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Trauma Counseling

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Lisa Lopez Levers , PhD, PCC-S, LPC, CRC, NCC is a professor of Counselor Education and Super-vision in the Department of Counseling, Psychology and Special Education at Duquesne University, Pittsburgh, PA. She is a licensed professional clinical counselor (endorsed supervisor, Ohio), licensed professional counselor (Pennsylvania), certifi ed rehabilitation counselor, and national certifi ed coun-selor. She has worked clinically with survivors of trauma and offered crisis intervention counseling since 1974. She has taught several trauma-related graduate courses over the last two decades, and she has provided crisis intervention training to such diverse groups as police offi cers and medical personnel. Levers is a Fulbright scholar with international recognition for her work with traumatized populations. She has done extensive trauma counseling, training, and research throughout the south-ern region of Africa and in Rwanda following the genocide, through a commission by the Rwandan Ministry of Health. She also worked with a team of mental health professionals in Russia, shortly after the end of the Soviet era, to initiate and develop a system of community-based foster care for vulner-able children there.

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Trauma Counseling Theories and Interventions

LISA LOPEZ LEVERS, PhD, PCC-S, LPC, CRC, NCC

Editor

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Copyright © 2012 Springer Publishing Company, LLC

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Library of Congress Cataloging-in-Publication Data

Levers, Lisa Lopez. Trauma counseling : theories and interventions / Lisa Lopez Levers. — 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8261-0683-4 — ISBN 978-0-8261-0684-1 (e-book) I. Title. [DNLM: 1. Counseling—methods. 2. Psychological Theory. 3. Stress Disorders, Traumatic—psychology. 4. Stress Disorders, Traumatic—therapy. 5. Stress, Psychological. 6. Survivors—psychology. WM 55]

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This book is dedicated to the lives and memories of

Robert Elwood Levers Born 1 January 1925, Died 9 April 2011

[Dad, you remain my lifelong hero.]

and

Manuel Vicente Lopez Born 24 June 1898, Killed 24 December 1955

[One bullet dramatically changed the lives of two sets of families forever.]

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vii

Contributors xi Foreword Susan Herman, JD xv Preface xvii Acknowledgments xxiii

SECTION I: TRAUMA AND CONTEXT

1. An Introduction to Counseling Survivors of Trauma: Beginning to Understand the Context of Trauma 1 Lisa Lopez Levers Appendix, Deirdre Stoelzle Graves

2. Historical Contexts of Trauma 23 Debra Hyatt-Burkhart and Lisa Lopez Levers

3. Theoretical Contexts of Trauma Counseling 47 Martin F. Lynch

4. Neurobiological Effects of Trauma and Psychopharmacology 59 John R. Tomko

SECTION II: TRAUMA OF LOSS, VULNERABILITY, AND INTERPERSONAL VIOLENCE

5. Issues of Loss and Grief 77 Judith L. M. McCoyd , Carolyn Ambler Walter , and Lisa Lopez Levers

6. Trauma Survivorship and Disability 98 Eboneé T. Johnson , Jessica M. Brooks , Elias Mpofu , Jasim Anwer , Kaye Brock , Evadne Ngazimbi , and Fambaineni Innocent Magweva

7. Sexual Trauma: An Ecological Approach to Conceptualization and Treatment 116 Laura Hensley Choate

8. Trauma Experienced in Early Childhood 132 Staci Perlman and Andrea Doyle

Contents

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viii Contents

9. Trauma Experienced in Adolescence 146 Andrea Doyle and Staci Perlman

10. Treating Adult Trauma Survivors 161 Barbara Peck

11. Intimate Partner Violence 178 Nancy N. Fair and Frank M. Ochberg

12. Elder Abuse 199 Erika Falk

13. Addiction and Psychological Trauma: Implications for Counseling Strategies 214 Patricia A. Burke and Bruce Carruth Appendix, Maureen Keating

14. Criminal Victimization 231 Laurence Miller

15. Traumatic Aftermath of Homicide and Suicide 249 Tumani Malinga-Musamba and Tapologo Maundeni

SECTION III: INTOLERANCE AND THE TRAUMA OF HATE

16. Existential Perspectives on the Psychology of Evil 264 Alison L. DuBois , Lisa Lopez Levers , and Charles P. Esposito

17. Racial and Ethnic Intolerance: A Framework for Violence and Trauma 280 Emma Mosley

18. Understanding and Responding to Sexual and Gender Prejudice and Victimization 297 Kathleen M. Fallon and Susan Rachael Seem

SECTION IV: COMMUNITY VIOLENCE, CRISIS INTERVENTION, AND LARGE-SCALE DISASTER

19. Contextual Issues of Community-Based Violence, Violence-Specifi c Crisis and Disaster, and Institutional Response 317 Lisa Lopez Levers and Roger P. Buck

20. School Violence and Trauma 335 Jeffrey A. Daniels and Jenni Haist

21. Workplace and Campus Violence 349 Eric W. Owens

22. Natural Disasters and First Responder Mental Health 369 Scott Tracy

23. Genocide, Ethnic Confl ict, and Political Violence 389 Kirrily Pells and Karen Treisman

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Contents ix

24. The Impact of War on Civilians 412 Elaine Hanson and Gwen Vogel

25. The Impact of War on Military Veterans 434 Roger P. Buck

26. Disaster Behavioral Health: Counselors Responding to Terrorism 454 June Ann Smith and Jo Ann Jankoski

SECTION V: CLINICAL ASSESSMENT AND TREATMENT ISSUES

27. Assessment in Psychological Trauma: Methods and Intervention 471 F. Barton Evans

28. Models for Trauma Intervention: Integrative Approaches to Therapy 493 Lisa Lopez Levers , Elizabeth M. Ventura , and Demond E. Bledsoe

29. Strategies and Techniques for Counseling Survivors of Trauma 504 Elizabeth M. Ventura

SECTION VI: COLLABORATIVE WORK IN THE AREA OF TRAUMA COUNSELING

30. Ethical Perspectives on Trauma Work 521 Vilia Tarvydas and Helena K. Y. Ng

31. Vicarious Traumatization 540 Jo Ann Jankoski

32. Therapist Self-Care: Being a Healing Counselor Rather Than a Wounded Healer 554 Cynthia Diane Rudick

33. Trauma and Supervision 569 Demond E. Bledsoe

34. Conclusion: An Integrative Systemic Approach to Trauma 579 Lisa Lopez Levers

Index 587

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xi

Contributors

Jasim Anwer, MBBS, MAppSc Provincial Hospital Coordinator (DEWS) and Epidemiologist, World Health Organization, Peshawar, Pakistan

Demond E. Bledsoe, MS, LPC, NCC Doctoral Candidate, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania, and Clinical Consultant, Wesley Spectrum Services, Pittsburgh, Pennsylvania

Kaye Brock, PhD Senior Lecturer, Epidemiology and Research Methods, The University of Sydney, Sydney, Australia

Jessica M. Brooks, MS, CRC Doctoral Student, Rehabilitation Psychology, Department of Rehabilitation Psychology and Special Education University of Wisconsin-Madison, Madison, Wisconsin

Roger P. Buck, PhD, LPCC, DAC Director, Counseling Center, Hocking College, Nelsonville, Ohio

Patricia A. Burke, MSW, LCSW, BCD, C-CATODSW Affi liated Faculty, Psychology and Addiction Studies, Union Institute & University, Montpelier, Vermont

Bruce Carruth, PhD, LCSW Private Practice, San Miguel de Allende, GTO, Mexico

Laura Hensley Choate, EdD, LPC, NCC Associate Professor, Counselor Education, Louisiana State University, Baton Rouge, Louisiana

Jeffrey A. Daniels, PhD Associate Professor, Counseling Psychology, West Virginia University, Morgantown, West Virginia

Andrea Doyle, PhD Assistant Professor, School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania

Alison L. DuBois, PhD Assistant Professor of Education, Westminster College, New Wilmington, Pennsylvania

Rev. Charles P. Esposito, MDiv, STL, MEd Catholic Priest, Pastor, and Counselor with Grief and Other Spiritually Focused Issues, Church of the Good Shepherd, Kent, Pennsylvania

F. Barton Evans, PhD Clinical Professor of Psychiatry, George Washington University Medical School, Washington, District of Columbia, Clinical and Forensic Psychology, and Charles George VA Medical Center, Asheville, North Carolina

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xii Contributors

Nancy N. Fair, MA Doctoral Candidate, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania, and Supervisor of Adult Counseling Services, Pittsburgh Action Against Rape, Pittsburgh, Pennsylvania

Erika Falk, PsyD Director, Geriatric Assessment Services, Institute on Aging, San Francisco, California

Kathleen M. Fallon, PhD Assistant Professor, Department of Counselor Education, The College at Brockport: State University of New York, Brockport, New York

Deirdre Stoelzle Graves Executive Director, The Dart Society, Kaycee, Wyoming

Jenni Haist, MEd Doctoral Student, Counseling Psychology, West Virginia University, Morgantown, West Virginia

Elaine Hanson, PsyD, JD Executive Director, SalusWorld, Denver, Colorado

Debra Hyatt-Burkhart, PhD Instructor, Counseling and Development, Slippery Rock University, Slippery Rock, Pennsylvania

Jo Ann Jankoski, EdD, LCSW, MS Assistant Professor, Human Development and Family Studies, Penn State University, The Eberly Campus, Uniontown, Pennsylvania

Eboneé T. Johnson, MS, CRC Doctoral Candidate, Rehabilitation Psychology and Special Education, University of Wisconsin-Madison, Madison, Wisconsin

Maureen A. Keating, MEd PCC-S LICDC Director of Women and Family Services, Community Health Center, Akron, Ohio

Lisa Lopez Levers, PhD, PCC-S, LPC, CRC, NCC Professor, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania

Martin F. Lynch, PhD, NCC Assistant Professor, Counseling and Human Development, Warner School of Education, University of Rochester, Rochester, New York

Fambaineni Innocent Magweva, MTech, MSc Disability Adviser, National Association of Societies for the Care of the Handicapped, Harare, Zimbabwe

Tumani Malinga-Musamba, MSW Lecturer, Department of Social Work, University of Botswana, Gaborone, Botswana

Tapologo Maundeni, PhD Associate Professor, Department of Social Work, University of Botswana, Gaborone, Botswana

Judith L. M. McCoyd, PhD, LCSW, QCSW Associate Professor, School of Social Work, Rutgers, The State University of New Jersey, Camden, New Jersey

