Trauma Work - An Introduction

What is Trauma?


The term ‘trauma’ in South Africa is quite relative in that it may refer to hijacking to political stress to employment issues – trauma is defined also as subjective to the victim/ survivor.

Trauma as a wounded soul

An event/ s that is experienced or perceived as so threatening that a person’s existing coping skills or resources are not really equal to the threat. His/her coping skills may furthermore be inadequate to dealing with the negative meaning attached to the stressor/event, which may lead to detrimental consequences in their lives.

• Trauma is not an illness
• It’s an internal reaction-  cognitive and perceptual dysfunction
• The survivor’s appraisal of the hazardous event/s largely determines the intensity with which it is experienced
• It’s a state of heightened psychological accessibility
• And could therefore be turned into an opportunity for growth

       Levels of traumatisation

• Primary:        On the scene (real time)
• Secondary:    Significant others
• Vicarious:      TV, newspapers, relief/ lay workers, counsellors & therapists

 
        Precipitating factors/ trauma events

• Loss
• Conflict
• Frustration
• Major adjustments
• Disasters and catastrophes : natural (earthquakes, floods); or human (terrorism, carjacking, robbery, rape)
• Developmental crisis
• Severe inner frustration
• Accidental crisis (death, suicide, terminal illness, insolvency, loss of a child, abortion, accidents, etc)

Other

Why Trauma Counselling?

Trauma counselling is a highly specific type of counselling for people in highly specific circumstances. The primary goal is containment, or crisis management; while the secondary objective is trauma resolution.

• It shortens the recovery period
• To reduce the impact of the event: symptom relief
• To strengthen coping skills so that survivors will be better able to cope with future problems: personal growth
• “not just band-aid therapy, but growth counselling”

 
Crisis or trauma intervention aims at definitive resolution of crisis in order to restore an optimum level of functioning as well as ready access to sources of help without delay or waiting lists. General time-limited treatment of estimated 4-6 weeks. 

   Trauma counselling is a specialised field

• Trauma counselling is a highly specialised field in which counsellors need specialised training in.
• Trauma counselling, furthermore, can only be implemented onto already existing, healthy, basic counselling skills.
• This is not a counselling area for a beginner. If you do not know what pre-morbidity is, how will you address it? If you do not know the symptoms of post traumatic stress, how will you ‘diagnose’ it? Or, if you do not understand the functions of survivor’s guilt, how will you cope with it?
• There are different types of trauma and the particular types require specific identifiable actions.
• Knowledge is needed of human developmental phases, crisis and/or trauma phases and various trauma counselling models, bereavement and loss (including phases, tasks, counselling skills), relevant disorders i.e. post traumatic stress, and others.
• This field is so specialised that SAITS do not even accept students who do not have the necessary experience and/or training background in counselling;
• …and that the HPCSA will subsequently be creating a special professional category for Trauma counsellors. At present, trauma counselling is one of the identified fields Bpsych students can specialise in.

 
Issues addressed in trauma training generally include:

•  The context of violence and trauma in South Africa 
  
• Victim empowerment in South Africa 
  
• Trauma assessment and diagnosis 
  
• Definitions of stress, crisis and trauma 
  
• Phases of trauma 
  
• Acute traumatic stress 
  
• Post traumatic stress reactions and disorders
  
• Complex and continuous trauma 
  
• Unusual responses to trauma 
  
• Victims' needs and rights 
  
• Basic victim/trauma support skills (like listening, empathy) 
• Principles in trauma support work 
• Cross-cultural issues in trauma support work 
  
• Resource planning, referral management and networking 
  
•  Self-care and vicarious traumatisation 
• Cross-cultural issues in trauma counselling 
• Different trauma counselling and debriefing models
  

Special issues in trauma counselling (will be selected depending on the particular needs of participants):

• traumatic bereavement 
  
• dealing with depression 
  
• anger and revenge management 
  
• trauma and HIV/Aids 
  
• dealing with suicide 
• dealing with traumatised children
• working with refugees or non-nationals 
  
