August 14, 2013 · 1:43 pm

When trauma isn’t “post”?


Over the last year or so I have been doing some thinking about those experiencing ongoing trauma. We talk of PTSD, Post-traumatic Stress Disorder, as a set of symptoms experienced after a traumatic event or time. But some people continue to live in ongoing trauma. I’m reading James Fergusson’s The World’s Most Dangerous Place: Inside the Outlaw State of Somalia. Early in the book, he talks of seeing “Sister Mary, a warm-hearted big-bosomed Ugandan in combat fatigues, dispensing medicines from a table in the ruins of the villa’s kitchen.” (p. 45). Sister Mary explains that there are two medical problems she sees. The one she treats most often is diarrhea. But, she says, the other problem she could not treat,

The people here are stressed, she explained. They are traumatized. They do not know where to turn.

You talk a lot in the West about PTSD-Post-Traumatic Stress Disorder…but for these people there is no “post”. The trauma never ends.

What can people do when trauma isn’t post? Do they have to wait until the traumatic experience is in the past in order to deal with it? What can we do for others who remain in precarious and life-threatening situations? A friend raised this question when working with a group of refugees in a UN temporary camp. Some of the suggestions that were given this friend

1. Helping refugees find some way to hang on to small measures of empowerment: set up classes for children, build huts for those who are just arriving, develop “positions” for adults to fill so the camp runs smoothly and has a modicum of safety.

2. Reinstate religious and cultural traditions where possible

3. Practice corporate lament along with other worship activities

4. Allow people to tell as much story as they wish, whether by voice or artistic rendering

Notice that these are finding ways to cope by (a) making the moment better and (b) bearing witness, even if they can do nothing about the crisis. When a person feels some level of ability to respond to a difficult situation, that person often experiences less trauma than those who are unable to express any agency. Further, when they feel that they matter to others (someone listened to whatever they had to say), they tend to have less long-lasting PTSD symptoms.

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August 12, 2013 · 5:55 am

Do you enable spiritual abuse?


There are several kinds of abuse that take place in church settings. On this site we have talked about pastoral sexual abuse, sexual abuse, and spiritual abuse. Most recently, we have been discussing the matter of spiritual abuse in concert with Carolyn Custis James over at the Whitby Forum. I commend you to read her post last week about the underlying belief system of spiritual abuse.

This week we both want to consider some of the types of people who may be prone to enable spiritual abuse. No one, as far as I have ever met, intends to enable abuse. But certain beliefs, attitudes, and motivations may make it easier for abusive people to maintain power and position in the church.

Here are a few of those enabling attitudes that you and I, friends of victims, might display from time to time:

  • Status anxiety. Someone in power gives me status. To speak up against that person would jeopardize my position. Therefore I will not speak up. I do not want to disrupt my position or destabilize an organization that feeds me.
  • Mis-application of log/speck metaphor. A friend is showing signs of distress from an experience of abuse. She is angry, hurt, and confused. I see some “over-reactions” and so I focus on the log in her eye and suggest she has no business speaking of the speck in the abuser’s eye. Similarly, I suggest that we leave vengeance to God and deny the right to seek justice.
  • Defenders of leaders. We like to have strong leaders. When someone suggests one of our leaders is not good, we may feel the urge to come to their defense (either to defend character or to forestall a bad outcome for the leader and his family). We may show undue concern for the leader’s legacy or future in ministry.
  • Fixers. Some of us love to fix others. We offer unsolicited advice. We decide to take action to make calls we weren’t asked to make. Unintentionally we may put the victim at greater risk with our advice.
  • Self-Doubt. Did I really see that leader use theology to manipulate another? I must be mistaken. I’d only look like a greater fool to bring it up again.
  • Bitterness. When we come to believe that the church will never do what is right in protecting the sheep, we may send the message to others that we ought not to expect leaders to be just, kind, gracious, and caring. A victim of spiritual abuse may observe our bitterness and feel they are caught between accepting spiritual abuse and being in Christian community. Rather than lose their only community, they stay in an abusive environment.

I am sure there are other forms of enabling. Consider this post of mine about some of the reasons we fail to do what is right in light of allegations of sexual abuse. Some of those reasons are also present when we fail to do what is right in light of spiritual abuse.

 

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August 5, 2013 · 5:47 am

Counselors: How do you deal with attraction to clients?


For my counseling friends, you may wish to read this piece by Ryan Neace about sexual attraction in the therapist office. Do you have someone to talk to in this kind of frank manner about the reality of attraction? How do you handle it?

