Transcript Trauma and the Missionary

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)
Which of these experiences did I find the
most traumatic? Why?
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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
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)
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Common Elements
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Feeling of helplessness
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Cultural aspects
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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
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husband unavailable
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Teaching
Sick
Best friends on home assignment
Other friends too far away (traffic) to help
Experiences of Fellow Missionaries
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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., bipolar, suicidology, cancer) of self or spouse
*Ferry sinking – hanging onto dead bodies overnight to
keep afloat until help came
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
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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)
Pragmatic Definition of Trauma
 Trauma
is anything that exceeds
one’s capacity to cope
Stress and Trauma are Related
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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)
Types of Stressors
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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
Common Stressors: From World Vision Survey
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Interpersonal
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Physical Environment
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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
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Travel difficulties, threatening checkpoints, rough roads
Excessive heat cold or noise
Shortages of resources
Housing/Privacy Issues
Vehicle Mechanical Problems
Organizational
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Separation from family due to work responsibilities
Conflicts between team members
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
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Feeling powerless to change the external situation
Fawcett (2003) as cited by Boecker (2007)
Impact of Traumatic Stress
Traumatic stress in a missionary population:
Dimensions and impact (Irvine, Armentrout & Miner, 2006)
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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
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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)
Hans Selye’s Research
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“Non-specific” stress responses
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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.)
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(1950’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.
Response to Acute Stressor
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Normal Response
 E.g.,
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(Schubert, 1987)
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
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Brief Psychotic Response
 Brief
Psychotic Disorder with marked stressor(s) or
Brief reactive psychosis (DSM-IV)
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Post Traumatic Disorder Response
Symptoms Related to
Posttraumatic Stress Disorder
(PTSD) and Dissociative
Disorders
Posttraumatic Symptoms
DSM-IV Criteria for PTSD
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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)
Reexperiencing
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Reexperiencing involves intrusive and
distressing:
 memories
 thoughts
 mental
images
 dreams
 flashbacks
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Additional reexperiencing symptoms for
children:
 traumatic
play
 dreams without recognizable content
 trauma-specific reenactments
Avoidant/Numbing
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Attempts to avoid exposure to reminders of
the trauma, including:
 thought
stopping
 social withdrawal
 amnesia for the trauma
 constriction of affect
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Avoidant symptoms for children include:
 constriction
of play
 social withdrawal
 decreased range of affect
Hyperarousal
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Hyperarousal symptoms include:
 irritability
 explosive
anger
 hypervigilance
 problems with concentration
 difficulty falling and staying asleep
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)
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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
BASK MODEL OF DISSOCIATION
 Behavior
 Affect (emotions)
 Sensation (physical)
 Knowledge
Full, integrated memory includes all four reassociated components.
Braun, 1988
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”
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BASK - BEHAVIOR
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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
BASK - AFFECT
 Affect
is dissociated from other
aspects of memory
 Example: feeling of fear for no
apparent reason
BASK – AFFECT (cont’d)
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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
BASK - SENSATION
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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
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
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DSM-IV Dissociative Symptoms
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Amnesia - A specific and significant block of time that
has passed but that cannot be accounted for by memory
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Depersonalization - Sense of detachment from one’s
self, e.g., a sense of looking at one’s self as if one is an
outsider
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A total cognitive avoidance response
The “K” component of BASK
A cognitive/affective avoidance response
The “A,” “S,” and “K” components of BASK
Derealization - A feeling that one’s surroundings are
strange or unreal.
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Either avoidance (e.g., distancing from actual surroundings) or reexperiencing (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
Dissociative Symptoms (cont’d)
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Identity Alteration - Objective behavior indicating
the assumption of different identities or ego states, much
more distinct than different roles
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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
Secondary and Associated
Symptoms
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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
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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
Factors Affecting Symptomatology
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
Factors of Individuals
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Biological
Developmental Level at Time of Trauma
Severity of Trauma
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Although subjective sense of impact more important
Social Context
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(Carlson, 1997; subpoints hg)
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
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“Innoculation” against the effects of a subsequent stressor
Reduction of an individual’s coping resources
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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).
