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All trauma is not the same

Tara S. Jungersen, Stephanie Dailey, Julie Uhernik, Carol M. Smith March 1, 2013

http://www.dreamstime.com/-image5401925Your first client of the day recently survived a Category 4 hurricane, while your next client reports that she survived a mass school shooting several years ago. Both clients have experienced trauma in the form of a collective community disaster. Nevertheless, the causes, symptoms, courses of treatment and counseling interventions may look different for these two clients. Counselors who do not know the difference risk providing inadequate or harmful services to each type of trauma survivor.

Disaster defined

Although many formal definitions exist, the term disaster is often described as a potentially traumatic event that is experienced collectively, has an acute onset and originates from natural or human factors that overwhelm local resources.

This definition highlights the categorical differences of disaster — namely, a natural or human agent — and places emphasis on trauma-inducing events, indicating that emotional responses are not uncommon during these ecosystemic crises. It also implies by the word potentially that not all individuals have the same reaction to disaster events. This definition eliminates traumatic events experienced by a single individual (for example, domestic violence, sudden bereavement or injury-causing accidents) and focuses on events such as hurricanes, earthquakes, acts of terrorism and mass shootings that affect entire geographic communities.

Emotional reactions

Counselors working with survivors of either natural or human-caused disasters witness a wide range of reactions common to both types of crisis. Following a disaster event, most survivors experience physiological and psychological reactions that include an acute physical stress response (fight, flight or freeze) as well as behavioral, cognitive, spiritual and emotional reactions. Somatization is the most frequently reported physical manifestation. Back or muscle pain, fatigue, gastrointestinal upset, problems with task performance, lack of appetite and sleep dysfunction are common physical challenges that disaster survivors report.

Although behavioral responses to disaster may involve aggression, domestic violence or increases in substance use, these behaviors are not typical unless they were pre-existing issues for the survivor. Common adverse behavioral stress reactions include isolation, withdrawal and developmentally inappropriate feelings of dependency (regression). Cognitive difficulties following a disaster are not uncommon and may include intrusive thoughts, flashbacks, memory problems, impaired concentration, dissociation, depersonalization, derealization or time distortion.

Common emotional reactions include feelings of fearfulness, anxiety, psychological and physical distress, depression, irritability, frustration or significant fear regarding one’s sense of safety and security. It is also not uncommon for some survivors to feel heroic, euphoric or invulnerable, especially during or immediately following the disaster event, because they have survived. Conversely, a feeling of psychological “numbness” is not unusual. Post-disaster adjustment problems can also occur and include increases in family stress and fears related to the event. According to Robert Ursano, survivors living with severe disabilities or disfigurement as a result of a disaster are approximately 35 percent more likely to experience psychological problems.

Given this wide range of emotional responses, many counselors may be confused about what to look for or how to best treat disaster survivors. Better understanding the categorical differences of disaster (natural versus human caused) and the associated emotional impact of these events can help. Moreover, better understanding of expected emotional reactions associated with the different types of disasters can help counselors identify which survivors might be at risk of longer term trauma reaction, as opposed to what James Halpern and Mary Tramontin refer to as “common reactions to abnormal events.”

The aftermath of natural vs. human-caused disasters

By definition, natural disasters are seen as uncontrollable and affect whole communities or entire populations with little or no advance notice. Natural disasters lack human involvement and are less likely than human-caused disasters to produce long-term adverse psychological effects in survivors.

Similar to natural disasters, human-caused disasters vary greatly in scope but can be divided into two types: technological accidents and acts of mass violence. Examples of technological disasters include transportation accidents, structural failings, fires and toxic waste accidents. Considered “acts of omission,” these events are typically the result of errors in system design, construction or management and most commonly the result of greed, negligence, poor planning or mismanagement.

Acts of mass violence, on the other hand, are considered malicious “acts of commission” and include the 9/11 terrorist attacks, the 2007 shooting on the Virginia Tech campus and the recent shooting at Sandy Hook Elementary School. The distinction between acts of mass violence and technological accidents is that during an act of mass violence, humans have intentionally premeditated significant brutality.

