Recommended
More Related Content
What's hot
What's hot (19)
Similar to Trauma And Post Traumatic Stress For 2009 National Conference
Similar to Trauma And Post Traumatic Stress For 2009 National Conference (20)
More from MedicalWhistleblower
More from MedicalWhistleblower (20)
Trauma And Post Traumatic Stress For 2009 National Conference
- 1. Trauma and Post Traumatic Stress Dr. Janet Louise Parker, B.S., M.S., D.V.M. Medical Whistleblower “People are like stained glass windows. They sparkle and shine when the sun is out; but when the darkness sets in, their true beauty is revealed only if there is a light within.” Elizabeth Kübler-Ross
- 2. Positive Stress (or eustress) Competent management Mature leadership Everyone is valued and supported. enhances well-being Enhances performance and fuels achievement.
- 3. Negative Stress (or distress) Threat Coercion Fear Dysfunctional and inefficient management Diminishes quality of life Injury to health
- 4. Post Traumatic Stress Post Traumatic Stress Disorder (PTSD) is a natural emotional reaction to a deeply shocking and disturbing experience. It is a normalreaction to an abnormal situation.
- 5. Who Gets PTSD Crime Victims Persons experiencing death of family member, friend, co-worker Returning Veterans Cancer Survivors & their family Domestic Violence Victims Sexual Assault Victims Targets of Workplace Bullying
- 6. Origin is External not Internal Any human being has the potential to develop PTSD Cause external – Psychiatric Injury not Mental Illness Not resulting from the individual’s personality – Victim is not inherently weak or inferior DSM-IV-TR (APA, 2000)
- 7. Impact of Trauma Difficulty trusting others and forming close relationships (may appear withdrawn, uncooperative, defensive or aggressive). Fear or concern about safety. Difficulty managing and expressing feelings. Lack of belief in self-worth and capabilities.
- 8. Hyper-arousal Hypervigilance Irritability Depression Prone to anger Exaggerated startle response Sleep disturbance Dissociation Problems of concentration Vulnerability to medical illness
- 9. Traumatic Memory Reenactment play Perceptual illusions Dissociation, memory retrieval Intrusive recollections Nightmares Emotional (somatic) memories, actingout/ reliving trauma.
- 10. Denial Avoidance Emotional numbing, Amnesia, Loss of active social interpersonal engagement, Substance abuse, Social/geographical isolation Desexualization, estrangement and detachment Obsessive-compulsive Attention diversion as defense
- 11. Self-concept, Ego states Demoralization, ego fragmentation Identity diffusion Vulnerability Loss of spirit and vitality, dysphoria, Prone to dissociation, hopelessness and helplessness Shame, guilt Misanthropic beliefs Faulty cognitions
- 12. Interpersonal relations: Alienation Mistrust Detachment “Boundary” problems with others Issues of loss, abandonment Impulsiveness Self-destructive relationships
- 13. Patterns of anticipation Individuals suffering from PTSD live daily life as if the traumatic experience is recent, even though it may have happened years earlier. Triggers will cause the event to be re-experienced. “Isolation and paralysis of the mind”(Holter, 2005, abstract).
- 14. NCPTSD, July 4, 2007 32 % War experiences 48 % Abuse (spousal, childhood, sexual, bullying) 19 % Crime 18 % Accidents 8 % Acts of terrorism 5 % Natural disasters
- 15. Response to Chronic Stress Breakdown of immune system Increased heart rate and blood pressure Increased cortisol level Shrinking of the hippocampus (affecting learning and memory) Enlargement of the amygdala (affecting emotional behaviors)
- 16. Dissociation PTSD is “soul murder” Disconnection between the traumatic events and the meaning associated with those events Interferes with ability to verbalize the events and their meaning
- 17. 3 Levels of Victimization Loss of feelings of safety, loss of perception of an orderly world, and loss of a positive sense of self. 2. People do not believe, and deny the severity of the trauma thus blaming and stigmatizing the victim. (Ridicule and Punishment) 3. Perceiving oneself as a victim with no personal power
- 18. Daubert Standard Standard for admitting expert testimony Scientific basis for professional opinions Federal Rule of Evidence 702 when evaluating claims of psychological injuries as authorized by the Civil Rights Act of 1991
- 19. Trauma-Informed Services Trauma-informed Problems/Symptoms are inter-related responses to or coping mechanisms to deal with trauma. Providing choice, autonomy and control is central to healing. Primary goals are defined by trauma survivors and focus on recovery, self-efficacy, and healing. Proactive – preventing further crisis & avoiding retraumatization. Traditional Approaches Problems/Symptoms are discrete and separate. People providing services are the experts. Trauma Survivors broken, & vulnerable. Primary goals are defined by service providers and focus on symptom reduction. Reactive – services and symptoms are crisis driven and focused on minimizing liability.
