Understanding Trauma and Resilience

Louise Harms

• Publisher: Bloomsbury Academic
• Year: 2015
• ISBN:
  9781350305892
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This book addresses the multifaceted nature of trauma by bringing together the many theoretical perspectives that explain how people cope with traumatic life experiences. Practitioners working across the people professions frequently find themselves working with service users, patients and clients who are survivors of trauma. Ranging between attachment, person-centred and anti-oppressive approaches, this text will help students and practitioners widen their approaches to such clients' experiences. Whether you are a student or practitioner of counselling, social work or mental health, this book provides the foundations for understanding people's responses and resilience against traumatic life experiences.

1

Theorising Trauma and Resilience

Introduction

We begin this discussion with a look at some of the issues in theorising trauma and resilience. In professional and lay contexts, ‘trauma’ and ‘resilience’ have become widely and popularly used words. For many survivors of different life events, these words capture the heart of their experiences, and for others, they miss the essence altogether. Many practitioners embrace these words as important areas of their professional specialisation, and others reject these categorisations. Researchers grapple with the diversity of ways in which these words are used and the challenge of operationalising these concepts rigorously and comparatively in the context of research. We look at these concepts, along with a multidimensional approach and self-care issues, as the foundations for this book.

Defining trauma

One glance at the research and practice literature shows that the word ‘trauma’ refers to many different events, from single incidents to chronic and complex post-traumatic stress experiences. In addition to referring to a particular triggering event, it can refer to the impact and aftermath experience, beginning to confuse notions of trauma as exposure and trauma as response.

Traumatic exposure

In relation to the exposure focus, the debate around what can and should be defined as ‘traumatic’ has continued over many years (Burstow, 2003; Weathers & Keane, 2007; Friedman et al., 2011a). While this debate may seem overly focused on semantics, the definition of trauma ultimately leads to what in turn becomes legally, socially, culturally and politically recognised. Recognition of events as traumatic or not determines whether wider systems of social support, for example, are put into place or whether people are expected to resume everyday life relatively unaffected.

In practice and research and in the wider community, commonly recognised traumatic events include natural and human-made disasters, war, forced migration and displacement, forced separations of children from their parents, abuse and neglect, torture, accidents and injuries, health crises and private assaults to emotional, physical, social and spiritual well-being. However, this list is by no means exhaustive; even beginning to list such events in this way raises the likelihood of omission or exclusion. Critically listing some events as inherently traumatic and others as less so will not help identify their impact on people. A term that has emerged in more recent years is ‘potentially traumatic events’ (PTEs; see Keyes et al., 2013, for example), avoiding the assumption that an event is, per se, traumatic.

Other distinctions lie in classifying trauma exposures as single incidents (such as a car accident or an assault) or multiple, long-term conditions of extreme adversity (such as wars, homelessness or droughts) where death and threat may be continually encountered. Other traumas are intergenerational in nature. It is often challenging to untangle the beginnings and endings of such interconnected events and their impacts on successive generations of families. This is particularly the case in child protection work. What may be a critical distinction is the perceived source or cause – whether the trauma is perpetrated by other people (intentionally or unintentionally) or seen as ‘natural’ events.

Typically, traumatic events are recognised as external events in people’s lives. Yet, some experiences are less widely recognised, if at all, as traumatic events and afforded little attention from others. Some events can be defined as ‘disenfranchised trauma’ experiences, adapting Doka’s (1989) ‘disenfranchised grief’ term. They are not recognised as being traumatic, yet they can create extreme distress and fear for people – for example, an episode of psychosis. An emerging body of literature has also highlighted the ways in which some human service responses can be traumatic in and of themselves, both in the immediate and longer term. While services (such as child protection) are about promoting well-being ideally, the surveillance and supervision by counsellors and protective services can create a suffocating environment in which it is impossible for families to function (Carolan et al., 2010). Other studies have highlighted that legal and service systems can be more problematic in the longer term for people than the traumatic event itself (Holman & Silver, 1996).

Less widely recognised, too, is the pre-existing vulnerability in many communities that can escalate into traumatic events over time. For example, Bankoff and colleagues (2004) have provided an insightful account into the importance of mapping vulnerability as it relates to where disasters occur and why – that is, taking into account the social and economic hierarchies in which people live prior to a disaster occurrence and the exposures to traumas that result. This challenges us to think about the extent to which vulnerability and trauma can be separated and the importance of working preventively with vulnerability so as to avoid the traumas occurring in the first place. In just skimming briefly over these issues of event type, frequency, intensity, cause and recognition, we can start to see that understanding the nature of ‘trauma’ is a nuanced, complex and contextual task.