• working with ex-combatants 
  
• working with rape survivors
• referral management

Pre-requisites for effective trauma counselling

• Location: traumatic people are not likely to travel far for help
• Availability; immediacy. 24 hour availability.
• Mobility: counsellors should be prepared to go out
• Procedural flexibility and versatility: variety of methods i.e. walk-in, telephone, home visits, support sessions, paraprofessional helpers and support groups, referrals, extended helping professionals
• Knowledge and Training: of basic counselling skills as well as specialised trauma counselling processes and techniques, psychological symptoms, when to refer, etc
• 
  

 Trauma work normally is divided into 3 different levels:


• level one - volunteers and community members in trauma support. This is for individuals who have no professional background in trauma work.
• level two - professionals in victim support and trauma management.
• level three - professionals who are working in the field of counselling but who are undergoing advanced training in trauma counselling.

 
Community, lay and pastoral workers as well as volunteers will operate on level 1.

• Lay workers are often the first on the scene and in some cases, the only support available to survivors (especially in rural areas). The first step to healing from trauma is ‘Containment’ (see: paragraph 7) Anybody can do containment as long as we follow certain principles.

• Lay workers can also assist in the case of Creating Meaning. This is usually the last step in trauma counselling and is only pursued if the survivor raises meaning issues:

(i)                   It requires the counsellor to engage with the survivor’s belief system

(ii)                 Aims at enhancing the survivor’s ability to understand him/herself as survivor rather than victim

(iii)                The short term nature of most trauma counselling models impedes in depth understanding of ‘facilitation of meaning’ since in certain clients, meaning can only be derived from thorough review of life story. Few trauma counsellors are also trained in spiritual matters which makes this an area where pastoral counsellors can work in conjunction with other helping professionals.


Lay workers can form part of the survivor’s social and supportive network.

• General support:

(i)                   create a warm, relaxed atmosphere, listen with interest, adopt a non-threatening or non-condemnatory attitude, give people an opportunity to tell and share their stories and not confront and challenge them.

(ii)                 It means offering encouragement, comfort and reassurance. Long term and short term support usually have 3 things in common: helping survivors to mobilize their spiritual and psychological resources and thus to cope with their burdens; the burden is shared in that they are helped to cope with it; they are provided with food, money, materials, tools, skills, and/or guidance to facilitate their coping with the situation.

• Environmental manipulation or change is aimed rather at removing the cause of the trauma. This help is frequently given to people in poor socio-economic circumstances. Medication prescribed to relieve stress also falls into this category, supporting the families of survivors (i.e. educate them how to deal with the situation) helping someone to bed, aiding in food preparation, assisting the survivor to return to normal daily routine as quickly as possible, help physically in the recovery efforts, assisting them to connect with a support network, etc. 

• Supporting families and/or friends, explaining to them what to expect, how to support the survivor and/or deal with the situation. . This could include educational talks and workshops on the experience of and reactions to trauma and violence.

 
In light of the Tsunami Disaster, develop and create a disaster plan in your community as preventative measures. Community workers and volunteers are sometimes the glue that keeps communities together, and you have the means to prepare your communities for natural and/or other disasters. Do a survey of the need for such preventative measures in your congregation and/or community and identify available resources for meeting such needs.

It should be made clear at the outset that people who get involved in trauma work must be available. They must have both the time and the willingness to have their own routines to be interrupted by the needs of survivors’ night or day.

What happens to people during a traumatic event?

