Irena Quinn presenation

Secondary Trauma Irena Quinn ISHAR Multicultural Women’s Health Centre 24 June 2008 Sydney

Objectives
Introduce concept of Primary Trauma
Introduce concept of Secondary Trauma.
Normalise the effects of ST.
Strategies for Self Care.

Primary Trauma
“ Overwhelming event” that renders one helpless and /or fearing for his/her life (Van der Kolk, 1987).
Breaks apart “ordinary ways of coping” (Terr, 1990).
It is “outside range of usual human experience…would be distressing to anyone” (DSM III-R).
“ And involves actual/threatened death, serious injury or threat to physical integrity of self and others” (DSM IV).

Primary trauma
Unintentional Trauma (in the case of a natural disaster or accidental death of loved one).
Intentional Trauma (abuse).
More difficult to deal with. It implicates human beings/value of relationships.
All abuse is traumatic.
Not all trauma is abusive.

Primary Trauma
Acts:
- War.
- Sexual, physical and emotional abuse of children.
Rape, Sexual Assault and Harassment .
Domestic violence.
Violent Crime (assault, robbery, burglary, stalking, abduction).
Workplace violence (harassment, intimidation, bulling, gossip).

Primary Trauma
Acts:
Life threatening Illness (AIDS, cancer)
Accidents (industrials, auto, boat, airplane)
Natural disasters
Prejudice (racism, sexism, homophobia, ageism, anti-disabilities)
Loss (death of loved ones, miscarriage, abortion, home and job).

Primary Trauma
Most likely victims (those with least power):
Children.
Women.
Minorities.
The disabled (physically/mentally).
Immigrants (especially those who are illegal).
Homeless.
Elderly.

Primary Trauma
Most likely offenders (those with most power)
Military. Day care personnel.
Police. Men.
Church Ministers. Those with history
Teachers. of abuse.
Coaches.
Parents.
Bosses/managers.

Primary trauma
Two phases :
Initial or Intrusive Phase (arousal) lasts few hours to eight weeks due to exhaustion of sympathetic system.
Denial Phase (avoidance) can lasts indefinitely. Symptoms, in some cases, can last a lifetime if left untreated.
Many individual move back and forth between two phases (with accompanying symptoms) several times over course of their lives (when trigged by external/internal events and /or in the face of new trauma).

Primary trauma
Initial or Intrusive Phase (Horowitz, 1976).
Symptoms: hyper vigilance, increased startle reaction; intrusive and repetitive thoughts, feelings and behavior; difficulties concentrating, emotional liability; sleep and dream disturbances; physical symptoms related to chronic arousal (i.e. nausea, diarrhea, sweating); compulsive repetitions, various forms of self-medication (i.e. alcohol and drugs) along with other activities designed to avoid internal and external triggers.

Primary trauma
Treatment implication .
Those caught in Intrusive Phase need psycho-education and support.

Primary trauma
Denial Phase (Horowitz, 1976 )– a host of defensive and distortive mechanisms .
Symptoms: emotional numbing; inability’s to appreciate significance of internal/external stimuli; avoidance of certain topics/situations; amnesia (partial or complete); constrictive/inflexible thinking; use of fantasy to counteract reality; sleep disturbances; physical complaints (i.e. bowel problems, fatigue, headaches, hyper arousal); impulsivity ; overactivity (as a means of destruction); social isolation; self-blame; phobic responses; depression, anxiety ; diminished self-care; foreshortened sense of future ; re-enactment, along with continued substance abuse.

Primary trauma
Treatment implication .
Those caught in Denial Phase need to recall, process and integrate.

Primary Trauma
Core components of the trauma reaction (Anita’s story)
- Anxiety.
Feeling of helpless.
Grief and depression.
Relationships and Capacity for intimacy changed.
Loss of trust.
Meaning and identity destroyed.
View of future altered.
Guilt and Shame.
Fear.

Primary Trauma
Recovery Goals (Anita’s story)
Restore safety and enhance control.
Reduce the disabling effects of fear and anxiety.
Restore meaning and purpose to life.
Restore dignity and value to reduce excessive shame and guilt.
Restore attachment and connection with significant other for emotional support and care.

Primary trauma
Treatment Approaches :
Critical Incident Stress Debriefing (CISD) addresses critical incidents before they turn into traumatic events. Very helpful to those with strong identity structures and social support (i.e. disasters)
Cognitive Re-Framing – places trauma-generated realizations into language. Modifies existing schemes of self, other, world and God so that they can hold implications traumatic events have for future living (i.e. depression/anxiety and intrusive symptoms).