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Unresolved issues may be driving people into service – abuse, survivor guilt,
unresolved grief
Other Factors
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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)
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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)
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Significant disruption to the individual, to the family,
property, or community as a result of the trauma
(Schubert, 1987 as cited by Boecker, 2007)
Factors that impact Trauma and
Stress Reactions
Background
Organizational
Support
Level of
Traumatic
Response
Traumatic
Event
Occupational
Environment
Fawcett (2003), as cited by Boecker (2007)
Resilience
Factors
Resilience
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Coping Styles
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Spirituality
Positive health behaviors
Social Support
Commitment
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Engagement with all aspects of life: social, work and family
Activities experienced as enjoyable and interesting
Belief in importance and value of self
Control
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Active vs. Avoidant
Perception that one can influence outcomes
Opposite of seeing self as passive recipient of circumstances
Challenge
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Belief that change is normal and anticipated
Adaptation of Fawcett (2003), as cited by Boecker (2007)
Intervention
Peer Debriefing – Critical Incident
Stress Debriefing (CISD)
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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)
Peer debriefing – Critical Incident
Stress Debriefing (CISD)
(cont’d)
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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)
Peer debriefing – Critical Incident
Stress Debriefing (CISD)
(cont’d)
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Goals
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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)
CISD Model – bathtub
Cognitive
Re-entry Phase
Introduction
Teaching Phase
Fact Phase
Thought Phase
Symptom Phase
Reaction Phase
Affective
Cautions
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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
CISD/CISM Training
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AACC accredited Critical Incident Stress
Management (CISM) training
 http://aacc.net/conferences/cism-07/
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ICISF (International Critical Incident Stress
Foundation) Listing of trainings
 http://www.icisf.org/training/calendarOfTrain.asp
Psychological First Aid (PFA)
(From:http://www.ncptsd.va.gov)
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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
Objectives of PFA
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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
Preparing to Deliver PFA
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Preparation
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Do you have adequate training for this particular population/setting?
 Do you know who is in charge/the command structure?
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Entering the setting
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Do you know what special needs there may be? (e.g., children, those with
disabilities etc.)
 Establish communication with organization/people in charge of operation
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Providing services for those who are
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Group settings
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Disoriented, confused, panicky, agitated/frantic, worried, angry, “shutdown”/withdrawn
Some principles can be used with groups (e.g., families, children,
adolescents)
Maintain a calm presence
Be sensitive to culture and diversity
Be aware of at-risk populations
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Children, risk-taking adolescents, pregnant women, injured, socially
disadvantaged
Core Actions for PFA
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Contact and Engagement
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Introduce yourself/ask about immediate needs
 Confidentiality
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Safety and Comfort
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Ensure immediate physical safety
Provide information about disaster response activities and services
Attend to physical comfort
Promote social engagement
Attend to children who are separated from their parents/caregivers
Protect from additional traumatic experiences and trauma reminders
Help survivors who have a missing family member
Help survivors when a family member or close friend has died
Attend to grief and spiritual issues
Provide information about casket and funeral issues
Attend to issues related to traumatic grief
Support survivors who receive death notification
Support survivors involved in body identification
Help caregivers confirm body identification to a child or adolescent
Core Actions for PFA (cont’d)
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Stabilization
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Stabilize emotionally-overwhelmed survivors
 Orient emotionally-overwhelmed survivors
 The role of medications in stabilization
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Information Gathering: Current Needs and Concerns
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Nature and severity of experiences during the disaster
Death of a loved one
Concerns about immediate post-disaster circumstances and ongoing
threat
Separations from or concern about the safety of loved ones
Physical illness, mental health conditions, and need for medications
Losses (home, school, neighborhood, business, personal property, and
pets)
Extreme feelings of guilt or shame
Thoughts about causing harm to self or others
Availability of social support
Prior alcohol or drug use
Prior exposure to trauma and death of loved ones
Specific youth, adult, and family concerns over developmental impact
Core Actions for PFA (cont’d)
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Practical assistance
 For
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immediate needs/concerns
Connection with social supports
 Family,
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friends, community resources
Information on coping
 Provide
info on stress reactions and coping to
help reduce distress and promote adaptive
functioning
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Linkage with collaborative services
 Immediate
or future
Counseling
Gingrich, H. D. (2002). Stalked by
Death: Cross-cultural trauma work
with a tribal missionary. Journal of
Psychology and Christianity, 21, 262265.
