Families living in poverty encounter multifaceted risks associated with the hardship of depleted resources, burdens of high stress and incivilities, and exposure to multiple traumas (Repetti, Taylor, & Seeman, 2002; Kiser & Black, 2005). Out of the many clients who are served by a public mental health system, over 90 percent of them have been exposed to a trauma. Further, millions of people experience at least one trauma in their lifetime (National Council for Behavioral Health, 2013). And though it has a notable impact on low-income families, trauma is not discriminatory; it can affect anyone no matter the age, gender, race or socioeconomic status.
Trauma is often unexpected and can range from a natural disaster (e.g., hurricanes, like Katrina in 2005 which displaced a million people, many of them in low-income neighborhoods, tornadoes, floods, etc.) to human-made (e.g., child abuse, domestic violence, stabbing, mass shooting, automobile accidents, etc.)
Trauma can have a devastating impact on clients’ lives. How trauma impacts individuals may be determined by their resilience, personal history, support systems, and mental health history. As a therapist, I have gained experience in trauma informed clinical practice, but I also have experienced my own trauma that influences my clinical work.
Types of traumas
The following highlight the types of trauma that clients may bring into therapy.
Physical trauma. Physical trauma can include sexual assaults and domestic violence. Research notes that women are four times more likely to experience sexual assault than men (Robinson & Rand, 2011). Individuals with cognitive impairments are more than twice as likely to be assaulted than individuals with other types of disabilities (Harrell, 2014). People who have been assaulted may “freeze up” or have only partial memories of the assault. Eighty-five percent of domestic violence victims are women and only a fraction of these cases are reported (Rennison, 2003).
Natural disasters. Natural disasters include events such as earthquakes, tornadoes, hurricanes, wildfires, tsunami, and floods. They can leave individuals and families feeling displaced, with intense emotional reaction, unpredictable feelings, and flashbacks. In areas where local support and resources are already strained every day for families, life becomes even more difficult to manage. Posttraumatic stress disorder (PTSD) is the most common mental health issue that is associated with disasters (Neria, Nandi, & Galea, 2008).
Health-related trauma. According to the American Association for the Surgery of Trauma (AAST; 2019), healthcare-related trauma is the leading cause of death for people 45 and younger. More specifically, trauma is the fourth cause of death for all ages, and out of those healthcare-associated traumas, traumatic brain injuries are the largest cause of death in the United States (AAST, 2019). Of course, in the days to come, we will see the fall out of traumas sustained from the current viral pandemic, the ramifications of which are yet to be fully seen. These types of traumas are just a few examples that clients may share in therapy impacting their overall wellbeing.
Responses to trauma
Most trauma survivors are very resilient and develop a coping mechanism, recovering with time and show little signs of distress (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). Only a small percentage of survivors show signs of trauma-related stress disorder (SAMHSA, 2014). However, trauma can have an emotional, physical, behavioral, and social impact on an individual and families. Emotional reactions from trauma survivors vary from anger, fear, shame, and sadness. They may feel as though they are “losing their mind.” Some people may have a difficult time regulating their emotions, which could lead to unhealthy ways of coping, such as substance abuse, gambling, compulsive behaviors, and self-harm. Some survivors may not feel any emotions at all; they feel numb. This is important to recognize because others may not be able to see the severity of the impact of the trauma (SAMHSA, 2014).
Some survivors may present with physical symptoms instead of psychological symptoms. These symptoms may include sleep problems, respiratory, gastrointestinal, cardiovascular, dermatological or substance abuse (SAMHSA, 2014). A traumatic experience can leave a survivor with cognitive distortions. Such alterations can include cognitive errors where the individual misinterprets a current situation as dangerous because it resembles the previous trauma. Survivors can experience excessive survivor’s guilt or assume responsibility. Further, intrusive thoughts can trigger strong emotional reactions and memories, as well as trauma-induced hallucination or delusions, triggers, and flashbacks (SAMHSA, 2014).
Behavioral reactions could be those associated with self-harm or self-destruction. Self-harm is a way for an individual to cope with the overwhelming emotions, the feeling of helplessness or feeling trapped (SAMHSA, 2014). An important key to recovery is establishing a support system. This is necessary to do as soon as possible. A support system can be a protective factor towards all the stress associated with trauma.