Disasters of human origin, particularly those that evoke fear, uncertainty, helplessness and loss of control, have greater emotional consequences than disasters that are not preventable. Not surprisingly, these events tend to produce higher levels of emotional distress than any other natural or human-caused disaster. As a result of human-caused acts of mass violence, trust within one’s community is broken. Furthermore, unlike natural disasters, which have a beginning and an end, human-caused disasters involve a seemingly ongoing danger that is unpredictable and potentially everywhere. Coping takes longer as people consider retaliation, seek justice, feel a need for equity and struggle to rebuild trust within their communities. Halpern and Tramontin state that “because fairness and justice are commodities that are not easy to achieve, recovery will be more difficult if they are requirements.”

Case studies

Counselors working in schools, community settings or private practice may be called upon to assist clients suffering from the trauma that results from natural or human-caused disasters. Studies have shown that individuals often experience symptoms of posttraumatic stress disorder (PTSD) for many years before seeking therapy, although counselors may also encounter clients who are in the more recent stages of trauma following a community disaster. The private practice case examples that follow illustrate the complexity of presentations by clients with complex trauma from disasters.

The first client, Sam, is 78 years old. He lives out of state but has come to counseling at the urging of his daughter, whom he is visiting for the holidays. Sam’s daughter is concerned that Sam seems sad and “just not himself.” She is surprised, yet glad, that Sam agreed to talk with a counselor for a brief counseling session. She adds that Sam has been grieving the loss of his wife, who died eight months ago. He had appeared to be coping well until recently, but now seems listless and withdrawn.

When the counselor meets with Sam, Sam is pleasant, articulate and expressive. He speaks of his grief at his wife’s passing but also mentions learning to handle day-to-day tasks that his wife formerly performed. He says to the counselor quietly, “What really bothered me was, the other night, I woke up in the middle of the night at my daughter’s house and didn’t know where I was. I was alone in the dark … just like I was when Sandy went through.” The counselor, in looking at this case through a “brief counseling” lens and a focus on grief, had missed indicators of possible trauma and subsequent PTSD. Sam explains that he lives alone in a house in New Jersey. He proudly tells how he safely rode out the storm but mentions that he was alone in the dark at night for several weeks because the electricity was out.

A counselor working with Sam would be aware of the role of natural disaster-induced trauma in designing appropriate interventions. Sam experienced the perceived loss of life and property during the hurricane, followed by isolation from support and basic services during the rescue and recovery phases. Counseling interventions would focus on building a relationship with Sam in order to allow him to tell the story of what he experienced. Additionally, the counselor would brainstorm with Sam about how to reconnect with scattered social supports who may have relocated after the storm as well as ensure that he has the resources to meet his immediate shelter and other basic needs.

The counselor would also process Sam’s feelings about the hurricane and the resulting upheaval of his life and belongings. The counselor would provide encouragement and validation of Sam’s strengths, resources and resilience, noting prior successful coping episodes. Sam might be experiencing a heightened sense of sadness due not only to facing hurricane reconstruction without his wife, but also because he may feel he would be a burden to his children or neighbors if he asks for help. He may also be experiencing frustration and anger at the slow speed of recovery and delivery of logistical support by local and federal agencies. However, he may also feel some solidarity in knowing he is not alone in experiencing this community disaster. Counselors should acknowledge the powerlessness natural disaster victims sometimes feel, while channeling the emotions into life- and safety-affirming actions such as drawing up plans for new living spaces or putting together an emergency “go box” of critical documents and items.

The second case involves Sue, a young wife and mother in her 20s who comes to counseling for help coping with stress related to chronic illness. Sue talks with the counselor about her irritability with her family and her frustration at coping with chronic fatigue syndrome. When the counselor inquires about her past symptoms and coping skills, Sue mentions offhandedly that she was a student at Virginia Tech during the shooting tragedy in 2007. She says she saw a counselor briefly after the shooting and acknowledges how that had been helpful at the time. But until now, Sue has not considered how her traumatic experience more than five years ago might still be reverberating in her life.

