Traumatic Stress and International Christian Workers: Assessment and Intervention

1. This presentation can be downloaded from www.careandcounselasmission.org Traumatic Stress and International Christian Workers: Assessment and Intervention AACC- September 29, 2011 Heather Davediuk Gingrich, Ph.D. Denver Seminary Care and Counsel International (CCI)

2. Which of these experiences did I find the most traumatic? Why? • Visiting missionary friends who lived in a dangerous part of the country • Hearing of a bus bombing within a block of the seminary • Hearing of a mall bombing in a mall we were in weekly • Our 10-year old diagnosed with potentially fatal dengue fever • Forced out of taxi when streets were flooded (within 3 months of arrival) • Stopped by traffic police when alone with a 3 and 4-year old • Seeing blood stains on roadway in front of our house where 2 people were murdered in the night • Sudden onset of urinary tract infection • Family pet dog hit by car • Finding out mall closing early because of coup attempt several miles away • Berating by a Filipino-Canadian for content of my presentation on the Philippines during first home assignment • Hearing of the Burnham’s kidnapping

3. Answer • Sudden onset of urinary tract infection • Family pet dog hit by car • Forced out of taxi when streets were flooded (within 3 months of arrival)

4. Common Elements • Feeling of helplessness • Cultural aspects • Not knowing where vet clinic was • Being turned away at first one • Not knowing what to expect at hospital/vet clinic • Fear of not being able to communicate sufficiently • Dealing with emotional reactions of children/house helper • Feeling of isolation • husband unavailable • Teaching • Sick • Best friends on home assignment • Other friends too far away (traffic) to help

5. Experiences of Fellow Missionaries • Single woman kidnapped and raped (she had been a virgin) while visiting friends – held for a week • Married man – long-time missionary – kidnapped – held for 3 months in a bamboo cage • Husband killed by suitcase bomb while picking up his wife at the airport • Woman came very close to death from dengue fever while husband was out of the country • Traveling companion/friend murdered 3 feet from her • Death threats • Driving a car that killed a national in an accident • Kidnapping by insurgents - marched through jungle at night for many months – caught in cross-fire of numerous gun battles – horrendous living conditions • Mental illness or serious physical illness on field (e.g., bi-polar, suicidology, cancer) of self or spouse • *Ferry sinking – hanging onto dead bodies overnight to keep afloat until help came

6. Experiences of Other Missionaries • Evacuation because of war • Witnessing war-related atrocities • In jeep that flipped over into water with only a small airspace in which to breathe

7. Although particular objective events are often defined as traumatic: • Subjective components actually most important in symptom development • “No trauma is so severe that almost everyone exposed to the experience develops PTSD”(McFarlane & Gerolama, 1996, p. 148) • Only 25-35 % of people who are exposed to a traumatic experience develop PTSD (Carlson, 1997, p. 4)

8. Pragmatic Definition of Trauma Trauma is anything that exceeds one’s capacity to cope

9. Stress and Trauma are Related • Definition of Stress “any force of nature or experience that disrupts physiological equilibrium” (Scaer, 2005) • We need a certain amount of stress to get going but stress can build to the point of being unhealthy • Most missionaries live at stress levels that are beyond the average person in their home culture – This could mean greater resilience or greater risk (From Boecker, 2007)

10. Types of Stressors • 3 categories of stressors: • Cataclysmic events- have a sudden, powerful impact and universally elicit a stress response, e.g., war, natural disaster, nuclear accident • Personal stressors - strong and unexpected • Background stressors - daily hassles, e.g. commuting, job dissatisfaction, type of job - short-term not as much of a problem, but long-term make require more adaptive responses Lazarus and Cohen as cited in Gatchel, 1994