Remember, sexual attraction is not limited to just wanting to have sex with someone. Ryan does a good job identifying types of sexual responses to others beyond outright lust and fantasy. Notice also his drawing attention to the myth of the sexual vortex.

“The pastor who refuses eye contact sends a clear message…‘You are seductive. You are a sexual vortex that I may get sucked in to.’ The slippery slope of my lust is your problem. And my ministry is too valuable to allow the likes of you to trip me up.”

Given that we all have examples of counselors and leaders who crossed sexual lines, the myth and fear of the vortex can keep us from addressing needs of others. And, as he notes, it sends a very loud message to some clients (mostly women) that they are a danger at the cellular level). What a burden we place on others!

Two questions for readers:

1. How do you respond to incidents of sexual attraction?

2. How would you want to respond to the question posed to Yalom copied below (about whether he would in a different situation be attracted to a female client)? Redirect? Focus on the “deeper question”? Answer it?

Yalom considers a female client who asks, “Am I appealing to men? To you? If you weren’t my therapist would you respond sexually to me?”

… [Yalom’s answer]:

If you deem it in the patient’s best interests, why not simply say… ‘If everything were different, we met in another world, I were single, I weren’t your therapist, then yes, I would find you very attractive and sure would make an effort to know you better.’ What’s the risk? In my view such candor simply increases the patient’s trust in you and in the process of therapy. Of course, this does not preclude other types of inquiry about the question—about, for example, the patient’s motivation or timing (the standard “Why now?” question) or inordinate preoccupation with physicality or seduction, which may be obscuring even more significant questions. (bold emphasis Ryan’s)

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August 2, 2013 · 11:47 am

Christian Cancer?


Biblical Seminary’s faculty blog has posted an older blog of mine on the “top form of Christian cancer”. Click here to go see what it is.

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August 1, 2013 · 5:08 am

Some additional thoughts I had after Rwanda


Over at the Seminary faculty blog, I’ve posted this short musing about Rwanda and some of the stories of loss and redemption we heard during the conference. Check it out and see one picture of a small group activity where we heard many of these stories. In truth, listening to these stories on the banks of exquisite Lake Kivu made for a surreal experience!

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July 31, 2013 · 1:06 pm

Treatment of complex trauma: Why mistrust of the counselor is necessary and good!


I am reading Christine Courtois and Julian Ford’s, Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach (Guilford Press, 2013). I won’t be blogging through each chapter but I do recommend it for those working with adult survivors of child sexual abuse, especially those who are new to “complex trauma.”

The first two chapters give an overview of complex trauma reactions and diagnoses. If you want to know more about complex trauma, see this post about another edited book by these two authors. Chapter three, “Preparing for Treatment of Complex Trauma” begins the meat of the book. In this chapter they take up the ever important issue of empathy, safety, and respect as foundation to therapy. They emphasize the need for,

safety within the therapeutic relationship with a therapist who is empathic and respectful yet is emotionally regulated with appropriate and defined boundaries and limitations. (54)

Challenging Counselor Safety Is Common and Good?

This empathy and trust relationship is both foundation and method of treatment (59). But while the therapist is responsible to see that at safe therapeutic relationship has been built, it requires the client to be involved in building such an environment. The truth is that the client’s role in building safety in the counseling office is by passive and active testing of limits. Most counselors tolerate suspicious questions the first or second time. But, it is important for counselors to,

being prepared to patiently and empathically respond to active or passive tests or challenges to trustworthiness as legitimate and meaningful communication that deserves a respectful reply in action as well as in words. (60, emphasis mine)

If the therapist understands and does not take mistrust as a personal affront, the therapeutic relationship can evolve gradually. The client can begin to recognize  that the therapist actually “gets” why he or she is initially skeptical, self-protective, or “realistically paranoid” and does not pressure the client to be a “happy camper” but instead works to earn trust by being honorable, reliable, and consistent. This also implies a view of the client’s initial mistrust as expectable in light of the client’s history–that is, as a strength rather than as a deficiency or pathology. (63)

Sometimes clients can present in an opposite way–to be entirely deferential and affirming the counselor before a track record can be developed. Therapists with these clients need also to be prepared to encourage a healthy level of distrust.

What is not helpful is “artificial neutrality or passive and intellectualized detachment on the part of the therapist…” (64). It is my sense that we usually do this when we are afraid of the client. Not so much afraid of being injured, but afraid of failing or being consumed by the trauma. Or, we get consumed by our own history. A healthy therapist must stay emotionally present yet aware of own internal machinations. A healthy therapist must be able to predict some of the angst that arises in treatment of complex trauma and able to prepare self and client for this inevitable distress.

