Groups for individuals with traumatic histories: practice considerations for social workers.

Author:Knight, Carolyn
 
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An impressive, ever-expanding body of empirical and theoretical literature describes the affective, social, behavioral, and physiological consequences of psychological trauma. Treatment approaches designed to minimize, ameliorate, and remediate the effects of trauma also have been presented, and the group modality is viewed as a particularly important therapeutic intervention. Foy and colleagues (2001) noted, for example,

By their very nature, many traumatic experiences involve interpersonal violence (e.g., rape, physical assault, domestic violence, torture, or combat) ... Other traumas, especially those resulting from natural disasters or accidents, may not involve interpersonal violence per se, but they do evoke individual reactions of fear, helplessness,

or horror. These emotions may cause survivors to question whether others are really available to assist and support them in times of extreme need and may result in subsequent disruption of trust. (p. 246)

Social work practice with groups, with its simultaneous focus on mutual aid, strengths, and empowerment, is particularly well suited to meeting the therapeutic needs of individuals with traumatic histories. Groups for specific populations of trauma survivors such as individuals affected by war, torture, and political oppression (Hulewat, 1996; Levine, 2001),Vietnam veterans (Langley, 1982; Pierson & Pierson, 1994), and survivors of childhood sexual abuse (Bagley &Young, 1998; Knight, 1996, 2005; Morgan & Cummings, 1999; Richter, Snider, & Gorey, 1997) have been described in the social work practice literature. This article presents a conceptual framework that helps social workers understand, generally, how group membership benefits individuals with histories of trauma and that reflects current theory and ongoing research. Distinguishing features of these groups, as well as professional challenges the social worker is likely to face in facilitating them are discussed.

NATURE OF TRAUMA

In the field of psychotraumatology, the term "trauma" has a specific meaning that continues to evolve in the face of ongoing discussion, debate, and research. The classic definition provided by van der Kolk (1987) emphasized both the dramatic nature of an event and the individual's ability to cope: "Trauma, by definition, is the result of exposure to an inescapably stressful event that overwhelms a person's coping mechanisms" (p. 25).

More recently, theorists have refined and expanded on this definition. In many instances, it is not one single event that is traumatic, it is the cumulative effect of similar events over a period of time. Furthermore, the event itself may not be "inescapable" in any objective sense or even inherently harmful. The deleterious impact presumably results from the individual's subjective interpretation of risk and vulnerability, which, in turn, is influenced by a variety of personal, familial, social, and cultural variables.

Klein and Schermer (2000), therefore, provided a more general definition of trauma that takes into account these realities and observed that trauma is a "severe and stressful violation or disruption that has serious psychiatric consequences for the individual, either soon or long after the event" (p. 5). Fournier (2002) placed less emphasis on pathology, noting that trauma is "a natural human response to the physical, psychological, social, and spiritual manifestations of stress in a person's life" (p. 116), thus acknowledging the existence of psychic, rather than merely physical, injury.

Posttraumatic Stress Syndrome

Although not all individuals who have experienced trauma suffer from posttraumatic stress disorder (PTSD), this is the most commonly used diagnosis. A stressful event is a necessary but insufficient condition for an appropriate diagnosis of PTSD (American Psychiatric Association, 2000; Matsakis, 1994). An individual also must exhibit one or more "re-experiencing responses," such as recurrent and intrusive recollections of the event, and intense psychological distress at internal or external triggers that symbolize or are associated with some aspect of it. An accurate diagnosis also requires that the individual experience three or more "avoidance and numbing responses" and display two or more "hyperarousal responses." Finally, the symptoms must persist for at least one month and result in significant distress or impairment in functioning.

The PTSD diagnosis may be a valuable tool for describing the range of symptoms that can result from exposure to trauma, but it does not take into account or reflect individual differences (Bowman, 1999). For example, empirical findings indicate an inconsistency between lifetime rates of exposure to an event classified as "traumatic" according to the DSM-IV, which are relatively high for both men and women, and the actual incidence of PTSD (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Norris, 1992; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). This research indicates that although men are much more likely to be exposed to traumatic events than women--two-thirds of men and one-half of women--the rate of PTSD is higher in women--10 percent of women and 5 percent of men. It is unclear whether it is the event itself, the level and intensity of the individual's exposure, or both, that leads to PTSD. However, the findings of a variety of studies increasingly suggest that among other factors, prior emotional functioning, temperament, developmental level, and cultural and social context affect an individual's potential to develop PTSD (Blake, Cook, & Keane, 1992; Hyer et al., 1994; Lonigan, Shannon, Taylor, Finch, & Sallee, 1994; Ormel & Wohlfarth, 1991).

