Victims' Response to Trauma and Implications for Interventions: A Selected Review and Synthesis of the Literature

2. LITERATURE REVIEW (cont'd)

2 LITERATURE REVIEW (cont'd)

2.5 Medicalization of Trauma

2.5.1 Relationship to DSM-IV Disorders

As discussed above, victimization and trauma affects each person differently and many victims experience social/communication problems, stress symptoms, anxiety, depression, isolation, poor relationship quality, and reduced intimacy (Nelson et al., 2002). Much of the research discussed has focused on diagnostic categories, especially post-traumatic stress disorder (PTSD). Not surprisingly, the individual's coping strategies mediate the specific problems such as PTSD/anxiety and depression (Byrne et al., 1999; Dempsey, 2002). In a study of the effect of violence on inner-city youth Dempsey (2002) found that the presence of violence in the commission of the crime and negative coping explained 30% of the variance in PTSD, 11% of the variance in anxiety and 20% of the variance in depression. This means that criminal violence and negative coping predict PTSD, anxiety and depression to practically significant, but varying, degrees. This section will review further research related to PTSD/anxiety and depression.

Post-traumatic Stress Disorder (PTSD) and Anxiety

In examining PTSD and anxiety, it must be emphasized that PTSD is a specific type of anxiety. Anxiety and fear can manifest as agoraphobia, other phobias, panic attacks, free-floating anxiety, generalized anxiety and PTSD. Specifically, common symptoms to most anxiety disorders include: fear/distress/worry, physiological symptoms (e.g., sweating, shaking, difficulty breathing, nausea, chest pain, dizziness, etc.), behaviour change (e.g., avoidance, rituals) and behaviours aimed at reducing distress (American Psychiatric Association, 1994). Similarly, PTSD occurs after a traumatic event and symptoms may include such anxiety symptoms as: fear, helplessness, intrusive and recurrent recollections, distressing dreams, reliving the event, intense distress, physiological reactivity; avoidance/suppression of thoughts/feelings, and specific symptoms such as sleep problems, irritability, angry outbursts, poor concentration, hypervigilance and exaggerated startle response (American Psychiatric Association, 1994). The key distinction in PTSD in comparison to other anxiety disorders is the trauma-inducing event. Thus, it is unsurprising that research and treatment initiatives related to coping with traumatic victimization have focused on PTSD.

Anxiety/fear has been associated with workplace violence (Rogers & Kelloway, 2000), sexual assault (Byrne et al., 1999), childhood sexual abuse, (Merrill, Thomsen, Sinclair, Gold & Milner, 2001), critical incidents (e.g., accidents, victimization, war trauma, etc. ) (Everly et al., 2000), violent crime (Byrne et al., 1999) and family violence (Wolkenstein & Sterman, 1998). PTSD specifically, has been identified as a relatively common result of victimization (Byrne et al., 1999). Of note, research by Ruscio, Ruscio & Keane (2002) indicated that PTSD does not represent a categorically distinct syndrome in relation to normal distress, but is at the extreme end of a continuum. These researchers indicated that this is important if we want to identify which victims are most likely to require and benefit from clinical intervention. Thus, we should use empirical research and clinical study to identify both the best criteria and the best cut-off for effective identification and service delivery (Ruscio et al. 2002).

One question that is often raised when examining PTSD is why does one person develop the disorder while others do not. Part of this discrepancy is likely due to the assumption of PTSD as a distinct entity, which may not be the case (Ruscio et al., 2002). In any case, certain factors seem to make people more susceptible to developing PTSD; these factors include personal psychiatric history, report of childhood abuse, and family psychiatric history (Brewin et al., 2000). These authors reported a lesser link between education, previous trauma, general childhood adversity and PTSD. They further noted that gender, age at trauma, and race predicted PTSD in some populations but not in others. Despite these links, they noted that crime/trauma related factors such as trauma severity, lack of social support, and additional life stress, had somewhat stronger effects than these risk factors (Brewin et al., 2000).

Ozer et al. (2003) completed an exhaustive meta-analysis examining the predictors of PTSD and found similar results at Brewin et al (2000). They found that the strongest predictor of developing PTSD was dissociation either during or immediately following the traumatic experience. They indicated that this relationship was strongest in those seeking mental health services and in those studies that had longer elapsed time between trauma and assessment. They found a small to moderate relationship between PTSD and perceived life threat, perceived lack of social support and reporting intensely negative emotional reactions during or immediately after the trauma. Thus, no reaction (dissociation) is predictive of developing PTSD and extreme emotional reactions are predictive of developing PTSD. This indicates that the victim needs to quickly process information, including emotional information, and engage positive coping mechanisms as soon as possible. Finally, Ozer et al. (2003) noted small but significant relationships between prior trauma history, personal psychiatric history and family history of psychiatric problems and development of PTSD in response to trauma. Through a closer examination of the trauma history research they found that there was a moderate relationship between trauma and PTSD if the traumatic event was a crime, as opposed to a natural disaster. Furthermore, in examining different personal psychiatric diagnoses they found that depression was moderately predictive of developing PTSD in response to trauma.

