Stress, Trauma, and Posttraumatic Growth

Social Context, Environment, and Identities

Roni Berger

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781136311604
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

What happens in the trauma's aftermath? How do its effects manifest differently on the individual, family, and community-wide levels? Stress, Trauma, and Posttraumatic Growth: Social Context, Environment, and Identities explores the way traumatic events are defined, classified, and understood throughout the life cycle, placing special emphasis on the complex intersections of diverse affiliations and characteristics such as age, class, culture, disability, race and ethnicity, gender identity and expression, immigration status, political ideology, religion, sex, and sexual orientation. The bookgives its readers a solid basis for understanding traumatic events and treating their effects and also shows the varied ways that trauma is conceptualized across cultures. Both new and seasoned clinicians will come away from Stress, Trauma, and Posttraumatic Growth with a deep understanding of the principles that guide successful trauma treatment.

Part I
Mapping the Arena

Concepts, Definitions, Classifications, and Theories

Some traumatic events are common and anticipated, such as the death of an older parent, the birth of children, or school violence; others are possible though not unavoidable, such as a serious disease, a road accident, or an earthquake; yet others are quite rare, such as being kidnapped or tortured, terrorist acts, or mass shootings in the workplace. The prospects for exposure vary depending on who people are (e.g. gender, socioeconomic status, race), where they live, and their personal, family, and work circumstances. For example, living in areas prone to natural disasters or in war zones increases the likelihood of traumatic exposures and living in poor communities increases the prospects of dire consequences of such exposure. Such encounters may become stressful or even traumatic when the amount of coping they demand exceeds the resources available for managing them.

This part of the book introduces the map for understanding stress and includes three chapters. The first offers definitions and explanations of main concepts; the second reviews diverse classifications of stressful events; and the third presents a concise overview of leading theories relating to stress, crisis, and coping of individuals, families and communities.

1
Concepts and Definitions

What is a stressor event? How does it compare to a traumatic event? What is the difference between stress, crisis, and trauma? Concepts and their definitions can be confusing. The following section presents core concepts in the field of stress, crisis, and trauma, some of which will be further developed in later chapters. These concepts refer to individual, group, and protective aspects.

Individual Aspects

Stressor Event

A stressor event is a life situation which places a demand or pressure on an individual, a family, or a community that produces, or has the potential to produce, a major change from the previous state so that regular responses cannot effectively address it. Bonanno and Mancini (2008) suggest that highly aversive events that fall outside the typical range of normal everyday experience should be viewed as potentially traumatic because not everyone experiences them as such. The source of a stressful event can be physical, psychological, financial or social, or a combination of these. The event can be normative – such as marriage, launching an adolescent, retirement, or relocation – or non-normative – such as an accident, divorce, an untimely death, or the birth of a child with a disability. All stressor events are complex, and made up of different traumatic moments, which include varying degrees of threat. While the original event may be a one-time occurrence, it often generates additional challenges and may have ripple effects that can last a long time.

Pile Up of Stressors

This concept, sometimes referred to as cumulative stress, was coined by McCubbin and Patterson (McCubbin, Thompson & McCubbin, 1996), and refers to the build-up of multiple stressful situations, which occur simultaneously and may lead to stress becoming a chronic condition in the life of the individual, family, or community. Stress pile-up can occur as a result of a continuous problem in the social environment (such as the decades of war in Afghanistan) or a single underlying ongoing stressor (e.g. a chronic illness) which produces ongoing stressors such as negative side effects, the appearance of various symptoms and challenges in functioning, or a series of unrelated events which occur immediately after each other leaving no chance to successfully address one stressor before the next one hits – for example, a child being injured a week after their grandmother has died. Any of these multiple stressor combinations may reduce the ability of those exposed to cope and function because of increasing demands and vulnerability. An example would be an original stressor event of a spouse’s prolonged battle with cancer, which may include multiple serial and cumulative stressor events such as repeated negative tests results and side effects of treatment, followed by their death, which may lead to numerous sequential stressors such as loss of income, or relocation that involves loss of friends, peer groups and neighborhood support systems.

Sometimes the effort to cope with and manage the original stressor event creates an additional stressor. For example, when women responded to their husbands’ absence due to military service in the Vietnam War by taking on roles traditionally fulfilled by men, disapproval from in-laws and other members of the extended family became an additional source of stress.

Stress

After years of debate as to whether stress is the function of individual traits, an objective characteristic of the environment or a result of the interaction between the two, currently dominant is the acceptance of the people– environment transactional model. While definitions of stress vary, most share at least three core elements. First, that a situation occurs which disrupts the usual stream of life and creates a state where the “normal” way of doing things does not work or is insufficient. This situation can originate from internal or external sources, be they major (e.g. being injured in an accident) or minor (e.g. failing a test), positive or eustress (such as winning the lottery, a promotion at work) or negative (e.g. loss of a loved one, being fired). A second major element across definitions of stress is that the situation is overtaxing because it demands resources that exceed those available for addressing it and thus a disparity is developed between the demands of the situation and the means for responding to it. Third, is whether the disparity is appraised by the exposed individual or system as strenuous, emotionally disruptive, endangering their well-being, and creating tension or as an opportunity for change and development.

