Abstract and Keywords
This entry summarizes the current state of knowledge about the nature of trauma and intervention with trauma reactions. It includes the history of traumatology, demographics, theory, research and best practices, controversies, and current trends as well as diversity issues and international and interdisciplinary perspectives.
The field of traumatology—the study of trauma—is relatively young; its current manifestation began in the 1980s. Its roots, however, date back to the nineteenth century.
As early as 1859, Briquet (Crocq & De Verbizier, 1989, as cited in van der Kolk, Weisaeth, & van der Hart, 1996) observed a connection between hysteria and childhood trauma, and in 1878, Tardieu and colleagues (Tardieu, 1878, as cited in van der Kolk et al., 1996) were among the first to document the sexual abuse of children. Shortly thereafter, Fournier suggested that some memories of incest were false (van der Kolk et al, 1996). By 1887, Charcot had identified "the hypnoid "(dissociative) state as the key element of trauma reactions (Charcot, 1887, as cited by van der Hart & Horst, 1989). Building on Charcot's work, Janet provided extensive case data demonstrating linkages between hysteria and trauma, and describing the phenomenon of dissociation and the fragmentation of traumatic memory (Crocq & Le Verbizer, 1989, as cited by van der Kolk et al., 1996) As a result, Freud proposed that childhood trauma, especially incest, caused hysteria (Freud, 1896, 1962a, as cited in van der Kolk et al., 1996). He subsequently abandoned this theory, however, and postulated that memories of sexual abuse were, instead, fantasies resulting from psychosexual conflicts (Freud, 1986, 1962b, as cited in van der Kolk et al., 1996). Later, when confronted with World War I veterans' symptoms, Freud proposed two models of trauma: (a) unbearable situations (for example, war) and (b) unacceptable impulses (for example, fantasies of childhood sexual abuse) (Krystal, 1978). Thus, from its beginning, those interested in traumatology struggled with such issues as the nature of traumatic memories, false memories, and distinguishing between the trauma of war from the trauma that can occur in intimate relationships (van der Kolk, Weisaeth, & van der Hart, 1996).
Throughout most of the 20th century, the segregation of civilian and wartime trauma reactions continued, including observations of reactions to disasters such as the 1942 Cocoanut Grove nightclub fire in Boston and the 1972 Buffalo Creek flood in West Virginia, and Kardiner's 1940s descriptions of the traumatic neuroses of war. It was not until the mid-1970s that the separate threads were united to identify a common reaction to any trauma, in part as a result of political efforts by Vietnam veterans and others.
This, in combination with advocacy from professional mental health practitioners and researchers, culminated in the introduction of post-traumatic stress disorder (PTSD) as a diagnosis in 1980 in the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders(DSM-III). At that time, trauma was defined as an event outside the range of normal experience. Because later research indicated that exposure to a trauma was common, however, the diagnostic definition changed to experiencing or witnessing an event involving “actual or threatened death or serious injury, or a threat to physical integrity of self and other” (American Psychiatric Association, 2000, p. 467) in the DSM-IV. This definition encompasses a wide range of experiences, such as war, torture, natural disasters, terrorism, physical abuse, sexual abuse and rape, assaults, serious physical illness or injury, and death of a loved one.
The 1995 National Comorbidity Survey reported prevalence rates for exposure to any trauma at 63% for men and 51% for women (Kessler, Sonnega, & Bromet, 1995). The most common were witnessing someone being killed or badly hurt, involvement in a fire or natural disaster, and involvement in a life-threatening accident. Men reported experiencing each of these—as well as combat, physical attacks, being threatened with a weapon, and being kidnapped—more frequently than did women. Women were more likely to report rape, sexual molestation, and childhood physical abuse or neglect.
Although exposure to traumatic events in the general population is widespread, the National Comorbidity Survey found the lifetime prevalence rate for PTSD to be 8% in the general population in the 1995 study, and 9% in the 2005 replication (Kessler et al., 2005). The 1995 study found that women were twice as likely as men (10% versus 5%) to have PTSD during their lifetimes. PTSD was more likely to result from exposure to some types of traumas over others. Among both men and women who experienced a trauma, rape was most likely to result in PTSD (65% of men, 46% of women), whereas childhood neglect was the least likely for women (28%), and childhood molestation the least for men (27%).
