Victims' Response to Trauma and Implications for Interventions: A Selected Review and Synthesis of the Literature
2. LITERATURE REVIEW (cont'd)
2.4 Coping Strategies
Coping can be defined as:
determined by cognitive appraisal. The central function [of coping] is the reduction of tension and the restoration of equilibrium. We have to distinguish between coping that is directed at managing or altering the problem causing the distress (problem-focused) and coping that is directed at regulating emotional response to the problem (emotion-focused) [bracketed information added] (Hagemann, 1992, p. 61).
The literature often distinguishes between negative coping that does not focus on the stressor (e.g., blaming others, withdrawal, resignation, self-criticism, aggression, wishful thinking) and positive coping strategies that focuses on self-change or changing the problem (e.g., social support, problem-solving efforts, seeking information). Dempsey (2002) found that use of negative coping techniques and exposure to violence was predictive of PTSD, anxiety and depression.
Furthermore, the victim may be coping with several different things at any one time: the shock of being a victim, the new (or repeated) experience of dealing with the criminal justice process, trying to make meaning of why they were victimized, reactions to others, attempting to return to a normal, previctimized state, dealing with the blow to the belief in a just and predictable world, self-blame and a myriad of other feelings, thoughts and socio-environmental pressures. Thus, one might expect that a major aspect of cognitive change relates to how the victim copes with the crime. Calhoun and Atkeson (1991) point out that as the victim starts feeling better, he or she needs fewer coping strategies or uses them less often, a possible indication of internal cognitive changes taking over for coping strategies. This section reviews some of the major coping behaviours and strategies employed by victims.
Use of social support
As noted above, when victimized the person often feels disorganized and out of sorts (Casarez-Levison, 1992) and will often seek others for support (Greenberg & Ruback, 1992; Leymann & Lindell, 1992; Norris et al., 1997). Everly et al. (2000) indicated that helpful social supports could provide information, companionship, emotional support and instrumental support. As Nolen-Hoeksema and Davis (1999) pointed out, receiving positive social support after a trauma is related to better adjustment. Researchers have distinguished between these several types of social support (Leymann & Lindell, 1992). Emotional support is characterized by a focus on esteem, concern and listening with a focus on the victim's feelings and emotional reactions. Appraisal support focuses on social comparison, affirmation and feedback targeted at helping the victim make sense of his or her experiences. Informational support focuses on advice, suggestions, directives and information that the victim might need. Finally, instrumental support focuses on tangible support such as money, shelter, time or effort (Leymann & Lindell, 1992). For example, although police and other members of the criminal justice system may not be emotionally supportive (Campbell et al., 1999) they may be more supportive with respect to providing information or offering tangible support through investigation (Norris et al., 1997). Furthermore, Greenberg and Ruback's (1992) decision-making model included social comparison (appraisal support) and information seeking (informational support) and their research reinforced the strong influence bystanders can have on the victim's decisions in providing these forms of support.
In discussing both natural (family, friends, peers) and professional supports (police, medical professionals, mental health workers), Norris et al. (1997) noted that victims benefit from talking to others about their experience. They indicated that victims seem to want to tell the story of their trauma over and over and to express their feelings about the trauma. Greenberg and Ruback (1992) discussed this retelling as the victim developing simulations to help makes sense of his or her victimization. This tendency may be the victim's attempt to gain understanding about the trauma and confirm their reactions with a trusted other (appraisal) or simply to share the emotions related to victimization (emotional). It is also possible that they want confirmation that their behaviour and actions during the crime were reasonable and correct (Nolen-Hoeksema & Davis, 1999). In a sense, talking to supports can result in the person re-framing their victimization experience so that they feel better about their behaviour, relating to the concept of cognitive simulations discussed above (Greenberg & Ruback, 1992). Recall, that social support seems to be very important in crime victim decision-making.