For individuals who have experienced some form of childhood trauma, a diagnosis of PTSD is particularly problematic. The results of several studies reveal that among individuals who have experienced similar types of childhood trauma, lifetime incidence rates of PTSD symptomology vary widely (Merry & Andrews, 1994; Rutter, 1994). Research suggests that these individuals exhibit many of the symptoms typically associated with PTSD, even though their childhood experiences and the specific events that were presumed to be traumatizing are not consistent with the requirements of the original diagnosis (Pelcovitz et al., 1997; van der Kolk, Roth, Pelcovitz, & Mandel, 1993; Zlotnick, Zariski, & Shea, 1996). For example, sexual abuse of a child often does not involve physical harm in the conventional sense or occur under circumstances that would be experienced by the child as "cruel" or frightening (Finkelhor, 1990; Herman, 1992).

Changes in an Individual's Perception of Self and Others

Limitations associated with the PTSD diagnosis have led several authors to propose the creation of alternative diagnoses, PTSD II or complex PTSD, that place less emphasis on the precipitating event and more on the deleterious consequences that result, particularly from long-term exposure to trauma (Herman, 1992; van der Kolk et al., 1993). Studies of individuals exposed to a range of traumatic events suggest that one of the most notable deleterious effects is the fundamental change in an individual's view of self that presumably results (Bard & Sangrey, 1986; Chu, 1992; Cole & Putnam, 1992; Kazdin, Moser, Colbus, & Bell, 1985; Kilpatrick, Veronen, & Best, 1985).

The trauma appears to disrupt, and in many instances destroy, the individual's sense of an "intact self" (Garfield & Leveroni, 2000). Particularly when the trauma occurred in childhood, the individual's sense of self is, for all intents and purposes, lost. Individuals who have been traumatized are presumed to lack the "self-esteem regulating psychic structure" (Stolorow & Lachmann, 1980) necessary for the development of an independent, cohesive, and stable sense of self. The individual's identity becomes externally derived through her or his interactions with "selfothers," rather than internally created and maintained (Kohut, 1977; Wolf, 1989). That is, the survivor takes her or his cues for what and how to think and feel from others' reactions, thoughts, and feelings.

Using the term "traumatic loss," Green (2000) addressed the effect of trauma on an individual's social reality and worldview. "[Traumatic stressors] attack people's most basic values, occur unexpectedly, make excessive demands, and are outside of the usual realm for which coping strategies have been developed" (p. 3). Events that are traumatizing not only lead to a violation of the person, they also result in a violation of her or his basic sense of how the world works. Such events shatter individuals' basic assumptions about themselves, others, and the social environment in which they live and exist (Janoff-Bulman, 1992; Pearlman & Saakvitne, 1995). An individual's concepts of right and wrong, justice and injustice, and good and evil are challenged, and often destroyed, and these disruptions may have the most damaging and long-lasting effects, as the results of several studies suggest (McCormick, Taber, & Kruedelback, 1989; Morgan & Janoff-Bulman, 1994).

Risk and Protective Factors

In the face of mounting research evidence and refinements in theory, the resilience and coping capacities exhibited by individuals who have survived traumatic events increasingly are being recognized. Theorists and researchers have attempted to discern the characteristics and variables associated with the individual and her or his environment that either intensify or mitigate the effects of trauma. A related line of inquiry and study has been directed at the ways in which individuals may benefit from a distressing event (Herman, 1997; Joseph, Williams, & Yule, 1995; McMillen, 1999). Research suggests that biological factors such as the individual's physical and mental health, the developmental stage of the individual at the time she or he was exposed to trauma, availability of support systems, previous history of trauma, and learned...

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