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July 30, 2013 · 11:11 am

How do trauma symptoms pass to the next generation?


As a clinician, I have had anecdotal experiences that the trauma experienced by a parent is passed on to a child who presents with many trauma symptoms despite not having experienced the initial trauma. We have witnessed what looks like this kind of transmission in places like Rwanda where children born after the genocide seem to experience many of the same symptoms of their parents.

Thus far, the data about generational transmission has been mixed. Looking at 2nd and 3rd generations of holocaust survivors, some research indicates that later generations can be affected; some research indicates no secondary traumatization. The problem with this research is that much is focused on the content of transmitted symptoms rather than the process. In the latest issue of Psychological Trauma (v. 5:4, 384-391), Lotem Giladi and Terece Bell have published a study looking at both content and process of trauma symptom transmission (“Protective Factors for Intergenerational Transmission of Trauma Among Second and Third Generation Holocaust Survivors”). The authors hope to have a clearer picture of risk and protector factors. As they say,

“The research question was not whether 2G and 3G experienced greater psychopathology than controls, but rather why some of them still carry some Holocaust-related psychological distress whereas others do not.” (384)

These researchers tested whether psychological concepts of differentiation of self (a Bowen concept indicating the ability to balance need for connectedness with family and need for being a separate self) and family communication (a previous study indicated that 2G holocaust survivors suppressed communication of negative emotion around their parents).

What did they find? 2G and 3G both showed greater levels of secondary trauma than controls (though all amounts of STS were in normal range) and surprisingly, the 3G group did not show less secondary trauma than did the 2G group. Indeed, greater differentiation of the self and better family communication among the generations of holocaust survivors positively correlated with  few secondary trauma symptoms.

So, how do trauma symptoms get transmitted to the next generation? We do not really know yet but one possible answer is that trauma tends to influence emotion regulation, anxiety regulation, and thus decreased self-soothing behaviors. This may get passed on to the next generation via suppressed negative feelings (children who do not want to make matters worse) and identification with the parent’s distress (and partially responsible for it).

For those readers who might wonder if their own trauma is causing secondary trauma in children, consider these things:

  • Most of the 2G and 3G holocaust survivor families are not terribly harmed. Most do well. So, it is not a given that your family is being harmed by your trauma symptoms
  • Open communication about the trauma symptoms and impact on family (without laying blame!) is likely helpful. Also communicate how coping with trauma symptoms can also teach a family some positive lessons as well (patience, gentleness, boundaries, etc.)

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July 26, 2013 · 9:39 am

Remember the “crack babies”? Results you might not expect


My local paper ran this essay this week: “Crack Baby” Study Ends With Unexpected But Clear Result. After 23 years, the study is over and the results might interest you. Turns out, cocaine is not the worst thing for you. It did not create underdeveloped children, mentally retarded children, emotionally disturbed children. Researchers found no evidence that cocaine accounted for clinically significant differences between exposed children and non-exposed children.

The Clear Result?

The clear result is not that cocaine has no negative impact (it does contribute to premature births and some other problems, but it doesn’t appear to contribute to life long problems in children born at full term.

The clear result is that both controls and exposed children were from the same environment: urban, minority, poor communities. The clear result is that POVERTY and VIOLENCE are significant contributers to things such as low IQ, exposure to traumatic experiences, etc.

Listen to some of these stats:

  • At age 4, control group average IQ: 81.9; exposed children average IQ: 79.0 (both significantly lower than average IQ of national population of children same aged
  • At age 6, 25% of kids in each group scored in abnormal range in math and letter/word recognition
  • By age 7, 81% had seen someone arrested, 35% had seen someone shot, 19% had seen a dead body outside
  • Drug use did not differ between groups: 42% had used pot (as young adults)

But some stats that astounded me:

Of the 224 kids, the researchers have kept track of 110. Here’s some additional data:

  • 2 dead, 3 in prison
  • 6 have college degrees, 6 on the way to getting a degree (these are the ones who they kept in touch with! I expect the percentage of college degrees to not would go down!)
  • and this one: 60 children born to the 110 participants (remember the ages of the participants must be between 23 and 26!)

Mix poverty with failing schools, fractured families, and you get folks who have few options to make it. Without much hope for a future, it is easy to give in to any pleasure or comfort for the moment. Thus, you see higher drug use and babies.

Good to remember that when we see a simple equation between problem and cause, we probably have it somewhat wrong.