Within the U.S. general population, there appear to be no significant differences in lifetime PTSD rates among the major racial-ethnic groups—the National Comorbidity Survey 2005 Replication found that Hispanics report the lowest rates (5.9%), followed by non-Hispanic whites (6.8%) and non-Hispanic blacks (7.1%). The intersection of race-ethnicity and poverty can markedly increase vulnerability, however. Trauma and PTSD rates are likely to be higher among people living in high-violence areas (for example, inner cities) than among the general population. Similarly, large-scale disasters, such as hurricanes Katrina and Rita in 2005, have a greater impact on those with few resources—among displaced families, almost half reported child mental health problems that were not present prior to those hurricanes (Abramson & Garfield, 2006).
Assessment of Trauma
Increased understanding about trauma exposure has led to a more complex understanding of the range of psychological reactions to trauma. As of 2013, there were two psychiatric disorders that include trauma exposure at the core of their definitions: acute stress disorder and post-traumatic stress disorder (PTSD). The former can begin within four weeks after exposure to the trauma. A disorder that lasts longer than four weeks is diagnosed as PTSD, and it can begin years after the onset of a trauma, although it is most likely to occur within the first three months. It is noteworthy that prior exposure to a trauma increases the risk of having PTSD after a subsequent traumatic event (Halligan & Yehuda, 2000).
It is now recognized that depression and anxiety disorders are also very common reactions to trauma. In addition, most people with dissociative disorders, substance-use disorders, child- disruptive-behavior disorders, and borderline personality disorder have a history of some type of trauma exposure. As a result, some clinicians and researchers (for example, Ross, 2000) maintain that trauma is responsible for a large portion of mental and substance-use disorders.
Many theories have played an important role in shaping understanding of the impact of and recovery from trauma. The specific theories and concepts discussed are information processing, Type I/Type II trauma, social cognitive theories, and disaster psychology. Information-processing theory underlies much of what, in the early 21st century, guides PTSD treatment and is based on the 1977 work of Lang. Simply stated, Lang proposed that fearful experiences are stored in the brain in emotionally charged images and related physiological, semantic, and behavioral responses; in order for new learning to occur, these networks must be activated and then emotionally processed, or “digested.”
Also key has been distinguishing between two major types of traumas, beginning with the work on childhood trauma by Lenore Terr (1991). Type I traumas are sudden and unexpected—such as the sudden death of a parent—and most typically result in the standard symptoms of PTSD. In contrast, Type II traumas are longstanding and repeated extreme events, such as ongoing violence exposure from war, physical abuse, or sexual abuse. Type II traumas more typically result in denial, psychic numbing, dissociation, and rage, although PTSD symptoms may also be present. Judith Herman's (1992) work added depth to understanding this latter type—she coined the term complex trauma to refer to Type II reactions and identified the following additional sequelae: affect regulation difficulties and pathological changes in relationships and in identity. She advocated conceptualizing many mental health problems, especially borderline personality disorder, as a consequence of trauma.
Critical to understanding the impact of trauma has been the work of several social-cognitive theorists (for example, Janoff-Bulman, 1992; McCann & Pearlman, 1990). Their theories focus on the importance of beliefs affected by trauma. Traumatic events can shatter a sense of safety and predictability, and they can result in self-blame. When trauma is caused by trusted others, as in the case of child abuse and family violence, it can result in subsequent trust problems in interpersonal relationships.
Finally, theories of disaster psychology and crisis intervention have guided the understanding of individual and community reactions and how best to intervene after a disaster. During the impact phase, when the disaster strikes, people need to focus on protecting themselves and others. Immediately following the disaster is the recoil and rescue phase, in which recovery and rescue efforts begin—intervention is directed at meeting practical and survival needs. People who are stunned and confused need to be both protected and compassionately directed to safe places. Following this, intervention focuses on connecting people with loved ones, obtaining accurate information, and establishing some sense of predictability. The recovery phase is the prolonged period of readjustment characterized by efforts to return to some stable day-to-day individual and community life; when damage and disruption have been significant, this phase can be lengthy. Often, disillusionment sets in as the attention of others is directed elsewhere and many needs continue to be unmet. This is when significant emotional and mental health problems may arise and when people may need to receive more focused trauma treatment (Raphael, 2000).
