Trauma: The Impacts of and on Spirituality

1. Trauma:The Impacts of and on Spirituality Sarah Case, Rachael Dolan, Jason Flaig, Wendy Seiber, Trisha Wilson Page 1

2. INTRODUCTION TO TRAUMA Page 2

3. Trauma in some form occurs every day to individuals, groups, hundreds, and even thousands • There is an ever growing demand for therapists who specialize in trauma • The field of trauma is increasing quickly and new interventions and theories are being designed • It is crucial that any therapist knows how to work with trauma • Some clients may be spiritual and want to work with their trauma in that form Why Trauma? Page 3

4. What is Trauma? Page 4

5. Types of Trauma Page 5

6. PTSD Page 7

7. Trauma and the Brain Post Traumatic Stress Disorder Other anxiety disorders Panic disorder Generalized anxiety disorder (GAD))

8. Hippocampus-Parahippocampus Amygdala Ventral Medial Prefrontal Cortex Amygdala Brain process in fear response

9. At-risk Populations (after at Disaster) • Children • Those who have been injured • Those who have had multiple relocations and displacements • Medically frail children and adults • Those with serious mental illness • Those with physical disability, illness, or sensory deficit • Adolescents who may be risk takers • Adolescents and adults with substance abuse problems • Pregnant women • Mothers with babies and small children • Disaster response personnel • Those with significant loss of possession • Those exposed first hand to grotesque scenes or extreme life threat

10. Spirituality

11. Psychology and Spirituality • Psyche and logos = soul and study • Psychology essentially means “the study of the soul” • Psychotherapist = servant or attendant of the soul • Psyche and pathos – the suffering if the soul • Delving into the soul of psychotherapy is part of our basic training in helping professions • Vulnerability from trauma can act as a beacon of spiritual connection

12. Trauma and Spirituality • Accessing such inner resource is an effective way to buffer the stress of trauma work and heal oneself from its emotional turmoil • A personal commitment to a process of inner development that engages us in our totality • Consists of a contemplative attitude, a commitment to living life fully, and searching for meaning

13. Spirituality cont. • Traumatic events often lead to dramatic changes in survivor’s world views so that fundamental assumptions about meaningfulness, goodness, and safety shift negatively • Those who core values are theologically founded, traumatic events often give rise to questions about the fundamental nature of the relationship between the creator and humankind

14. Resiliency

15. Themes of Resiliency Non-reactive resiliency • Shows little or no reaction to the crisis • Impact can be lessened for people who hold strong religious beliefs Homeostatic resiliency • React to the stressor but return quickly to a state of normalcy and equilibrium

16. Positive growth • Achieve personal growth through the adversity • Can take the stressor and learn and grow from it in to a better overall situation A person can display a mixture of themes, presented in sequenced or demonstrated singly. Predictors of Type: • Trauma severity • Childhood abuse • Self esteem • Previous trauma • Family support • Community support • Optimism and hope • Sex and Race • Good health care • IQ

17. Resiliency in Religions • Many stories of resiliency from the Bible • Example: Story of Job and his faith despite the suffering and hardship • The Gospel verifies for those who have faith a freedom that releases us to be who we are meant to be regardless of the circumstance Christianity Judaism • In the Hebrew Bible are stories about human suffering along with the persistent ability to overcome • The celebration of Seder focuses on the combining of hardship and resiliency through story and symbol • Biblical law teaches people to not dwell on the past but to learn from the suffering and create a partnership with God to remove all aspects of suffering on earth

18. We are all Buddhas and have the capacity to endure what sorrows come our way from the resiliency within • The Buddha says there is 10,000 joys with 10,000 sorrows. It is a natural part of being alive and alert. • The world is filled with suffering and pain. Pain is inevitable but suffering is how we react to the pain. Buddhism Islam • The Quran is full of guidance in resiliency and forgiveness • Muslims believe in fatalism and that everything that happens comes from God. • Daily prayers offer a time to strengthen the relationship with God • Ramadan and Hajj is a time for peace and coming together.