Laurence Miller, PhD Independent Practice in Clinical and Forensic Psychology, Boca Raton, Florida, Adjunct Professor, Florida Atlantic University & Palm Beach State College, Boca Raton & Lake Worth, Florida

Emma Mosley, PhD, NCC Assistant Professor, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania

Elias Mpofu, PhD Professor, Head of Discipline, Rehabilitation Counselling, Faculty of Health Sciences, The University of Sydney, Sydney, Australia

Helena K. Y. Ng, MS, NCC Doctoral Candidate, Counselor Education and Supervision, Duquesne University, Pittsburgh, Pennsylvania

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Contributors xiii

Evadne Ngazimbi, PhD, LPC, NCC Assistant Professor, Department of Psychology and Counseling, Northern State University, Aberdeen, South Dakota

Frank M. Ochberg, MD Clinical Professor, Psychiatry, Michigan State University, East Lansing, Michigan

Eric W. Owens, PhD, NCC, ACS Assistant Professor, Department of Counselor Education, West Chester University of Pennsylvania, West Chester, Pennsylvania

Barbara Peck, EdD, LPC Therapist, Chestnut Ridge Counseling Services, Uniontown, Pennsylvania, Adjunct Faculty, Graduate School of Counseling, Waynesburg University, Waynesburg, Pennsylvania

Kirrily Pells, PhD Policy Offi cer, Young Lives, Oxford Department of International Development, University of Oxford, Oxford, United Kingdom

Staci Perlman, MSW, PhD Assistant Professor, Department of Social Work, Kutztown University, Kutztown, Pennsylvania

Cynthia Diane Rudick, PhD, LPCC-S Private Practitioner and Professional Mediator and Arbitrator, Fordyce & Associates, Canton, Ohio, and Professor of Continuing Education, John Carroll University, Cleveland, Ohio

Susan Rachael Seem, PhD, LMHC, NCC, ACS Professor, Department of Counselor Education, The College at Brockport: State University of New York, Brockport, New York

June Ann Smith, PhD, LMHC, LCSW, LMFT, NCC, ACS Associate Professor, Department of Counseling and Development, Long Island University, C.W. Post Campus, Brookville, New York

Vilia M. Tarvydas, PhD, LMHC, CRC Professor, Rehabilitation and Counselor Education, The University of Iowa, Iowa City, Iowa

John R. Tomko, PharmD, BCPP Assistant Professor of Pharmacy Practice, Mylan School of Pharmacy, Duquesne University, Pittsburgh, Pennsylvania

Scott Tracy, EdD, LPC, NCC, CSC, EMT-P Director and Assistant Professor of Graduate Counseling, Waynesburg University, Waynesburg, Pennsylvania

Karen Treisman, BA, DClinPsy Clinical Psychologist, Department of Applied Psychology, Canterbury Christchurch University, Tunbridge Wells, United Kingdom

Elizabeth M. Ventura, PhD, LPC, NCC Assistant Professor, Graduate and Professional Studies Counseling Program, Waynesburg University, Canonsburg, Pennsylvania

Gwen Vogel, PsyD Licensed Clinical Psychologist, Director of Field Operations, SalusWorld, Denver, Colorado

Carolyn Ambler Walter, PhD, LCSW Professor Emerita, Center for Social Work Education, Widener University, Chester, Pennsylvania

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xv

Over the last two decades, we have made great progress confronting the realities of trauma.

The academic community has begun to pay appropriate attention to trauma—to documenting the prevalence of trauma in the lives of so many members of our society, to understanding the aftermath of traumatic events, and to preparing future clinicians and counselors to recognize the centrality of traumatic experiences in the lives of their clients.

The practice community is fi nally acknowledging that trauma is widespread—that good practice must include universal screening for trauma, a sharp focus on the role of trauma as an underlying cause of so many social problems, and a collaborative approach to building resilience.

The general public, however, remains unaware of the role that trauma plays in everyday life. Too often, individuals who are survivors of trauma face the shame of coming forward, or simply suffer with the consequences of the traumatic incident in their lives. Too often, they are given subtle messages that recovery is a solitary process and that nobody can help them.

We now know that it takes courage for people who have experienced trauma to trust others enough to share their stories. Who would understand? Who would believe them? Who would listen without judging? The horrors of human existence often feel unspeakable. Service providers often seem dismissive. It is not surprising, then, that research conducted in the United States and abroad indicates that very few victims of violence seek professional assistance.

It is also diffi cult for “healers” to bear witness to this trauma, which often involves deliberate acts of human cruelty. Their faith in people is tested; their vision of humanity contorted. It may be easier for them to look away, to minimize the stories, to deny the horror.

I come at these issues as someone who has worked for many years with victims of crime. My perspective has been informed by the emerging understanding of the impact of trauma, particularly the impact of intentional human cruelty. Like many readers of this book, I have witnessed fi rsthand the debilitating effects of violence. I understand the feel-ing of inadequacy that comes with the realization that some wounds cannot be healed.

Perhaps unlike many readers of this book, however, I situate my work with crime victims in a justice framework. I try to imagine what our communal response to victims should be in the aftermath of crime. I fi nd it critically important to defi ne government’s obligations to victims and to ask what communities and individuals should do to pro-vide a just response.

Foreword

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xvi Foreword

While I have worked in a number of capacities to improve the criminal justice response to crime victims, on a more fundamental level, I have conceptualized—and advocated for—a justice response that does not depend on the criminal justice system. I believe we need an additional set of responses both within and outside the criminal jus-tice process called Parallel Justice. Unlike the traditional criminal justice process, which focuses on the apprehension, prosecution, and conviction of offenders, Parallel Justice envisions a societal approach dedicated to helping victims of crime rebuild their lives. I believe all victims of crime deserve assistance to regain a sense of safety, to recover from the trauma they have suffered, and to regain a sense of control over their lives.

There is a creative synergy between the concept of Parallel Justice and the recent focus on trauma. Crime is often a traumatic experience. Accordingly, justice requires a thorough understanding of, and effective response to, the trauma experienced by vic-tims. Stated differently, the urgency to create Parallel Justice is fueled by our apprecia-tion of the nature and extent of trauma.

We have made a lot of progress in our response to victims over the past generation. In terms of crime victim services, we have developed a much greater understanding of the need for trauma victims to reestablish a sense of safety. For example, in the early 1970s, we had only a handful of shelters for battered women in this country, and now we have over 2,000. More and more health care professionals are trained to recognize the context of many intentional injuries, so they are more likely to recognize gang members, battered women, and abused children, not just gunshot wounds, black eyes, and broken arms.

But we still live in a world where too many people admitted to our emergency rooms are crime victims who have suffered traumatic incidents. Too many people who access our homeless shelters are homeless because they have experienced trauma in their lives and are having diffi culty coping. Too many people need drug and alcohol treatment because they are trying to numb their trauma-related pain. Too many people in prison have been on both sides of violent acts and have never addressed either the trauma they infl icted on others, or the trauma and violence that they experienced themselves.

And, unfortunately, too many of our criminal justice, health care, and social service institutions are still not equipped to identify or address this trauma.

So I am quite pleased to celebrate the publication of this book. From my work with victims, I have come to believe that even otherwise well-intentioned and well-trained practitioners often feel unprepared to respond to trauma. Our societal justice goal should be to help victims of crime reintegrate back into healthy and productive com-munal life. We will never succeed in helping victims rebuild their lives if the people they turn to for help are not trained to respond effectively.

This book validates the emergence of a new fi eld of trauma studies and a growing body of trauma-related best practices. The lessons in this volume refl ect the powerful awareness that trauma is experienced in a context—within a life, a family, a community, and a culture—and that each individual experiences it differently.

We now live in a diffi cult netherworld. We know much more about the widespread nature of trauma and its far-reaching ripple effects. We know how to improve practice and what new research questions to ask. But our understanding of the problem far out-strips our ability to respond effectively. We still have so much more to do.

I hope this book accelerates our progress.

Susan Herman, JDAssociate Professor, Pace UniversityFormer Executive Director of the National

Center for Victims of CrimeAuthor of Parallel Justice for Victims of Crime

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xvii

The inspiration for this book came perhaps as early as late 1975. It was toward the end of my master’s degree, when I was an idealistic 23-year-old counselor intern, also volunteering my services at a crisis intervention agency where I was getting my “real-world” education. I remember learning in a graduate class not to worry about incest abuse; according to the authoritative wisdom at the time, we would never see a case of incest, and if we were to see one, it would only occur one time in a million cases. I recall fi nding this odd at the time, considering the strength of the universal cultural taboo regarding incest. I thought it strange that the incest taboo would be so profound and so enduring in the face of one in a million odds. But what did I know? So I accepted the knowledge of experts who told me to believe something that seemed so counterintuitive.

Shortly after fi nishing my master’s degree in December 1975, I turned 24 and left on a backpacking journey to various countries in Europe. I also served as one of the few American delegates at the International Tribunal on Crimes against Women (orchestrated by Dr. Diana E. H. Russell, professor emerita), held in March 1976, in Brussels. At the tribunal, I learned about multiple cases of incest, along with other types of gender-based and political violence. Regarding the incest, I reasoned that it was possible because of the international presence—thousands of women from hundreds of countries, representing millions of people around the world—narratives of multiple incidences could have been attributable to global scale alone, but I remained unsettled about the statistical accuracy of what the experts had said and what we were taught. Regarding the other types of vio-lence, I recall being very stunned and feeling so woefully unprepared to process many of the horrible fi rsthand accounts of atrocities that were reported at the tribunal as well as what I learned from some of the other women in casual conversation. For example, I met Aboriginal women from Australia who had experienced severe cultural oppression; I bunked with women from South Africa who provided personal details about the evils of apartheid. I learned more at the tribunal than my young mind even could absorb on a conscious level. In retrospect, I have come to regard this experience as profoundly rel-evant training for my next 15 years of community mental health work and my ensuing career as an academic.