A high level of PTSD after previous trauma also seems to be a risk factor. Brunet, Boyer, Weiss and Marmar (2001) found that 75% of those who had high levels of PTSD symptoms after the initial trauma also reported high PTSD symptoms for a subsequent trauma. This relationship was not observed in those who reported moderate and low PTSD symptoms. Brunet et al. (2001) concluded that clinicians should assess the presence of previous PTSD symptoms and the severity of any previous PTSD episodes when they assess risk of further PTSD symptoms. Similarly, researchers have linked higher heart rare after a traumatic experience to subsequent diagnosis of PTSD, indicating that physiological arousal may be important in the development of PTSD (Bryant, Harvey, Guthrie & Moulds, 2000).

In examining the dynamics of trauma reaction and PTSD, Gilboa-Schechtman and Foa (2001) found that sexual assault victims reported significant PTSD symptoms within the first two months after the assault. In fact, delayed peak reaction (period of the worst symptoms) to a traumatic event has been associated with increased pathology. They theorized that this delay related to being emotionally numb in the earlier phase of coping with trauma and that this individual difference in coping affects subsequent recovery. This finding may also relate to the reported successes with early interventions with PTSD that allow the client to process emotions, develop skills, manage their fears and return to normal daily living (Harvey & Bryant, 2002). In other words, directly addressing the victimization and associated trauma, linked with skill development, appears to be a productive avenue of intervention and study.

Cultural issues may also be important to examine when trying to assess PTSD. Norris, Perilla and Murphy (2001) compared Mexican and U.S. samples with respect to PTSD symptoms after a natural disaster. They noted that the natural disaster were quite similar, both were hurricanes that landed in similar areas and caused similar damage. They found that both samples showed similar relationships between severity of trauma exposure and PTSD symptoms. However, once they controlled for the severity of trauma, the Mexican sample reported higher in intrusive thoughts and avoidance symptoms, whereas the U. S. sample reported higher arousal symptoms. They noted that culture (or environment/learning) might play a role in determining avoidance/numbing and hyperarousal (Norris et al., 2001).

As noted above, PTSD and other anxiety disorders are understandable and treatable manifestations of trauma. In victims, these problems are very intrusive and potentially long-lasting effects of victimization, permeating many aspects of their lives. Similarly, the medical establishment has noted other psychiatric disorders that are related to traumatic victimization. Specifically, the discussion turns to depression as a possible outcome of victimization.

Depression

Often researchers focus on both depression and anxiety in the same research. Similar to anxiety disorders, depression has been associated with workplace violence (Rogers & Kelloway, 2000), sexual assault (Byrne et al., 1999; Gilboa-Schechtman & Foa, 2001; Mezy, 1988), childhood sexual abuse, (Merrill et al., 2001), abuse (Martínez-Taboas & Bernal, 2000), family violence (Wolkenstein & Sterman, 1998), and critical incidents (Everly et al., 2000). Depressive symptoms may include low mood, low appetite/weight loss, sleep problems, energy changes, self-blame/guilt, worthlessness/ hopelessness, difficulty concentrating and thoughts of death (American Psychiatric Association, 1994)

In trying to understand the dynamics of victimization and depression, Daley, Hammen and Rao (2000) noted that episodic stress could help deepen depression but that chronic stress seems to be more related to onset of the first depressive episode, rather than later ones. In other words, a more chronic stressor, such as the stress a victim of family violence may feel, is more likely to wear down the victim. Whereas, an acute stress such as single episode assault by a stranger, may deepen feelings of depression. They indicate the need for research to clarify the changes that occur in the relationship between stress and depression over the course of the disorder (Daley et al., 2000).

Although they related it to severity of crime, Gilboa-Schechtman and Foa (2001) noted that victims of sexual assault, versus non-sexual assault, were more likely to experience depression. They theorized that anxiety and PTSD are common to all traumas, but that depression is related to only certain types of trauma. They noted:

Because most of the parameters of emotional reaction were more severe following sexual assault than following nonsexual assault in both data sets, it remains possible that the differences we have identified between the two types of assault are attributable to rape being a more severe trauma than nonsexual assault (Gilboa-Schechtman & Foa, 2001, p. 398).