19. Trauma Resiliency Model Helps create resiliency to these physical symptoms by restoring equilibrium to the nervous system • Tracking of the nervous system • Grounding • Resourcing • Shift and Stay • Completion of defense (Frozen vs. Flight or Fight) Survivors can exhibit physical or somatic symptoms from emotional trauma • Shaking and trembling • Increased heart rate • Myofascial pain (Chronic muscle pain) • Diabetes • Heart disease • Other stress related diseases

20. Spiritual Responses to Trauma • Spiritual doubts • Despair • Withdrawal from church and community • Loss of faith • Questioning old beliefs • Life loses meaning • Sense of the world changing • Spiritual Resources • Vigils, memorials, healing rituals • Community prayer • Church attendance can become more prevalent in a community after trauma has occurred

21. Wolin Developmental Model of Resiliency • Insight • Understanding and the ability to comprehend the tragedy or make it meaningful • Spirituality and religions serve to give meaning to the world and events that happen in it • Independence • Successful survivors stop looking outside themselves for fulfillment • Self transcendence is part of many religions including aspects of meditation, prayer and connection to the spiritual

22. Relationships • Having strong relationships within the family and the larger community provides valuable resources in times of crisis • Spiritual communities often create an atmosphere of unconditional love where people feel safe, nurtured and supported • Initiative • Transformations consist of exploring and creating positive endeavors reflecting problem solving skills to tackle difficulties • Believing that transformation is possible is a common theme in religions and theology

23. Creativity/Humor • Humor and creativity allow the individual the opportunity to find comedy and inspiration in the tragic • Spirituality encourages creativity within contemplation • Laughter is healing for the soul • Morality • Ethics and morals are a result of interpreting and clarifying values in society and then relating them to the individual • Often considered the domain of religion and spirituality, morals create a framework from which the individual can attach meaning in times of suffering

24. Clinical Considerations

25. Case Study Client: Jeff Cain • 35-year-old single Caucasian male who is an Active Duty Marine Presenting Problem: • Was called to active duty in Baghdad. Describes his deployment as “high intensity,” saying that he witnessed an explosion that killed three of his friends. Witnessed dead and injured civilians and Iraqi soldiers on multiple occasions Involved in an attack that left him with shrapnel in his neck, chronic pain, reports feeling anger since the incident. • Began to develop insomnia, hyper vigilance and a startle response • Reports dreams which are intense and frequent, as well as intrusive thoughts and flashbacks • Since returning home, he has withdrawn from his peer group, reports feeling detached from others. Avoids going out where there will be crowds or loud noises, has a lack of interest in the things he enjoyed before deployment. He refuses to attend church despite having a strong Christian faith system Current Functioning: • Cl. demonstrates difficulty completing daily tasks, being in public, maintaining relationships. Avoids conversations about past traumatic events with friends and family. • Cl. Would like to begin school again but wants to address these symptoms as he readjusts to civilian life. No mental health history • Cl. continuously asks “Why would God allow such torment and war to exist? It isn’t right.” Diagnosis: • Post Traumatic Stress Disorder.

26. Approaches to Client Work with Trauma Survivors

27. Interventions Don’ts

28. Interventions Do’s

29. Mindfulness

30. An interview with a Haitian

31. Debriefing of Case Study

32. Current Events

33. The Crisis in the Pacific • "Today's events reminded us of just how fragile life can be"  • President Obama • "Require people to join together in order to overcome the catastrophe"  • Japan Prime Minister  • Global efforts to assist Japan should focus on longer term concerns such as trauma counseling and helping people to rebuild  • The Japanese are so resilient and tend to accept things for what they are and do the best with what they have   • Experience with past disasters suggest that some types of psychological first aid may help those who have lived through them, but others can actually cause harm • critical incident stress debriefing: can double the chance of PTSD • have to respect individual coping mechanisms  • strangers (counselors) have to use interventions that are culturally attuned 