- 20. Understanding Trauma Understanding trauma response and its triggers. Anxiety causes traumatized individuals to have difficulty in processing information. Recognize behaviors as adaptations. Identify and reduce triggers to avoid re-traumatization.
- 21. Poor Support – Intensifies Damage When an individual suffering from PTSD is unable to resolve issues related to the trauma he/she is unable to establish a new baseline of biopsychosocial functioning.
- 22. Secondary Re-Traumatization The loss of human potential is incalculable. Society has a tendency to blame the victim for not being able to simply “get over it” and this cultural lack of support can be classified as secondary wounding and promotes a victim mentality, thus keeping the problem going. “Human beings, like plants grow in the soil of acceptance, not in the atmosphere of rejection.” John Powell, S.J.
- 23. Re-Experiencing Trauma Re-experiencing original trauma (symbolically or actually). Trauma Survivor responds as if there is danger even if it is not actual danger. Triggers may be subtle and difficult to identify. “One of the most courageous things you can do is identify yourself, know who you are, what you believe in, and where you want to go.” Sheila Murray Bethel
- 24. Trauma Victims Disposable? Our society views many objects as disposable and when an object is tarnished or dented the tendency is to deem its value gone, throw it away, and rush to the stores to replace it. Humans are not objects, and the growth potential available though the healing process is infinite.
- 25. From Vulnerability to Strength Celebration – Self Actualization Overcoming Vulnerability – Recognition Compensation – Self Esteem Needs Sharing with Others (Sense of Belonging) Exploring Protection Needs Identifying Safety Needs Denial of Vulnerability Elimination of Danger Vulnerable
- 26. Promoting Safety Because PTSD is “soul murder” and splinters the sense of self, and creates acute mistrust in the individual’s environment . Provide a safe physical environment. Provide emotional safety: tolerance for wide range of emotions. A Sense of Safety is Critical to relationship building.
- 27. Build Trust – Long Term Process PTSD changes the diagnosed individual’s life and greatly impacts the lives of those with whom they are close and regularly interact. Trusting relationships are essential to combat the dehumanizing effect of trauma.
- 28. Supporting Control,Choice & Autonomy Trauma survivors feel powerless. Equalize power imbalances. Recovery requires a sense of power and control. Relationships should be respectful and support mastery. Trauma Survivors should be encouraged to make choices.
- 29. Communicating Openly “If I can listen to what he tells me, if I can understand how it seems to him, if I can sense the emotional flavor which it has for him, then I will be releasing potent forces of change within him.” Carl Rogers Respect Trauma Survivor’s right to open expression. Discourage withholding information or keeping secrets.
- 30. Integrating Care Because of the dehumanizing nature of trauma it is important that care approaches deal with the client holistically as opposed to treatments designed solely to reduce symptoms. Trauma Survivor’s symptoms and behaviors are adaptations to trauma. Services should address all of the survivor’s needs rather than just symptoms.
- 31. Fostering Healing Humans are not objects, and the growth potential available though the healing process is infinite. Instilling hope. Strengths-based approach. Future orientation. Cultural Competence
- 32. Inward Reflection Trauma causes individuals to look spiritually inward. The “healed self that was once traumatized can project itself into the future with joy, serenity, and a measure of wisdom.” Walsh (1985)
- 33. According to Wilson et al., 2001 Individuals, once healed, are “potential guides, healers, teachers, and may be subjects of scientific inquiry concerning resiliency, salutogenesis, and self-efficacy” UPSIDE to Trauma?