After an initial 6-month stint as the fi rst professional counselor on a female maxi-mum security ward at a large state psychiatric facility (at the very beginning of that state’s implementation of its newly enacted patient rights and deinstitutionalization legislation) followed by my transition to the community mental health sector (where I spent the next 15 years of my career), it did not take long to see how wrong the experts

Preface

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xviii Preface

actually were regarding incest abuse as well as other types of sexual assault. I read the fi les of the women in the state facility, and I listened to the narratives of my clients at the community mental health center; certainly not all clinical reports are accurate, but nei-ther should reports of personal events automatically be disregarded or dismissed. Not only were my clients teaching me about incest abuse, I also was witness to the psycho-social aftermath of all sorts of traumatic events; some of them were more unspeakable than others, and many of them were beyond the ability of a young clinician to process, especially at a time (beginning in the mid-to-late 1970s) when so little in the profes-sional literature addressed trauma.

Eventually, I began to see clients with increasingly more complex trauma histories. I already had become one of the few go-to therapists when the local, newly established rape crisis and domestic violence centers had a client who needed immediate counsel-ing services—again, it was the mid-to-late 1970s, centers dealing with sexual assault and partner abuse were just developing, and most did not have in-house counselors. I had gained the trust of the agencies, having a reputation for being willing to rearrange my schedule to see someone, usually a female victim of interpersonal violence, who was in immediate crisis.

The clinical challenges were great, and there was a point at which I had to search throughout the city to acquire the trauma-specifi c clinical supervision that was not available at the community mental health center where I was employed. This led to connecting with a group of therapists who had formed a trauma study group, which provided a format for our supporting one another in our clinical work with trauma survivors. This also hints at some of the systemic challenges during this same time frame. An example of such a challenge occurred in the late 1970s, when the director of one of the rape crisis agencies (I was a board member at the time) and I compared notes about trends we had been observing with clients at our respective agencies. Both being master’s level mental health practitioners, we decided to initiate the fi rst incest survivor support group in a large metropolitan area in northeastern Ohio. When word got out regarding recruitment for the group, both of our agencies began to receive hostile and threatening calls from members of the mental health establishment attrib-uting all sorts of catastrophic outcomes to such a support group, including the patron-izing accusation that we would be “feeding the delusions of these poor women.” The satisfactory ending to this story was that the administrator of my agency was a femi-nist who insisted that we proceed with our plans, and the rape crisis center had a supportive board of directors, enabling its director to move forward as well. We con-ducted the support group, to the benefi t of the clients involved, and, indeed, there were no associated catastrophes.

After providing 15 years of community mental health services and engaging in trauma-focused private practice, I made a transition to the professoriate, teaching graduate courses in counselor education. Part of the motivation for my move was that of course the university environment would be more intellectually progressive, and of course I would be able to put into instructional practice all that I had learned on the front lines of community mental health and working with traumatized clients. What a surprise it was to engage a whole new set of systemic and administrative challenges, along with a recapitulation of the unease with which issues of trauma are regarded, even by academicians who are knowledgeable about clinical mental health matters. I learned quickly that I would need to acquire new sets of skills to navigate the academic sys-tem of getting new trauma-related courses approved. It seemed that, at the time, the academy was not ready for graduate courses that focused on issues of interpersonal violence and other trauma events. Although I preferred to take this on as an advocacy project rather than a fi ght, there was only one academic institution (of the four where

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Preface xix

I have taught) at which I did not need to advocate strongly to be able to teach an elective course associated with issues of trauma (I have greatly appreciated my mentors at the University of New Orleans, Louis Paradise and Peggy Kirby, for believing in my ability to design and teach the well-received Children and Violence course).

At many junctures in the current textbook, the authors of the chapters highlight a variety of the controversies, throughout the decades, which have surrounded the clini-cal issues of trauma. I feel like I have survived some of the battle zones of these contro-versies in both my clinical and academic work, in terms of advocating for the clinical needs of traumatized clients as well as the instructional needs of counseling students. All of this brings us to the present landscape in which the human services fi eld fi nally has recognized the overwhelming presence of everyday trauma in the lives of many people along with the frequent highly publicized global disasters to which we are more immediately exposed than ever before. Preservice academic programs, especially those training entry-level master’s practitioners who arguably provide the bulk of direct psy-chosocial services, need to catch up with what our graduates are certain to see once they enter the fi eld—indeed, what our students already are seeing, and for which many are unprepared, in their pregraduation practicum, internship, and other fi eld-based experi-ences. I have had the privilege of teaching several elective courses on counseling sur-vivors of trauma for over 2 decades now. Although more and more good books that are devoted to issues of trauma are published regularly, I have not yet found a textbook that serves as an adequate source for grounding students and clinicians with an introduc-tion to the theories and practices associated with trauma while also preparing them for the emotional intensity of trauma work. I fi nally decided, humbly, that perhaps I should take on the responsibility of preparing such a textbook.

The Relevance of This Textbook Those of us who have done clinical work for any length of time know that trauma is as ubiquitous as the many other psychosocial issues that we consider to be pervasive, for example, issues like alcoholism and substance abuse. We all have dealt with so many cases in which clients present with a plethora of other issues, but once we scratch the surface of the situation, we often learn that the real problem is not the alcoholism or the substance abuse—or the depression, or the anger, or any number of other clinical issues that permeate the problems bringing people to mental health clinics or to the offi ces of private practitioners to seek help—rather, it is the underlying experience of trauma. Still, it has taken the helping professions some time to grapple with the ubiq-uity of trauma and to understand the effects of traumatic events on the people who experience them.

The major purpose of this book is to provide a much-needed text for a trauma-specifi c course in the preservice training of master’s level professional counselors, social workers, psychologists, and other human service providers. Because trauma is such a pervasive and overwhelming phenomenon, and because there are so many mental health clinicians practicing today without the advantage of having had trauma- or crisis-related course work or supervision as a part of their respective cur-ricula, such a text is relevant to and much needed by a variety of practicing human service providers.

This textbook offers a relatively comprehensive review of the various types of traumatic experiences; the human vulnerability for traumatic experiences across the life span; and the intersections among trauma, crisis, and disaster events. It discusses pertinent diagnostic and case conceptualization issues as well as presents individ-ual and systems interventions and collaborations. The perspective from which this

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xx Preface

textbook was conceptualized and organized is one that is anchored in an ecological and systemic view of people’s psychosocial needs and interactions. A unique feature of this textbook is that, at the end of each chapter, the authors have provided a list of helpful resources for use by students, instructors, and clinicians. These resources are specifi c to the trauma-related topic of the chapter and include websites, manu-als, fi lms, instructional videos/DVDs, and a variety of other useful tools. In addi-tion, most of the chapters have appendices that either offer a case study or explicate an important detail to assist readers in understanding the relevance of the chapter topic. An Instructors Manual is available from Springer; it includes sample syllabi for a semester-long course and a week-long seminar, along with discussion questions and activities for each chapter. Qualifi ed instructors can request the manual by e-mailing [email protected]

The Content of This Textbook Trauma Counseling: Theories and Interventions is a much-needed textbook that focuses on relevant issues of traumatic, crisis-related, and disaster events from a systemic para-digm. In the chapters in Section I, “Trauma and Context,” the aim is to offer a founda-tion for understanding the various trauma-associated issues in this textbook. Chapter 1, by Lisa Lopez Levers, introduces a bioecological and systemic perspective of trauma that establishes the tone for the rest of the book. In Chapter 2, Debra Hyatt-Burkhart and Lisa Lopez Levers provide the historical context for how we have come to regard trauma-related issues, explicating a number of the controversies surrounding the devel-opment of a clinical understanding of trauma. Martin F. Lynch discusses a variety of theoretical contexts related to trauma counseling in Chapter 3. The neurobiological effects of trauma and psychopharmacology are detailed in Chapter 4 by John R. Tomko. Together, these four chapters provide a foundation for considering contextual, theoreti-cal, and neurobiological aspects of trauma.

In Section II, “Trauma of Loss, Vulnerability, and Interpersonal Violence,” relevant constructs are explicated, such as loss and grief. This section also offers information about the traumatic events that may be experienced by specifi c age groups, people who are vulnerable, and other particular populations. Judith L. M. McCoyd, Carolyn Ambler Walter, and Lisa Lopez Levers discuss important psychosocial constructs associated with loss and grief in Chapter 5. In Chapter 6, Eboneé T. Johnson, Jessica M. Brooks, Elias Mpofu, Jasim Anwer, Kaye Brock, Evadne Ngazimbi, and Fambaineni Innocent Magweva discuss issues of disability and trauma survivorship. Laura Hensley Cho-ate, in Chapter 7, emphasizes an ecological approach to conceptualizing and treating sexual trauma. In Chapter 8, Staci Perlman and Andrea Doyle explicate the nature of traumatic experiences of early childhood; in Chapter 9, Doyle and Perlman describe the developmental aspects of trauma that may be experienced in adolescence. Barbara Peck discusses the clinical treatment issues of adult trauma survivors in Chapter 10. Intimate partner violence is the focus of Nancy N. Fair and Frank M. Ochberg’s Chapter 11. In Chapter 12, Erika Falk identifi es the traumatizing effects of elder abuse. Patricia A. Burke and Bruce Carruth describe the interactions of addictions and psychological trauma in Chapter 13, identifying effective counseling strategies. In Chapter 14, Lau-rence Miller describes the traumatic experiences associated with criminal victimiza-tion. Tumani Malinga-Musamba and Tapologo Maundeni detail the specifi c traumatic aftermath of homicide and suicide in Chapter 15. These 11 chapters identify and exam-ine many of the psychosocial constructs and relevant issues associated with personal trauma and interpersonal violence.

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Preface xxi

The focus of Section III is on “Intolerance and the Trauma of Hate.” Alison L. DuBois, Lisa Lopez Levers, and Charles P. Esposito begin the section with their discussion, in Chapter 16, of existential perspectives on the psychology of evil. In Chapter 17, Emma Mosley highlights how racial and ethnic intolerance serve as a framework for violence and trauma. In Chapter 18, Kathleen M. Fallon and Susan Rachael Seem explicate sex-ual and gender prejudice and victimization and suggest best clinical responses. These three chapters emphasize the personal and social dynamics of othering in an attempt to unravel some of the dark side tendencies of humanity.

