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OverviewBridging responses: A front-line worker’s guide to supporting women who have post-traumatic stress On this page:
Who is this guide for? This guide is for people working on the “front lines” - general practitioners, nurses, police officers, and those working in community health agencies, hospitals, public health services or emergency room settings, clinics and shelters that provide direct services to women. It provides general information to help you identify and understand post-traumatic stress resulting from abuse or violence. It also provides guidelines for asking about these issues so you can offer clients assistance and referral information. What is the guide about? There is an increased awareness in the mental health field that many women who seek treatment for depression, suicidal feelings, substance use problems, difficult or abusive relationships, and self-inflicted harm are experiencing post-traumatic stress or complex post-traumatic stress responses. Most often, these problems arise from a history of chronic child abuse or neglect. Women experiencing post-traumatic stress may seek help from a number of services. This guide was written with a diverse audience in mind. Front-line workers may need background information that explains some of the complex responses they hear from trauma survivors. Many of the physiological, psychological and other responses of your clients may actually be the effects of trauma. We hope this guide will serve as a quick reference to help you recognize the signs of post-traumatic stress responses. Some front-line service providers are unsure of their role when working with women they suspect to be experiencing post-traumatic stress. The challenge for service providers on the front lines is that their contact with trauma survivors is often brief. As a result, they understandably worry about raising such a sensitive topic with their women clients if they can’t provide ongoing therapy or support. The purpose of this guide is to help you:
What is post-traumatic stress? Post-traumatic stress is the result of exposure to a traumatic or extremely emotionally and psychologically distressing event or events. Traumatic experiences have traditionally been defined as life-threatening. Many women who experience post-traumatic stress, however, do not think their experiences were that serious. Furthermore, the traditional definition doesn’t capture the experiences of countless women who survived not only past or present physical and sexual abuse, but also childhood neglect and emotional abuse. A more complete definition is as follows: a traumatic experience is an event that continues to exert negative effects on thinking (cognition), feelings (affect) and behaviour, long after the event is in the past. Post-traumatic stress is referred to as Post-traumatic Stress Disorder (PTSD) in the clinical literature. However, labelling the symptoms of post-traumatic stress as a “disorder” may have the unintended effect of pathologizing (attributing problems to a “pathology” or innate disorder in) those affected by trauma. Women who have experienced abuse, or other traumatic events, should not be stigmatized. Instead, it is important to recognize that the effects and symptoms of abuse-related trauma are themselves normal responses. They are ways of coping with the harm inflicted by the abuse. There is valuable information in the clinical literature dealing with the treatment of PTSD. Where it is necessary for clinical accuracy, then, this guide will make use of the term PTSD. However, because language is so important and the need to avoid pathologizing women is so critical, the effects of trauma are mostly described in this guide by a new and slightly modified term - post-traumatic stress responses (PTSR). People react to traumatic experiences in vastly different ways. Some of the responses are obvious, such as intrusive memories or panic attacks. Other responses, such as feeling numb and empty, are subtle and difficult to identify. These responses may continue for years following the traumatic event(s) or, in some cases, responses may subside and return later, which is often the case with survivors of childhood abuse. While the outward display of PTSR varies widely, three categories - or “clusters” - of responses are associated with post-traumatic stress:
Abuse, violence and post-traumatic stress in women’s lives In recent years, we have come to realize that many women seeking help from front-line services have experienced some form of violence as children and/or as adults. The complexity of the long-term effects of this violence, though, is not often fully recognized. This includes, most importantly, PTSR. The developmental, emotional and psychological consequences of violence and trauma are often underestimated, and often misunderstood. Yet it is imperative that those providing service to women with abuse histories be sensitive to the impact of trauma so they can steer them toward appropriate sources of help. Recognizing, consciousness-raising around and “naming” the violence in women’s lives is an important part of understanding the nature of this experience. It’s not enough, though, to merely identify violence in women’s lives. Front-line workers must help women understand that seemingly unrelated mental health problems are actually responses to - and attempts to cope with - the psychological and physiological disruptions caused by abuse- related trauma. Some of the signs of trauma are anxiety, sleeplessness, depression, eating disorders, self-harming behaviour and agitation. In many cases, women don’t recognize the effects of abuse-related trauma in themselves, yet they struggle in their daily lives to cope with their distress in its hidden forms. As a result, some women believe they are “crazy” because they can’t make sense of the effects of trauma in their lives, and can’t connect these effects to earlier traumatic events they've experienced. As front-line, first-contact workers, you can learn to recognize some of the common effects of post-traumatic stress. You can help these women find help and work toward healing from abuse-related trauma. Different kinds of post-traumatic stress - simple and complex It’s become clear that simple post-traumatic stress resulting from a one-time incident - such as a rape or a serious car accident - is markedly different from the complex set of responses