In many ways, these debates have been reflected in the American Psychiatric Association’s Diagnostic and Statistical Manual of Psychiatric Disorders (DSM; APA, 1980, 2000, 2013), evolving definition of trauma for the purposes of a diagnosis of post-traumatic stress disorder (PTSD), since its first inclusion in the 1980 version (Weathers & Keane, 2007). The purpose of the definition in this case is to determine whether someone has been exposed to trauma and therefore can be assessed as having a diagnosis of PTSD. A diagnosis of PTSD is significant not only in terms of access to appropriate mental health support in many contexts but also often in terms of access to appropriate legal recognition and compensation.

The new definition of trauma exposure in the DSM V (APA, 2013) reflects significant shifts yet again in the effort to define trauma exposure, as shown in Box 1.1.

Box 1.1 The definition of trauma exposure in the DSM V

The person was exposed to one or more of the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways:

● Experiencing the event(s) himself/herself

● Witnessing, in person, the event(s) as they occurred to others

● Learning that the event(s) occurred to a close relative or close friend; in such cases, the actual or threatened death must have been violent or accidental

● Experiencing repeated or extreme exposure to aversive details of the event(s) (e.g., first responders collecting body parts; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies or pictures, unless this exposure is work related

Source: The American Psychiatric Association (2013).

This new definition is much narrower compared to previous editions. In the new definition, the primary emphasis in the events described is on embodied threat (death, injury and/or sexual violation) – to a person or to others they are closely connected with or where someone directly witnesses the actual or threatened physical harm. The extent to which this focus on physical threat will accurately convey the breadth of traumatic events is yet to be tested. Emotional abuse is known to lead to similar psychosocial outcomes as physical abuse, yet it may no longer qualify as a traumatic exposure, given the difficulties in linking emotional abuse with actual or threatened physical harm. Similarly, the separation of children from families may not qualify – previously, acknowledgement of the PTSD caused by the experience of forced government removal of Aboriginal children in Canada and Australia (Petchkovsky & San Roque, 2002; Bombay et al., 2009) or others into foster care (Salazar et al., 2013) has been an important step in establishing healing and reconciliation resources.

Traumatic impacts

As you can see, trauma is understood as a trigger or exposure event in diverse ways. The same is true in terms of how trauma is thought of as an impact or a response. Commonly, traumatic events are recognised as such because they have disrupted, overwhelmed and destroyed a person’s or community’s sense of well-being and safety and capacity to cope as before.

Each of the theoretical approaches we look at understands these traumatic disruptions differently. Rights-based approaches emphasise that traumatic events violate a fundamental sense of social justice, control and agency, for example. Psychodynamic approaches seek to explain the impact of past, often childhood traumas on adult functioning and development. There is consideration of the emotions of trauma – shame, guilt and anger, for example – and both the unconscious and conscious expressions of anxiety. The impact of trauma is seen as not only lasting but also highly influential on later adult experience. Psychiatric approaches focus on the presence of disorders such as PTSD or depression – that is, the symptoms of trauma.

Grief also has an important place in trauma understandings. Many traumatic events evoke both trauma and grief reactions. The losses inherent in many traumatic events – of life, world views and beliefs, a sense of safety, places, roles and routines – can lead to profound experiences of sadness and yearning and processes of mourning and remembrance. Despite this, trauma and grief research and theories have tended to remain separate, with relatively few people considering the overlap in traumatic bereavement (Raphael & Meldrum, 1994; Stroebe et al., 2001). As a result, as Parkes (2008, p. 464) notes: ‘Bereavement services have developed separately from the field of traumatic stress.’ Throughout this book, we will touch on the points of connection between trauma and grief, although maintaining a dominant focus on trauma understandings.

Many people also report positive trauma impacts in the form of post-traumatic growth, recovery and resilience (Tedeschi & Calhoun, 1995; Harms, 2001). These broader understandings of traumatic impacts are also critical, and we now look at some of these ideas.

Defining recovery and resilience

While the previous discussion considered the ways in which traumatic experiences leave people with negative outcomes, a vast evidence base exists for people adapting and surviving well, that is, evidence for a salutogenic approach to the impact of trauma. Others experience oscillation between functioning well in some parts of their life at some times, and not so well in other parts and/or other times. Therefore, concepts such as recovery, resilience and post-traumatic growth are helpful in understanding the full reality of people’s experiences.

Recovery

Recovery, like trauma, is also defined in many different ways. From a practice and research perspective, it is an important concept to consider – what is regarded as the ‘outcome’ point for therapeutic work with people? What words best reflect these states? What are we there to ‘do’ or to encourage? How does a person come to see themselves and their coping capacity in the longer term? The evidence base for trauma recovery is mixed, in large part due to these varying definitions of what it is.