In Section IV, the emphasis on “Community Violence, Crisis Intervention, and Large-Scale Disaster” presents a broader systemic context for understanding the effects of trauma on groups of people. Lisa Lopez Levers and Roger P. Buck detail the contextual issues of community-based violence, violence-specifi c crisis and disaster, and institu-tional response in Chapter 19. In Chapter 20, Jeffrey A. Daniels and Jenni Haist focus on the traumatic effects of school violence. Eric W. Owens discusses workplace and campus violence in Chapter 21. Scott Tracy explains some of the natural phenomena associated with natural disasters in Chapter 22, outlining important mental health issues related to fi rst responders. In Chapter 23, Kirrily Pells and Karen Treisman consider the com-munity and personal effects of genocide, ethnic confl ict, and political violence. Elaine Hanson and Gwen Vogel discuss the impact of war on civilians in Chapter 24, and in Chapter 25, Roger P. Buck examines the impact of war on military veterans. Conclud-ing this section, in Chapter 26, June Ann Smith and Jo Ann Jankoski address the issue of disaster behavioral health, examining the ways in which counselors can respond to terrorism. These eight chapters illuminate the profound impact that large-scale violence and natural and human-made disasters can have on individuals, families, communities, and nations.

The focus of Section V is on “Clinical Assessment and Treatment Issues.” In Chap-ter 27, F. Barton Evans analyzes assessment methods and interventions associated with psychological trauma. Lisa Lopez Levers, Elizabeth M. Ventura, and Demond E. Bled-soe identify and discuss larger scope integrative approaches to trauma intervention in Chapter 28, thus emphasizing the importance of more systemic models. In Chapter 29, Elizabeth M. Ventura details selected strategies and techniques for counseling survi-vors of trauma. These three chapters offer a framework for beginning to consider the nature of clinical work with clients who have experienced traumatic events.

Section VI highlights “Collaborative Work in the Area of Trauma Counseling.” Vilia Tarvydas and Helena K. Y. Ng begin the section by presenting ethical perspectives on trauma work in Chapter 30. Jo Ann Jankoski explicates vicarious traumatization in Chapter 31, highlighting the need for counselor self-awareness. In Chapter 32, Cynthia Diane Rudick focuses on the importance of therapist self-care, encouraging clinicians to be healing counselors rather than wounded healers. In Chapter 33, Demond E. Bledsoe emphasizes the absolute necessity of clinical supervision when working with survivors of trauma. Lisa Lopez Levers concludes this section and the book, with Chapter 34, by asserting the need for continued development of ecological applications and offering a conceptual framework for an integrative systemic approach to trauma (ISAT) model. The focus of these fi ve chapters is on the critical juncture between the personhood of the clinicians and their professional conduct; collaborative work refers to the interconnection of ethical behavior, acute self-awareness and self-refl ection, responsible supervision, and advocacy for a systemic approach that brings all of these collaborative endeavors back to the best interests of clients who have experienced traumatic events.

The six sections of this book are interrelated in many ways. First, the various sec-tions underscore the pervasiveness of traumatic experiences across societies, in general,

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xxii Preface

and specifi cally within mental health populations. Second, the authors of each of the chapters attest to the ultimate importance of therapists being able to recognize the effects of trauma in their clients and knowing how to assess and treat victims of trauma, crisis, and disaster events. Third, the connections between individual experiences of trauma and larger contextual issues are highlighted. Finally, bearing clinical witness to the lived experiences of trauma survivors is emphasized across the sections of this textbook as part of a larger systemic process. We need to view clients who have been affected by traumatic events as whole people, we need to acknowledge our own roles and responses in the therapeutic relationship, and we need to engage the contextual and systemic aspects of trauma work if we are going to assist our clients in healing and growing. Trauma Counseling: Theories and Interventions is a textbook that aims to provide a basis for doing this important work.

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xxiii

To my mother, Gloria Isabella Lopez Levers: “Salud!”

I wish to acknowledge the unwavering support of my dear friends: Mogakolodi Nelson Boikanyo, Sarah Castelli, Jo Ann Jankoski, Carole Justice, Helen Manich, Ngwakwana Malema, Emma Mosley, and Cynthia Diane Rudick. Thank you.

I also want to thank Donovan Jackson and his little brother Darron for the daily smiles, laughter, and hugs that kept me going.

Acknowledgments

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1

Section 1: Trauma and Context

An Introduction to Counseling Survivors of Trauma: Beginning to Understand the Context of Trauma

LISA LOPEZ LEVERS

CHAPTER 1

INTRODUCTION

The world can be a violent and dangerous place, thus making people vulnerable to all sorts of traumatic experiences. Emotional trauma typically is viewed as infl icting severe harm to a person’s psyche. Traumatic events can have profound effects on the individuals who experience them, and the impact of such stressful events or circum-stances usually results in people feeling overwhelmed, vulnerable, betrayed, helpless, frightened, and alone. The infl uences of trauma may manifest in many ways; some may be unique to the individual, whereas others appear to be more culture based, and yet others may be relatively universal. Some traumatic experiences are so unspeakable that victims go without verbalizing the cruelty or assault infl icted upon them. The symp-toms of trauma, as clinically defi ned by the psychiatric profession at the current time, represent only one dimension of the lived experience of trauma. There are many ways that people experience and live through traumatic events. This textbook aims to explore these variations in a way that can help social science and human services students and clinicians to understand trauma from a systemic and contextual perspective and to learn about the best practices associated with trauma counseling.

Traumatic events can cause not only physical and psychological wounds, but deep spiritual or existential wounds as well. For many victims, the notion of reliving the trauma is agonizingly unthinkable; yet, with great courage, many come forward, seek-ing trauma counseling. The request for trauma counseling also serves as a request to engage in what needs to be a healing journey for the client. By defi nition, then, for thera-pists working with traumatized clients, trauma counseling inherently involves a focus on the client’s healing process and a holistic view of the person. In order to understand the whole person who has experienced trauma, clinicians need to grapple with the ubiquity and the ugliness of traumatic events as well as to engage with the complexity of trauma-associated responses. The aftermath of a traumatic event is profoundly personal; at the same time, the lives of individuals intricately intersect with the lives of other people and also with pets, places, time, social institutions, and cultural systems. So, many treat-ment questions emerge concerning trauma, and the answer frequently is, “it depends.” It depends on the developmental stage at the time of the trauma event; it depends on whether the trauma event was of a personal nature or a large-scale disaster; if per-sonal, it depends on whether the perpetrator was a trusted family member/friend or a stranger; it depends on the extent of the person’s support system; it depends on gender

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2 Trauma and Context

and cultural perspectives; it depends on numerous variables that are not always evident immediately. For these reasons, and precisely because so much about working with a trauma victim depends on the person’s circumstances, this book offers a comprehensive view of trauma and disaster events, one that is situated within a systemic understand-ing of the whole person.

Of necessity, once a survivor of trauma seeks counseling, this person’s support sys-tem extends to the therapeutic milieu, thereby including the therapist, clinical super-visors, the treating agency, and any larger arenas of the treatment system. Survivors of trauma need the clinical world to be more aligned and harmonized in this matter. Once we make the decision to work with traumatized clients, we owe them this level of respect. This kind of integrative approach requires a holistic and systemic perspective of trauma; it requires looking at trauma through a particular contextual lens. I intend for this fi rst chapter to offer such a lens, one that enables the reader to begin to under-stand the impact of traumatic experience from multiple personal and systemic perspec-tives. The purpose of this chapter is to ground the construct of psychosocial trauma within its various phenomenological, clinical, and sociocultural contexts. My aim is to have crafted this in a way that enables readers to see readily and to understand clearly the connections between the personal and the systemic impacts of trauma. I hope that this is accomplished through the discussion of relevant contextual issues in the fol-lowing sections: (a) Context for Thinking About Trauma, (b) Defi ning Trauma, and (c) Counseling Implications. These sections are followed by a brief summary of the chapter and relevant resources for instructors, students, and clinicians.

CONTEXT FOR THINKING ABOUT TRAUMA

Since the earliest days of psychoanalysis in the late 19th century, professional discus-sions about the construct of trauma have been fraught with controversy. Even Sigmund Freud recanted some of the trauma-related parts of his theory in response to the furor that it caused in affl uent Viennese society. Whereas the historical details and nuances are important, as they relate to how the international psychotherapeutic establishment has come to comprehend and deal with issues of trauma, before turning to a histori-cal understanding of trauma in Chapter 2 of this text, it is essential, in this chapter, to address the variety of meanings, controversies, and contexts associated with the dis-course on trauma.

Clinicians from the various helping disciplines—professional counselors, psychiat-ric nurses, psychiatrists, psychologists, social workers, and other behavioral scientists, along with religious helpers and other spiritual guides—have recognized the profound impact that traumatic experiences can have on individuals’ psyches, and this has been ongoing, long before the more or less recent wave of related research and theory build-ing of the last couple of decades. Psychotherapists working with trauma survivors have realized that the resulting effects of trauma range from acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and other serious psychopathological responses, to existential crises, to posttraumatic growth. Those working in the fi eld have learned from clients that the causes of trauma differ widely and include interpersonal violence, sexual assault, physical maltreatment, political- or community-scale violence, war, vari-ous crisis situations, large-scale disasters, and witnessing or vicariously experiencing any of these. Yet controversies continue to abound concerning the etiology, diagnosis, and treatment of trauma-related sequelae and disorders.

Some of these controversies relate directly to systemic failures that impede rather than assist traumatized people in acquiring access to needed help. In many ways, the


An Introduction to Counseling Survivors of Trauma 3

controversies may refl ect an elementary psychodynamic about helping professionals and about the very nature of trauma. It may be much easier to intellectualize about abstract diagnostic constructs than to grasp and to engage with the perverse reality of a parent raping or sodomizing his or her child or of a child soldier who has been trained to kill his immediate family and his neighbors. Offering counseling to survivors of trauma can be emotionally intense work and thus requires a strong self-refl ective ori-entation. Some clinicians may feel that they are bearing witness to evil, whereas others elect to refer traumatized clients elsewhere.

Understanding the effects of traumatic events is a complex endeavor. Trauma affects people on multiple levels, including in the most intimately personal, as well as in relational, social, and cultural ways. Examining some of the various theories of human development can offer a base upon which to build understandings concern-ing the effects of trauma. For this reason, I believe that it is helpful to revisit briefl y some of the relevant models of human growth and development before moving on to trauma theory. In this section, I focus on relevant issues of life span development and the importance of a bioecological perspective, thus providing the background for the next section of this chapter on defi ning trauma.