This severity-depression link is consistent with clinical expectations, since severe trauma is more likely to threaten the core of the individual. The simultaneous experience of fear and anxiety that might be associated with all types of victimization and trauma works to deepen distress. Thus, as others have noted (Mikulincer et al., 1993), we need to recognize the role of intense distress in the potential development of depression and other pathologies in victims.

An interesting theory links depression to the finding that having a history of previous victimization results in an increased chance of re-victimization. Daley et al. (2000) noted that depressed individuals have characteristics, or behaviours, that increases their likelihood of experiencing stressful events. This is referred to as stress generation. Although one must be aware of the slippery slope related to "victim blaming", it does make sense that depressive symptoms such as self-blame/guilt, worthlessness/ hopelessness, and difficulty concentrating interfere with the use of normal coping and problem solving. The depressed person's tendency to use negative and self-deprecating thinking is likely to interfere with any attempt to positively interpret events in their life (Davis et al., 1998). Thus, the person continues in a downward spiral, wherein failure experiences heighten susceptibility to further depression.

Depression and anxiety seem to be the more common diagnoses associated with trauma and victimization. PTSD is uniquely linked to victimization in requiring a specific event or events that relate to the anxiety symptoms as part of its diagnostic criteria. The reader should keep in mind that these diagnostic categories are more related to extreme reactions to trauma and victimization. However, in any criminal event, there are a multitude of variables that may affect the victim, including victim-perpetrator contact, use of weapon, use of violence, witnessing versus experiencing the crime, etc. Further, each victim has a particular history, resiliency and coping ability that may affect how he or she experiences and copes with victimization. This uniqueness makes group interventions an interesting challenge. The next section focuses on the characteristics of Critical Incident Stress Management to victimization as a method to prevent subsequent trauma and pathology.

2.5.2 Application of Critical Incident Stress Management

Critical Incident Stress Management (CISM) offers one possible intervention that may be useful in helping crime victims quickly receive information, access services, and avoid deepening of negative symptoms (Everly et al., 2000). CISM arose out of a merging of crisis intervention models and group psychological debriefing techniques and represents a range of interventions (Everly et al., 2000). CISM appears to be applicable to all stages of the crisis. Precrisis preparation or training can be important for those people who are at increased risk of being victimized, this would include bank personal, personal care workers, etc. After mass disasters or riots, large- scale procedures can be mobilized to help victims cope with the immediate effects of the trauma. In certain cases, individual acute crisis counselling may be employed to help victims who need more intensive attention (e. g., primary victims or those experiencing profound reactions). Defusings are brief small group discussions that focus on imparting very specific information. Critical incident stress debriefings are longer small group discussions wherein the leader goes into more detail and there is more opportunity for group members to share experiences. In some cases, family crisis intervention techniques may be employed to help the victim and his or her family cope with the repercussions of the crime. Finally, in recognition that CISM is not the same as therapy, follow-up procedures, and/or referral for psychological assessment or treatment may be needed to help those victims who continue to experience difficulty (Everly et al., 2000). There are several versions of CISM offered, but there appears to be some common elements that are important: cathartic sharing of the story, social support, and adaptive coping. Sharing the story and social support are important function of group interventions, and can be very powerful for participants (Foy et al., 2001). Adaptive coping training may include both cognitive and behavioural elements and focus on information processing, cognitive appraisal, expectations, and skill development (Everly et al., 2000). It is noteworthy that CISM began as an attempt to help caregivers and trauma workers deal with the stress associated with dealing with critical incidents and was not originally developed to help primary victims. Thus, it may be best applied to shelter workers or others dealing with victims. However, it has been generalized to direct victims of trauma (Everly et al., 2000).

As Everly et al. (2000) reported, there are several models of CISM, which emphasize, to varying degrees group process, cognitive problems, decision-making, emotional problems, interpersonal relationships, symptom management and information. These interventions focus on helping people make the transition back to everyday life in an attempt to minimize the negative effects of the crime-related trauma. With respect to crime victims, this model would be most applicable to groups of victims, such as hostages, since the group nature of CISM is important. In fact, these approaches are often quite popular in these cases as they represent an attempt by the system to address potential problems associated with trauma (Kenardy, 2000). CISM may be less useful to victims of individual trauma, as the crime-specific characteristics are important mediators to severity of reaction. However, the principles may inform individual intervention and education efforts with victims and are clearly applicable to those working with victims.