Trauma-related disorders
According to the American Psychiatric Association (APA; 2013) acute stress disorder (ASD) is the development of distinguishing symptoms that last from three days to one month. A trauma survivor’s initial reaction to the trauma would meet the criteria for ASD (APA, 2013). ASD resolves within three days to four weeks after the event. Also, ASD requires 9 out of 14 symptoms to be present out of the five categories of intrusion (APA, 2013). The vital feature of PTSD is the characteristic of the symptoms that develop after a person is exposed to a traumatic event (APA, 2013). PTSD is the most commonly diagnosed trauma-related disorder (Kessler et al., 2008) and the major difference in determining which disorder an individual has is the onset and duration of the symptoms.
Clinical implication
In my role as a Trauma Survivors Network coordinator, I support trauma patients who enter the doors of the level one trauma hospital. As this program grows, there will be the ability to assess patients for acute stress disorder and follow up after five weeks of the trauma to be assessed for PTSD. It is essential to assess everyone because not everyone who goes through something traumatic, no matter how trivial or devastating the event was, develops PTSD.
While in the hospital, the survivors will be connected to a peer supporter. The supporter will be a survivor who has the same type of injury, such as a traumatic brain injury, a spinal injury or orthopedic injury. The survivor, who may feel isolated and as if no one understands, will have the opportunity to talk to the supporter. The supporter will be able to replace that sense of isolation with a sense of belonging, understanding and help normalize the situation. The supporters can share their own experiences regarding what to expect, help guide the new survivor through the recovery process, and provide encouragement when needed. This approach will help alleviate the fear of the unknown. Another valuable resource that is provided by the Trauma Survivors Network includes the Next Steps program, which teaches survivors how to be more active and take control of their recovery. In addition, the family of the survivors will be able to attend a session to hear stories of strength and recovery from peer supporters and get information about caregiver stress.
As a clinician, when seeing clients, initial assessments should consist of family history, understanding the dynamics within the family system and inquiring about a support network. It may be beneficial for a clinician to place oneself in the survivor’s perspective, in order to widen the therapeutic lens. By doing this, the clinician can better understand the survivor’s relationship with family, community, other interpersonal and societal aspects that all play a part in the recovery process. This perspective allows the clinician to help both the survivor and the broader system involved. Following are suggestions for clinical interventions to help survivors, while understanding that each client is different, and the interventions cannot be applied universally.
One of the models to use when working with trauma survivors is cognitive behavioral therapy (CBT), specifically, trauma-focused cognitive behavior therapy. The goals are to help reduce PTSD symptoms in children and adolescents who suffered from sexual abuse and as a result developed depressive symptoms and behavior problems. There are four fundamental parts that are beneficial to any trauma survivor: psychoeducation, coping strategies, gradual exposure, and cognitive processing (Ramirez et al., 2014). Psychoeducation is vital because it provides the survivor and the family with a basic understanding of the survivor’s condition. It can also give the survivor and his or her support system insight into the possible challenges they may face in the future. Knowing this information empowers the survivor and increases his or her quality of life. Next, survivors must utilize positive coping strategies. These strategies can consist of, but are not limited to, deep breathing exercises, meditation, journaling and even spending time with people. Having coping strategies in place can help the survivor who needs to re-center, is losing hope and/or feels not in control of life.
Lastly, exposure therapy may help survivors face their fears as fear leads to avoidance, a temporary solution to the problem (Zoellner et al., 2011). The survivor needs to face such fear in order to conquer it. This can be done in a safe place to help reduce avoidance and ultimately desensitize the fear.
Trauma is all around us and often clients’ most intimate therapeutic moments are revealing their trauma. Therapists have the power to hold this space and provide healing. In these moments it is necessary for therapists to allow cognitive processing to occur for survivors who experience PTSD symptoms. The therapist can help the survivor become more aware of emotions and thoughts, and in return, the survivor can identify any automatic thoughts. The therapist in turn can probe thoughts that modify any maladaptive thoughts.