Life Span Development Numerous theories and models exist to help us in understanding how people grow and develop across the life span. Several relevant psychological models have infl uenced our knowledge of human development and motivation, including Maslow’s hierar-chy of needs and the developmental theories of Freud, Erikson, and Piaget. However, although these theories are necessary to our understanding, they are not suffi cient in addressing the concerns of individuals who have been traumatized. They do not lay out an adequate foundation for grappling with some of the fundamental questions of development, especially child development, as these concern traumatic experiences, for example: How does a traumatic event or ongoing trauma interrupt or delay develop-mental tasks? What developmental trajectories might we expect when abnormal events occur in the lives of ordinary people? How do these alternative developmental trajecto-ries refl ect individuals’ environmental conditions, especially concerning relative levels of risk, security, and attachment? In spite of their inadequacy to answer questions of trauma fully, these models offer important background information and are discussed briefl y in the following text.

Maslow Although more of a motivational theory, Maslow’s (1998) widely recognized model has some utility in considering certain aspects of trauma. The model has posited that the categorical needs of human beings are hierarchical; these needs are represented in the fi gure of a pyramid (see Figure 1.1). The base of the pyramid represents physiologi-cal needs , those involving such basic necessities as food, water, and shelter. The rungs of the pyramid, in ascending order above physiological needs include the following: safety needs , composed of such features as security, law, order, and stability; love and belonging , composed of such elements as affi liation and friendships; esteem , composed of such attributes as confi dence, respect, and status; and, at the very top of the pyra-mid, self-actualization , or the ability to realize one’s full potential. It is important to note that each of these need levels can be interrupted and affected by violent or traumatic events. One practice limitation of this model is that it often is engaged by professionals at the esteem level, without much consideration of the important foundational needs



at the base of the model. An example of this would be a school counselor or a school psychologist who focuses on a child’s self-esteem without understanding that the child might have walked to school from a local domestic violence shelter where his or her mother sought safety the night before, or that the child might not have had dinner the night before or breakfast that morning. The child potentially would have diffi culty focusing on self-esteem issues when more basic and immediate needs have not been addressed. This model is one that offers necessary constructs about basic needs, but it is not suffi cient in explaining the needs of at-risk individuals or those who have expe-rienced a traumatic event.

Freud, Erikson, and Piaget Important pioneers in theories of human development, Freud, Erikson, and Piaget have presented their developmental theories as stage models. A comparison of these stages can be seen in Table 1.1.

SelfActual-ization

Esteem

personal growth and fulfillment,

realization of potential

achievement, respect, responsibility, status

Love and Belongingfamily, affection, friendship, affiliation

Safety Needsphysical and emotional security, stability, order

Physiological Needshealth, shelter, food, water

Figure 1.1 Maslow’s Hierarchy of Needs

The data for the diagram are based on Hierarchy of Needs from “A Theory of Human Motivation,” in Motivation and Personality , (2nd ed.) by A. H. Maslow. Copyright 1970 by Abraham H. Maslow. Copyright 1991 by Wm. C. Brown Publishers. Adapted with permission.



Freud’s theory of psychosexual development includes fi ve sequential stages: oral, anal, phallic, latency, and genital. However, these stages, like much of Freudian theory, long have been criticized for many reasons. For our purposes in this chapter, it suf-fi ces to say that beyond noting their historical importance, these stages tend to be less relevant to the contemporary discourse on developmental issues, at least outside of a psychoanalytic context.

Infl uenced by Freud, Erikson’s sequential eight-stage developmental theory has involved the completion of stage-specifi c tasks and resulting alternative consequences or crises when these tasks are not completed in stage-salient ways. Although Erikson’s model was designed with the healthy individual in mind, it is helpful to see, especially in the initial stages, how early childhood maltreatment potentially can establish path-ways of development that may deviate from a healthy norm and even initiate a develop-mental trajectory eventually marked by developmental psychopathology. For example, let us consider the case of a child who is so severely abused or neglected during the fi rst year of life that this child is not able to engage in a trusting relationship with a primary caregiver. Instead, the child learns to mistrust the world around him or her. This has serious implications for the child’s developmental pathway, from both psychological and biological perspectives, as well as for attachment issues, at the time and in the future (child and adolescent attachment issues are discussed more fully in Chapters 8 and 9 of this book).

Piaget’s sequential sensorimotor and operational periods have relevance to phys-ical and neurocognitive development; in fact, as we have continued to learn more about brain function (National Research Council and Institute of Medicine, 2000), it becomes clearer how early childhood deprivation and maltreatment can affect the developing child (neurological issues related to trauma are discussed in Chapters 4 and 10 of this book). Some may argue that such age- or stage-dependent theories are somewhat deterministic and reductionist. Far too often, purely psychological approaches may ignore other factors in the environment and may place the onus of developmental deviations on the individual. For these reasons, I argue that these

Table 1.1Comparison of Freud, Erikson, and Piaget’s Stage Th eories

Stages (Approximate Age Ranges) Freud Erikson Piaget

Infancy (birth to around 18 months)

Oral Trust vs. mistrust Sensorimotor period

18 months to 3 years Anal Autonomy vs. shame and doubt

Preoperational thought

3–5 years Phallic Initiative vs. guilt

6–12 years Latency Industry vs. inferiority Concrete operations

12–18 years Genital Identity vs. role confusion Formal operations

Young adulthood (around 19–40 years)

Intimacy vs. isolation

Middle adulthood (40–65 years)

Generativity vs. stagnation

Maturity (65 years to death) Integrity vs. despair

The information in this table is drawn from the work of Freud, Erikson, and Piaget.



historically important theories allow us to understand necessary information about individuals, but that they are not suffi cient in helping us to understand the full needs of trauma survivors.

Additional models . Purely mechanistic models do little to assist our understand-ing of peoples’ lived experiences and worldviews. So in contrast to the aforementioned more linear and more or less purely psychological models, other theoretical models, which also have infl uenced our understanding, perhaps better account for individuals’ worldviews and their interface with social infl uences. These theories include Bowlby’s (1969/1982, 1973, 1980, 1988) attachment theory, Bandura’s (1977) social learning theory, and Vygotsky’s (1978, 1986, 1997) social development theory. It is not my purpose in this chapter to analyze the corpus of these works; rather, I raise these pertinent and pervasive theories of human development and social learning to remind us of concepts that are necessary in understanding human development but perhaps not suffi cient for understanding the impact of traumatic events on the developing and growing indi-vidual. Just as Lerner (2002) has emphasized the centrality of the nature versus nurture (genetic vs. environmental/contextual infl uences) discourse along with the interplay of continuity and discontinuity dynamics throughout the life span, I turn the conversation to a more ecological perspective.

Toward a Bioecological Perspective Uri Bronfenbrenner (1979, 1981, 1994) has offered an elegant model for understand-ing the comprehensive infl uence of multiple systems on children’s development. Simply put, ontogenic (individual) development is nested within larger systems that affect the person’s development (see Figure 1.2). From proximal (closer) to distal (at a greater distance), these systemic infl uences include the microsystem (immediate family environment), the mesosystem (situations in which two or more microsystems come together to have some effect on the individual’s life), the exosystem (commu-nity and neighborhood), the macrosystem (broad cultural values and beliefs), and the chronosystem (denoting sociohistorical time as well as the real-time personal events and developmental transitions in an individual’s life since birth). Environmental fac-tors, along with genetic predispositions, infl uence the child, and continual recipro-cal transactions within the environment, or ecology, determine risk and protective factors. After the initial development of his ecological model, Bronfenbrenner later renamed the model, changing it from the former ecological model to the more newly termed bioecological model , thus reemphasizing the interactions between heredity and environment.

Most contemporary theories of development have acknowledged the roles of both heredity and environment, and many have suggested the importance of a systemic perspective. Lerner’s (2002, 2006) notion of developmental contextualism, for exam-ple, has offered a framework for integrating important developmental theories and beginning to arrive at a developmental systems theory. The literature on developmen-tal psychopathology (e.g., Belsky, 1993; Cicchetti & Lynch, 1993, 1995; Cicchetti & Toth, 1995) has provided a developmental–ecological framework for understanding the profound interplay between normal development and abnormal events, especially in the form of child maltreatment. Developmental psychopathology has emphasized the role of attachment in children’s lives (Belsky, Spritz, & Crnic, 1996), seeking to assess connections between the quality of attachment and the impact of maltreatment. This perspective has offered a baseline for comprehending the effects of chronic violence on children—and by extension, some of the trauma-related sequelae of adults who expe-rienced severe maltreatment in early childhood. Developmental psychopathology has



served as a rich mechanism for examining the risk factors, as well as the compensatory or protective factors, which exist across the multiple and interactive environments in which we all live (e.g., Garmezy, 1993). From this theoretical paradigm, Cicchetti and Lynch (1993) have detailed a related ecological– transactional model that offers an ave-nue for understanding, in a comprehensive way, the infl uence of multiple factors—at multiple levels—on children’s development. Such an articulation of the transactional nature of development is paramount to understanding the complex, sometimes para-doxical, effects of maltreatment on children at multiple systemic levels.

An understanding of the bioecological model, its transactional and systemic nature, and the role of attachment across the life span is an essential aspect of understanding the impact of trauma. An ecological–transactional perspective allows us to situate the lived experiences of traumatized persons within the time and space of a relevant ecol-ogy in order to understand the trauma event as well as personal meaning making. Lynch and Levers (2007) have suggested the compatibility of ecological, transactional, and motivational perspectives in applying developmental theories to trauma counsel-ing (relevant theoretical constructs are discussed in Chapter 3 of this book).

Macrosystem

Exosystem

Exten

ded F

amily

Neighbors

Social Services

Mass

Media

Economics,

Political System, Social Institutions, Social ValuesMesosystem

Microsystem

Family School

PeersReligion

Neighborhood

The Individual

ChronosystemPassage of Time

FIGURE 1.2 Bronfenbrenner’s Bioecological Model of Human Development



DEFINING TRAUMA

Beginning to defi ne trauma and its psychological effects is a daunting task. The effects of traumatic events are complex, refl ecting the intricacy of the human beings who are exposed to trauma. Traumatic events involve objective or factual situations, and DSM -related criteria attempt to quantify symptoms in an objective fashion. However, the way in which people experience traumatic events is highly subjective, and trauma theories must allow for the reality that people construct personal meanings from their traumatic experiences.