The counselor working with Sue needs to understand her presenting complaints of stress and irritability not only within the context of her previous trauma at Virginia Tech, but also within the context of the media’s current coverage of another mass school shooting (Sandy Hook Elementary School). As with Sam, who survived a natural disaster, counseling interventions with Sue would focus on relationship building, telling the story of the event, reconnecting with social supports and validating her previous successes and record of resilience. However, the counselor must also process the added layer of moral injury that Sue may be experiencing resulting from a seemingly preventable trauma. The counselor would process any feelings of guilt that surface with Sue, whether related to survivor’s guilt or lingering blame for the perpetrator or rescuers.

One helpful intervention for guilt is to allow the client to process what she wished to see happen or what her intentions were with a particular action or inaction. Another intervention would be for the counselor to collaborate with Sue to identify acts of justice and fairness in her community. This serves as a step toward re-establishing Sue’s sense of trust. Sue’s experience of this human-caused disaster may result in a longer episode of care because she must overcome the overriding perception of danger that surrounds her in her community, even as she simultaneously manages her medical condition.

Understanding both Sam’s and Sue’s experiences as they relate to post-disaster trauma provides a different framework for assisting them. For Sam, for Sue and for so many others who will seek counseling for trauma experiences, the counselor can be a lifeline for healing. The learning and trauma training required of counselors is ongoing and sometimes arduous. However, we owe our best to our clients and our colleagues in providing the trauma work we are called to do.

Join the ACA Trauma Interest Network

The Trauma Interest Network (TIN) is a group composed of American Counseling Association members dedicated to greater understanding of traumatology and promotion of this special area of counseling.

Currently, the TIN is a Listserv resource that welcomes all who are interested in learning and sharing about traumatology — the study and treatment of trauma. The Listserv provides a forum for sharing trauma-based interventions, practical clinical interventions, trauma-focused research and trauma trainings.

The TIN promotes awareness and understanding of traumatology because we believe that it requires focused training and supervision. Although the concept of trauma may be uncomfortable for people — even for counselors — the TIN hopes that the associated stigma may be reduced by providing awareness and resources for counselors. Counselors should be aware of events in clients’ lives that may have a negative impact on their healthy functioning, including experiences such as combat stress, traumatic loss or cyberbullying. We can move beyond our fears as counselors and develop trauma-informed clinical competence.

Although the Council for Accreditation of Counseling and Related Educational Programs requires traumatology to be infused into the education process, many counselors — seasoned and newly licensed alike — have not received adequate training to deal with the various elements of trauma they encounter in practice.

Recent events such as Hurricane Sandy and the mass shooting at Sandy Hook Elementary School underscore the need for additional research on trauma-based therapies and interventions. The TIN can be a clearinghouse for information and training opportunities.

The TIN plans on becoming more immersed in the ACA community through leadership and knowledge-based activities. Please take this opportunity to get involved with the TIN by contacting Holly Clubb at hclubb@counseling.org and joining the Listserv. And please join us for our Networking Meeting at the ACA 2013 Conference & Expo in Cincinnati.

Healing is promoted by a community. Please join ours.

— Chantelle Taylor & Venessa Farn

Tara S. Jungersen (Nova Southeastern University), Stephanie Dailey (Argosy University/Washington, D.C.), Julie Uhernik (private practice) and Carol M. Smith (Marshall University) are members of the ACA Trauma Interest Network. Send correspondence regarding this article to tj290@nova.edu.

Letters to the editor: ct@counseling.org

 

2 Comments

  1. Joy Nussen

    Thank you for the article on trauma. Curious why EMDR isn’t mentioned given it has recently been recommended as front line treatment by the world health organization.

    Reply
  2. Tara Jungersen

    Dear Joy:

    Thank you for your comment! We do agree that EMDR is an effective evidence-based approach for disaster-related trauma symptoms. Our intent with this article was to differentiate between natural and human-caused disasters, which did not permit full exploration of all of the available treatment options. EMDR is such an important technique that we believe it deserves its own dedicated article, as opposed to a cursory mention in one of our case studies.

    More information about recommendations for the treatment of trauma can be found in the following WHO Guidelines: http://www.who.int/mental_health/emergencies/stress_guidelines/en/index.html

    I hope that readers will incorporate this information into their trauma counseling repertoire.

    Kind regards,
    Tara Jungersen

    Reply

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