that follows chronic, multiple and/or ongoing traumatic events. Such events include chronic childhood abuse or prolonged experiences of assault and violence in an intimate relationship (for example, violence perpetrated by a spouse or caregiver). Judith Herman (1992) explains that prolonged repeated trauma occurs in situations where a person is captive, unable to flee, or is under the control of the perpetrator. These conditions render the person powerless and allow the perpetrator ongoing coercive control. Such conditions may be found in situations varying from prison camps, some religious cults and conditions of war to some families, or institutions such as residential schools. Captivity can be achieved by physical force, as with prisoners of war, or by a combination of physical, economic, social and psychological means, as is typically the case for battered women and abused children. The result of this ongoing coercive control is psychological trauma that differs greatly, in complexity and range of effects, from that resulting from a one-time traumatic event. As a result, a new diagnosis has been developed, called Complex PTSD. Although this new diagnosis has not yet been officially recognized in the DSM-IV (the fourth and current edition of the Diagnostic and Statistical Manual of Mental Disorders, the most-used guide to diagnosing mental health problems), it is currently captured under the general DSM-IV category of “Disorders of Extreme Stress Not Otherwise Specified.” This is an important development in understanding and treating trauma, and Complex PTSD is expected to be included in the DSM-V. Herman (1992) outlines three broad areas of psychological disturbance that distinguish Complex PTSD from simple PTSD. The first area involves the types of responses or effects, which are more complex, widespread and persistent in Complex PTSD (due to the prolonged nature of the trauma). The second area involves the kinds of characteristic personality changes that accompany Complex PTSD, including difficulties with relationships and identity. The third area relates to the survivor’s increased vulnerability to further victimization, both in the forms of self-harm as well as harm perpetrated by others. Women are about twice as likely as men to develop post-traumatic stress. This is probably because women are much more likely to experience interpersonal violence, such as rape, or physical abuse in an intimate relationship, or childhood sexual abuse. Some women have also experienced ongoing and prolonged violence, as is often the case in wife assault or incest. Still other women face ongoing threats of violence and sexual assault as a result of living in a society where violence against women and children is far too widespread. Why do we need to know about complex post-traumatic stress disorder? Many women who seek treatment in mental health clinics have histories of long-term emotional, physical and sexual abuse. Most mental-health professionals have previously not understood that prolonged abuse experiences can cause a person to develop a spectrum of complex psychological trauma responses. Many trauma survivors who sought mental health services have been given more than one diagnosis (at the same time) to describe their difficulties, such as bipolar disorder, schizophrenia-paranoid type and borderline personality disorder. These diagnoses are descriptive labels for symptoms and behaviours, and they emphasize pathology. Traditional psychiatric diagnoses do not consider the context (for example, traumatic event/s) in which a person may have developed these responses; in other words, many “symptoms” that women exhibit represent their attempts to cope with and adapt to traumatic stress. These diagnoses focus on what is “wrong” with this person, rather than on what horrible things have happened to this person. These multiple diagnoses have serious consequences for treatment: therapy and other treatments can rarely be successful when the underlying issues of trauma and neglect are not identified or addressed. Research conducted on a sample of people diagnosed with Complex PTSR found that those who sought treatment typically had histories of prolonged and/or multiple traumatic experiences (van der Kolk, in press). Simple PTS responses include intrusive re-experiencing of the trauma, numbing and hyperarousal (excessive physiological arousal such as insomnia, startle reaction, and irritability). The people who had histories of prolonged abuse or multiple traumas experienced not only the effects of simple PTSR, but also had a variety of other psychological problems, characteristic of Complex PTSR. These additional problems included:
Features of complex PTSD Changes in affect regulation (the ability to manage feelings and impulses)
Changes in consciousness
Changes in self-perception
Changes in perception of perpetrator
Changes in relationships
Changes in systems of meaning
Changes in the body due to psychological and emotional distress (somatization)
The people interviewed in this study said it was these problems, rather than the effects of simple post-traumatic stress, that created the most psychological distress for them and prompted them to seek help. Childhood abuse and Complex PTSD The impact of trauma depends on many things. In cases of abuse in childhood, the overall impact depends on developmental issues, such as the age at which the child abuse began; the nature, severity and duration of the abuse; and the relationship of the perpetrator. The impact also depends on whether the abuse took place in a larger context of severe neglect and emotional invalidation. Emotional invalidation means that a person’s feelings, such as anger, distress, or hurt, are not attributed to the harmful or abusive events. Instead, for example, the feelings are minimized or the person is accused of being “over-sensitive” or “paranoid.” Adults who grow up with these types of childhoods are most likely to develop Complex PTSR. They will likely experience a host of psychological problems, including:
