Basic Psychology

Trauma- PTSD and Grieving

Prof.Lakshman Madurasinghe

Definition of Trauma

Derived from Greek Word meaning ‘wound’.

Pure Def: Event that threatens ones life.

Broader Def: Any physical, sexual, emotional or spiritual wound that involves threat to ones life or sense of self.

Psychotraumatology

“… spans all levels of human functioning, from physiology to the soul. It cuts across the disciplines of psychology, psychiatry, medicine, sociology and philosophy, influencing the minutiae of biology as it simultaneously challenges the most profound concerns of human existence”

(Linley, 2004:601)

“The world breaks everyone, then some become strong at

the breaks”

Ernest Hemingway

Positive Adaptation

Life (thesis) shattered by trauma (antithesis) and regenerated through and toward wisdom (synthesis).

Three dimensions of wisdom identified from a review of the wisdom literature:

1. Recognition and Management of Uncertainty

2. Integration of Affect and Cognition

3. Recognition and Acceptance of Human Limitation

Positive Adaptation to Trauma: Wisdom both as Process and Outcome Linley (2003) Journal of Traumatic Stress Vol 16

Positive Adaptation•According to World Disasters Report (2002) approximately 170 million people were affected by natural disasters, catastrophes and wars in 2001.

•In the general population lifetime prevalence of ‘traumatic events’ in 50% of people.

•Only 1-3 % develop PTSD.

•Some people show positive post traumatic growth.

Positive Adaptation

•Recognition and Management of Uncertainty

Trauma shatters our fundamental assumptions about the world e.g., Assumptions of Invulnerability, Rationality, Morality and Identity.

Wisdom: Recognising that the world is uncertain, the constant nature of change and how to manage this uncertainty effectively.

Positive Adaptation

2. Integration of Affect and Cognition

Neither affect or cognition has primacy over the other as both are essential to higher human functioning.

Wisdom = Connected Detachment. Recognising and being guided appropriately by emotions but not being at the mercy of them

Positive Adaptation

3. Recognition and Acceptance of Human Limitation

Recognition and acceptance of the limits of human knowledge and the finitude of life

Wisdom = Acknowledging how much he/she doesn’t know. Appreciating the worth, value and finitude of the human condition.

Positive Adaptation

“greater traumatic experience, dealt with by means of positive reinterpretation and acceptance coping, in people who are optimistic, intrinsically religious, and

experience more positive affect, is likely to lead to reports of greater adversarial growth

(Linley & Joseph, 2004)

Specific Trauma

Post-Traumatic Stress Disorder (PTSD)

DSM-IV-TR DIAGNOSTIC CRITERIA

A. Following exposure to a traumatic event a person may persistently:B. Re-experience the traumatic event.C. Avoid stimuli associated with the trauma.D. Experience increased arousal.E. Symptoms ( Criteria B,C,D) last >1 month F. Above causes significant distress or impairment in social, occupational, or other imp. areas of functioning.

Additional Symptoms•Alcohol and drug abuse.

•Anger.

•High use of nonmental health care.

•Children’s experience of their parents PTSD symptoms place them ‘at risk’ for developing PTSD themselves.

•Impaired learning and academic achievement in children.

•Difficulty maintaining stable employment.

•Anxiety Disorders

•Depression.

•Troubled marital and family relationships.

Human Brain

Taken from ‘Mapping The Mind’ Rita Carter (1998 p.22)

Main Components of the Limbic SystemTaken from ‘Mapping The Mind’ Rita Carter (1998 p.40)

Taken from ‘Mapping The Mind’ Rita Carter (1998 p.152)

Taken from ‘Mapping The Mind’ Rita Carter (1998 p.143)

Implications for Therapy•Potential for therapy to do further harm and increase PTSD symptoms if not managed effectively.

•IMPORTANT: Establish client safety and client self mastery/control FIRST.

•Close monitoring and management of client’s physiological state throughout the session is essential.

•Increase cognitive awareness of trauma narrative and discriminating features whilst containing physiological responses.

•Refer: if unable to identify or manage PTSD symptoms

Complex Trauma

Age 0-1

 Psychosocial tasks Trust in environment and caretakers. Being taken care of.

