CONCEPTUAL ISSUES 13

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1 1 Conceptual Issues Trauma has become a very popular concept in psychology, psychiatry, and the social sciences, and its popularity is stil! growing rapidly. The starting point of this exceptional development was the introduction of the diagnostic concept ofposttraumatic stress disorder in The sudden anei broad acceptance of trauma is remarkable. As early as the end of the 19th century, scientists were studying the consequences of shocking events on their patients. Hermann Oppenheim introduced the concept of traumatic neurosis. Pierre Janet, Josef Breuer, and Sigmund Freud examined the traumatic nature of the disturbance of hysteria. The term trauma became established in the scientific vocabulary, but gradually, the interest in phenomena related to the impact of violence, abuse, and other extreme events moved to the background. Nevertheless, it returned cyclically, after World War 1, after World War Il, and after other dramatic catastrophes and calamities. The current concern developed as a result of the aftermath of the interference of the United States in Vietnam, the increasing attention to victims of urban violence, and the need to help abused women and children. This interest appears to be rather permanent, but it remains an intriguing and fascinating question whether it will be cyclical once again or whether trauma has decisively acquired an inherent position in modern science of human beings. Essential to the scientific study of trauma is that attention be focused on events, situations, and circumstances. Starting points are serious life conditions that confront an individual with powerlessness, disruption, and death, as in acts of violence, human-made and natural disasters, combat, human rights violations, and the sudden loss of loved ones. The origin of the individual's problems is found in an externa! factor, something outside the person. The scientific study of trauma uncovers the effects of atrocities, war, and losses on individuals and explains how and why their adjustment may be disturbed. In a sense, Il

2 12 PARTI one could speak of a paradigmatic break in psychology and psychiatry. While, in the traditional approach, clinicians and researchers concentrated on personality and other intrapersonal factors, now they start their investigation with something outside the person. It appears tobe a rather simple point of departure: a distinct event that can be determined by everybody and that can be defined as very painful and obnoxious by everybody. For instance, the Diagnostic and Statistica! Manual of Mental Disorders of the American Psychiatric Association starts its description of the concept of posttraumatic stress disorder with the assumption that the individual has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone. It seems clear, then, that people suffer because of these experiences and that they develop well-defined types of disorders that can be examined in research and health care. U nfortunately, it is not that easy. There are severa! conceptual confusions, in particular in relation to the apparently uncomplicated concept of posttraumatic stress disorder. What do we mean by the seemingly innocent expression "beyond usual human experience"? How do we assess the severity of an event? What is the subjective meaning of trauma? There is considerable puzzlement about the following significant tssues: l. To which events do the concepts of trauma and posttraumatic stress disorder apply? What are the characteristics of the specific stressor? 2. What is the precise relation between the event and its consequences? 3. Is disorder the necessary result of an extreme event? Is anyone who has been confronted with the particular event by definition a patient? 4. To which persons does the term apply-victims in the literal sense, bystanders, rescue workers and other professionals, or family members? 5. Are trauma and posttraumatic stress disorder universal concepts in the sense that they allow us to understand the behavior of people of other cultures? These issues are addressed in the chapters of the first part of Beyond Trauma. These chapters ali deal with conceptual matters and dilemmas in the field of traumatic stress; they ali attempt to provide answers and solutions; and they ali make clear from different perspectives that many recent publications on traumatic stress lack conceptual clarity. Common to ali these chapters is the statement that contextual and circumstantial

3 CONCEPTUAL ISSUES 13 factors in the traumatizing experience and in their aftermath have to be taken into serious consideration. This statement is central to the first chapter. Summerfield argues that behavior is as much socially constructed as it is a function of the psychological attributes of an individual. Most models in medicine and psychology are limited because they do not embody a socialized view of mental health. However, exposure to trauma and its aftermath is not generally a private experience. It is in a social setting that the traumatized who need help reveal themselves and that the processes that determine how victims cope with the events are played out over time. Summerfield states that traumatic experiences need to be conceptualized in terms of dynamic interactions between the victimized individual and the surrounding society, evolving over time, and not only as a relatively static, confined entity to be located within the individual. The role of social forces in transforming individual traumatic experiences is a theme of this chapter, as well as the search of victims for social justice. The narrow application of the traditional scientific method frequently leads to a separation of illness from its social roots and, therefore, from issues of human rights. Posttraumatic symptoms are not just a private and individual problem but also an indictment of the social contexts that produced them. The author illustrates this fact with examples from his own research on war-displaced peasants in Nicaragua. As mentioned above, the trauma literature has grown significantly since the advent of the concept of posttraumatic stress disorder. The inclusion of this diagnostic concept in psychiatric and psychological nomenclature has played a central role in focusing society's concern on the impact of trauma. Previously, there was a tendency to underestimate the role of trauma and to use individual vulnerability as the reason for people's suffering. This meant that the victim's suffering was dismissed and stigmatized. However, care fu! examination of the litera ture suggests that traumatic events do not have a uniquely powerful relationship to the onset of subsequent symptomatology. Against this background, McFarlane addresses a series of fundamental issues. He suggests that contradictions and problems arising out of the complex relationship between the stressor and posttraumatic stress disorder are often ignored for a variety of politica!, social, and cultural reasons. The traumatic stress literature has not systematically grappled with questions concerning the role of the stressor in causing the typical symptoms of disorder, although there is a clear need to examine the reasons why such variability exists between different traumatic events. There is a series of problems of definition and measurement of