Information seeking
As noted above, victims may attempt to cope using social support, but the goal of the support can vary. Seeking information is one way victims try to cope with victimization (Hagemann, 1992). This may, as Greenberg and Ruback (1992) held, help the person make decisions regarding further action. Information may also provide further direction regarding status of a criminal case, learning new kills, identifying treatment resources or a host of other issues the victim believes are salient to his or her well-being. Unfortunately many victims may have difficulty accessing appropriate information (Campbell et al., 1999). Critical Incident Stress Management (discussed in a subsequent section) is one potential method of meeting this need for information (Everly et al., 2000; Turner, 2000).
Cognitive Reframe of victimization: Emphasize the positive aspects of having survived
In research on sexual assault victims, Hagemann (1992) noted that some victims seem to benefit from being able to label their status as victim or survivor of sexual assault. In fact, Thompson (2000) examined sexual assault victims who had not received help and found that some women initially embraced the label victim because it was linked to a lack of blame and responsibility. However, through a process of adjustment, they switched to the label survivor because of positive connotations including strength, recovery and being a fighter. This self-talk and self-labelling are important cognitive strategies that help some victims regain a sense of understanding of the crime and control over their life. These findings seem similar to those of Davis et al. (1998) who noted that people adjusting to loss often use two related cognitive strategies: a) making sense of the event and b) finding benefit in the experience. Further, these authors indicate that meaning-making is more important early in adjustment, whereas perceiving benefit is a longer term process. If this process were confirmed empirically among victims, it could be used to assess progress (rather than simply a reduction in symptomatolgy).
Cognitive Reframe of victimization: Self-comparison
Not only do victims seem to benefit by redefining themselves as survivors, some victims also seem to be able to focus on the strength associated with successfully coping with trauma (Thompson, 2000). Research by McFarland and Alvaro (2000) supported this view. They found that victims were more likely to report greater improvement in their personal attributes after traumatic life events than after mild negative life events. However, acquaintances of these victims did not note the same dramatic changes. Through a series of studies, these researchers concluded that victims tend to degrade their pre-trauma strengths in an effort to see positive growth resulting from trauma (McFarland & Alvaro, 2000). In a sense, in the process of meaning-making victims will work to preserve the concept of growth. The philosophy embraced by some victims appears to be: that which does not kill you, makes you stronger.
Reframe victimization: Social comparison
Victims will often engage in upward or downward comparison to understand and cope with their victimization. Upward comparison relates to comparing oneself to other victims that are better off. Thus, these individuals seem to act as inspiration to other victims (Greenberg & Ruback, 1992). However, there is also the risk that these "models" may leave the victim feeling disheartened about their own state, feeling that they can never make that much progress. Downward comparison refers to comparing oneself to those who are worse off. Thus, victims may find solace that their victimization did not leave major physical scares or that their loss was not as great. Both of these processes will likely help victims improve their understanding of their victimization, but it appears that downward comparison helps the victim feel better (Hagemann, 1992; Greenberg & Ruback, 1992; Thompson, 2000). It is noteworthy that when such negative models are not immediately available, victims will create scenarios wherein they received even greater physical, emotion or personal damage (Greenberg & Ruback, 1992). This internal "it-could-have-been-much-worse" exercise seems to help the victim gain perspective, and may even relate to a focus on the positive aspects of being a survivor (Thompson, 2000). Ultimately, the goal of this activity is to learn acceptance of one's own victimization experience (Hagemann, 1992), a goal in some treatment approaches (Layne et al., 2001).
Activities in service of regaining control
Victims, in their attempt to regain feelings of control and safety can also take specific action to regain control. Hagemann (1992) indicated that some victims take self-defence classes. One could argue that pursuing the perpetrator through the justice system also helps the victim alleviate his or her loss of control (Greenberg & Ruback, 1992).
Activism
Some victims seem to gain benefit from becoming victim advocates or activists (Hagemann, 1992). It appears these victims take their victimization from a personal to a more social level, trying to change elements of society they feel contributed to their victimization.