Healthy Parenting Meets infants basic needs; allows infant to discover body boundaries

Messages “your human” “your important” “your needs are ok”

Dysfunctional Parenting. Neglect Abuse Objectification

Messages “Exist only when I want you” “don’t have needs”

Outcomes of Abuse for Child Mistrust, Anxiety

Messages to Self “I’m not important” “My world is not safe”

MPD Development Need for dissociation, Infant may split off newly forming personality parts: wants, needs, feelings

Outcomes for MPD Adults “I don’t know what to think or feel” “I must always watch and see how others do things” “Wants and needs make me feel out of control” “I must be in control”

Ages 1-3Psychosocial tasks Autonomy Personal control of body Doing things “on your own”

Healthy Parenting Allows child to separate

Messages “I am me; you are you” “you can have some control” “Its ok to do things” “You can think and feel”

Dysfunctional Parenting. Separateness is punished Engulfment or abandonment

Messages “I control you” “Control yourself” “Your doing it wrong” “Be the way I want” “Don’t think, don’t feel”

Outcomes of Abuse for Child Shame and doubt Helplessness, Anxiety, Over compliance vs. hyperactivity

Messages to Self “I can’t do it/I have to” “I feel out of control” “I am bad” “ I won’t feel”

MPD Development Dissociation allows splitting off good vs bad behaviour and containment of “bad” feelings.

Outcomes for MPD Adults “I don’t know what to think or feel” “I must always watch and see how others do things” “Wants and needs make me feel out of control” “I must be in control”.

Ages 3-5

Psychosocial tasks Initiative, Risking, Exploring, Separating real from not-real

Healthy Parenting Provides safety for exploration; defines real vs not real.

Messages “I will protect you” “You can do it” “You don’t make bad things happen” “You can still have needs” “I will be here when you need me”

Dysfunctional Parenting. Constriction and/or neglect Confusion Double bind messages

Messages “If you risk initiate, you’ll get hurt” “If you get hurt or if I get hurt, it’s your fault” “Don’t trust yourself” “No one will protect you”

Outcomes of Abuse for Child Guilt, Anxiety, Entrapment Role Reversal Hypervigilance

Messages to Self “I’m to blame” “I’m responsible for making others feel good” “It’s my fault when I (or others) feel bad”

MPD Development Increased use of fantasy and dissociation. Splitting of reality, moral values. Dissociation of personality states allows accommodation to double binds

Outcomes for MPD Adults “If anything goes wrong its my fault, and I must punish myself” “I still don’t know what is good, bad real, or true” “I can’t trust myself”.

Ages 6-12

Psychosocial tasks Competence and intellectual and social skills Experimenting with ways of doing things

Healthy Parenting Allows further separation, with boundaries and support.

Messages “You can trust others”. “The world is an interesting place” “You can use thinking and feeling to help you know”

Dysfunctional Parenting. Isolation

Messages “Don’t tell our secrets” “The outside world will hurt you” “Home is the only safe place”

Outcomes of Abuse for Child Inferiority Anxiety

Messages to Self “I can’t think/act for myself” “I’m stupid/wrong” “If I fail its my fault” “I’m a bad person” “I must try to look right”

MPD Development Advanced dissociation allows encapsulation and disownment of abuse. “Created selves” perform as needed on outside world. Intellectualisation, denial and copying increase as coping. Dominant personalities may begin to form.

Outcomes for MPD Adults “I have to conceal how or who I really am”. “I must keep the secrets” “Nothing bad happened” “I must look ok”

Ages 13-18

Psychosocial tasks Ego identity belonging to a group, Separation from home Developing sexuality

Healthy Parenting Allows further separation, with boundaries and support. Sets boundaries but allows limits to extend as child responsibleness increases. Allows difference and disagreement.

Messages “We support you in your effort to discover yourself and be responsible for yourself” “We love you”

Dysfunctional Parenting. Constricting or non existent boundaries. Symbiotic bond remains.

Messages “I don’t care what you do” “I’ll tell you what to do” “Get lost/go away” “Don’t leave” “You’ll never make it on your own” “You can’t trust anyone but us”

Outcomes of Abuse for Child Anxiety, Lack of identity or several identities among various social groups. Continued emotional enmeshment with abusers. Extreme fluctuations in behaviour and moods or compulsive conformity and over achievement. Drug use. Sexual problems. Eating disorders.

MPD Development Dissociation and denial become necessary to cope with intense internal chaoss and conflicts between personalities. Amnesic barriers strengthen. Dominant personality develop autonomy. Personality disorders may become encapsulated in personalities.