11. Common Stressors: From World Vision Survey • Interpersonal • Separation from family due to work responsibilities • Conflicts between team members • Physical Environment • Travel difficulties, threatening checkpoints, rough roads • Excessive heat cold or noise • Shortages of resources • Housing/Privacy Issues • Vehicle Mechanical Problems • Organizational • Lack of direction from management • Lack of recognition for work • Being asked to perform duties that are outside ones professional training • Criticism of work by agency authorities • Community/Host Country • Feeling hostility from the host country/environment • Being watched or under surveillance • Oppressive leadership in the community • Criticisms of work by media or community members • Existential • Feeling powerless to change the external situation Fawcett (2003) as cited by Boecker (2007)

12. Impact of Traumatic Stress

13. Traumatic stress in a missionary population: Dimensions and impact(Irvine, Armentrout & Miner, 2006) • N=173 • 80.1% reported traumatic stress • 35% reported their symptoms have continued • 38% reported some form of permanent negative change • Non catastrophic events had greater total impact than catastrophic ones • no differences of impact on acute or gradual onset • Support failure (SF: i.e., interpersonal and organizational) most frequent • 75 % of those reporting SF had a permanent negative change • “ We had a hurricane and not one of the leaders called or wrote…. No one really reached out to me or was even sensitive or seemed to care about what I was going through… I felt completely alone and rejected” (p. 333) • Younger missionaries more likely to experience permanent negative change • 2/3 of population reported a positive sequel to their stressful experiences (i.e., mixed)

14. Hans Selye’s Research(1950’s) • “Non-specific” stress responses • regardless of the stressor, there is a predictable triad of responses: 1) enlargement of adrenal glands ( 2) shrinkage of thymus gland and 3) bleeding ulcers • stressor excites hypothalamus→, pituitary stimulated to produce ACTH (adreno-corticotrophic hormone) →,adrenal stimulated to secrete corticoids,→ shrinkage of thymus (which is involved in immune defense) • “General adaptation syndrome” (G.A.S.) • 1) alarm reaction (initial decrease in resistance 2) stage of resistance (adaptation to continued stressor; alarm reaction disappears) 3) stage of exhaustion • following long-term exposure; alarm reaction disappears, but are irreversible effects • diseases of adaptation occur, e.g., kidney disease, arthritis, cardiovascular disease (Gatchel) • “Specific effects” that specific stressors have in addition to the non-specific or G.A.S.

15. Response to Acute Stressor (Schubert, 1987) • Normal Response • E.g., G.A.S. (hg) • Adjustment Disorder Response (DSM-IV) • Clinically significant symptoms develop within 3 months of onset of stressor, and do not last longer than 6 months after termination of stressor or its consequences • Can be acute or chronic, with depressed mood, anxiety, mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, unspecified • Brief Psychotic Response • Brief Psychotic Disorder with marked stressor(s) or Brief reactive psychosis (DSM-IV) • Post Traumatic Disorder Response

16. Symptoms Related to Posttraumatic Stress Disorder (PTSD) and Dissociative Disorders

17. Posttraumatic Symptoms

18. DSM-IV Criteria for PTSD • Exposure to traumatic event (specific criteria) • 1 or more re-experiencing symptom • 3 or more avoidant • 2 or more hyperarousal • Duration of more than 1 month (less than 1 month see Acute Stress Disorder)

19. Reexperiencing • Reexperiencing involves intrusive and distressing: • memories • thoughts • mental images • dreams • flashbacks • Additional reexperiencing symptoms for children: • traumatic play • dreams without recognizable content • trauma-specific reenactments

20. Avoidant/Numbing • Attempts to avoid exposure to reminders of the trauma, including: • thought stopping • social withdrawal • amnesia for the trauma • constriction of affect • Avoidant symptoms for children include: • constriction of play • social withdrawal • decreased range of affect

22. Hyperarousal • Hyperarousal symptoms include: • irritability • explosive anger • hypervigilance • problems with concentration • difficulty falling and staying asleep

24. Additional Symptoms for Children • behavioral regressions (e.g., language, toilet training) • new fears or aggression • loss of social, academic and self-care skills • inappropriate sexual behavior (if sexually abused) • somatic symptoms (as traumatic reenactments)

25. Definition of Dissociation Disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment (DSM-IV-TR), sensation and motor function. Normal versus Pathological Dissociation