Avoidance: Active Behavioural Avoidance
Avoidance can manifest as behavioural avoidance, such as staying in apartment or taking time off work (Hagemann, 1992) or avoiding through self-medication, using alcohol and drugs (Everly et al., 2000; Hagemann, 1992; Mezy, 1988; Wolkenstein & Sterman, 1998). Generally speaking, researchers agree that such approaches are a band-aid solution to the underlying trauma, but they may have an adaptive element by helping the person slowly build on small success experiences. In other words, initial avoidance may allow the victim to take time to "lick their wounds" and gather resources to rebuild their life and deal with other challenges (e. g., the criminal justice system).
Avoidance: Denial and Self-deception
Basically acting as a type of psychological avoidance, denial and self-deception work to help the individual erase the memories, at least temporarily. Thompson (2000) discussed the active blocking of memories and feelings to help cope with overwhelming emotions. Stillwell and Baumeister (1997) indicated that people have a tendency to bias their recall to cast themselves in a more positive and sympathetic light. Mikulincer, Florian and Weller (1993) pointed out how people who use avoidant strategies to cope with trauma are more likely to deny or minimize their internal distress. Although these approaches may hamper help-seeking, they may also minimize initial distress (Hagemann, 1992). Ullman (1999) agreed and indicated that although avoidance strategies (e. g., substance abuse, withdrawal from others) are usually linked to greater problems, they could also be adaptive in helping the victim get through the initial trauma.
Avoidance: Dissociation
Use of dissociation to cope seems to be more common in people with a history of frequent and severe traumatic experiences (Martínez-Taboas & Bernal, 2000). Similar to using substances or psychological defences to reduce trauma memories, Harvey and Bryant (2002) indicated that naturally occurring dissociation might help the victim cope with trauma. They note that dissociation may interfere with memory encoding during the original trauma. This cognitive change allows the victim to forget particularly difficult elements of the trauma and may result in reduced distress. However, Ozer et al. (2003) indicated that those who experience dissociation either during or immediately after the traumatic experience were more likely to develop PTSD. They noted that this relationship was most evident in those who later requested mental health services. Thus, dissociation may be a double-edged sword, it may help in the short-term, but could place the victim at increased risk for later problems.
Confrontation: Cognitively narrowing the focus
Holman and Silver (1998) pointed out that when people are presented with complex stimuli, their ability to process the information is compromised. Thus, they may cognitively slow down time in the present to cope with all the stimuli. In effect, they cognitively make their subjective world move in slow motion so that they are able to process events. These authors point out that this would be an adaptive response, but that in some cases this "foreshortening" of the future can become maladaptive as the victim becomes focused on the traumatic event to the exclusion of other experiences (Holman & Silver, 1998). Further, recall that Greenberg and Ruback (1992) found that arousal, specifically anger, resulted in improved recall. Thus, the arousal may allow the victim to focus their attention on the specifics of the crime. However, this focus may become maladaptive as the person works to process the victimization as only part of their life experience.
In conclusion, victims have many possible coping strategies at their disposal and their choice of strategy is likely a combination of cognitive skills in problem-solving, history and individual personality variables. The above list is not exhaustive as each person will have their own unique set of thoughts and feelings and these will work in synergy to create coping strategies and behaviours. Thus, there will be as many specific strategies as there are victims. This list serves as a guide to understanding the link between underlying cognitive activities and coping activities. However, one common finding in both research and theorizing is that social support has a major effect on decision-making and subsequent coping. The following sub-sections examine the relative utility of natural and professional supports for victims of crime.