Most disaster survivors (children and adults as well as disaster rescue or relief workers) 
experience normal stress reactions after a traumatic event. These reactions may last for several days or even a few weeks and may include:

• Emotional reactions: shock; fear; grief; anger; guilt; shame; feeling helpless or hopeless; feeling numb; feeling empty; diminished ability to feel interest, pleasure, or love
• Cognitive reactions: confusion, disorientation, indecisiveness, worry, shortened attention span, difficulty concentrating, memory loss, unwanted memories, self-blame
• Physical reactions: tension, fatigue, edginess, insomnia, bodily aches or pain, startling easily, racing heartbeat, nausea, change in appetite, change in sex drive
• Interpersonal reactions: distrust, conflict, withdrawal, work problems, school problems, irritability, loss of intimacy, being over-controlling, feeling rejected or abandoned

Severe stress reactions -

• Dissociation (depersonalisation, derealisation, fugue, amnesia)
• Intrusive re-experiencing (terrifying memories, nightmares, or flashbacks)
• Extreme emotional numbing (completely unable to feel emotion, as if empty)
• Extreme attempts to avoid disturbing memories (such as through substance use)
• Hyper-arousal (panic attacks, rage, extreme irritability, intense agitation)
• Severe anxiety (debilitating worry, extreme helplessness, compulsions or obsessions)
• Severe depression (loss of the ability to feel hope, pleasure, or interest; feeling worthless)

Big trauma or small trauma – or no difference? And how will these predisposing           factors influence people to cope with traumatic events?

Some individuals have a higher than typical risk for severe stress symptoms and lasting PTSD,  depending on pre-morbidity:

• Heredity
• Personality i.e. high levels of basic tension, labile people, locus of self-control, ability to adapt to the environment
• Interpretative frameworks: subjective judgment, interpretation of situations
• Coping resources (or lack of)
• Social support:  social support has 5 functions namely emotional, instrumental, social or recreational, services, advice and information
• Exposure to other traumas (e.g., accidents, abuse, assault, combat, rescue work)
• Chronic medical illness or psychological disorders
• Chronic poverty, homelessness, unemployment, or discrimination
• Recent or subsequent major life stressors or emotional strain (e.g., single parenting)
• Disaster stress may revive memories of prior trauma and may intensify preexisting social, economic, spiritual, psychological, or medical problems.
• For those who have previously experienced traumatic events, subsequent traumatic experiences may stir up memories and exacerbate symptoms related to previous traumas. Thus, some people will feel like the most recent trauma is opening old wounds. These symptoms should also be normalised and are likely to abate with time. It may be helpful to ask people what strategies they have successfully used in the past to deal with trauma reactions, and encourage them to continue using these techniques.

Individuals who continue to experience severe distress that interferes with normal functioning after three months are at higher risk for continued problems. These individuals should be referred for appropriate treatment. 

Group Exercise
J is a 19 year old teenager who comes from a wealthy, middle-class family. Her mother, who suffers from a nerve disorder, is a fashion designer, while her father made his money in the computer market. As child J received private schooling and has recently started going to a ‘finishing school’ for young girls. For her 18th birthday, she received her own car and flat to live in. When she finishes her education, she will probably get married to her school sweetheart, who is a stock broker, and intends to get involved in charity work.

 C on the other hand, comes from the Hills. Her father is a binge- alcoholic who works at the local mines and who also beats up her mother every other Friday around pay day. When C was 14, her brother died from black lung disease. Recently her father also lost his job after a mining accident. Her mother works as local washing woman in town. C went to public school and now works as a cashier and packer at the local grocery store during the day, while she studies at night through a home study college to become a lawyer.

 Hypothetical scenario: J and C accidentally attend the same social gathering during which time a robbery takes place. The captives are terrorized several hours by the robbers that includes assault with dangerous weapons and rape. J suffers from a broken nose, 2 cracked ribs, and a sprayed ankle. C suffers from broken ribs, a broken arm, bruised face, broken collarbone, and severe internal injuries due to the rape. She also complains of constant headache and blurred vision after receiving several blows to the head, although later X-rays has turned up no visible damage.

1.        Which of the two girls is likely to experience the event more traumatic?
2.        Why?


Understanding Trauma a little bit better

• This framework is especially relevant and useful during the containment phase of trauma debriefing/counselling.

• The framework is useful with diverse types of trauma as well as with clients from different cultural backgrounds.
• Survivors respond to particular parts of the framework according to their own particular needs – Phases therefore also interchangeable.
• Framework can be integrated into own particular therapeutic styles.
• Short term nature of this framework precludes adequate addressing of i.e. possible transference and counter transference reactions.
• Bereavement counselling should be integrated in the case of traumatic bereavement.
• Most trauma models assume a level base of verbal ability and thus needs to be adapted for use in clients with limited verbal skills. In such cases the addition of music, art, clay work, sand play, or other alternative therapies can be of help.