26. BASK MODEL OF DISSOCIATION • Behavior • Affect (emotions) • Sensation (physical) • Knowledge Full, integrated memory includes all four re-associated components. Braun, 1988

27. BASK - KNOWLEDGE • Trauma survivor has full or partial cognitive knowledge of traumatic event • Cognitive knowledge of the trauma is dissociated from behavior, affect and sensation • Generally what people mean when they say “I remember”

28. BASK - BEHAVIOR • Behavior is dissociated from other aspects of memory • Individual acts in a certain manner without knowing why • Examples: -avoiding contact with particular nationals -avoiding certain types of travel (e.g., refusing to ride in a jeep) -nausea at specific foods

29. BASK - AFFECT • Affect is dissociated from other aspects of memory • Example: feeling of fear for no apparent reason

30. BASK – AFFECT (cont’d) • There are no feelings attached to the cognitive knowledge of the memory -flat affect -matter-of-fact tone of voice e.g., can talk about atrocities as though discussing the heat of the coming summer

31. BASK - SENSATION • Physical sensation is dissociated from other aspects of memory • Individual may have cognitive knowledge of the traumatic event, be aware of related affect, and understand some behavior, but not remember the pain or pleasure associated with the trauma • Examples: -body memories – physical symptoms such as bleeding or severe pain occur in the present but are unexplained

32. Integration • Any, or all 4 BASK components can be dissociated from each other • All 4 BASK components of an experience need to be integrated for full integration of an experience

33. DSM-IV Dissociative Symptoms • Amnesia -A specific and significant block of time that has passed but that cannot be accounted for by memory • A total cognitive avoidance response • The “K” component of BASK • Depersonalization - Sense of detachment from one’s self, e.g., a sense of looking at one’s self as if one is an outsider • A cognitive/affective avoidance response • The “A,” “S,” and “K” components of BASK • Derealization - A feeling that one’s surroundings are strange or unreal. • Either avoidance (e.g., distancing from actual surroundings) or re-experiencing (e.g., a full flashback where one is not in touch with current reality but is reliving the traumatic event) • The “K” component of BASK

34. Dissociative Symptoms (cont’d) • Identity Alteration - Objective behavior indicating the assumption of different identities or ego states, much more distinct than different roles • Avoidance (another part of self takes on the traumatic memory) or re-experiencing (another part of self internally relives the event) • “B,” “A,” “S,” and “K” components of BASK • Identity Confusion - Subjective feelings of uncertainty, puzzlement, or conflict about one’s identity

35. Secondary and Associated Symptoms • Developed in response to the core trauma symptoms • Include depression, aggression, low self-esteem, disturbances in identity, interpersonal relationships, guilt and shame • Example of secondary symptom • Person shows aggressive behavior after a traumatic experience, then receives negative feedback from the social environment • Could result in low self-esteem or depression Carlson, 1997

36. Factors Affecting Symptomatology

37. General Factors Affecting Symptomatology(Carlson, 1997) Three defining features of traumatic events that are necessary although not sufficient for developing PTSD symptoms: • Perception of the Event as Negative • Suddenness (although study by Irvine et al., 2006, calls this into question) • Lack of Controllability

38. Factors of Individuals(Carlson, 1997; subpoints hg) • Biological • Developmental Level at Time of Trauma • Severity of Trauma • Although subjective sense of impact more important • Social Context • Fits with Irvine et al.’s study re: System Failure (SF), i.e., in SF, not only is the social context not supportive, but can be a source of TS in itself • Prior and Subsequent Life Events • “Innoculation” against the effects of a subsequent stressor • Reduction of an individual’s coping resources • E.g., child abuse associated with PTSD in war vets • Growing up in a traumatic environment makes one a prime candidate to unwittingly seek out traumatic situations in adult life (Grant, 1995). • Unresolved issues may be driving people into service – abuse, survivor guilt, unresolved grief