2.4.1 Use of Natural Supports
The above discussion repeatedly noted the importance of support for crime victims. Support can be primarily emotional, appraisal, informational or instrumental (Leymann & Lindell, 1992), however, it is likely that support encompasses all these goals in differing degrees. Thus, support persons will move from simply listening to the victim, to providing another perspective, to recommending resources to providing food, shelter, money. Obviously the specific manifestation of the support is based upon the previous relationship between the victim and supporter, as well as the level of distress. No matter what the specific nature of the support, support itself seems important to helping ease the victim's distress. Recall the above discussion of the research by Norris et al. (1997) who examined the psychological consequences of crime in a longitudinal telephone survey in Kentucky. These researchers examined activators, reactions, consequences and moderators with respect to the victimization process. In examining natural supports as moderators, they found that beliefs about support availability had a strong impact on reducing depression and anxiety. That is, simply having confidence that he or she could receive support if requested, was enough to help reduce symptoms. This finding is even more profound when combined with the finding that there was no effect for actual received support (Norris et al., 1997). In other words, the person appears to gain stability and support from the belief that help will be available if they need it. If victims access that support, it does not appear to have an added benefit over knowing that support is available. This may relate to the victim needing to believe the world is safe and will support him or her, rather than the specific supports received from others. This also has implications around the importance of visibility of victim support programs. An examination of the specific types of support shows a differential effect. Emotional and informational support from natural sources showed a positive impact on anxiety. Anxiety is reduced as the victim receives support. Further, perceived social support around replacing the loss associated with victimization reduced both anxiety and depression (Norris et al., 1997). Perceived social support was also identified as important in the development of PTSD, with those who reported more perceived support, also reported fewer PTSD symptoms (Ozer et al., 2003).
These results indicate that the victim need not receive support as long as he or she feels supported by friends and family. One possible explanation for this result is that victimization affects the victim's perceptual world (the world is not safe; people are evil; I'm unprotected; I'm alone) and that beliefs that challenge these perceptions (despite their veracity) have a positive affect on symptoms. This finding is specifically important to the focus of this paper, cognitive effects of crime. This result indicates that cognitive elements alone can improve coping post-victimization. That is, the simple belief (a cognitive element) that one will receive support is enough to buffer the psychological symptoms of trauma, such as anxiety and depression. This conclusion is partially supported by Kliewer, Murrelle, Mejia, Torres de G. and Angold (2001) who found that support from family buffered the negative effects of witnessing family violence.
Not surprisingly, actual received support also reduces the victim's crime-related fear (Norris et al., 1997). These authors interpret this finding as indicating that most family and friends may be able to understand and successfully intervene in crime related fear. Thus, many crime victims can benefit from social support and seem to use any available supports, even strangers, to help them navigate the victimization and coping process (Greenberg & Ruback, 1992). However, people in the victim's natural support system may be less able to assess, and intervene in, problems associated with certain trauma related symptoms, such as depression and anxiety. Other research has found that victims rate natural supports as more useful than professional supports (Leymann & Lindell, 1992). These researchers examined the possible sources of support after armed robbery and subdivided support sources into: primary (natural), public authorities, professional providers, company authorities, judicial functions and curiosity seekers. They found that natural supports were rated the most helpful, public authorities (police, etc.) were second and professional providers (personnel officer, psychologist, nurse, physician) were third. Unsurprisingly, they found that victims rated curiosity seekers, such as journalists and customers, as the least helpful. They also found women reported receiving more positive social support than men (Leymann & Lindell, 1992). Although men did not report as much positive support, they were more likely to be contacted by police for statements.
Although natural supports can be effective and rated highly by victims, there are costs to relying on natural systems. In discussing ruminators, Nolen-Hoeksema and Davis (1999) indicated the very important reality that accessing social networks does not automatically mean accessing support. They found that ruminators, those people who dwell on the crime and their reactions, benefit greatly from social support. Non-ruminators also benefit from support, but not to as high a degree. Despite the potential for great benefit, ruminators tend to report that their support network was inadequate. These authors pointed out that although natural supports may be initially interested in helping the victim, they may grow tired of hearing the same complaints or descriptions. Under this dynamic, natural supports may encourage the ruminator to ignore the trauma or to put the crime "behind them". Thus the ruminator does not receive the type of support for which he or she is looking. In this case, the natural support is not reinforcing the ruminators preferred coping style and is likely failing at providing the type of appraisal support the ruminator wants (agreement on their chosen course of action). Upon discovering that their supports appraised their actions differently, victims may feel criticized, both for behaviours during the crime or thoughts or feelings they have about the trauma. In other words, seeking appraisal support could result in the person hearing things they do not want to hear. In fact, even when people are trying to be helpful they may do things that hurt rather than help. This may be the result of the natural support preferring different coping strategies than the victim. Thus, if the victim needs emotional support but their friend thinks they need information, this would be experienced as a breakdown in support. The reverse is also true: those seeking information may be frustrated if their support wants to focus on emotions.