Primary Trauma .
EMDR (Eye Movement Desensitization Reprocessing) – based on systematic desensitization. Crucial component is repeated eye movement (while processing traumatic material). Helps client access and stay focused on network of traumatic material (trauma constellation). Repeated eye movements purportedly help integrate traumatic material into memory thus preventing a re-emergence of traumatic thoughts/events. Helpful with some, but not all, victims of trauma.

Primary Trauma
Behavioral – gradually increases exposure to traumatic material. Enables client to confront traumatic events without excessive anxiety (i.e. abuse/trauma).
Psychodynamic – analyses early internalizations (object relations), childhood abuse, defenses, character injuries and transferential dynamics (i.e. developmental injuries, personality disorders and identity issues).
Psychopharmacology – manages insomnia, hyper arousal, concentration difficulties, re-experiencing, depression/elevated moods (i.e. depression, anxiety and intrusive thoughts).

Primary Trauma
Narratives – Clients are experts of their lives. Focus on clients strengths and resources. Externalizing conversations and reflection practices. Through stories clients give meaning to their experience (s). Normalize experience.
Dream work – dreams are often symbolic or literal re-enactments of traumatic experience (s). Dreams frequently provide initial access to traumatic material (along with deeper meanings).

Primary Trauma
Sand Play – very effective approach for representing internal reality, especially on regards of trauma. Borders of sand tray help victims contain experiences that constantly threaten to overwhelm and for which there are often no words.
Art Therapy/Art as Therapy – provide shape and form to internal realities that often can not be expressed in words. Extremely helpful (especially with children and ESL adults).

Primary Trauma
Body Work – working out chronic muscular tension (i.e. Bio-Energetic Therapy), is very effective way of bringing traumatic material into awareness. Very helpful with those who have psycho-somatic symptoms.
Groups (Therapeutic, Self Help/Support, Psychodrama) confront denial, normalize experience and connect participants. Very helpful if run properly. Helpful groups tend to be relatively homogeneous.
Rituals – testimonies, visiting original scenes, memorials, educative missions, commemorative ceremonies and political actions. All create networks of solidarity, validate experience and prevent suppression.

Primary Trauma
Unresolved trauma is a major factor, if not a cause of, anxiety, depression, suicide, chronic fatigue, eating disorders, self-mutilation, substance abuse, various personality disorders, schizophrenia, schizotypal disorders, along with various phobias, bi-polar disorders, rheumatoid arthritis, neurological impairments, chronic pain and a host of sexual and bodily complaints.

Secondary Trauma
Those living/working in traumatic environments or related to victims such as policeman, soldiers, fire-fighters, teachers, counsellors, ministers, relief workers, doctors, nurses, hospice workers and family members are deeply affected by their stories, losses, and wounds of clients/loved ones.

Vicarious Traumatisation
Repeated exposure to stories of trauma creates stress reactions.
Trauma is toxic.
One cannot be close to trauma without being affected.
Regular detoxification is essential to self care and career longevity.

Secondary Trauma
Bodily reactions
- Stress.
- Chronic Fatigue.
- Diminished Self Care.
- Headaches along with various somatic c complains.

Secondary Trauma
Psychological reactions.
- Social withdrawal.
- Reduction of formerly pleasurable activities.
- Increases in work.
- Self sacrifice and care for others.
- Low –grade depression/anxiety.
- Inability to become rejuvenated through sleep/recreation.
- Drug and alcohol abuse.
- Other forms of addiction.
- Survivor guilt and unresolved grief.

Secondary Trauma
Attitudinal Reactions I
- Crisis of faith.
- Hyper-attunement to the “dark-side”.
- Poor decision making.
- Feeling powerlessness.
- Gravitation towards professions involving violence.
- Over or under involvement in the problems of others.

Secondary Trauma
Attitudinal Reactions II
- Impairments in interpersonal relationships, community living and prayer life.
- Relations to self, others and world become characterized by cynicism, pessimism, mistrust, anger, aggression and terror.
- Daily routines becomes structured around avoiding victimization, restoring justice, rescuing others or total withdrawal.

Common issues for helpers
Anger at source of victimization.
Anger at client because of intensity of affect.
Anger at society because of failure to help.
Fear of personal vulnerability and potential for victimisation.
Anxiety of ability to help client.
Guilt over being exempted and not suffering.
Empathetic sadness and grief reaction upon hearing the trauma story.
Avoidance of the trauma stories.

Worker’s Roles
Perpetrator (Anger)
Condemns client.
Refuses to work with client.
Rescuer (Guilt)
Takes on advocacy role for client.
Takes all responsibility for client’s recovery.
Victim (Frustration)
- Disappointed. Views client as unreasonable and ungrateful.
Not motivated to work with client.
Complaints about them.