39. Other Factors • Choice of Psychological Defense • E.g. peritraumatic dissociation • “Dissociation at the moment of trauma appears to be the single most important predictor for the establishment of chronic PTSD.”(Van der Kolk, Weisaeth, & van der Hart, 1996, p. 66) • Gender, Race and Culture • Temporal Stability or Instability of Symptoms • Discrete vs. Chronic Traumatic Experiences (Carlson, 1997; van der Kolk and McFarlane, 1996; van der Kolk, Weisaeth, and van der Hart, 1996; deVries, 1996) • Significant disruption to the individual, to the family, property, or community as a result of the trauma (Schubert, 1987 as cited by Boecker, 2007)

40. Factors that impact Trauma and Stress Reactions Background Organizational Support Level of Traumatic Response Traumatic Event Occupational Environment Resilience Factors Fawcett (2003), as cited by Boecker (2007)

41. Resilience • Coping Styles • Active vs. Avoidant • Spirituality • Positive health behaviors • Social Support • Commitment • Engagement with all aspects of life: social, work and family • Activities experienced as enjoyable and interesting • Belief in importance and value of self • Control • Perception that one can influence outcomes • Opposite of seeing self as passive recipient of circumstances • Challenge • Belief that change is normal and anticipated Adaptation of Fawcett (2003), as cited by Boecker (2007)

42. Intervention

43. Peer Debriefing – Critical Incident Stress Debriefing (CISD) • Definition – The CISD is a structure small group or individual crisis intervention process. It is an active temporary and supportive small group or individual process that focuses on building a group’s resilience and the ability to bounce back from a traumatic exposure. (pg. 126 CISD manual, as cited by Boecker, 2007)

44. Peer debriefing – Critical Incident Stress Debriefing (CISD) (cont’d) • What it is not • Psychotherapy (counseling)– or a substitute for psychotherapy • A treatment for PTSD or any mental or physical disease or disorder • A cure for PTSD or any mental or physical disease or disorder • An organizational problem solving process for administrative problems (pg. 126 CISD manual, as cited by Boecker, 2007)

45. Peer debriefing – Critical Incident Stress Debriefing (CISD) (cont’d) • Goals • Lower tension and mitigate a small group or individual’s reaction to a traumatic event • Facilitation of normal recovery processes of normal people with in a small group or one on one who are having normal reactions to an abnormal event. • Identification of people who may need additional support or in some cases a referral to professional counseling. • Best applied – within 24-72 hours after a traumatic event. Providers must assess for psychological readiness for assistance. • Providers must be trained and follow the standard procedures (pg. 126 CISD manual, as cited by Boecker, 2007)

46. CISD Model – bathtub Cognitive Re-entry Phase Introduction Teaching Phase Fact Phase Thought Phase Symptom Phase Reaction Phase Affective

47. Cautions • Never view peer debriefing as a definitive solving of peoples’ needs • Assess for long term issues (cumulative stress or trigger trauma that is brought to the surface) • ALWAYS know your limitations • Know when people need to get longer term help

48. CISD/CISM Training • AACC accredited Critical Incident Stress Management (CISM) training • http://aacc.net/conferences/cism-07/ • ICISF (International Critical Incident Stress Foundation) Listing of trainings • http://www.icisf.org/training/calendarOfTrain.asp

49. Psychological First Aid (PFA)(From:http://www.ncptsd.va.gov) • Immediate response in disaster/terrorist situations (within first few days or weeks) • For children, adolescents, parents, families, and adults • Developmentally and culturally adaptive • Flexible – based on needs of individuals • Recognize that not everyone will respond the same way • Different than debriefing (which is not allowed) • Free info and manuals available at above website

50. Objectives of PFA • Establish human connection • Enhance safety and provide ongoing physical and emotional comfort • Calm and orient distressed survivors • Help survivors talk about immediate concerns/needs • Offer practical information and assistance to address immediate needs • Connect survivors to social supports • Support adaptive coping (e.g., acknowledge coping efforts and strengths) • Provide info to enhance coping • Be clear about your availability and link them to other support services • It is NOT to elicit details of trauma