In discussing crisis intervention initiatives for victims of sexual assault, Calhoun and Atkeson (1991) indicate that many victims are reluctant to seek out full-fledged treatment in the first few months following victimization. However, these authors indicate that brief crisis-intervention models may help the victim express initial emotions, allow information sharing, identify and secure social support, anticipate future problems, develop feelings of safety, cope with daily demands, mediate with medical/legal agencies and, perhaps most importantly, arranging follow-up. Thus, the goal of crisis intervention is to help the victim adjust to the immediate stress of victimization but not specifically address possible long-term consequences (Calhoun & Atkeson, 1991). This more modest approach may be more practical and realistic than trying to minimize development of post-traumatic stress.

In a small pilot study, Foa, Hearst-Ikeda and Perry (1995) compared a matched assessment-control to a brief cognitive-behavioural program (2 hours per week for one month) for victims who experienced PTSD symptoms as a result of sexual and physical assault. These authors focused on participants who met the criteria for PTSD, except the requirement of symptoms present for at least one month. The program focused on exposure, relaxation training and cognitive restructuring and occurred within one-month post victimization (mean of 15 days). At the end of the month, 7 of the 10 women in the treatment program showed a reduction of symptoms to the degree that they would no longer meet the altered criteria for PTSD and showed a mean reduction in severity of 72%, as rated by independent evaluators. Only 1 of the 10 women in the assessment control group no longer met altered criteria for PTSD and the mean reduction in severity was rated at 33% (Foa, Hearst-Ikeda & Perry, 1995). These impressive results support the argument for early treatment, however the small sample size indicates the use of caution in over interpreting the results. Of note, this program also does not fall under the umbrella of crisis intervention as most participants began two weeks after the assault.

Frank et al. (1988) indicate that those who seek immediate treatment do not differ substantially from those who seek treatment later, and both groups benefit from treatment. This is consistent to other researchers who find that victims may show a reduction of symptoms regardless of length of time between victimization and treatment (Resick et. al., 2002). Thus, the timing of treatment may simply reduce the amount of time the victim must live with distress, a worthwhile goal (Frank et al., 1988). Recall, however, that clinicians and others must respect the victim's self-appraisal regarding his or her reaction to criminal victimization (Mikulincer et al., 1993). This is especially important in that professionals do not want to cause more distress by pursuing already traumatized victims. Such a break in empathy could replicate the differential power imbalance the crime victim felt when being victimized and create further difficulties, reducing the likelihood of later treatment seeking. Thus, clinicians must be sensitive to the needs and wishes of the victim with respect to receiving crisis services or treatment.

It is important to note that we are far from universal agreement on CISM's utility for any trauma victims. Several researchers have indicated that there is little solid empirical evidence that CISM or debriefing reach their desired goals (Everly et al., 2000; Kenardy, 2000; Turner, 2000). Everly et al. (2000) indicated the need for improved operational definitions of traumatic events, psychometrically sound standardized outcome measures and standardization of intervention procedures. However, general proponents of CISM concluded that there is enough evidence to make some firm conclusions. First, trauma and post-traumatic stress are linked in many victims. Second, there is some positive support for the efficacy of CISM in alleviating psychological distress associated with trauma. Third, there is a need for solid empirical research and outcome research on CISM. Fourth, there is a need for more on-site, field research examining the utility of CISM. Finally, decision-makers must support research, especially research that focuses on the possible negative effects of CISM (Everly et al., 2000). This is important as one major debate in the literature relates to those who believe that CISM procedures, especially defusing and debriefing, interferes with the person's natural healing process and may even deepen trauma (Kenardy, 2000). Sound empirical research is obviously needed to tease apart the relationship between trauma, trauma interventions and subsequent recovery.

If proven effective, CISM could offer an inoculation effect for crime victims. At first glance, it offers a quick and consistent way to impart information, link victims to services, identify symptoms and help the victim make an informed decision regarding whether he or she requires help. However, the caveats related to the limits of CISM noted above should not be ignored. Although severity appears to be a common factor to trauma reactions, victims are a heterogeneous group. Clinicians risk deepening trauma by mixing severity levels. Social comparisons, such as upward and downward comparison, may have adverse effects on the victim, requiring sensitive management on the part of the clinician. Individual differences in coping also have an effect on how the person deal with both the victimization, but also on how they deal with offers and extensions of help. Further, early treatment may have a positive affect on the victim, but needs to be approached with caution. One must understand that victim reaction is based on a mixture of crime characteristics (violence, sexual assault, severity, etc.), social characteristics (comparison, support, etc.) and the victim's own pre-trauma characteristics. Pre-trauma characteristics are the focus in the next section.