In their unique focus-group research with clinicians, Nelson, Wangsgaard, Yorgason, Higgins Kessler and Carter-Vassol (2002) explored the challenge of working with dually traumatized couples (couples in which both partners have a history of trauma). They identified one particularly damaging dynamic they labelled the "preoccupied-dismissing" couple. In this dynamic, partners take complementary positions with respect to how they deal with trauma. For example, one partner may become preoccupied, ruminative or overwhelmed with the effects of the event, whereas the other partner may deny, suppress or dismiss the effects of the event. Thus, it is easy to imagine each partner trying to get the other to adopt his or her own coping style. The result is likely to be both partners will feel unheard and unsupported, potentially exacerbating the original trauma.
Returning to the research on ruminators, Nolen-Hoeksema and Davis (1999) found that although these victims benefit from support, dealing with "nonsupportive others" layers more stress over the original trauma and creates more distress. This impedes the ruminator's ability to improve. Their research indicated that when ruminators reported that their family members or friends were critical of them, did not agree with important decisions they had made, or were otherwise in conflict with them, they experienced more distress. They point out that these negative responses give ruminators more things to worry about and raise more questions about their own behaviours or emotional reactions (Nolen-Hoeksema & Davis, 1999). In contrast, positive support that allowed sharing of emotions seemed to help ruminators cope with their distress and concerns more actively and effectively.
Thus, some victims may find it helpful to seek out professional support. In the ideal world, most professionals have training in listening, providing emotional support, providing information and social comparison. They should also be better equipped to cope with repetitive stories and accounts. Professionals should also be better able to identify and provide the specific support needed by the victim. Furthermore, victims need not be concerned about damaging other aspects of the relationship since the goal of the relationship is focused on dealing with the victimization of trauma. Thus, we now turn our attention to professional supports.
2.4.2 Use of Professional Supports
As noted above, many professionals can act as support to the victims. Police and criminal justice personnel offer instrumental support in the form of investigation, arrest, prosecution and possibly incarceration and may also provide information, appraisal and emotional support. Medical personnel also provide instrumental support through addressing physical damage and gathering evidence. Medical professionals may also provide informational support (STDs, victim services contact), appraisal and emotional support, depending on the individual skills and inclination of the professional. Social services and shelters can provide instrumental support through replacing money/goods, providing a safe environment, etc. and may also provide other types of support. Finally, mental health workers can also provide support, typically within informational, emotional and appraisal areas. This section is going to focus on those professionals who provide emotional, informational and appraisal support; typically, these include mental health workers, shelter workers and those in victim services.
In his discussion on the effects of domestic violence, Lawson (2001) indicated that professional support offers recognition of, and education around, the various types of abuse, processing emotions related to the crime, debriefing, skills teaching (communication, conflict resolution), practical planning (e.g., developing safety plans), and identifying and using social support systems. He also noted that professionals could help the victim develop self-esteem, challenge negative societal/familial norms and deal with family issues. In other words, professionals can act as a support to the natural support system, thereby benefiting the client. Gorman, (2001) also indicated that therapists could work within the clients' frame of reference to help them to cope with victimization. The victim can then focus on telling his or her story, rather than trying to convince the support person that his or her perspective is correct. Thus, on the surface, it appears that professionals may offer important supports and strategies that help victims of crime, and perform a complementary function to natural supports.