- 34. Inspirations “Great minds have purposes, others have wishes. Little minds are tamed and subdued by misfortune, but great minds rise above them.” Washington Irving “Sometimes I think that the main obstacle to empathy is our persistent belief that everybody is exactly like us.” John Powell, S.J. “The deepest craving of human nature is the need to feel appreciated.” William James “Great Things are not done on impulse but by a series of small things brought together.” Vincent van Gogh
- 35. Contact: Dr. Janet Parker DVM Executive Director Medical Whistleblower P.O. Box C Lawrence, KS 66044 MedicalWhistleblower@gmail.com
Editor's Notes
- This does not discount the impact the individual’s pre-trauma worldview, belief system, values orpersonality has on the interpretation of the trauma, but it does indicate that the individualis not inherently weak or inferior. Rather, it indicates severe trauma and stress createweakness in the individual, and not the reverse. (Matsakis, 1996) A trauma is awounding, thus individuals suffering PTSD are injured, not mentally ill, even thoughdiagnosed with a disorder from the DSM. This is confusing for mental healthpractitioners and laypersons alike. But the distinction is important if mental healthpractitioners desire to assist a traumatized client. (Field, 1996; Namie, 2000; Namie,2006; Hunter, 2007)
- Feelings, and the physiological reactions to these feelings, becomepatterns of anticipation, which in turn create more maladaptive feelings. Thus there is amutual interaction between the two that promotes “isolation and paralysis of themind”(Holter, 2005, abstract).The dehumanising aspect of the trauma creates feelings of not having a right toexist and promotes a sense of being a fraud because the individual, although actually ahuman, no longer feels connected to humanity and the human race. Treatment, therefore,becomes difficult because of a lack of trust, isolation from society, and a fear of feeling.(Currim, 2004; Hunter, 2007) Part of the dehumanising of the trauma is the “breakdownof cathexis, i.e., the failure of empathic connection at the time of the trauma”…resulting in“an inability to keep upright an inner empathic, emotional connection” (Holter, 2005,
- PTSD is often thought of as a war injury, yet an online survey conducted by theNational Center for PTSD (U.S.) reveals only 32 percent of respondents acquired thedisorder from war experiences. The majority of respondents (48 percent) are traumatizedthrough various forms of abuse (spousal, childhood, sexual, bullying). The statisticscontinue with 19 percent from crime, 18 percent from accidents, 8 percent from acts ofterrorism, and 5 percent from natural disasters. (NCPTSD, July 4, 2007)NCPTSD. (May 22, 2007). FAQs about PTSD assessment: For professionals. RetrievedJuly 4, 2007, fromhttp://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_prof_faqs_assessment.htmlNCPTSD. (June 1, 2007). How common is PTSD? Retrieved July 4, 2007, fromhttp://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_how_common_is_ptsdhtmlNCPTSD. (June 25, 2007). Helping a family member who has PTSD. Retrieved July 4,2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/helping_a_family_member.htmlNCPTSD. (July 4, 2007). PTSD today? Retrieved July 4, 2007, fromhttp://www.ptsdinfo.org/Not all trauma leads to PTSD. In fact, most people who experience a trauma donot develop the disorder. Sixty percent of men and 50 percent of women experience atrauma severe enough it might lead to PTSD. Yet only an approximately 8 percent of menand 20 percent of women will have a maladaptive reaction to the trauma and meet PTSDcriterion as listed in the DSM-IV-TR. Risk factors include being a victim of or witness toa traumatic event that was long lasting or severe and caused serious injury or danger.Feelings of helplessness and a severe reaction such as crying, shaking, vomiting, anddissociation are important contributors. (Schupp, 2006; NCPTSD, June 1, 2007)This disorder was first described in Vietnam War veterans, but has also been called "battle fatigue" and "war neurosis" in past wars. More than 50 percent of combat veterans may experience some form of PTSD, although the milder forms may not be diagnosed or treated. Combat veterans tend to experience more severe forms of PTSD because the duration and severity of trauma during war is greater, but the disorder is frequently diagnosed in civilians who have experienced and survived serious trauma. For example, the victims of serious accidents, rape survivors, people burned out of their homes, survivors of other natural disasters such as tornadoes, hurricanes and earthquakes, and violent crime victims all may develop PTSD. In each of these events, the threat of death or serious injury is present, and those who develop PTSD realized, or believed, that their lives were on the line.