Ideal range of involvement
Curiosity.
Empathy.
Developing strategies.
Developing partnership.
Focusing on resilience, strengths and resources.
Maintaining boundaries and limits.
Professional detachment.
Holistic Self care.

Organisational signs and symptoms
Widespread cynicism and pessimism.
Increase illness or absenteeism.
Ethical or boundary violations.
Reduction in motivation and productivity.
Higher staff turnover.

Levels of Awareness about ST in the Workplace
High
- Supportive conditions are assured.
- Decent work schedule and preventative care are assured.
- Workers are educated beforehand about the impact on themselves, their families and those they work with.
- Signs and symptoms of ST are acknowledged. Colleagues, supervisors and others address the issue.

Levels of Awareness about VT in the Workplace
Medium
- VT is recognised as a condition that creates work-related problems.
VT is recognised as a potential hazard of the work situation.
More attention is paid when workers show signs.
Circles of support are implemented at the workplace.

Levels of Awareness about VT in the Workplace
Low
Only extreme cases are acknowledged and these are sensationalised.
Cases are considered to be rare.
The existence of vicarious traumatisation at the worksite is denied.
Incidents are dismissed as isolated circumstances.

Secondary Trauma
Strategies:
- Recognize
- Normalize
- Respond (personally and professionally)

Secondary Trauma: Prevention and Self Care
Personal:
- Regular exercise and relaxation.
- Humour.
- Regular and adequate sleep.
- Healthy Diet and Regular holidays.
- Spending time with those who Celebrate life.
- Acknowledging limits/Monitoring levels of stress.
- Engaging in pleasurable and meaningful activities .

Professional I
- Preparation – know what trauma (symptoms and phases), along with risks working with victims of trauma.
- Ability to Self-diagnose (secondary stress reactions).
- Local support and buddy system.
Key: Regular sharing of work experiences with supportive peers. Weekly debriefing is ideal.
- Re-entry debriefing (after heavy experience).

Professional II
- Personal counselling when counter-transferential issues impede treatment.
-Training and consultation –therapeutic skills must be continually upgraded. The more effective therapist is less chance of “burn out” and feeling helpless/incompetent when working with victims of trauma.
- Supervision.
- Spirituality of trauma – system of beliefs and/or spirituality capable of addressing/holding traumatic material and implications that therapist is exposed to on a regular basis.

Organizational Trauma
Executive Dishonesty – lies, partial disclosure of information, lack of transparency and unethical practices.
Lack of proper redress in regard to firing, blocked promotions, sexual harassment, violent threats and character assassination.
Downsizing/redundancies done in cold and/or inhuman manner and often without collaboration or honesty.
Violence – character assassination, sexism, racism, homophobia, sexual assault, sexual misconduct, exploitation and murder.

Organizational Trauma
Personality disorders – key personnel with borderline/narcissistic personality disorders and /or substance abuse problems.
Theft and Embezzlement.
Corporate mismanagement.
Crisis-oriented management – lack of strategic planning and competent leadership.
Spiritual condemnation/blackmail by leaders, especially in religious organizations.

Introducing trauma awareness to an organisation.
Phase 1 – Research (i.e. find an agent of change).
Phase 2 – Presenting to the Proper person .
Phase 3 – Follow up.
Phase 4 – Further follow up.
Phase 5 – Long Range and Strategic Planning.
Education: - What trauma is.
- Trauma and its various forms.
- Short and long term effects of Trauma.
- Self Care for individuals and organisations.
- Regular debriefing for those returning from field assignments/critical incidents.

Introducing trauma awareness to an organisation.
Training
Individual (at all levels of the organization) need to be continually resourced and trained in order to:
Raise trauma awareness
Upgrade skills in regard to self care and treatment .
Policies and Procedures
Phase 6 - Reflecting on the Organization
.

Resources:
Grant, R., 2000, A comprehensive and Integrative Approach to the Diagnosis and Treatment of Trauma , Oakland, California.
Brown, D.,1997, Memory, Trauma treatment and the Law , WW Norton, NY.
Figley, C. (Ed.), 1985, Trauma and Its Wake , V1 and V2, Bruner Mazel, NY.
Figley, C. (Ed.), 1999, Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in those who treat the traumatized , Bruner Mazel, NY.
Herman, J. 1992, Trauma and Recovery , Basic Books, NY.
Horowitz, R, 1982, Stress Response Syndrome, Jason Aronson, NY.

Activity 1
Photo language
Reflection on our values and beliefs.

Secondary Trauma
Contact details:
Irena Quinn
Email: [email_address]
Phone: (08) 9345 5335
Thank you

Irena Quinn presenation

by mhcc on Jul 27, 2011

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