4 14 PARTI traumatic events that need to be refined in future research. In his chapter, McFarlane examines these problems in depth and suggests significant solutions. First, the reliability and validity of measures of the intensity of an individual's exposure have not been systematically examined. The assumptions inherent in the construction of exposure scales require discussion. Second, there are a number of problems in the statistica! models used to analyze the data. The current statistica! models of the effects of trauma and the methods of statistica! analysis contain a series of built-in assumptions that are seldom questioned. For instance, current methods of statistica! analysis have tended to assume simple causal relationships rather than to examine the possibility that triggering and vulnerability factors may have different acute and longitudinal effects. Again, McFarlane ends with the conclusion that central to understanding the impact of trauma is the fact that the context plays a critica! role in influencing the interpretation of the event and the method used to cope with it. The purpose of the next chapter, by Creamer, is to develop a cognitive processing model of the reactions after traumatic stress and to evaluate that model empirically. Cognitive processing models are particularly attractive from a cultural and social perspective on trauma. They explain the interrelationships between cultural and societal variables, on the one hand, and individual behavior and experience, on the other. How a potentially traumatic event is interpreted may be influenced largely by cultural expectations and social norms; what is traumatic in one culture or one society may not be so in another. During the recovery phase, rituals, attitudes, and expectations may facilitate or impair the survivor's ability to come to terms with the experience. Cognitive processing models have been central to the understanding of posttrauma reactions. They focus on schemata containing information about the individual's past experience, as well as assumptions and expectations regarding future events. A traumatic event shatters these preexisting views. For recovery to occur, the new information from the traumatic experience must be processed until it can be made congruent with these inner models, and preexisting schemata must be modified to accommodate the new information. These attempts to integrate threat-related information result in considerable distress and a desire to avoid, or escape, thoughts and reminders of the trauma. The chapter by Creamer integrates existing conceptualizations into a longitudinal model that is empirically evaluated. Data were obtained following a multiple shooting in a city office block in Melbourne, Australia, in which people died and were injured. In its implications for treat-

5 CONCEPTUAL ISSUES 15 ment, this model highlights the importance of confronting the traumatic memories. Since such activation is likely to be accompanied by high levels of distress, however, it is important to provide strategies and interventions for managing or reducing these aversive responses. It can be speculated also that recovery from trauma may be facilitated in those cultures that encourage activation of the traumatic memory networks. Mere knowledge of the exposure of a loved o ne to a trauma tic event may be traumatizing as well. Nevertheless, most publications that focus on people confronted with traumatic events exclude those who experienced the events indirectly. The chapter by Figley and Kleber focuses on these secondary victims: the victim's spouse and/or children, friends and neighbors, colleagues at work, and helping professionals such as rescue workers, emergency personnel and psychotherapists. These people are in some way close to the victim or survivor. Secondary traumatic stress refers to the stress symptoms resulting from hearing about an extreme event experienced by a friend or loved one or from attempting to help the traumatized or suffering person. This exposure may be a confrontation with powerlessness and disruption as well. The authors review the scientific literature associated with secondary effects of traumatic stress and describe the various groups of people indirectly influenced and touched by trauma. Conceptual issues and theoretical explanations are examined as well. What is the distinction between primary traumatic stress and secondary traumatic stress? Where is the demarcation line between direct effects and indirect effects of combat, disaster, war and violence? Which psychological problems can be still regarded as consequences of traumatic stress? Which causes of secondary traumatic stress can be distinguished? The last chapter of Part 1 is again a critical discussion of well-known concepts in the modern scientific literature. Human rights violations and the suffering of the victims have often been the starting point in trauma research for critical reflections on well-known concepts. Many clinical experiences and research findings have been accumulated concerning the physical and mental care of victims of human rights violations in Chile since 1973, during the dictatorship as well as in the slow transition to democracy. The Chilean scientist Becker examines the concept of posttraumatic stress disorder on the hasis of this expertise. The successive process of traumatization is, in his view, highly important. Traumatic experiences are often continuous, and a definite termination cannot be distinguished. lntroducing the idea of sequence to trauma theory makes it possible to understand the chronic problems of victims. Becker also emphasizes that the proposed changes in scientific concepts

6 16 PARTI make generalizations in future research more difficult, as we have to analyze trauma in reference to specific social and cultural contexts. Any comprehensive analysis must be built on the differences much more than on the similarities. Trauma is indeed context-bound. That fact creates an enormous task of carefully constructing context-bound definitions of illness, trauma, and expectable symptomatology.