Women with a history of childhood physical, sexual or emotional abuse or neglect may develop PTSR when faced with an additional trauma later in life, such as sexual assault, abuse by a partner, divorce or loss of a loved one. For reasons of clarity, throughout the rest of this guide the discussion will mainly refer to post-traumatic stress responses (PTSR), to capture the various types of post-traumatic stress (simple and complex). Chronic abuse in childhood - on its own or combined with a lack of emotionally connected parenting (being able to recognize and respond appropriately to a child’s emotional state) - profoundly shapes and negatively affects a person’s cognitive, emotional, and psychosocial development. These negative effects are worsened when childhood abuse occurs in an environment where a child is also deprived of essential emotional needs, such as safety, constancy and emotional validation. Trauma in a bio-psycho-social framework Trauma can change a person’s life when it leads to disruptions in emotion, consciousness, memory, sense of self, attachment to others and relationships. What’s more, trauma doesn’t just affect women’s minds. It affects their bodies as well. Responses of the body are known as physiological responses. When children are abused by their own caretakers, or while sleeping in their own beds, they cannot fight or flee. They are often trapped physically by the perpetrator, trapped emotionally by their attachment to the perpetrator or else they are made powerless by their mistaken beliefs that they are to blame for the abuse. Similarly, many adult women are trapped in relationships with abusive men - they may fear their abusers will kill them if they attempt to leave. When a person is trapped, his or her sympathetic nervous system is activated. As a result, they often have a surge of physiological arousal - with no outlet for this arousal - resulting in agitation, tension and anxiety. Prolonged trauma increases and generalizes physiological arousal. Trauma survivors often complain that they are not able to establish a state of calm or comfort. Instead, they too often feel chronically anxious, agitated and tense. This increased physiological arousal often results in insomnia, tension headaches, gastrointestinal disturbances, and back and pelvic pain. Traumatic experiences, therefore, alter the functioning of the central nervous system as well as general physiological functioning. In this way, trauma has both emotional and physical effects. Trauma is best discussed in a framework that takes into account the physiological and psychological levels on which trauma is experienced, as well as the social context in which the trauma occurs. This is known as the bio-psycho-social framework. In this bio-psycho-social framework, all responses to trauma are understood as attempts to cope with the stress of trauma. People adapt - mentally, physically, behaviourally and socially - to traumatic experiences. The social context and circumstances that define and shape girls’ and women’s lives also shape the ways they cope with trauma. For many women, disempowerment doesn’t end when they are free of their childhood abusers. They often have an ongoing experience of disempowerment because of gender inequality, racism, and poverty in their lives. Gender inequality, in which women are seen as having a lesser social value, often causes women to feel powerless, vulnerable and at the mercy of others. This social disempowerment then shapes and intensifies a woman’s reaction to being abused. Powerlessness in society When a child’s bodily autonomy and integrity and sense of efficacy (sense of competence and ability to make things happen) are harmed by experiences of childhood abuse or neglect, the child is rendered powerless (disempowerment). Feelings of powerlessness are increased when a child is fearful, unable to have adults validate her hurtful experience, and when she realizes that her dependence on adults has her trapped in the abusive situation. The use of force and threat are not even necessary in many cases of child abuse, especially when the abuse is perpetrated by trusted family members. The fear of losing a life-sustaining relationship is threatening enough for a child. Most children respond to this experience of disempowerment and entrapment by accommodating the needs of the abuser. They learn to comply with whatever their abuser expects of them, in hopes of avoiding further abuse or rejection. They learn that it is not safe to assert their own needs and will. Too often, mental health providers do not fully understand the social and psychological factors that shape these adaptations and responses in women’s lives. As a result, mental health providers may be impatient with trauma survivors, perceiving them as “chronic victims” who should just learn to assert themselves. This failure to understand can make women feel further blamed, and ashamed for the ways they have tried to protect themselves and manage. The social conditions of many women’s lives help keep them fearful, hypervigilant (always on the lookout for danger), disempowered and vulnerable. As well, inequality affects mental health and can exacerbate the long-term effects of abuse in childhood. For example, women who face ongoing racism, homophobia, sexism or conditions of poverty may respond by using coping strategies such as hypervigilance or disconnection (taking themselves mentally out of a situation), because they are triggered by these threatening and disempowering experiences. The responses to these experiences include ongoing depression or sleeping disorders. Many women adapt by disconnecting through self-harm or the use of medication, alcohol and other drugs. Abuse survivors are often told their experiences are in the past, and they should no longer feel the same need for self-protection. However, the reality is that many women are still vulnerable and exposed to ongoing violence and social marginalization, especially lesbians, women of colour, women with disabilities, and women living in poverty. The role of front-line workers As a critical first step, front-line workers can play an important role in addressing issues of safety in women’s lives. Women who have post-traumatic stress cannot reap much benefit from therapeutic interventions when they don’t have a safe place to live or enough money to survive. An important part of understanding trauma, therefore, involves recognizing and understanding the effects of social inequality on women. It also means that psycho-educational supportive counselling (education on psychological responses and processes) and help with basic needs are important parts of working with trauma and women with post-traumatic stress.
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Last updated: Nov 02, 2007 11:18 AM Published: Nov 21, 2008 1:33 PM ID#P23907 |