Outcomes for MPD Adults “I don’t know who I am, how I feel, or what to do”. “I want to be whole, but I don’t know how”

Grief

A loss/trauma experience involves the following five stages of emotional response:

(1)denial (2) bargaining (3) anger (4) despair (5) acceptance.

•These five stages can occur in either the sequence presented or in any variety of sequence.

•The stages can recur during a loss experience. •One stage can last a long time, uninterrupted.•These five stages can occur in either the sequence presented or in any variety of sequence.•The loss process can last anywhere from three months to three years. •These stages of grief are normal and are to be expected.

 It is healthier to accept these stages and recognize them for what they are rather than to fight them off or to ignore them.

•Working out each stage of the loss response ensures a return to emotional health and adaptive functioning.

•Getting outside support and help during the grieving process will assist in gaining objectivity and understanding.

Stage 1. Denial

We begin to use:Magical thinkingExcessive fantasyRegressionWithdrawalRejection

Stage 2. Bargaining

We begin to:Shop aroundTake risksDo for others

Stage 3. Anger

We begin to use:Self blamingSwitchingBlamingAggressive angerResentment

Stage 4. Despair

We can begin to experience:GuiltRemorseLoss of hopeLoss of faith and trust

Stage 5. Acceptance

We can now:Describe the terms & conditionsFully describe the risks & limitationsCope with our lossTest the concepts & alternativesHandle the information

We begin to use:Rational thinkingAdaptive behaviourAppropriate emotionPatience & self understandingSelf confidence

STAGES OF GRIEF REVISITED

(1)denial (2) bargaining (3) anger (4) despair (5) acceptance.

• Physical Needs

• Psycho-Spiritual Needs

Survivors have …

• A concern for basic survival• Grief over loss of loved ones and loss of valued and meaningful possessions• Fear and anxiety about personal safety and the physical safety of loved ones

WHAT ARE THEIR CONCERNS

•Sleep disturbances, often including nightmares and imagery from the disaster

•Concerns about relocation and the related isolation or crowded living conditions

•A need to talk about events and feelings associated with the disaster, often repeatedly

•A need to feel one is a part of the community and its recovery efforts

WHAT ARE THEIR PROBLEMS

You can provide:

1. help and support to a survivor

2. a climate of acceptance

To do this you need1. Empathy “Your hurt is my hurt”2. Respect

“You are made in God’s image”3. Genuineness

“I really care about you”4. Warmth

•Empathy

To understand someone from his point of view, by sensing and experiencing his feelings and perspective

Apathy; Empathy, Sympathy

You also need

5. Clear thinking6. Common sense7. Self awareness 8. Concreteness

NORMAL RESPONSE TO

TRAUMA

Right after a traumatic event, normal people experience a range of normal

reactions, including: anxiety, feeling “revved up;” fatigue; irritability; hyper-vigilance; increased emotionality; problems sleeping; exaggerated startle response, change in appetite; feeling overwhelmed; impatience; withdrawing from family and friends

•Psychic numbing •includes a sense of being emotionally numb after a trauma, experiencing a sense of unreality, dissociative amnesia, in which the traumatic event is pushed out of awareness, “spacing out” and using substances to “numb out

Normal Patterns of grief•Shock and crying•Guilt (“Why was I spared?”)•Hostility•Restless activity•Usual life activities lose their importance•Identification with the deceased

HOW TO HELP

1. ESTABLISH RAPPORTRapport refers to the feelings of interest and understanding that develop when genuine concern is shown. Conveying respect and being nonjudgmental are necessary ingredients for building rapport.

Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their hearts.

•Attend nonverbally – Eye contact, head nodding, caring facial expressions, and occasional “uh-huhs” let the survivor know that the worker is in tune with them.

• Don’t be afraid of silenceIn moments of silence, pray silently, and if appropriate, touch the person gently on the hand or shoulder. Show that you care. Let God’s love flow through you.

•Paraphrase – When the worker repeats portions of what the survivor has said, understanding, interest, and empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the survivor know that he or she is being heard. Good leadings are: “So you are saying that . . .” or “I have heard you say that . . . ”

•Reflect feelings – The worker may notice that the survivor’s tone of voice or nonverbal gestures suggests anger, sadness, or fear. Possible responses are, “You sound angry, scared etc., does that fit you?” This helps the survivor identify and articulate his or her emotions.