One approach is to understand recovery as the absence of PTSD or post-traumatic stress symptoms. This conceptualisation has dominated a lot of studies – the absence of psychopathology is seen as the presence of recovery. In this sense, research highlights that for most people, recovery is possible, given the prevalence rates for PTSD. For example, Johnson, Thompson and Downs (2009, p. 331) highlight prevalence studies that show the following:

Among persons who have experienced a traumatic event in their lifetime, the prevalence of current PTSD is 9% to 12% for women and about 6% for men.

Thus, based on these types of prevalence figures, 88–91% of women and 94% of men recover. This conceptualisation of recovery, however, does not extend to the full possibilities of trauma aftermath experiences, nor does it reflect the World Health Organisation’s (WHO) definition of health: ‘A state of complete physical, mental and social well-being, and not merely the absence of disease’ (WHO, 2003).

A second approach, therefore, is to see recovery as a return to functioning, typically along a trajectory of experiences. One of the early conceptualisations of this model came from O’Leary and Ickovics (1995), who outlined trajectories from survival, to recovery, to thriving. Whereas survival is seen in the manner ‘the individual affected by a stressor continues to function, albeit in an impaired fashion’, recovery is seen as ‘a return to baseline’ functioning (O’Leary, 1998, p. 425). In this model, the possibility of thriving is defined as ‘the ability to go beyond the original level of psychosocial functioning, to grow vigorously, to flourish’ (O’Leary, 1998, p. 425). Others adapted this model to define the possible experiences as succumbing, survival with impairment, resilience (recovery) and thriving (Carver, 1998, p. 246). Bonanno and colleagues’ (Bonanno et al., 2011; Bonanno & Mancini, 2012) more recent work has continued to chart this idea of trajectories people may follow as they adapt post-trauma. Bonanno (2004, p. 20) defined recovery as

a trajectory in which normal functioning temporarily gives way to threshold or sub-threshold psychopathology (e.g., symptoms of depression or Posttraumatic Stress Disorder (PTSD)), usually for a period of at least several months, and then gradually returns to pre-event levels. Full recovery may be relatively rapid, or may take as long as one or two years.

This conceptualisation of recovery highlights the resumption of ‘normal functioning’, or a return to everyday living where participation is possible. The idea is one of learning to ‘live with’, in the sense that experiences become part of who we are, part of our unique story, to the point where it enables us to engage with the demands and possibilities of living and even living well. Throughout the chapters of this book, we look at the conditions, both internal and external, that promote this experience of recovery.

A third approach is a stage approach to recovery based on the achievement of specific tasks, as outlined by Judith Herman (1992). These specific tasks, however, are seen in the context of the following two statements:

Resolution of the trauma is never final; recovery is never complete. The impact of a traumatic event continues to reverberate throughout the survivor’s lifecycle. (Herman, 1992, p. 211)

Understood in that way, Herman (1992, p. 155) proposes the following:

Recovery unfolds in three stages. The central task of the first stage is the establishment of safety. The central task of the second stage is remembrance and mourning. The central task of the third stage is reconnection with ordinary life.

This understanding of recovery highlights a strongly embedded social model of trauma recovery. Relational, social and cultural reconnection is the final process and marker of recovery. As Herman (1992, p. 212) reminds us: ‘Though resolution is never complete, it is often sufficient for the survivor to turn her attention from the tasks of recovery to the tasks of ordinary life.’ However, it still raises questions as to what ‘ordinary life’ means. For a person living in highly conflicted parts of the world, ‘ordinary life’ over many years may be lived in the context of civil war. A focus on ordinary life may bring us into thinking about our basic human needs and rights and what promotes a fulfilling or good life.

Throughout the chapters ahead, you will see that the different approaches emphasise different conceptualisations of recovery – as an outcome, as a process, as a baseline we return to or as an improved state of living after trauma.

Resilience

Bonanno and Mancini (2012, p. 77) note that ‘the ability to maintain normative or baseline levels of functioning is not rare but often the most common response to potential trauma’. Despite the acknowledgement of how common the response of resilience is in the aftermath of trauma, research has tended to focus less on this aspect and more on the psychopathological outcomes. Broadly speaking, resilience focuses our thinking on people’s capacity and the resources to ‘bounce back’, or as Froma Walsh (2002, p. 35) suggests:

A more apt metaphor for resilience might be ‘bouncing forward’ to face an uncertain future. This involves constructing a new sense of normality as we recalibrate our lives to face unanticipated challenges ahead.

The study of resilience is ‘a search for knowledge about the processes that could account for positive adaptation and development in the context of adversity and disadvantage’ (Crawford et al., 2006, p. 355). However, there is widespread debate about what resilience is and how it can be understood and measured.

Agaibi and Wilson (2005, p. 198) propose that resilience is ‘the ability to adapt and cope successfully despite thre...