Current theories about trauma offer a framework for understanding the vari-ous types of trauma, such as simple versus complex, and the different ways in which people respond, such as being completely overwhelmed and stuck there versus mak-ing meaning of the trauma in a way that eventually may produce growth and trans-formation. Although many discussions of PTSD appear in the chapters that follow in this textbook, the diagnostic category of PTSD is only one facet of defi ning trauma. Laurence J. Kirmayer (2007), MD, James McGill professor and director of the Division of Social and Transcultural Psychiatry at McGill University, offers the following comment regarding PTSD:

Diagnostic constructs also work as metaphors, both in terms of their explicit use as conceptual models and their implicit connotations as labels that affect social relations between people. The construct of PTSD, which has dominated discussions of the treatment of trauma in recent years, emphasizes the endur-ing effects of fear conditioning on subsequent adjustment and response to later stressors. But PTSD is a limited construct that captures only part of the impact of violence, ignoring issues of loss, injustice, meaning and identity that may be of greater concern to traumatized individuals and the their families and chil-dren or later generations. (p. vi)

The various discussions in this textbook acknowledge PTSD as an important but limited construct. Indeed, as explicated in Chapter 2, the history of the Diagnostic and Statistical Manual of Mental Disorders illustrates the extent to which the notion of PTSD is socially constructed and ever changing, even within the psychiatric model.

One powerful tool in understanding the effects of trauma is through interdisci-plinary means. For example, during my initial exposure to clinical trauma narratives early in my career as a young counselor, I recall thinking about the cubist paintings that I had seen in European museums, perceiving the trauma experience through the disciplinary lens of my undergraduate work in literature and art history. Focus-ing on the deconstructed images in the Cubist paintings, like those of Picasso, for example, assisted me to comprehend, even in a limited fashion, the fragmentation that traumatized clients had experienced and tried to share with me. Psychiatry and psychology are not the only professional fi elds of endeavor that enhance under-standings of trauma; rather, not only do other social and behavioral sciences focus on issues of trauma, for example, counseling, sociology, social work, anthropology, nursing, and other allied health professions, but those pursuits involving the arts and humanities and fi elds such as technology and journalism also contribute to illuminating the effects of trauma (see Appendix 1.1). In this section, I emphasize some of the multiple facets of how people experience trauma through the following discussions: trauma as a clinical issue; the phenomenology of trauma; trauma as a systemic issue; and the intersection of constructs related to stress, crisis, disaster, and trauma.



Trauma as a Clinical Issue The word “trauma” has been popularized and often is used to indicate almost any stressor experienced by an individual. However, in its clinical sense, trauma refers to events that are extremely diffi cult and overwhelming for individuals (Briere & Scott, 2006). One might think that turning to the offi cial nosology of the profession would provide a clear defi nition of the clinical sense of trauma; however, this would not be an entirely accurate assumption. The Diagnostic and Statistical Manual of Mental Disor-ders, Fourth Edition, Text Revision ( DSM-IV-TR ) specifi es two trauma-specifi c diagnostic categories: PTSD and ASD; these are classifi ed within the Anxiety Disorder category. Although it is not unusual for someone with PTSD also to experience dissociation or depersonalization, such symptoms are classifi ed separately, within the Dissocia-tive Disorders category. A constellation of other symptoms (e.g., self-destructive and impulse-control behaviors, somatic complaints, and hostility, to name a few), which may be associated with trauma, also are categorized separately with other disorders. Comorbidity of PTSD with other DSM diagnoses is discussed in further detail in Chapter 2 of this book, but in the DSM-IV-TR , the American Psychiatric Association (APA, 2000) emphasizes this very point in the following passage:

Posttraumatic Stress Disorder is associated with increased rates of Major Depressive Disorder, Substance-Related Disorders, Panic Disorder, Agorapho-bia, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Social Pho-bia, Specifi c Phobia, and Bipolar Disorder. These disorders can either precede, follow, or emerge concurrently with the onset of Posttraumatic Stress Disorder. (p. 465; Extracts reprinted with permission from the Diagnostic and Statisti-cal Manual of Mental Disorders, Fourth Edition, Text Revision [Copyright ©2000]. American Psychiatric Association.)

Thus, differentiating the diagnostic classifi cations associated with trauma, espe-cially PTSD, can be diffi cult, especially for the new or inexperienced clinician. The importance of accurate assessment, discussed in Chapter 27 of this book, cannot be underscored enough.

In the DSM-IV-TR , the APA (2000) characterizes the core features or criteria of PTSD in the following way:

The essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threat-ened death or serious injury, or other threat to one’s physical integrity; or wit-nessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close asso-ciate (Criterion A1). The person’s response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorga-nized or agitated behavior) (Criterion A2). The characteristic symptoms result-ing from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and per-sistent symptoms of increased arousal (Criterion D). The full symptom picture must be present for more than 1 month (Criterion E), and the disturbance must cause clinically signifi cant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). (p. 463)



The major differentiation between ASD and PTSD is that “the essential feature of Acute Stress Disorder is the development of characteristic anxiety, dissociative, and other symptoms that occurs within 1 month after exposure to an extreme traumatic stressor” (APA, 2000, p. 469).

The history of the psychiatric and psychological diagnosis and treatment of trauma, as well as its codifi cation in the DSM s, has been fraught with controversy and a lack of professional agreement. For example, in a correspondence to the The British Journal of Psychiatry , the Royal College of Psychiatrists’ fl agship journal, Miller, Resnick, and Keane (2009) argue that PTSD has a distinct phenomenology and point to data that “raise concern about conceptualising PTSD simply as the manifestation of a vulner-ability to anxiety-related psychopathology” (p. 90). According to some (e.g., Friedman, Keane, & Resnick, 2007), in the last couple of decades, even though progress has been gained in the area of PTSD, there also have been numerous challenges.

Criticisms of current DSM codifi cations have led to increasingly greater discourse surrounding the rationale for including a trauma spectrum disorders category in the DSM (e.g., Moreau & Zisook, 2002; Scaer, 2005) as well as the need for a complex trauma classifi cation (e.g., Briere & Scott, 2006; Courtois, 2004; Herman, 1992/1997). Given US involvement in recent war situations over the past decade, the issue of trauma spec-trum disorders has continued to gain even more attention in America (e.g., O’Donnell, Begg, Lipson, & Elvander, 2011). Many have advocated for differentiating between PTSD and complex PTSD (a discussion of complex trauma is found in Chapter 2 of this book). According to a DSM-V -related American Psychiatric Association (APA; 2010) website, the architects of the DSM-V (anticipated for publication in May 2013) intend to implement a separate Trauma- and Stressor-Related Disorders category. However, although of interest, perhaps of equal concern to most clinicians as the diagnostic categories associated with trauma is the phenomenology of trauma and its clinical manifestation among clients who seek assistance in dealing with the aftermath of traumatic events.

Phenomenology of Trauma People’s lived experiences of traumatic events are highly personal and subjective; and at the same time, some of the phenomena associated with trauma are fairly consistent, across cultures and from person to person. Some of the issues related to the core experi-ence of trauma and to trauma as an existential issue of suffering are explored briefl y in the following text.

Core Experience of Trauma In her landmark book, Trauma and Recovery , Judith Lewis Herman, MD (1992/1997) has identifi ed the core experiences of trauma as terror and disconnection. Stating that “psychological trauma is an affl iction of the powerless. . . . [in which] the victim is rendered helpless by overwhelming force” (p. 33), Herman has qualifi ed the experi-ence of terror as one of disempowerment, helplessness, and abandonment; she has cast disconnection in similar terms as Courtois (1988, 2004), that is, as shattered trust. When an individual has experienced a traumatic event, the person’s worldview and the very foundation of his or her being can be shaken or crushed, what Stolorow, Atwood, and Orange (2002) have framed as “the shattering of an experiential world” (p. 123). Herman has noted that “traumatic events call into question basic human relationships” (p. 51); victims of trauma may experience disconnection from loved ones or other signifi cant people in their lives, as well as a sense of separation from self.



Hyperarousal is an initial major symptom of trauma, what Herman (1992/1997) has described as a “permanent alert, as if the danger might return at any moment” (p. 35). This startle response is relatively easy for most clinicians to recognize. Herman further has described the additional two sets of PTSD symptoms: those that are intrusive and those that are constrictive. Symptoms of intrusion include those readily associated with PTSD, such as “reliving” the trauma through fl ashbacks and nightmares; symptoms of constriction include some that are less likely to be attributed as quickly to PTSD, such as depression, numbing, and a detached state. One of the most important aspects of Herman’s work has been her recognition of what she has termed “the dialectic of trauma” (p. 47). In the absence of appropriate intervention, when a victim of trauma develops PTSD and the condition goes untreated, the person eventually may begin to vacillate between symptom sets; the dialectic of trauma is represented by this cycling, back and forth, from intrusive symptoms to constrictive symptoms. It is easy to see, especially if a history of trauma has not been documented adequately, how observ-ing a client who is presenting with either set of symptoms could receive an inaccurate diagnosis. At surface, someone exhibiting intrusive symptoms might appear agitated and anxious, and someone exhibiting constrictive symptoms might appear depressed. Therefore, it is extremely important for clinicians who are working with trauma sur-vivors to ask about trauma history and to recognize this dialectic in order to avoid misdiagnosis.

Stolorow (2007) has stated that one theme of trauma is that it “is built into the basic constitution of human existence” (p. xii). Such a phenomenological perspective of trauma is essential in understanding others’ lived experiences of trauma as well as in enabling counselors in helping survivors to recover and heal. Herman (1992/1997) has articulated a stage-wise recovery process aimed at addressing the core experiences of trauma. She has detailed the clinical work that needs to take place in each of the following phases: (a) establishing safety, (b) reconstructing the trauma story, and (c) reconnecting with ordinary life. This recovery process corresponds to phenomenologi-cal aspects of trauma and assumes the potential for an existential transformation from victim to survivor . In addition, Herman’s model illuminates the need for therapists to be highly intentional in their clinical work with survivors of trauma.

Suffering as an Existential Component of Trauma When people are subjected to the most adverse of human situations, they naturally experience psychic pain and suffering. Miller (2004) has posited that most people seek psychotherapy to relieve suffering and are therefore not focused on the clinical aspects of symptomatology, asserting that the science of psychology has long ignored this aspect of the therapeutic encounter. Daneault et al. (2004) have asserted that a major mandate of medicine—and by extension, psychiatry and other psychological prac-tices—is the relief of suffering. Yet very little analysis of the construct of suffering has existed in the professional literature (Makselon, 1998).