•Allow expression of emotions – Expressing intense emotions through tears or angry venting is an important part of healing; it often helps the survivor work through feelings so that he or she can better engage in constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to feel.

Do say:

•These are normal reactions to a disaster.•It is understandable that you feel this way.•You are not going crazy.•It wasn’t your fault, you did the best you could.•Things may never be the same, but they will get better, and you will feel better.

Don’t say: X•It could have been worse.

•You can always get another pet/car/house.

•It’s best if you just stay busy.

•I know just how you feel.

•You need to get on with your life.

It is best when workers allow survivors their own experiences, feelings, and perspectives

THINGS TO TRY:

•THINGS TO TRY:•periods of appropriate physical exercise, alternated with relaxation will alleviate some of the physical reactions.•• Structure your time; keep busy.•• You’re normal and having normal reactions; don’t label yourself crazy.•• Talk to people; talk is the most healing medicine.•• Be aware of numbing the pain with overuse of drugs or alcohol, you don’t need to complicate this with a substance abuse problem.

•THINGS TO TRY:• Keep a journal; write your way through those

sleepless hours.•• Do things that feel good to you.•• Realize those around you are under stress.•• Don’t make any big life changes.•• Do make as many daily decisions as possible that will give you a feeling of control over your life,•i.e., if someone asks you what you want to eat, answer him even if you’re not sure.•• Get plenty of rest.•• Don’t try to fight reoccurring thoughts, dreams or flashbacks - they are normal and will decrease•over time and become less painful.

•FOR FAMILY MEMBERS & FRIENDS•• Listen carefully.•• Spend time with the traumatized person.•• Offer your assistance and a listening ear if (s)he has not asked for help.•• Reassure him that he is safe.•• Help him with everyday tasks like cleaning, cooking, caring for the family, minding children.•• Give him some private time.•• Don’t take his anger or other feelings personally.•• Don’t tell him that he is “lucky it wasn’t worse;” a traumatized person is not consoled by those

•SPECIAL EFFECTS ON YOUNG CHILDREN

• Return to earlier behavior, such as thumb

sucking or bed wetting•Clinging to parents

• Reluctance to go to bed• Nightmares• Fantasies that the disaster never happened• Crying and screaming• Withdrawal and immobility• Refusal to attend school• Problems at school and inability to concentrate

•Help for Your Child • Talk with your child about his or her feelings and your feelings. You will find that many of your feelings are shared, regardless of your child's age. Encourage your child to draw pictures of the disaster. This will help you understand how he or she views what happened.

• Talk with your child about what happened, providing factual information that she or he can understand.

• Reassure your child that you and he or she are safe. Repeat this assurance as often as necessary.

• Review safety procedures that are now in place, including the role your child can take.

• Hold your child. Touching provides extra reassurance that someone is there for her or him.

•

•Also observed was repetitive playing of monotonous "quake" and "cemetery" plays, which lacked joy, pleasure, and creativity, and spontaneously produced similar, gloomy, black-white-red drawings of the devastating disaster. It is probable that children manifested fears, sadness, and anger related to the quake experience and compulsively, but ineffectively, tried to process the trauma

Armenian experience

YOU MUST LOOK AFTER

YOURSELF

Safety Procedures

Identify safe locationsKnow what to do in case of an alert

HYGIENE

Health issues

Rules to follow: Treat all blood or potentially infectious body

fluids as if they are contaminated. Always wear personal protective equipment in

exposure situations. Replace equipment that is torn or punctured. Remove equipment before leaving the work area. Wash hands immediately after removing

equipment

Gloves Gloves should be made of latex, nitril, rubber, or

other water impervious materials. Inspect gloves before use Double gloving can provide an additional layer of

protection. If you have cuts or sores on your hands, you should

cover these with a bandage or similar protection as an additional precaution before donning your gloves.

Don’t touch the outside of used gloves

Goggles, Face Shields & Aprons

Use goggles if there is a risk of splashing or vaporization of contaminated fluids

Face shields provide additional face protection for the nose and mouth.

Aprons protect

Hand Washing Handwashing is one of the most important

(and easiest) practices used to prevent transmission of blood carried pathogens.

Wash hands or other exposed skin thoroughly as soon as possible following an exposure incident.

Use antibacterial soap Don’t use harsh, abrasive soaps

Hygiene RulesIf you are working in an area where there is

reasonable likelihood of exposure, you should never:

Eat Drink Smoke Apply cosmetics or lip balm Handle contact lenses