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July 25, 2013 · 5:59 am

Telling Painful Memories: Recommendations for Counselors


[What is below was shared with Rwandan caregivers and counselors. It is written in simpler English and has no footnotes. Academically oriented readers will recognize the interventions come from narrative exposure therapy models for children].

Counselors invite others to tell their stories of pain, heartache, fears, and traumas so that they can find relief from their troubles. However, not every way of talking about past problems is helpful and some ways of talking can actually harm the person. So, it is important that all caregivers and counselors understand how to help others tell their difficult stories in ways that invite recovery and do not harm.

Good Storytelling Practices

Counselors who do the following can encourage healthy and safe storytelling of difficult events:

  1. Allow the client to tell their story at their own pace without pressure
  2. Allow the client not to tell a part of their story
  3. Use silence and body language to show interest
  4. Encourages the use of storytelling without words (art, dance, etc.) or with symbols
  5. Ensures the difficult stories start and end at safe points
  6. Encourages good coping skills before story telling
  7. Points out resiliency and strength in the midst of trauma
  8. Encourages the story to be told from the present rather than reliving the story

Unhelpful Practices

Here are some things that we should avoid doing when helping another tell a difficult story

  1. Frequent interruptions
  2. Forcing the person to tell their story
  3. Asking the person to relive the story
  4. Avoiding painful emotions
  5. Exhorting the person to get over the feelings; telling them how to feel
  6. Only talking about the trauma, ignoring strengths and other history
  7. Ending a session without talking about the present or a safe place

**Trigger Warning: rape, threatened violence

A Case Study With 2 Storytelling Interventions

Patience, a 13 year old girl, suffered a rape on her way to school last month. The rapist’s family paid a visit to the girl’s family and offered money as a token of penance. The girl’s father accepted the money because, “nothing can make the rape go away so we will take the money for now.” Patience was told by some family members to not tell anyone about the rape and to just act as if it never happened. However, Patience is suffering from nightmares, refuses to go to school, and sometimes falls down when she catches a glimpse of the rapist in town. Her father has threatened to beat her if she doesn’t return to school or help out with the chores at home. Her favorite aunt, a counselor/caregiver, learns about the rape and asks her to come for a visit in a nearby city.

[Warning: these two interventions are not designed to rid a person immediately of all trauma symptoms. In addition, these interventions must be used only after a counselor has formed a trusting relationship with the client.]

  1. Symbolic story telling. The aunt tells Patience that keeping a story bottled up inside can cause problems, like shaking a bottle of soda until it bursts out. Using a long piece of rope (representing her entire life) and flowers (representing positive experiences) and rocks (representing difficult experiences), the aunt directs Patience to tell her life story. They start with her first memories of her mother, father and two brothers. She tells of her going to school, the time when her mother got really sick but then got better again, the time when her cousins moved away, and the time when a boy told her he liked her. Patience noticed how she had many flowers along the rope and only a few rocks. Then, they put a large stone down on the rope representing the rape. Patience had difficulty saying much at all. She remembered being afraid, the weight of the man, the pain, and worry that her family would reject her. She remembered getting up and going to school and acting as if nothing happened. Her aunt noted that Patience was a strong girl—she had gone to school for a week before telling her mother. So, Patience placed a tiny flower next to the rock to represent that strength. After stopping for a cup of tea and some bread, the aunt asked Patience to notice how much more rope was left. This represented her future. Patience was surprised to see the rope and said that she didn’t think she would have a future now that she was spoiled. Her aunt encourages her to consider what she would like to be in her future. They continued to discuss this over the next day. By the time Patience returned home, she was able to see that she still had a future. Seeing the rapist still bothered her. However, she was able to go to school with two friends along a new path so that she would feel safe. Patience kept a drawing of the rope with the flowers and rocks and extra rope to remind her that she had a good future.
  2. Accelerated Storytelling. About six months later, Patience visited her aunt again. She was still going to school and able to do more chores (getting firewood and buying food in the market). However, she still suffered from nightmares and sometimes fell down when she heard footsteps behind her. This time, her aunt asked her to help create a “movie” of event. Before Patience was to narrate the rape, they first recounted the safety she felt at home before the rape and the safety she felt when she told her mother about the rape and was comforted. Next, her aunt asked her to identify all of the “actors” in the play: her mother, father, herself, brothers who went to school without her, classmates, teacher, and rapist. Patience then made a figurine out of paper for each actor and drew a small map of her village including the path from home to school. Then, the aunt asked her to tell her story as fast as she could from safe place to safe place and to only look at the figurines (and to move them along the map). Her aunt noted those places where Patience slowed down in the story. When she paused, the aunt asked her to try to keep moving. Once the story was complete (when she told her mother about the rape), she asked Patience to tell the story backwards as quickly as possible. Then, she instructed Patience to tell the story forwards again twice as fast. However, this time, Patience stopped part way through the story. She added one detail she had not disclosed before. She recalled that a young boy of about 5 was peering at them from behind some bushes. Her aunt encouraged her to finish the story and thanked her for her courage. Patience indicated that she was so ashamed of being seen in such a position. Again, her aunt thanked her for working so hard but asked her to tell her story forwards and backwards one more time. Patience noticed that she was less upset by the presence of the 5 year old than she had been the first time through the story.

