Understanding the Recovery Process Knowing how recovery happens puts you in more control of the recovery process.
Recovery is an ongoing, daily, gradual process. It is not a matter of suddenly being cured.
Some amount of continued reaction to the traumatic event(s) is normal and reflects a normal body and mind. Healing doesn’t mean forgetting traumatic war experiences or having no emotional pain when thinking about them.
Healing may mean fewer symptoms, symptoms that are less disturbing, greater confidence in your ability to cope with your memories and reactions, or an improved ability to manage your emotions.
Coping with Traumatic Stress Reactions: Behaviors that DON’T Help These are behaviors you should not use to cope.
Using drugs and alcohol to reduce anxiety, relax, stop thinking about war experiences, or go to sleep. Alcohol and drug use cause more problems than they cure.
Keeping away from other people. Social isolation means loss of support, friendship, and closeness with others, and more time to worry or feel hopeless and alone.
Dropping out of pleasurable or recreational activities. This leads to fewer opportunities to feel good and feel a sense of achievement.
Using anger to control others. Anger helps keep other people away. Anger may keep bad emotions away temporarily, but it also keeps away positive connections and help from loved ones.
Trying to constantly avoid people, places, or thoughts that are reminders of the traumatic event. Avoiding thoughts about the trauma or treatment doesn’t keep away distress, and it prevents you from making progress on coping with stress reactions.
Working all the time to try to avoid distressing memories of the trauma (the workaholic).
Coping with Traumatic Stress Reactions: Behaviors that CAN Help There are many ways you can cope with posttraumatic stress. Here are some things you can do if you have any of the following symptoms:
Unwanted distressing memories, images, or thoughts
Remind yourself that they are just that, memories.
Remind yourself that it’s natural to have some memories of the traumatic event(s).
Talk about them to someone you trust.
Remember that, although reminders of trauma can feel overwhelming, they often lessen with time.
Sudden feelings of anxiety or panic.These are a common part of traumatic stress reactions and include sensations of your heart pounding and feeling lightheaded or spacey (usually caused by rapid breathing). If this happens, remember that:
These reactions are not dangerous. If you had them while exercising, they probably would not worry you.
It is the addition of inaccurate frightening thoughts (e.g., I’m going to die, I’m having a heart attack, I will lose control) that makes them especially upsetting.
Slowing down your breathing may help.
The sensations will pass soon and you can go about your business after they decrease.
Each time you think in these positive ways about your arousal/anxious reactions, you will be working toward making them happen less frequently. Practice will make it easier to cope.
Feeling like the trauma is happening again (flashbacks)
Keep your eyes open. Look around you and notice where you are.
Talk to yourself. Remind yourself where you are, what year you’re in, and that you are safe. The trauma happened in the past, and you are in the present.
Get up and move around. Have a drink of water and wash your hands.
Call someone you trust and tell them what is happening.
Remind yourself that this is a common traumatic stress reaction.
Tell your counselor or doctor about the flashback(s).
Trauma-related dreams and nightmares
If you awaken from a nightmare in a panic, remind yourself that you are reacting to a dream and that’s why you are anxious/aroused,not because there is real danger now.
Consider getting up out of bed, regrouping, and orienting yourself.
Engage in a pleasant, calming activity (e.g., listen to soothing music).
Talk to someone if possible.
Talk to your doctor about your nightmares; certain medications can be helpful.
Difficulty falling or staying asleep
Keep to a regular bedtime schedule.
Avoid strenuous exercise for the few hours just before going to bed.
Avoid using your sleeping area for anything other than sleeping or sexual intimacies.
Avoid alcohol, tobacco, and caffeine. These harm your ability to sleep.
Do not lie in bed thinking or worrying. Get up and enjoy something soothing or pleasant; read a calming book, drink a glass of warm milk, or do a quiet hobby.
Irritability, anger, and rage
Take a time out to cool off or think things over. Walk away from the situation.
Get in the habit of exercising daily. Exercise reduces body tension and helps get the anger out in a positive and productive way.
Remember that staying angry doesn’t work. It actually increases your stress and can cause health problems.
Talk to your counselor or doctor about your anger. Take classes in anger management.
If you blow up at family members or friends, find time as soon as you can to talk to them about it. Let them know how you feel and what you are doing to cope with your reactions.
Difficulty concentrating
Slow down. Give yourself time to focus on what it is you need to learn or do.
Write things down. Making to do lists may be helpful.
Break tasks down into small do-able chunks.
Plan a realistic number of events or tasks for each day.
You may be depressed; many people who are depressed have trouble concentrating. Again, this is something you can discuss with your counselor, doctor, or someone close to you.
Having difficulty feeling or expressing positive emotions
Remember that this is a common reaction to trauma, that you are not doing this on purpose, and that you should not feel guilty for something you do not want to happen and cannot control.
Make sure to regularly participate in activities that you enjoy or used to enjoy. Sometimes, these activities can rekindle feelings of pleasure.
Take steps to communicate your caring to loved ones in little ways: write a card, leave a small gift, or phone someone and say hello.
A Final Word Experiment with these ways of coping to find which ones are helpful to you. Practice them; like other skills, they work better with practice. Talk to your counselor or doctor about them. Reach out to people that can help, in the VA, Vet Centers, your family, and your community. You’re not alone. (www.ncptsd.va.org)
SET TASK
If possible, interview 3 people from different cultural backgrounds to find how they deal with crisis situations. Another option is to interview a social or community worker who deals with
people from different countries to discuss their handling of crises with people from other cultures. Alternatively, watch a foreign film directed and about people from a culture different to your own, and take note of how they deal with crisis situations.
Try to discover the following: How do different cultures perceive depression among youth? women? aged? How likely are people from those cultures to seek counselling (from professionals or others) in crisis situations, and why? How did the people your observed cope with a traumatic situation such as grief, depression, family violence, extreme poverty or war?
ASSIGNMENT
1. How can cultural values influence the likelihood of seeking professional help in crisis situations and receptivity to that help? Be specific.
2. Explain culture shock and its possible manifestations in a client.
3. Compare your society’s typical responses to the responses described by people from different cultures, noting both similarities and differences.
4. Write a brief report on your findings from the set task (500 words max.).