34. Ethics and Person of the Therapist Issues

35. Vicarious Trauma the transformation therapists undergo because of empathic engagement with clients' trauma material. With repeated exposure to graphic details of abuse, therapists may experience vicarious traumatization that continues to intensify if unaddressed. (Brady, Guy, Poelstra, Brokaw 1999)

36. Vicarious trauma – therapist spirituality • therapists who are exposed to trauma vicariously are confronted with spiritual challenges. • Trauma work affects the therapist most in the spiritual domain. • Therapists' basic faith is challenged when faced with their clients' stories of trauma and human cruelty. • Conducting therapy with trauma survivors forces therapists to question their own sense of meaning and hope. • The therapist's view of the human condition may become increasingly pessimistic, resulting in inordinate suspicion in the motives of others. “…most malignant aspect of vicarious traumatization is the loss of a sense of meaning for one's life, a loss of hope and idealism, a loss of connection with others, and a devaluing of awareness of one's experience …" (Pearlman and Saakvitne (1995b) In (Brady, Guy, Poelstra, Brokaw 1999)) "I had lost many of my essential beliefs that had brought me to this profession and to my specialty in trauma. My view of the world had changed. I no longer believed that people are basically good. Rather, I had become afraid of the evil inclination. I felt certain that it was more powerful than the human desire to be good. I was no longer as clear about the meaning of life.” (Barrett, 2009)

37. Vicarious Trauma – Our ResponsE • Know the symptoms and be aware if you experience them. • Symptoms of PTSD – • Know your risk • New/less experienced clinicians • Female (at higher risk for PTSD overall) • Know proactive preventions ASERVIC Competency: The professional counselor actively explores his or her own attitudes, beliefs, and values about spirituality and/or religion. (Green Cross Foundation, greencross.org)

38. Vicarious Trauma – Our ResponsE ASERVIC Competency: The professional counselor continuously evaluates the influence of his or her own spiritual and/or religious beliefs and values on the client and the counseling process. Establish self care, preventative measures and coping methods early in your career. Start during Clinical training!! (Green Cross Foundation, greencross.org)

39. ASERVIC Competencies • Engage in self-exploration of religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of diverse belief systems • Can demonstrate sensitivity and acceptance of a variety of religious and/or spiritual expressions in client communication • Can assess the relevance of the religious and/or spiritual themes in the counseling process as benefits the expressed preference of each client • Is sensitive to and receptive of religious and/or spiritual themes in the counseling process as benefits the expressed preference of each client • Uses a client’s religious and/or spiritual beliefs in the pursuit of the client’s therapeutic goals as benefits the client's expressed preference

40. Ethics: Religion and Spirituality • Do not impose therapist's beliefs or values on the client. • Provide adequate therapist worldview data in the informed consent process. • Focusing mainly on religious goals rather than therapeutic goals (although there will clearly be overlap) is a violation of the therapeutic contract. • Therapist's competence in the area of conducting therapy with religious clients is important----consult if necessary • Clarify doctrinal issues rather than argue over them • Be careful of avoiding religious issues by misusing the client's resources • Be aware of blurring professional boundaries necessary for maintenance of the therapeutic relationship • Don’t stay focused on just religious issues, that causes other treatment to be ignored • Refer to appropriate clergy/shaman for spiritual and religious functioning

41. Ethics: Trauma • Trauma can be known and measured • Trauma can be repaired • Our culture of advocacy and expert testimony affirms that trauma can be easily translated, assimilated, and passed around for cultural consumption • Not all traumatized individuals carry psychic injuries that conform to the criteria for PTSD • Reductionism • We are blind and death to the devastations that lie outside our medical diagnoses • Being humble and careful enough in questioning whether we have the vocabulary and ethics to be attentive and tender to the aftermath of trauma • Re-traumatization • Can take years of work on therapy to fully address the devastations that are wreaked by torture and persecution • In choosing to categorize traumatized subjects as “victims” or “survivors” we purport to describe a psychological condition but are actually affirming a hope and enforcing a political and ethical agenda • “Trauma seems to be much more than a pathology, or the simple illness of a wounded psyche: it is always the story of a wound that cried out, that addressed us in the attempt to tell us of a reality or a truth that is not otherwise available. How we listen to a receive that reality defines the ethics and ultimately the fate of our society.”