 
   What happens to the body during a traumatic event? 

Biological - 

• Limbic system – epinephrine, nor-epinephrine & Glucocorticosteroids
• Adrenaline =fear hormone
• Nor-epinephrine =aggression hormone
• Lactic acid
• Options = fight or flee
• Trauma situation = can’t fight; can’t flee
• Rendered incapable – freeze; immobilise
• Cerebral cortex goes into ‘safe mode’ = stand by. The survivor is not capable of abstract thinking during this time
• No sleep that night – chemicals can not be re-deposited in body, has to be used
• Body next day stiff and sore due to overload of neuro-chemicals

 
Psychological - 

• Mind comes ‘back on’, defenses come up i.e. crying, shaking, trembling, pacing, bravado, social bluntness, numbness, etc
• Defenses might include avoidance, intrusion, suppression, anger, dissociation, depersonalization, dissociative amnesia
• No sleep – intrusion, irritability, inability to concentrate, irritation, exaggerated startle response, hyper vigilance/hyper arousal symptoms
• ‘feeling like they loosing it’
• possible survivor guilt

 
Social -

• people ‘out there’ will not understand
• ‘it is over, only still in your mind’
• ‘forget about it’
• ‘be grateful you’re still alive’
• ‘you’re in control’
• trivialisation
• exhaustion

 I just got on the scene…
 
Never! start with counselling per se. Remember the physiological changes the survivor is going through? The brain has ‘shut down’- he/she will not be able to give voice to their trauma nor be able to think logically through the process. The survivor is still in the ‘shock phase’.

Then what should I do?

Containment/ Defusing:

• The first priority is to be a team player by respecting and working through the site chain of command. Being a team player also means pitching in to provide basic care and comfort to survivors and workers.
• A close second priority is to make personal contact in a genuine way with survivors and rescue workers. Listen; don't give advice.
• Ask the survivors how they and their children are doing and find out what you can do to help. If they need it, provide them with food, beverages, practical supplies (e.g., clothes, blankets, sunscreen, magazines, writing implements, telephone), and a comfortable place to sit. Try to get the survivor/s to a safe place, away from the actual ‘site of happening’.
• Clean up of survivors.
• Mobilise those who are better off, to assist the others.
• Enquire about social support i.e. have individuals a safe place to go to for the night; transport? Make necessary arrangements if needed.
• Medical support if needed.
• In the case of rape: Survivor should not clean up but taken to the necessary authorities for medical examinations and reporting of the assault.
• Never hand out ‘sugar water’ of alcohol. Due to the abundant neurological chemicals already present, you will only worsen the symptoms.
• .Ask about present medication and advise to continue with it.

·         NB: Normalise symptoms. This includes explaining and anticipating symptoms. Explain what to expect i.e. you will not be able to sleep tonight. Explain physiological trauma. Explain that what the survivor experiences, is ‘normal behavior to abnormal circumstances’.

Your primary goals are:

PROTECT:   Help preserve survivors' and workers' safety, privacy, health, and self-esteem.
DIRECT:  Get people where they belong; help them to organise, prioritise, and plan.
CONNECT: Help people communicate supportively with family, peers, and service providers.
DETECT: Screen, triage, and provide crisis care to those at-risk for severe problems. Seek professional assistance if needed.
SELECT: Refer people to health, spiritual, mental-health, social, and financial services.
VALIDATE: Use formal and informal educational opportunities to affirm the normalcy and value of each person's reactions, concerns, ways of coping, and goals for the future.

Group Exercise
Refer back to the previous exercise. You just got on the scene. It is still a situation of total confusion with crying and bleeding people all over the place.