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July 24, 2013 · 3:45 pm

Tuza 2.0: Day Six and Seven


[June 28-29, 2013, Kibuye to Kigali, Rwanda]

Since my little fire mishap in the middle of the night, this conference has gone ever so smoothly. Our only difficulty has been figuring out what to cut since our talks now take twice the time due to translation time. The cuts have been to case studies in order to protect the cherished small group times. I opened our morning session with a devotional on “the cup of sweet water” and our need to address the bitter water that flows out of us. In a conference like this where we talk about domestic violence and sexual abuse, it is easy to think about evil “out there” in its most grotesque images. However, we all have the roots of this evil even if it only show up as pride and arrogance. I ended our devotional reminding us of the grace and hope given us in 1 John 1:9.

Our morning session consisted of Dr. Beverly Ingelse giving a talk about caring and counseling children who have suffered abuse. After a break and a group picture, we returned to our small groups to respond to some of Bev’s questions and to discuss cases. In my group we went fairly off topic to hear how two of our group members survived the genocide and how they are now dealing with children who did not go through the genocide but have symptoms of traumatic reactions (depression over lost Aunts and Uncles, dissociation during memorial periods, chronic fear). Just in these two stories, they counted 115 murdered extended family members! It boggles the mind of those of us who have only read about such experiences.

Just before lunch I gave a brief talk about how to facilitate storytelling in ways that does not further traumatize the teller. We looked at common behaviors of counselors that support recovery and common behaviors that may hinder recovery. Look for those in an upcoming post!

We concluded our conference a few hours earlier than expected so that attendees could return home to manage household duties prior to Saturday’s Umuganda, or monthly required civil service. We concluded with a short “What’s next?” session led by Baraka. A couple of key ideas were proposed and repeated:

  • One day set aside for hearing and responding to case studies
  • Seminars about integrity for pastors and lawyers (apparently, some very public abuse cases (by pastors) have rocked the counseling community in recent months
  • Network building: the attendees discussed formal or informal counselor network (to promote learning, peer supervision, and support. They requested technical assistance from AACC.

After our last lunch overlooking beautiful Lake Kivu, we boarded a bus and returned to Kigali. I sat next to Worship and her mother (a most precious toddler who batted her eyes at me and played peekaboo with me for 3 hours). Arriving in Kigali at dusk, we ended our day with a meal and good conversations.

Day Seven (the last)

The day started quiet and lazy with a savoring of my favorite breakfast: tropical fruit salad, coffee, and a croissant. It is good that it started this way because last night, neighbors of the retreat house decided that midnight to 5 am would be a good time to remove a sheet metal roof. The workers worked diligently and loudly, singing and laughing right outside my window. Around 5 I fell asleep for about 2 hours. These would be the only 2 hours for the next 40 or so.

As this was our last day in Rwanda, some wanted to get a bit of shopping done. I wanted to be sure to get some Rwanda tea and coffee. We hung around until about noon, when the required civil service was completed. Then, we struck out for good places to buy a few items. Though this is my third trip to Rwanda, it is my first to a shopping district. Some of our team looked for dresses, others for artistic work. I bought a few things but mostly enjoyed the people watching (and being people watched). Back at our Solace Ministries, we got our bags ready and watched a Rwandan wedding get underway. We were told after 3 hours that the bride had yet to make an appearance and that this is quite common–a good reminder of the differences in time culture!

By 9 pm we were boarding our plane to return home. I found it interesting that much of this flight (including the stop in Uganda) is filled with young (mostly female) adults looking to be college age. Some we spoke with had just spent 6 weeks with a professor and seeing various NGOs at work.

This has been a short but fulfilling trip. I look forward to returning in 1 year with our first round of Global Trauma Recovery students.

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