A core consequence of all types of trauma, crisis, and disaster events is human suffering. Mental, emotional, existential, and physical suffering can affect people in a variety of negative ways, including personality changes, health status, and the ability to function on multiple levels. The connection between suffering and illness— illness defi ned as an ethnomedical concept, relative to cultural construction—is profound and calls for existential and multicultural approaches (Levers, 2006a, 2006b). Suffering also can affect people positively, in the long run; the connection between suffering and trans-formation has been the subject matter of theological and philosophical discourses for centuries. Although a lacuna exists in the contemporary scientifi c literature regarding



a psychology of suffering, the theoretical and existential basis for this discourse exists, for example, among such notable scholars as Bruner (1990), Frankl (1959), Fromm (1947), and May (1992). Understanding the nature and the phenomenology of human suffering can assist clinicians in defi ning the subjective meaning making of trauma survivors, thereby guiding the quality of client-informed interventions. This process is central to the transformation from being a victim to being a survivor and is a profound step toward recovery.

Trauma as a Systemic Issue Although the clinical features and phenomenological aspects of trauma involve victims at the individual level, there are at least three areas of potential systemic impact. First, groups of people may simultaneously experience the same natural disaster, accident, or human-made catastrophe; many of them may develop trauma-related symptoms. Second, when groups of people are affected by a traumatic event or a disaster, there is usually a coordinated reaction by an offi cial system of responders. Third, even when a traumatic event only involves an individual, as explained previously in the bioecological model, the person is nested within and potentially affected by any or all other systems at the microsystemic, mesosystemic, exosystemic, macrosystemic, and chronosystemic levels. The implications for how a victim or survivor of trauma may be able to navigate these various systems and for how systemic responses to crisis, disaster, and trauma events adequately help or fail to help victims are too numerous for a full discussion in this chapter. However, some of the systemic features of trauma are next explored briefl y in terms of their cultural, public health, social justice, and pedagogical dimensions.

Cultural Dimensions of Trauma Just as cultural assumptions have been made across mental health theories and prac-tices, culture profoundly shapes peoples’ experiences of trauma, along with mold-ing the rites and rituals of grief and suffering that enable the expression of trauma (Drožd̄ek, 2007b). Locating trauma—and by extension, PTSD—in a global context raises transnational issues. As Breslau (2004) has suggested, “. . . problems [are] gen-erated when the process of defi ning the disorder is viewed simplistically as a matter of scientifi c technology rather than as a cultural practice in itself” (p. 121). Expres-sions of suffering and healing vary across cultures and arise from differing world views; for people outside of Western cultures, as well as for non-Western people who have immigrated to a Western country, an ethnomedical perspective may be useful ( ethnomedicine is a subspecialty area of medical anthropology, focusing on indigenous paradigms of healing and cultural variations of constructs like illness and disease). Culture has informed the ways in which people make meaning of trauma, the rituals for expressing the impact of trauma, and the manner in which people are able to heal. For example, Castillo (1997) has asserted that “cultural schemas affect the subjective experience and expression of dissociation” (p. 219). Dissociation is but one symptom-atic manifestation of trauma that offers a good example of cultural nuance. Dissociation has been pathologized within Western biomedicine. Yet when examining non-Western paradigms of indigenous medicine or traditional healing, dissociation actually may play a proactive role in the transactions between client and healer (e.g., Comaroff, 1978, 1980, 1982; Kleinman, 1986; Levers & Maki, 1995; Moodley, 2005; Torrey, 1986; Turner, 1968) and also can offer adaptive mechanisms (Castillo, 1997) such as with the use of yoga, hypnosis, tai chi, mindfulness, and other focus-oriented techniques as part of the recovery process.



Public Health Dimensions of Trauma Professionals working in the arena of traumatology increasingly have cited the effects of trauma on individuals as a public health issue (e.g., Drožd̄ek, 2007a; Musisi, 2004). A growing corpus of literature has highlighted the impact of early childhood adversity on later health across the life span (e.g., Felitti, 2002; Felitti et al., 1998; Lanius, Vertmetten, & Pain, 2010). Breslau (2004) has suggested that “epidemiological surveys have been an important vehicle for bringing PTSD into the global health arena” (p. 117). The rise of all types of technology has increased the capacity for more violence on broader scales; com-munication technology has increased the potential for members of the public to witness acts of violence, immediately, even when they are not present. The reality of amplifi ed violence increasingly has become a part of the global discourse on trauma (e.g., Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002; Levers, 2012; Levers, Magweva, & Mpofu 2007). Some analysts even have concluded that the issue of trauma has been exploited for political and economic reasons; in her exploration of associated challenges, James (2004) has introduced the notion of a trauma portfolio , a kind of hierarchical cataloging of events that have institutional currency.

Social Justice Dimensions of Trauma Geopolitical atrocities continue to occur internationally, even though the phrase “never again” has been repeated over and over in reference to events such as the enslavement of Africans, the near extinction of indigenous peoples in North America, the Jewish Holocaust, apartheid in South Africa, the Bosnian genocide, the Rwandan genocide—and now, again, in reference to the Democratic Republic of Congo and to Sudan. Cir-cumstances like these have exposed people to such a degree of extreme cruelty and unspeakable horror that the ensuing trauma not only affects the individuals directly involved but can live on as transgenerational trauma. Trauma that continues across gen-erations, also called historical trauma , (e.g., Alexander, 2004; Estrada, 2009; Sotero, 2006), has been discussed at greater length in Chapter 2 of this book.

Both human-made and natural catastrophes can leave the poorest, the youngest, the oldest, and the weakest in highly vulnerable positions. The world has witnessed the devastation of the most vulnerable in recent instances such as Hurricane Katrina, earthquakes in Haiti and Japan, and so forth. Children (Lanius, Vertmetten, & Pain, 2010) and older adults (Bonnie & Wallace, 2003) have been exploited in many ways that can evoke trauma responses (issues associated with child and adolescent trauma are discussed in Chapters 8 and 9, and with elders in Chapter 12 of this book). Levers and Hyatt-Burkhart (2011) have questioned human rights violations associated with migra-tion, for example, among Mexicans trying to enter the United States via Arizona, or Africans trying to enter Europe via Greece, and asserted that these can have a traumatic effect on the immigrants.

Trauma-based issues that represent human rights violations need to be examined from a social justice perspective. The effects of a traumatic event can be intensifi ed and worsened when the traumatized person also has cause to feel that he or she has been betrayed by the very social community that should be extending assistance. This was the palpable pain that was witnessed in living rooms across the country and around the world when victims of Hurricane Katrina were televised on the nightly news, corralled in the most unsanitary conditions and begging for water. Although trauma survivors whose rights have been violated need to be treated individually and to engage in a recovery process, the group aspect of a social justice perspective may require some type of restorative or reparative justice to take place. Restorative justice, which focuses on the needs of the victim rather than legal principles or the punishment of the offender, has



been used, as one example, in the Gacaca courts in Rwanda, offering a format for rec-onciliation between victims and perpetrators in a situation where parties need to live together again in the same society (this aspect of the Rwandan genocide is discussed in greater detail in Chapter 23 of this book).

Pedagogical Dimensions of Trauma Opportunities for in-service and professional association trainings concerning all issues related to trauma have swelled during the last several decades. However, preservice clinical instruction, specifi cally related to the psychosocial impacts of trauma, has been less forthcoming, as has much focus on the clinical supervision of trauma-related cases, although there have been some recent attempts to redress this tremendous training gap. For example, the Council for the Accreditation of Counseling and Related Educa-tion Programs (CACREP, 2009) recently instituted the curricular requirement, for both the master’s level and doctoral training of professional counselors, that content related to the area of crises, disasters, and other trauma-causing events be included in the cur-riculum of accredited programs. Counseling, psychology, and social work programs gradually have been adding courses that deal with trauma and crisis issues, but little is known about pedagogical best practices and trauma.

Simon and Eppert (1997); Simon, Rosenberg, and Eppert (2000); and Walcott (2000) have noted the existence of pedagogical problems and diffi culties in teaching the mat-ters that are associated with trauma. Obviously, care needs to be taken not to over-whelm or traumatize students in the process of helping them to understand the clinical dimensions of trauma. At the same time, educators concerned with trauma issues need to create opportunities for advancing relevant skill sets. Although adding courses that are specifi c to trauma, especially at the graduate level, is a necessity, embedding trauma-sensitive skills across the curriculum would go a long way in addressing the instructional gap. For example, working with survivors of trauma requires empathic engagement; this is a skill that typically is included in a basic techniques course and so presents an opportunity for illustrating the skill as one related to trauma as well as other mental health issues. So in addition to offering an adequate clinical knowledge base within a specialty trauma course, preservice programs could enhance the way they teach basic counseling skills across the curriculum to include issues of trauma.

Intersection of Constructs Related to Stress, Crisis, Disaster, and Trauma Issues associated with trauma constitute a major focus of this book. Crisis intervention and crisis theory are detailed in Chapter 19, and various types of disaster situations are examined in Chapters 20–26 of this book. Of relevance at this juncture are the nexus of constructs regarding stress, trauma, crisis, and disaster experiences and the importance of differentiating their varying characteristics (Yeager & Roberts, 2003).

In the now classic The Stress of Life , Hans Selye, MD (1956/1978) was the fi rst to talk about the impact of stress, both biologically and emotionally, on humans. Stress is a hormonally driven, therefore automatic, physiological state that occurs in response to situations that demand change. This state is not necessarily always negative—Selye also coined the term eustress , which implies the kind of “good” stress that can moti-vate an individual—but when people talk about being “stressed out,” the connotation usually relates to a negative state of tension or agitation. Even this kind of pressure is not necessarily a “bad” thing, as under precipitating circumstances, stress activates a primitive part of the brain to initiate the fi ght-or-fl ight response; stress is like the body’s instant messaging system for protecting us from danger. It is when danger has



passed, and we are unable to “turn off” the stress response that the effects of pro-longed stress can begin to take a toll on our bodies, including on important regulating systems like the endocrine and immune systems. Alternatively, sometimes when we are under extreme stress, instead of defaulting to the fi ght-or-fl ight response, our bod-ies instead go into a kind of freeze response, like a deer in the headlights; although not necessarily stressful, in and of itself, this type of inertia may replace the fi ght-or-fl ight response or even heighten the original danger.