1. What are your goals?
2. How will you go about establishing them?

The Ethics of SelfCare

• Understand the ethical wisdom of self-care;
• Develop an awareness of the warning symptoms of vicarious traumatisation/ stress/ burnout;

• Develop an awareness of dysfunctional coping skills;
• Consider their own coping skills in appropriate life contexts;
• Develop and maintain functional coping skills;
• Develop their self-care practices; and/or to adjust their self-care approaches according to their particular needs.

 
Why?

• Therapy taxes the emotional and physical resources of the therapist.
• The job characteristics of therapy:

(i)    repetitive contact with people
(ii)   intense interpersonal contacts
(iii)   long-term involvement
(iv)    the giving role
(v)     clients do not have to give back anything in the form of gratification or rewards

• Occupational risks such as the possibility of client suicide
• Observation of others’ pain; or the continuous expose there of
• Witnessing others’ pain pushes buttons: your own pain and/or previous traumas, possible aggression, anger and helplessness at ‘making it better’. How do you cope with this?

 
Some consequences of vicarious traumatisation and/or negligent selfcare


As a defense against the unbearable feeling of helplessness, the therapist may try to assume the role of rescuer. The therapist may take on more and more of an advocacy role for the patient. By doing so, she implies that the patient is not capable of acting for herself. · The more the therapist accepts the idea that the patient is helpless, the more she perpetuates the traumatic transference and disempowers the patient · 
Negligent and unethical practices towards clients ·         
Personal psychological disorders 
 Burnout

REFERENCES 

 Hajiyiannis, H & Robertson, M 1999. Counsellors’ appraisals of the Wits trauma counselling model: Strengths and limitations. Paper presented at conference Traumatic stress in South Africa – working towards solutions Johannesburg, South Africa. 27-29 January 1999.
Herman, J 1997. Trauma and Recovery. New York: Basic Books.
Jacobson, GF (Ed) 1980. Crisis intervention in the 1980’s. San Francisco: Jossey-Bass.
McCubbin, HI & Patterson, JM 1983. The family stress process: the double ABX model of adjustment and adaption. Marriage and Family review 6: 7-37.
McGee, TF 1968. Some basic considerations in crisis intervention. Community Mental Health Journal 4: 319 – 325.
Morley, WE 1970. The theory of crisis intervention. Pastoral Psychology 21 (39) 14-20.
Retief, Y 2004. Genesing vir Trauma in die Suid-Afrikaanse konteks. Paarl: Struik Christenlike boeke.
Stiglingh Consultants 2005. Trauma and treatment of survivors of trauma. 2-Day Workshop Notes: Pretoria.
Stone, H 1976. Crisis counselling. Philadelphia: Fortress.
Switser, DK 1986. The minister as crisis counsellor. Nashville:Abington.
APAHelpCenter.org :The APA's consumer website containing brochures, tips and articles on the psychological issues that affect our physical and emotional well-being.
http://www.usd.edu/dmhi/Pubs/availability.html :University of South Dakota -Disaster Mental Health Institute Website. Contains short booklets on coping with disaster that can be printed from the website.
http://www.mentalhealth.org/schoolviolence/teens.htm :Center for Mental Health Services website. After Disaster: What Teens Can Do
http://www.mentalhealth.org/schoolviolence/parents.htm. :Center for Mental Health Services website. After a Disaster: A Guide for Parents and Teachers
http://www.nasponline.org/NEAT/crisis_ 0911.html: National Association of School Psychologists. Coping with a national tragedy. Has several resources including Helping Children Cope with Tuesday's Acts of Terrorism.
http://www.nimh.nih.gov/publicat/violence.cfm: National Institute of Mental Health Website. A comprehensive section entitled Helping Children and Adolescents Cope with Violence and Disasters. Contains more in-depth information on Trauma, PTSD, etc.



 Disclaimer: Please note that this presentation does not qualify learners to present themselves as professional trauma workers nor equip them with extended knowledge in the field of trauma counselling. Interested parties should obtain accredited training in this regard if they wish to continue in the field of trauma specialisation. 
First Presentation 2006: SAAP National Conference & Seminars, Pretoria.