- Because PTSD creates a constant state of intense stress the body’s reaction to thiscauses neurobiological changes. Glucocorticoids, epinephrine, and norepinephrine pulsethrough the body as part of the normal reaction to stress. These chemicals are importantfor human survival but excessive amounts cause the brain to malfunction. Because ofhyperarousal, the body of an individual suffering from PTSD gets too much of thesechemicals, even when no threat is present. The chronic stress promotes physical ailmentsand a breakdown of the immune system. Other difficulties include increased heart rateand blood pressure, changes to the distribution of cortisol (affecting mood and energylevels), shrinking of the hippocampus (affecting learning and memory), and enlargementof the amygdala (affecting emotional behaviours). (Horowitz, 1999, as cited in Schupp,2006; Resick, 2001; Pinel, 2007; Hunter, 2007)
- Dissociation interferes with the client’s ability to process appropriate meaning, thus respond appropriately, aswell as verbalize the events and their meaning. (Messler Davies, 1997; Hunter, 2007)Treating the symptoms of PTSD is not sufficient. Because of the destruction ofthe sufferer’s sense of self and ability to relate to themselves and others in a healthymanner, the symptoms are “linked to a dissociated representational memory system whichis implicated in”…a “profoundly negative self-perception” (Parson, 1998, abstract). Thisis demonstrated by dissociative behaviours and emotional swings, partly connected to thebi-phasic arousal states. (Parson, 1998, Schupp, 2006) Although cognitive behaviouraltherapy will meet with some success it is important the therapist promotes post-traumaticintegration of the trauma memories and the “new normal” in which the individual withPTSD lives. This needs to be done through “mutual relational dynamics” (Parson, 1998,abstract) within a trusted client–counsellor relationship. (Matsakis, 1996; Parson, 1998;Schupp, 2006; J. Douglas, personal communication, May 15, 2007)
- Due to the fragmentation of the sense of self, This is essential because horrific trauma is dehumanising and in order to come to terms with the trauma the victim dissociates, which impairs perception of identity and personhood. Thebi-phasic response in relation to allostatic load perpetuates maladaptive stress responses.
- In cases of sexual harassment, retaliation, and other forms of employment discrimination. First, the contribution experts can make by presenting a framework to assess and understand the nature, duration, intensity and severity of emotional injuries is outlined. Specialized knowledge helpful in assessing these claims is reviewed in light of the scientific literature on stressors, anxiety disorders, somatoform disorders, depression, posttraumatic stress disorder, and ways in which related symptoms manifest regarding events in the workplace or following loss of employment. Second, the role of qualified experts to facilitate determinations of causation is discussed, highlighting factors that bear on preexisting harm, intervening injurious events, the exclusion of alternate sources of mental distress, emotional harm and humiliation, and mitigation of damages.
- This leaves the individual vulnerable to triggers that bring on a re-experiencing of the trauma,in effect over the long run, intensifying the trauma. (Wilson, et al., 2001) The allostaticload and resulting bi-phasic arousal response do not allow for an escape from the reactionto the trauma. There is also a concern of the client developing Learned HelplessnessSyndrome. (Seligman, 1975, as cited in Matsakis, 1996) This can only be “counteractedthrough learning and changes in the social structure” (McEwen & Wingfield, 2003,abstract)Since anxiety is part of PTSD, teachers and parents need to be aware of a traumatized individual’s difficulty inprocessing information. This is also linked to Maslow’s (1970) hierarchy of needs.According to his theory “being needs”, the three higher-order needs, cannot be met untilthe “deficiency needs”, the four lower-order needs, are met.
- This is also linked to Maslow’s (1970) hierarchy of needs.According to his theory “being needs”, the three higher-order needs, cannot be met untilthe “deficiency needs”, the four lower-order needs, are met.PTSD changes the diagnosed individual’s life and greatly impacts the lives ofthose with whom they are close and regularly interact. The explosive rage, depression,isolation, anxiety, cognitive difficulties, and lack of vitality combine to cause loved onesto question if life will ever return to normal. Families and teachers can best help theindividual with PTSD by learning about the diagnosis and levels of victimization so as toavoid secondary wounding and enabling behaviour. A strong support network is essentialfor healing and families are an integral part of that network. Trusting relationships areessential to combat the dehumanizing effect of trauma. Also, according to the WorkplaceBullying and Trauma Institute findings (Namie, 2000) it is the most competent employeeswho tend to be targeted and 82 percent of those targeted either voluntarily or involuntarilyleave their jobs. (Namie, 2000; Blasé & Blasé, 2003; Namie, 2006)Because of the dehumanizing nature of trauma it is important that treatmentapproaches deal with the client holistically as opposed to treatments designed solely toreduce symptoms. (Wilson, et al., 2001) Mental health practitioners need to be aware ofthe criterion found in the DSM-IV-TR as well as the various ways to measure traumaexposure. However, in determining a PTSD diagnosis it is important to be