Latest Research and Best Practices
The International Society for Traumatic Stress Studies (ISTSS) (Foa, Keane, Friedman, & Cohen, 2009) and organizations such as the U.S. Department of Veterans Affairs Department Defense (2010) periodically review the literature and issue practice guidelines. The PTSD practice guidelines for adults that were current in 2013 identified that trauma-focused cognitive-behavior therapy, stress-inoculation therapy, and eye-movement desensitization and reprocessing (EMDR) were the psychosocial treatment methods with strong research support. A Cochrane Collaboration review of PTSD treatments, conducted by Bisson and colleagues (2007), recommends cognitive behavior therapy or EMDR for psychological treatments, and for pharmacological treatment, the selective serotonin reuptake inhibitors.
Current research has also focused on identifying risk factors for PTSD. Among the most accepted factors are prior traumatic or significant loss experiences, dissociation during the current traumatic event, severity and duration of the trauma, proximity to the trauma, lack of social support, prior psychiatric disorder, and heavy alcohol or drug use during the trauma (Halligan & Yehuda, 2000; Litz, Gray, Bryant, & Adler, 2007).
Research on PTSD treatment for children is still in its early stages, but the intervention with the strongest support has been trauma-focused cognitive-behavior therapy. Research on acute stress disorder and early intervention is in its preliminary stages.
Because of a lack of large-scale research, treatment of people with more complex trauma reactions is guided by general practice standards. The consensus is that intervention with this population should follow a phase-oriented approach that focuses on establishing safety, stabilization, and developing coping skills prior to beginning any trauma-focused interventions (Chu, 1998; Herman, 1992).
Diversity and Multicultural Content
Exposure to trauma varies widely among vulnerable and diverse populations. People living in high-poverty communities often have the highest rates of exposure. Clearly, some populations, by the nature of their circumstances, such as war refugees, have high trauma-exposure rates. Because of the circumstances they are fleeing, refugees entering the United States often have high rates of trauma-related mental health problems. Understanding the cultural meaning of the trauma, as well as the cultural resources and spiritual traditions that can assist in healing, is essential to helping clients from diverse cultural backgrounds (Wilson, 2007).
Recent conceptualizations recognize the impact of historical trauma on multiple generations of disadvantaged or oppressed populations, such as Native Americans and African Americans. The impact of trauma across generations has also been documented among Holocaust survivors and Japanese-American internment-camp survivors, as well as within families experiencing multigenerational interpersonal violence (Danieli, 1998).
The conceptualization of trauma, and especially of PTSD, as a unique area of study is relatively recent. Most published PTSD research has been done by researchers in developed countries, primarily the United States and Israel. Trauma, however, is clearly not an experience that is limited by national borders or experiences—global conflicts and natural disasters affect most nations. Mass violence and disasters affect entire communities and nations. As a result, recovery from trauma must be a nationally and community-based process that includes cultural and religious practices as keys to effective coping.
Global conflict has been a major cause of trauma exposure. The mental health consequences of war vary with many factors, including the severity of the trauma as well as the degree to which the violence affects the whole populace and disrupts social structures. It is not uncommon for more than half of a population to report psychiatric symptoms and for PTSD to be diagnosed at rates of 25% or more, with women and children having the highest rates (Murthy & Lakshminarayana, 2006).
Recent research has shed important light on the impact of trauma on biology and neurobiology, especially in the early years of life, when critical aspects of brain development are affected. In addition, cognitive-sciences research has resulted in increased understanding about the nature of memory and traumatic memory. As a result, social workers working in the trauma field need to be knowledgeable about both of these areas. Planning and responding to disasters requires a wide range of professionals working together, including police, fire, paramedics and other rescue personnel (often called first responders), urban planners, medical and public health professionals, and engineers. But macrolevel social workers have a great deal of expertise in organizing and leading teams, and building partnerships and collaborations.