As noted above, Norris et al. (1997) found that about 12% of victims sought mental health services, with most from the violent crime group. Non-violent victims accessed services at level roughly equivalent to the general population. This equal access between non-violent victims and the general population indicates that they probably did not suffer increased distress because of the crime, but it is possible that the crime was the specific catalyst to help-seeking behaviour. In examining crime victims, the two major predictors of help-seeking behaviour were depression and the use of violence in the commission of the crime. These elements generate a hypothesis that victims who experience more distress are more likely to seek professional support. Thus, it is possible that victims of both violent and non-violent crime, who experience distress, are more likely to seek help. Severity of reaction influences help-seeking behaviour, but so does severity of offence. This finding must be studied in more depth but it makes logical sense. Of note, in receiving services, they also found that professional help was only effective if the help was prompt and continuing (Norris et al., 1997). This is a very important finding, indicating the utility of early intervention for crime victims. However, in an environment increasingly focused on brief interventions, victims may be challenged to identify appropriate services.
In a multinational study, van Dijk, Mayhew and Killias (1991) found that only 3.8% of victims reported that they received any form of victim support, with the United States at 10.0% and Canada at 5.5%. The percentage receiving help was highest among victims of sex crimes (15.1%) and lowest with theft (2.4%). For those victims who did not receive any form of professional assistance, the researchers asked if the victim felt such support would be useful. On average, 35% of victims reported feeling that victim support would have been helpful. Sixty-two percent of sex crime victims reported a desire for help, while 52% of those who were threatened said they would have wanted help. They note that their results regarding desire for support must be viewed cautiously, as there may have been cultural differences in survey interpretation. For example, the researchers noted that some respondents may have interpreted "support" as financial support (van Dijk et al., 1991), as reflected in a relatively high number (45%) of victims of bike theft reported that they would have liked support.
At this point, it makes sense to briefly review an example of a professional intervention that seems to have empirical support. This treatment approach was specifically chosen to show how cognitive changes could improve the victim symptoms, related to the overall topic under discussion. Resick et al. (2002) completed an outcome study of cognitive-processing therapy (CPT). Over 12 sessions, clinicians teach clients to challenge distorted beliefs (e.g., denial and self-blame), overgeneralized beliefs about oneself and the world and pre-trauma beliefs/assumptions. The client then learns new, more balanced self-statements. CPT also includes an exposure element by having clients write, and share, a detailed account of the traumatic incident. Resick et al. (2002) compared CPT with prolonged exposure and a minimal attention in 171 sexual assault victims. The prolonged exposure group included education, breathing retraining and behavioural exposure to environmental reminders of the trauma and exposure to the trauma memory through imagination. The minimal attention group underwent the assessment procedures only and were phoned every two weeks to see if they required emergency services. After six weeks, the researchers randomly assigned those in the minimal attention group to either CPT or prolonged exposure.
Both CPT and prolonged exposure were successful in treating chronically distressed sexual assault victims. Those in the attention alone did not show any significant improvement. CPT was best at helping to reduce guilty cognitions (e. g., self-blame, feelings of wrong-doing, etc.). A further analysis of this data showed some PTSD symptoms initially became worse before they became better (Nishith, Resick & Griffin, 2002). However, PTSD symptoms show a dramatic reduction after the first exposure session (session in which the victim has to present her or his detailed account of the sexual assault). They indicated that exposure may be an active ingredient of change in professional interventions (Nishith et al., 2002). Thus professional support may offer specific, targeted strategies to help particularly distressed victims to move beyond their symptoms.
One caveat in looking at professional support involves clinical bias. Nelson et al. (2002) indicated that clinicians often assume that people who have experienced a potentially traumatic event will automatically be traumatized. In fact, such a "non-reaction" may be viewed as pathological in and of itself, relating it to dissociation or "shock" (Mikulincer et al., 1993). However, these authors emphasized that clients must be the authority regarding their own reaction. To ignore the client's self-appraisal is to risk being non-supportive, and deepening the trauma response. The clinician must proceed carefully in cases wherein the clinician is unsure about why the victim is not displaying trauma related symptoms. Clinicians may be able to provide therapeutic support and education (Nelson et al., 2002) that help the victim better identify her or his own needs. This alliance allows the victim and clinician to work together towards improvement. The clinician may also be able to help the client, especially those who are particularly distress, through the judicious application of diagnosis. Diagnosis with an identified disorder often helps the victim access services. It is to diagnosis and the medicalization of trauma that we now turn.
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