Although stress is a common feature of everyday life and has the same psychophysi-ological effects, whether real or imagined, unrelenting stress can be biologically and emotionally harmful. In this instance, a person may need to engage in stress manage-ment techniques and prevention activities to alleviate the pressure and tension. A crisis or disaster is usually a time of increased stress or danger. A crisis is an event or situation in which a person perceives a threat to be greater or more intolerable than his or her abil-ity to cope with or assimilate the circumstances. A disaster is usually a sudden accident or a natural or human-made catastrophe that may or may not be perceived as a crisis or a trauma, depending on the individual. A traumatic event is typically so overwhelming that the victim experiences a sense of terror or helplessness. Not every stressor consti-tutes a crisis or a disaster, and not every crisis or disaster is traumatizing. However, a traumatic event typically involves extreme stress and some element of crisis.

It is useful for every mental health professional to be equipped with basic stress management and crisis intervention skills. Several recent texts detail the skills neces-sary for crisis and disaster counseling (e.g., Cavaiola & Colford, 2011; Dass-Brailsford, 2010; Echterling, Presbury, & McKee, 2005; Greenstone & Leviton, 2011; Jackson-Cherry & Erford, 2010; Kanel, 2012; Roberts, 2005). These skill sets do not rely on long-term counseling as much as assisting clients to regulate their responses to extremely stress-ful or crisis-oriented situations or disasters; they require the counselor to attend to what needs to be done, in the most immediate sense. However, survivor responses to trau-matic events, especially if the response is enduring enough to qualify as PTSD, usually require longer term counseling, and this suggests that the mental health professional have clinical preparation in delivering trauma counseling. Determining when a per-son’s sense of intense fear or horror, in response to an overwhelming event, moves from the stress of a crisis to a fully traumatic experience may rely on the clinician’s ability to combine two different sets of counseling skills: (a) active listening to the client’s nar-rative, and (b) keen assessment and diagnostic skills (Roberts, 2002). Developing both of these skill sets requires professional experience, but acquiring as much training as possible is also an essential factor.

COUNSELING IMPLICATIONS

Several implications arise from the aforementioned overview of a contextual and systemic perspective of trauma. Perhaps a pertinent fi rst implication is that the most effective approach to understanding trauma is one that engages multiple disciplines. Drožd̄ek (2007a) points to the importance of interdisciplinarity, from local to transna-tional trauma events and responses to these events. As discipline-based professionals, we can learn from our confederate colleagues of all disciplinary persuasions.

A second implication relates to trauma therapists being adequately grounded in their understandings of the clinical and contextual factors associated with trauma. This is a double-edged issue of professional responsibility: (a) preservice training programs need to offer adequate instruction concerning the ubiquitous mental health issue of trauma, and (b) clinicians working in the arena of traumatology need to ensure that



they have an adequate education, whether preservice or in-service training, to support their work with trauma survivors.

Mental health professionals who work with survivors of trauma can provide more effective and culturally sensitive treatment when they conceptualize client concerns through the bioecological and transactional models described in this chapter. So a third implication is that these models offer an interdisciplinary format for understanding client risks, for engaging and enhancing existing protective factors, and for creating mechanisms that facilitate client recovery. A related fourth implication regards a sys-temic understanding of the impact of trauma. Because of the very personal nature of the usual traumatic event, along with the overwhelming intensity that is typical of any trauma situation, people who experience a traumatic event are affected profoundly in every area of their lives. To ignore the dynamics between individuals and the relevant systems that play essential roles in everyday living is really to ignore central features of the trauma situation.

When clinicians fi rst recognize trauma and begin to treat the client, this constitutes an ecological transition for the therapist, thus providing a strong reason for seeking clinical supervision, a fi fth implication. Working with survivors of trauma entails intellectually demanding and emotionally charged scenarios, ones that require clinicians to maintain professionally appropriate boundaries. In addition to the central importance of boundar-ies, therapists working with traumatized clients need to be keenly aware of the potential for countertransference. The need for self-refl exive skills, for the ability to formulate inten-tional treatment strategies, and for unwavering attention to boundary and countertrans-ference issues speaks to the essential importance of clinical supervision when working with trauma (see Chapter 33 of this book for a fuller discussion). Even highly experienced trauma counselors fi nd clinical supervision helpful, and for more seasoned therapists, this can be conducted as peer supervision or even in trauma-informed learning groups that are developed by clinicians to support one another in this intense line of work.

Therapeutic intentionality is an important sixth implication for counseling. For a long time, clinicians working in community settings that are not trauma or survivor specifi c (in the sense that rape crisis centers and domestic violence shelters attend par-ticularly to traumatic events) have had tendencies to provide crisis intervention immedi-ately to distressed or traumatized clients, perhaps without even recognizing the trauma per se; they then may refer these clients so that the trauma is likely to be caught so much later that there are additional and more complex sets of problems for the clients. This seems to constitute therapeutic defaults rather than intentional therapy. The mental health fi eld has been defaulting on trauma, in this sense, for decades. In order to avoid systemic failures and to aspire toward best practices, the delivery of mental health services to trauma survivors needs to be trauma informed (trauma-informed care is discussed in Chapter 28 of this book), to be offered from a pluralistic professional perspective, and to advance strategies of care that are intentional rather than of a default nature.

CONCLUSION

The construct of trauma has sparked controversies for well over a century, and we have arrived at multiple ways of perceiving trauma. This chapter has emphasized that the effects of a traumatic event are perhaps best understood from a multidisciplinary per-spective, and that an awareness of the bioecological and transactional nature of life span development can assist therapists in dealing with the aftermath of clients’ traumatic expe-riences. The connection between the personal and the systemic has been highlighted.



A clinician’s ability to understand the profound effects of a traumatic event on the psyche of a client goes well beyond codifi ed clinical defi nitions and includes a phenome-nological understanding of clients’ lived experiences of trauma. This chapter has identi-fi ed some of the common criticisms of DSM categorizations of trauma-based diagnoses, particularly PTSD, as these have established the basis for contemporary arguments that favor the consideration of a complex trauma classifi cation or a trauma spectrum disor-ders category. The intrusive and constrictive symptom sets of PTSD have been identi-fi ed, and Herman’s (1992/1997) notion of a dialectic of trauma has been presented.

In addition to defi ning trauma from a clinical perspective, insight has been derived from a contextual viewpoint, thereby enabling an examination of the cultural, pub-lic health, social justice, and pedagogical dimensions of trauma. This chapter also has reviewed constructs associated with stress, crisis, and disaster, exploring their nexus with relevant trauma issues. The counseling implications of this chapter’s contextual orientation toward trauma have been identifi ed, emphasizing the need for adequate training and clinical supervision. Trauma has been viewed here as a complex human issue that requires informed and intentional personal and systemic responses.

Trauma Journalism Deirdre Stoelzle Graves Trauma journalism is dangerous, emotionally challenging work. Covering earth-quakes in Japan and Haiti, the shootings in Tucson, and all manner of tragedies and violence at home and abroad carries personal and professional risks.

Founded in 2003 by a group of alumni fellows of the Dart Center for Journalism and Trauma, the nonprofi t Dart Society provides direct outreach and information to journalists who cover the most diffi cult stories of our time. We undertake direct outreach missions and sponsor symposia to enable trauma journalists to share expe-riences and further the type of reporting that connects humanity. Through The Mimi Award , the Dart Society annually recognizes editors who are committed to helping journalists stay safe and sane, and who guide the reporting process to excellence.

Our founder, psychiatrist Frank Ochberg, MD, calls our work a “ministry of pres-ence”—being there for fellow members and colleagues who need us. We’ve worked alongside journalists rebuilding their neighborhoods and their lives after Katrina and 9/11, helped reporters and photographers struggling to make sense of community tragedy, most recently after the shootings in Tucson earlier this year. We also maintain contact with members and colleagues covering confl ict and tragedy abroad—in the Caucasus, Africa and the Middle East, Afghanistan, Latin America, and Australasia.

The Dart Society strives to be a paragon of nonprofi t organizations, and we have the relationships with fellow journalism organizations, academic programs, trauma experts, and nonprofi t professionals to ensure that this happens.

Ochberg fellow Melissa Manware Treadaway, a former crime reporter at The Charlotte Observer , wrote the following about what the Dart community means to her:

I care about the Dart Society because it is made up of people who think like I think, who see what I saw, who write what I wrote, who internalize their

APPENDIX 1.1

(continued)



stories—and who need likeminded people to support them. . . . This organi-zation—the Dart Center and the Society—gave me a lot. And I think it’s my responsibility to give back.

Journalists are different from the cops and the lawyers. We are different from the soldiers and the brass, the EMTs and the surgeons who save lives. We are not considered fi rst responders like 9/11 rescuers, although we’re right there at the scene. Nor do we have the training of a psychiatrist or a soldier to know what to do when things get ugly. But we learned the hard way, ducking bullets, blood, and insanity to report the kinds of stories no one wants to read and no one wants to tell.

What we do know is how other journalists feel when they witness the genocides in Rwanda and Bosnia, when they interview the parents of mur-dered schoolchildren or survivors of 9/11.

We try to make sure, above all, that our fellow journalists know we have their backs when they’re on assignment, and that when they come back, we’ll be there for them— journalists helping journalists.

We in the Dart Society have had the benefi t of coaching from Frank Och-berg and his peers at the International Society of Traumatic Stress Studies; we know they have our backs as mentors.

As the Dart Society begins to come into its own, we cement our mission: to provide outreach and support to journalists who cover violence, trauma, and social injustice.

A former board member, Tina Croley, proposed the goal of a “Dart” in every newsroom. Being selected for the Ochberg Fellowship means you are a news-room leader, a natural peer supporter, and as Frank says, an “indigenous rabbi.”

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SA’s roles and actions 2011-2014 . (http://store.samhsa.gov/product/SMA11-4629 ) Substance Abuse and Mental Health Services Administration. (2011). Trauma and justice . (http://www.

samhsa.gov/traumaJustice/ ) Trauma Information Pages. (n. d.) Trauma support . (http://www.trauma-pages.com/support.php )

Films and Videos Films for the Humanities & Sciences. (Producer). (2008). Zimbardo speaks: The Lucifer effect and the psy-

chology of evil . [DVD]. Insight Media. (Producer). (1976). Everybody rides the carousel . [DVD]. Insight Media. (Producer). (2007). Maslow’s hierarchy of needs . [DVD]. Insight Media. (Producer). (2001). Aggression, bullying, and intimidation . [DVD]. Walt Disney Productions. (Producer). (1968). Understanding stresses and strains . [Video]. Zimbardo, P. G. (Producer). (2004). Quiet rage: The Stanford prison study . [Video].

APPENDIX 1.1 (continued)



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