Since controversy has marked this field from the beginning, social workers face many challenges in working with trauma survivors. One of the most heated debates concerns trauma and memory, and the question of amnesia for traumatic experiences, sometimes called recovered memories on one side of the debate and false memory syndrome on the other. Of particular concern was whether practitioners could create false memories inadvertently through their interventions. This debate was most intense in the 1990s and culminated in efforts to come to a scientific consensus. In 1997, the International Society for Traumatic Stress Studies (ISTSS) issued the following consensus points: there is evidence that memory is imperfect and reconstructive, there is evidence that people do forget traumatic memories and can later recall them with accuracy, and traumatic memory may be different from normal memory (Roth & Friedman, 1997). More research is needed on this issue before there can be a scientific consensus. Memories are most likely to be recalled in situations in which there are cues present that resemble the original trauma. It is possible to influence people such that they develop strongly believed false memories, and practitioners who do not follow accepted practices with trauma survivors may promote a false “recovered memory.”
Other debates have focused on controversial treatments, most often EMDR and psychological debriefing. For example, although EMDR is now recognized as effective, the PTSD practice guidelines developed by ISTSS note that the role of the eye movements in EMDR’s efficacy remains controversial and unclear because of methodologically poor research (Friedman, Cohen, Foa, & Keane, 2009). A Cochrane review of psychological debriefing noted the lack of research support for its effectiveness and some evidence that it can cause harm under some conditions. The review, however, also underscored the generally poor quality of the research (Bisson, McFarlane, Rose, Ruzek, & Watson, 2009). Overall, how best to intervene with trauma symptoms immediately following a trauma is a topic of much debate and current investigation, although the early research suggests some support for Psychological First Aid and some cognitive-behavioral interventions (Bisson et al., 2009)
Trends and Directions
Trends and directions include identifying effective treatment of complex trauma reactions, including the co-occurring problems of PTSD and substance abuse; focusing on early intervention; improving disaster management; identifying and treating trauma reactions in children and adolescents; studying alternative trauma treatments (for example, yoga, art, and so forth); and exploring emotional abuse as a type of trauma. There has also been a growing interest in secondary traumatic stress (STS), sometimes called vicarious traumatization—that is, trauma symptoms that can occur in those who work with trauma survivors. One study of social workers found that half reported symptoms of STS (Bride, 2007). Other new areas for research are on the potential negative psychiatric effects of media coverage of disasters on those who are exposed to it through watching or reading about it, and identifying biological processes involved in trauma reactions. Finally, there has been increasing interest in posttraumatic growth and resilience.
Implications for Social Work
Given the high prevalence rates of trauma exposure in many vulnerable and disadvantaged populations, social workers must understand the impact of trauma and how to identify the range of trauma reactions. Many social workers see a trauma perspective as congruent with the strengths perspective, because much of what is traditionally considered as psychopathology (for example, client self-injury) can be seen as adaptive and meaningful within the context of the original traumatic situation. The person-in-environment perspective of social work is especially helpful in understanding and intervening in trauma-related problems. For macrolevel social workers, the concepts of community vulnerability and resilience come into play when working with neighborhoods, cities, regions, and the country.
Trauma-informed policy and practice are very compatible with the values of social work in that the need to empower clients who have experienced trauma is considered essential (Smyth & Greyber, 2013). As a result, there is a critical need for social workers to advocate for trauma-informed policy and practice in all systems. Additional funds and resources are needed to train and mobilize first responders and to help build the infrastructure that could minimize the traumatic impact of large-scale disasters and the impact on populations of chronic threats of attack on everyday functioning.
The micro-, mezzo-, and macro perspectives of social work are ideally suited to the tasks of creating resilient communities and in working on disaster preparedness. Within this latter context, social work has much to offer in ensuring that community-evacuation planning incorporates the special needs of people with disabilities, children, and frail elders. Finally, social workers should play key roles within their own organizations to ensure that disaster preparedness plans are in place to provide service at times of service disruption.
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