aware thatsomeone suffering from PTSD has honed avoidance strategies and may not be able toverbalize their experience. (Hunter, 2007; NCPTSD, May 22, 2007)Many therapists practice narrative therapy believing this is essential to overcomingthe trauma. However, this approach may be harmful for some clients suffering fromPTSD. According to Schupp (2006) some clients do better never narrating the trauma andshould instead focus on coping techniques to deal with triggers. Because of the reexperiencingaspect of PTSD, grounding strategies to assist the client in remaining in thepresent are important. (Matsakis, 1996; Foa, Keane, & Friedman, 2000; Wilson et al.,2001; Schupp, 2006; Hunter, 2007; J.Douglas, personal communication, May 15, 2007)Grounding techniques are an important part of emphasizing that the current experience offear is an illusion. (Kopp, 1988; Wilson, et al., 2001) Other therapy strategies, such as debriefing, cognitive behavioural therapy (CBT),eye movement desensitization and reprocessing (EMDR), resource development andinstallation (used in conjunction with EMDR), psychodynamic therapy, emotionalfreedom techniques (EMT), exposure therapy, gestalt therapy, traumatic incidentreduction therapy (TIR), a form of neurolinguistic programming called visual/kinestheticdissociation (V/KD), logotherapy, visual imagery, various forms of creative therapies (artand journal), and hypnosis are used for treating PTSD. (Matsakis, 1996; Foa, et al., 2000;Wilson, et al., 2001; Schupp, 2006; Hunter, 2007) Hunter, 2007, feels hypnosis isineffective and damaging to clients with PTSD and should never be attempted, whereasothers view hypnosis as effective for reducing the anxiety associated with PTSD. (Daly &Wulff, 1987, as cited in Foa et al., 2000; J. Douglas, personal communication, May 15,2007)Because of the dehumanizing nature of trauma it is important that treatment approaches deal with the client holistically as opposed to treatments designed solely to reduce symptoms. (Wilson, et al., 2001) Mental health practitioners need to be aware ofthe criterion found in the DSM-IV-TR as well as the various ways to measure traumaexposure. However, in determining a PTSD diagnosis it is important to be aware thatsomeone suffering from PTSD has honed avoidance strategies and may not be able toverbalize their experience. (Hunter, 2007; NCPTSD, May 22, 2007)Many therapists practice narrative therapy believing this is essential to overcomingthe trauma. However, this approach may be harmful for some clients suffering fromPTSD. According to Schupp (2006) some clients do better never narrating the trauma andshould instead focus on coping techniques to deal with triggers. Because of the reexperiencingaspect of PTSD, grounding strategies to assist the client in remaining in thepresent are important. (Matsakis, 1996; Foa, Keane, & Friedman, 2000; Wilson et al.,2001; Schupp, 2006; Hunter, 2007; J.Douglas, personal communication, May 15, 2007)Grounding techniques are an important part of emphasizing that the current experience offear is an illusion. (Kopp, 1988; Wilson, et al., 2001)Other therapy strategies, such as debriefing, cognitive behavioural therapy (CBT),eye movement desensitization and reprocessing (EMDR), resource development andInstallation
- Because PTSD is “soul murder” (Schupp, 2006, p.59) and splinters the sense of self, the acute mistrust in the individual’s environment and possible co-morbid issues,such as depression and anxiety, can lead to social isolation and a decrease in socioeconomicstatus. (McEwen, 2000) The loss of human potential is incalculable.North American society has a tendency to blame the victim for not being able tosimply “get over it” and this cultural lack of support can be classified as secondarywounding and promotes a victim mentality, thus keeping the problem going. (Matsakis,1996; Namie, 2006) Additionally, our Canadian justice system views crime as occurringnot against individuals but against the crown, or society as a whole. This attitudereinforces the depersonalization of trauma and encourages PTSD among victims of crimeand reinforces their lack of human value in our disposable society. (S.B. Monaghan,personal communication, June 3, 2006)ConclusionsTrauma is destructive. But is there an upside to trauma? Some theoristsclaim there might be. Walsh (1985) feels trauma causes individuals to look inward and bylooking inward they become more in touch with their humanity and more able to reach outto others, thereby promoting a more complete human community. Wilson, et al. (2001)hopes that the “healed self that was once traumatized can project itself into the future withjoy, serenity, and a measure of wisdom” (p.12).Currently our society does little to support those suffering from PTSD. A changein attitude is essential if human potential is to be realized. Individuals, once healed, are“potential guides, healers, teachers, and may be subjects of scientific inquiry concerningresiliency, salutogenesis, and self-efficacy” (Wilson, et al., 2001, p.13). Our society viewsmany objects as disposable and when an object is tarnished or dented the tendency is todeem its value gone, throw it away, and rush to the stores to replace it. Humans are notobjects, and the growth potential available though the healing process is infinite.If the client is viewed, and learns to view his or her self, holistically, he or she is moreable to restore “a meaningful sense of self-sameness and self-continuity which”…promote feelings of “worth, dignity, wholeness, purpose, and an essential feeling ofvitality” (Wilson, et al., 2001, p.12).
- (Wilson, et al., 2001, p.13).