Stress is an ongoing process rather than a stable state. Some amount of stress is part of the normal course of everyday life and its total absence may lead to boredom while excessive, unrelenting stress may become a burden and lead to difficulty in functioning. The normal amount of stress varies by profession and life circumstances. Thus, emergency work, military service, or parenting a child with special needs, for example, are characterized by a higher level of routine stress than is experienced by most people. What constitutes stress is somewhat subjective and there is no “optimal” amount of stress for individuals, families or communities as the threshold of tolerance varies by personality and the unique characteristics of those exposed. Some people thrive on an intense and demanding schedule with many unanticipated events whereas others experience as stressful even minute changes to their routine. The occur-rence of a stressor event stimulates a chain of physiological-neurochemical reactions, increased heart rate and blood pressure, and a sense of alertness. Stress has been documented as being associated with increased susceptibility to health issues such as coronary ailments and the immune system’s reduced ability to fight disease. In families, groups and communities, it triggers a parallel chain reaction of systemic dynamics such as inter-subsystems relationships. For example, Berger (2010b) identified processes of splitting, and projection of anger, guilt, and shame in a group of Black, Latino and Caucasian students during a stressful visit to the torture slave castles in West Africa.

Distress

Although definitions vary and are often vague, there seems to be consensus that distress (often called psychological distress to distinguish it from biological distress) is a combination of negative feelings of being easily annoyed or irritated, emotional pain, sadness, anxiety and fearfulness, and having uncontrollable temper outburst as a result of a subjective sense that something is wrong, whether or not that feeling is associated with actual impairment in any area of functioning. Distress is typically the outcome of exposure to highly stressful events which is not successfully decreased, controlled or eliminated (McCubbin, Thompson & McCubbin, 1996). It may include cognitive, somatic, and affective components. Psychological distress is considered a normal reaction to internal or external stimuli which are perceived negatively and it only becomes pathological when the response is disproportionate to the circumstances (Horwitz, 2007). Manifestations of distress may be somatic (headaches, neck and back pain, gastrointestinal problems, loss of hair and of weight, and heart-burn), emotional (sadness, anxiety, depression, anger), cognitive (e.g. difficulty concentrating) or social (withdrawal, combativeness and difficulty in intimate relationships).

Crisis

Definitions of crisis also vary. Hill (1949), in his seminal work on separation and reunification during and following the Second World War, defined it as a sharp or decisive change or life event which renders old patterns inadequate, with a resulting state of disorganization. In a family, a crisis is what happens when an unanticipated event reveals a failure of the rules, norms, behavior, or infrastructure used to handle it. An analysis of crisis literature suggests that most definitions of crisis include several core elements: 1. a disruption of normal life conditions or the steady state of an individual, a family, a group, or a community; 2. the abrupt or hazardous nature of the disruption; 3. perception of the disruption as a cause of considerable disturbance that compromises normal stability; 4. viewing the situation as insurmountable because regularly used coping strategies and resources that are usually helpful in managing issues are found to be insufficient or ineffective for resolving the problem; 5. possible development of the extreme response of distress, disorganization, disequilibrium, and impairment of the ability to function or cope with the situation and rectify it. Most crisis literature emphasizes its time-limited nature (4–6 weeks).

Crises may have situational, developmental, or social/cultural origins. A situational crisis results from an extraordinary and unanticipated event – such as war, a sudden death, a diagnosis of a life-threatening disease, or a natural disaster – which challenges the fundamental assumptions of one’s life. Developmental or evolutional crises are normal stages of development. The concept originated in ego psychoanalytic developmental psychology, particularly the work of Erikson (1963), who identified eight major phases in a person’s life. Each chronological phase presents a dominant age-specific developmental task or crisis. Successful accomplishment of the task and resolution of the crisis allows moving forward to the next phase whereas failure to do so may lead to getting stuck or regressing. Such developmental crises are normative and tend to be universal. The same idea has been applied to families and their transitional crises around diverse phases in their life span such as marriage, the birth of a first child, raising children, launching an adolescent, and so forth. The origins of a social/cultural crisis are discriminatory norms such as racism, sexism, and homophobia. While some have seen stress and crisis on a continuum, others have attempted to distinguish them as discrete separate entities. In this book I take the former approach, based on my scholarly knowledge and clinical experience.

Trauma

The word trauma originates from Greek, literally meaning a wound or injury. The definition of this often-used and seemingly clear concept is challenging as it has been used interchangeably to describe not only horrific, often potentially life-threatening events, but also the experience of those exposed to the event and responses to the experience. It is often claimed that trauma is in the eyes of the beholder. The definition of trauma in the DSM-V (2013), the bible of mental health clinicians in the US for the diagnosis of mental health disorder, is:

direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1) others.

(APA, 2013, p. 274).