My Own Trauma Narrative and Impact on My Family
Transparency of my own trauma allows me to connect with my clients who have also experienced trauma. After sustaining a life-threatening injury, suffering coma, brain injury and cardiac arrest, I had my own challenges of trauma, exacerbated by issues with my mother. Thankfully, my therapist helped me process my feelings and set boundaries with my mother while I recovered; boundaries that would be beneficial and give me time to re-center and focus on recovery. During the time of the cut-off, I went to physical therapy, my mental health therapist and other doctor appointments. My therapist suggested writing a letter to my mom when things seemed to be improving. She explained that it would be helpful to express my thoughts and I could decide if I wanted to give my mom the letter or burn it. I found this challenging, and concluded that the letter would be beneficial because it would allow me to say what I wanted without interruption. In the end, I did not give the letter to my mom, instead voiced my feelings to her, mentioning how relieved I was to have a break from her. I expressed my childhood trauma of growing up in her household. This expression led to instant relief. I finally built up the courage to tell my mom this feeling I had harbored for years; I became my own person, and was at peace.
Unfortunately, my mom did not speak to me for a while after the conversation. She needed to process the new shift and boundaries in our relationship. When she finally contacted me, she said she made parenting changes and our relationship changed tremendously from that day forward. I was even able to go over to her house and do physical therapy activities, walking up and down the driveway to help increase my endurance, and jump on the trampoline to help with coordination and balance. Repairing the relationship with my mom had a significant impact on my entire system. For example, being able to work on physical therapy with her allowed time for my husband to relax, which relieved caregiver stress. My brothers were able to conceptualize forgiveness surrounding a traumatic event. I was able to turn my ambivalent/anxious attachment into a secure attachment with my mom.
It is necessary for therapists to allow cognitive processing to occur for survivors who experience PTSD symptoms.
Kimiko Cheeley, MAMFT, LMFT, is an AAMFT Clinical Fellow and Palliative Care coordinator and Trauma Survivors Network coordinator at The Medical Center, Navicent Health, in Macon, GA.
REFERENCES
American Association for the Surgery of Trauma. (2019). Trauma facts. Retrieved from http://www.aast.org/trauma-facts
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: Author.
Harrell, E. (2014). Crimes against persons with disabilities, 2009-2012. Washington, DC: U.S Department of Justice.
Kessler, R., Heeringa, S., Lakoma, M., Petukhova, M., Rupp, A., Schoenbaum, M., Wang, P. S., & Zaslavsky, A. (2008). Individual and societal effects of mental disorders on earnings in the United States: Results from the national comorbidity survey replication. American Journal of Psychiatry, 165(6), 703-711.
Kiser, L. J., & Black, M. A. (2005). Family processes in the midst of urban poverty. Aggression and Violent Behavior, 10(6), 715-750.
National Council for Behavioral Health. (2013). How to manage trauma. Retrieved from https://www.thenationalcouncil.org/wp-content/uploads/2013/05/Trauma-infographic.pdf
Neria, Y., Nandi, A., & Galea, S. (2008). Post-traumatic stress disorder following disasters: A systemic review. Psychological Medicine, 38(4), 467-480.
Ramirez, M. A., Lyman, R. D., Jobe-Shields, L., George, P., Dougherty, R., Daniels, A., & Delphin-Rittmon, M. (2014). Trauma-focused cognitive behavioral therapy: Assessing the evidence. Psychiatry Services, 65(5), 591-602.
Rennison, C. M. (2003). Intimate partner violence, 1993-2001. Washington, DC: U.S Department of Justice.
Repetti, R. L., Taylor, S. E., & Seeman, T. E. (2002). Risky families: Family social environments and the mental and physical health of offspring. Psychological Bulletin, 128(2), 330-366.
Robinson, J. E., & Rand, M. R. (2011). Criminal victimization in the United States. Washington, DC: Bureau of Justice Statistics.
Substance Abuse and Mental Health Services Administration. (2014). A treatment improvement protocol: Trauma-informed care in behavioral health services. Rockville: U.S Department of Health and Human Services.
Zoellner, L. A., Feeny, N. C., Bittinger, J. N., Bedard-Gilligan, M. A., Slagle, D. M., Post, L. M., & Chen, J. A. (2011). Teaching trauma-focused exposure therapy for PTSD. Psychological Trauma, 3(3), 300–308.
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