42. Things to NOT Say • (Acknowledge but do not initiate the statements) • I know how you feel • It was probably for the best • He is better off now • It was her time to go • At least he went quickly • Let’s talk about something else • You should work towards getting over this • You are strong enough to deal with this • That which doesn’t kill us makes us stronger • You did everything you could • It could be worse • Someday you will have an answer

43. Attend to Grief and Spiritual Issues • “Do you have any religious or spiritual needs at this time?” • Do not contradict what a person says about their beliefs • Do not try to answer “Why was this allowed to happen?” • Ask if the person wants to see a clergy member • Locate a religious object important to the person if deemed helpful • If asked to join in prayer, you may decline or may simply say “Amen” at the end • If the person talks about miracles, do not take this as them loosing touch with reality • Do not judge those who express anger with their religious beliefs • Be a willing, non-judgmental listener

44. Professional Issues • Adequate training in trauma and its impact • Full understanding of nature and dynamics of trauma • Awareness of power and control dynamics • Acquisition of additional therapeutic skills • Gender preferences in matching client and counselor • Cultural sensitivity • High degree of self-awareness, especially own abuse experiences • Attachment style • Clarity and explicitness • Boundaries • Tolerating uncertainty • Flexibility of approach • Understanding and preventing secondary traumatic stress • Role of practitioner self-care

45. Impact of Working with Survivors of Trauma • Compromised safety • Dissociation • Post-traumatic stress symptoms • Collapse or constriction of boundaries • Compromised ability to tolerate uncertainty • Powerlessness, sense of inadequacy • Need to be in control and feel safe • Lack of resources • Anger and rage • Shame and guilt • Disconnection from client • Shattered assumptions about the world • Transference and counter-transference reactions • Secondary traumatic stress

46. Impact on Personal Functioning • Emotional • Anger and rage, sadness, depression, hyper arousal, hypervigilence, anxiety, apathy, numbness, terror, frustration • Cognitive • Impaired concentration, confusion and disorientation, dissociation, forgetfulness, rumination and preoccupation, guilt, impaired trust, disbelief • Physical • Somatic reactions, impaired immune functioning, change in Cortisol levels, self-medication, changes in appetitive behaviors • Behavioral • Withdrawal, isolation, avoidance, irritability, impatience, increased neediness

47. Impact on Functioning • Spiritual • Loss of meaning and purpose • Hopelessness • Disconnection from others • Loss of vitality • Loss of spirituality • Loss of faith in humanity • Loss of joy

48. The Importance of Self-Care • Counselors need to ensure self-care through balancing trauma work with more general client work, taking regular breaks, and making time to relax • To counteract working with trauma, counselors need to stay connected to ordinary, everyday activities outside of trauma, such as time with family and friends and activities that are grounding or inspiring

49. Recovery, Coping, and Resources

50. Recovery and Coping • The coping process will occur differently for each person • May have different coping needs at different times  • Allow yourself to turn off the news and get some distance from the crisis when need to  • Get plenty of rest when you're tired, and use the energy you have if you experience hyperactivity at times  • Talk to people as much as you need to  • Spend time with others, even if you don't feel like talking • Don't make any major life decisions or big life changes if at all possible  • Do things that feel good to yourself  • Allow yourself to cry, rage, and express your feelings when you need to • Reaching out to others in a supportive way can sometimes be helpful