Similarly, in the European parallel of the DSM, the International Statistical Classification of Diseases, and Related Health Problems 11th Revision (ICD-11), trauma is viewed as resulting from an encounter with an overwhelming, negative, and extremely painful experience that is incongruent with the existing repertoire of perceptions, interpretations and coping strategies, and is likely to create distress. While loss and trauma are different, grief over the loss of people, objects, ideals, and beliefs is often central to the experience of trauma.

In agreement with Freud’s view of traumatic events as potent enough to penetrate the protective shell of the ego, there is consensus among scholars and practitioners that trauma challenges the natural need of people for the world to be predictable, just, orderly, and controllable such that they can anticipate the sequence of events in their life, know what will most probably happen at certain times, and plan with some safety. Such challenges may have psychological and neurological aspects and both short- and long-term impact to various degrees on diverse aspects of feelings, thinking, behavior, social relationships, and self-perception.

Complex Trauma

This describes a unique type of trauma characterized by its timing at critical developmental phases and its destabilizing of core elements of the self and one’s interpersonal relationships. It refers to extended exposure to multiple simultaneous, sequential, or prolonged traumatic events, most often in the context of interpersonal relationships (such as intimate partner violence), placing the person at risk for severe health and mental health problems (van der Kolk et al., 2005). The term emerged in the 1990s when researchers and practitioners began to realize that some forms of trauma were much more pervasive and complicated than others (Courtois, 2008). In children it typically involves the continuous experience of abuse and/or maltreatment, often in the context of an unsafe community. Complex trauma is viewed as altering basic self-structure, attachment, and relational systems (e.g. with family), and connections with broader communities.

Retraumatization

Retraumatization may occur when the report of a traumatic experience by the victim meets reactions of disbelief, minimization, and pressure to keep it a secret and go on with life as if nothing happened. Some types of stressful experiences such as rape and childhood sexual abuse are especially vulnerable to retraumatization. Thus, a victim of domestic violence in a conservative cultural context who escapes the abuser to seek shelter with her family of origin but is told “go back to your [abusive] husband” may be retraumatized. Some practitioners have been concerned that the use of intervention strategies that require revisiting the traumatic event, such as exposure therapy (discussed in Chapter 9), may have negative effects of retraumatization. Retraumatization has rarely been presented as an issue in treatment (Karlin et al., 2010).

Vicarious (Secondary) Traumatization

Diverse and somewhat different though closely related concepts have been used to describe indirect impacts of trauma exposure on those who experience it second hand via intensive personal or professional relationships with direct victims. They include compassion fatigue, secondary traumatic stress (Figley, 1995), vicarious effects (McCann and Pearlman, 1999), empathic strain, secondary traumatization (Rosenheck & Nathan, 1985), and co-victimization. The phenomenon of a contagious trauma was originally identified in family members of combat veterans and survivors of sexual assault. Following Carl Jung’s idea of the “wounded healer” to connote the pain of therapists caused by interaction with the pain of those they treat, it was later expanded to professionals who provide services to trauma survivors, such as police officers, nurses, social workers, psychologists, psychiatrists, and clergy (Figley, 1995; Killian, 2008). It involves a caregiver’s pain and identification with the direct victim’s suffering, and its manifestations resemble those of direct victims (Ellwood et al., 2011). Increasing recognition of secondary traumatization led to the journal Traumatology dedicating its December 2011 issue to it.

Group Aspects

Concepts with nuanced differences have been used to describe exposure to a common stressor event of a group of people who share a characteristic or an affiliation, such as religion, racial/ethnic background, profession or sexual orientation, or living in the same place (Wieling & Mittal, 2008). It has been defined as the “cumulative emotional and psychological wounding over the lifespan and across generations, emanating from massive group trauma experiences” (Yellow Horse Brave Heart, 2003, p.7), and its effects can reverberate through and be transmitted from one generation to another by the process of transposition.

Collective or Mass Trauma

An immense trauma experienced simultaneously by a large number of people can be an isolated event or an ongoing series of circumstances such as the decades of exposure to civil wars and armed conflicts in Liberia, Sudan, and the Middle East. When such a shared and widespread exposure to radical technological, political, economic, or physical changes is experienced by members of a certain group and is interpreted as fundamentally incongruent with core values and identity, it may lead to the demise of a previously orderly and taken-for-granted universe. This type of trauma is viewed as the most threatening, with the longest endurance in the collective memory or subconsciousness (Alexander et al., 2004; Sztompka, 2000). While some claim that the concept of historical trauma should be limited to events created by people rather than natural disasters, often a more inclusive view is used. Examples of such trauma include major political reform – such as recent revolutions in the Arab world – war and terror, genocide, ethnic cleansing or persecution of an indigenous religion – su...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Acknowledgments
• Introduction
• Part I Mapping the Arena: Concepts, Definitions, Classifications, and Theories
• Part II Pathogenic and Salutogenic Outcomes of Exposure to Stress in Individuals, Families, and Communities
• Part III Understanding Stress and Trauma from Developmental and Cultural Perspectives
• Part IV Addressing the Outcomes of Stress and Traumatic Exposure
• References
• Index