Phase-oriented Treatment
Safety
 Assessment
 Trauma Work
 Integration
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(Adapted from Herman, 1992/97)
Safety
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Physical/emotional/spiritual
 Within
and outside of the therapeutic
relationship
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Symptom management
 Journaling,
talking, prayer, meditation,
bibliotherapy, normalizing
 Agreements with self
 Ideomotor signalling
Assessment Instruments
Categories of Trauma Assessment Instruments
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Those that measure exposure to potentially traumatic events
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PTSD scales that closely follow DSM symptom criteria
Symptom checklists
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E.g., MMPI-PTSD (PK) Scale
Scales developed for culturally specific, or cross-cultural
research
Structured Interviews
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E.g., Traumatic Experiences Checklist
PTSD scales from larger inventories
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E.g., Revised Civilian Mississippi Scale for PTSD and Traumatic Stress
Schedule
Impact of Event Scale
Combinations of measures of exposure and symptoms
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E.g., Trauma History Questionnaire
E.g., Clinician-Administered PTSD Scale
Protocols
Assessment Instruments for
Dissociation/Dissociative Disorders
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Somataform Dissociation Questionnaire (SDQ5 or SDQ-20) (Nijenhuis, 1999)
Dissociative Experiences Scale-II (DES-II),
Adolescent Dissociative Experiences Scale,
and Child Dissociative Checklist (Putnam, 1997)
Structured Clinical Interview for DSM-IV
Dissociative Disorders-Revised (SCID-D-R)
(Steinberg, 1993)
Trauma Work
Trauma Work
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Talking, writing about details of trauma
“Exposure Therapy” (Taylor, 2006)
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Generally refers to specific cognitive-behavioral techniques
involving some type of exposure to traumatic memories
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Integration of BASK components
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E.g., taping client recounting details of traumatic event, then having
them listen to tape for 60 minutes every day
My experience has been that if a memory is recounted, with all
BASK components accessed, the memory will be integrated, and
further exposure is not necessary
May involve several recountings of event (i.e., facts, then
including affect etc.), or one recounting, with all BASK
components re-experienced
Importance not only of catharsis, but of integrating experience
into over-all understanding of life, beliefs, and calling
EMDR
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A specific technique for processing/integrating traumatic
experience
EMDR – Eye Movement
Desensitization and Reprocessing
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EMDR uses specific psychotherapeutic procedures to
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access existing information
introduce new information
facilitate information processing and
inhibit accessing of information
EMDR is used within an 8-phase approach to trauma
treatment in order to insure sufficient client stabilization
and reevaluation before, during and after the processing
of distressing and traumatic memories and associated
stimuli
http://emdria.org/displaycommon.cfm?an=1&subarticlenbr=3
The Challenge
To be aware of the situations that can lead
to traumatic stress
 Have appropriate procedures in place
 Intervene appropriately
…so that by entering into the depths of
others’ suffering, we can see them restored
to effective service for the Kingdom of God.
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Copies of this presentation can be
downloaded from
www.careandcounselasmission.org
References/Bibliography
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American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders
(text revision). Washington, DC: Author.
Boecker, B. (2007). Trauma and the missionary: An education project. Unpublished manual for
Denver Seminary Class, CO 646 Counseling for Trauma and Abuse.
Braun (1988). The BASK model of dissociation: Clinical applications. Dissociation, 1(2), 16-23.
Carlson, E. (1997). Trauma assessments: A clinician’s guide. New York: Guilford Press.
EMDR International Association, EMDRIA’S definition of eye movement desensitization and
reproecessing. Retrieved April 23, 2007
http://emdria.org/displaycommon.cfm?an=1&subarticlenbr=3
Fawcett, J. (Ed.). 2003. Stress and trauma handbook: Strategies for flourishing in demanding
environments. Monrovia CA: World Vision International.
Gatchel, R. J. (1994). Stress and coping. In B. Parkinson & A. M. Colman (Eds.), Emotion and
motivation. London: Longman.
Grant, R. (1995). Trauma in missionary life. Missiology: An International Review, 23, 71-83.
Gingrich, H. D. (2002). Stalked by Death: Cross-cultural trauma work with a tribal missionary.
Journal of Psychology and Christianity, 21, 262-265.
Herman, J. (1992/97). Trauma and recovery: The aftermath of violence-from domestic abuse to
political terror. New York: Basic Books.
Irvine, J., Armentrout, D. P. & Miner, L. A. (2006). Traumatic stress in a missionary population:
Dimensions and impact. Journal of Psychology and Theology,34, 327-336.
Mitchell, J. & Everly, G. (1992). Critical Incident Stress Debriefing: An operations manual for the
prevention of traumatic stress among emergency services and disaster workers. Maryland:
Chevron Publishing Corporation.









McFarlane, A. & Girolamo, G. (1996). The nature of traumatic stressors and the
epidemiology of posttraumatic reactions. In B. A. van der Kolk, A. C. McFarlane,
& L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience
on mind, body, and society. New York: Guilford Press.
Nijenhuis, E. R. S. (1999). Somatoform dissociation: Phenomena, measurement,
and theoretical issues. Assen, The Netherlands: Van Gorcum.
Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental
perspective. New York: Guilford Press.
Shapiro, R. (2002). EMDR treatment: Overview and integration. In EMDR as an
integrative psychotherapy approach: Experts of diverse orientations explore the
paradigm prism. Washington, D. C.: American Psychological Association.
Schubert, E. (2005). The trauma spectrum: Hidden wounds and human
resiliency. New York: Norton.
Selye, H. (1974). Stress without distress: How to use stress as a positive force to
achieve a rewarding lifestyle. New York: New American Library.
Steinberg, M. (1993). Structured Clinical Interview for DSM-IV Dissociative
Disorders (SCID-D). Washington, DC: American Psychiatric Press.
Taylor, S. (2006). Clinician’s guide to PTSD: A cognitive-behavioral approach.
New York: Guildford Press.
van der Kolk, B. A., Weisaeth, L., & van der Hart, O. (1996). History of trauma in
psychiatry. In B. A. vander Kolk, A. C. McFarlane, & L. Weisaeth (Eds.),
Traumatic stress: The effects of overwhelming experience on mind, body, and
society. New York: Guilford Press.