Individual Differences and Secondary Traumatic Stress

by Keith Plouffe

“You have all been traumatized,” the Air Force chaplain announced to a room of military police and rescue personnel. As an enlisted member of the base crisis response team, I felt compelled to call the chaplain on his blunder, while at the same time restrained by military protocol. I looked at my boss, a clinical psychologist and chief of the base mental health clinic, and saw him looking back at me, his NCOIC, with the same confused expression I, no doubt, wore. The crisis response team consisted of the psychologist, me, and various other military members from chaplains to family service personnel who had completed training in Critical Incident Stress Management (CISM) created by Jeffrey Mitchell.

The team assembled, against the advice of the psychologist, for an intervention with first responders to a suicide. A male had hung himself and the base police and medics had cut him down. This occurred during a time when the Air Force had mandated the use of the Mitchell model. It was also a time of growing evidence against the model's effectiveness - the Red Cross and the VA had already moved away from it. Hearings were taking place with military psychologists arguing for the complete removal of CISM from use due to evidence of potential harm. In that context, the psychologist and I agreed that the incident did not warrant an intervention by the crisis response team, rather leadership in the first responders' organizations should hold an operational debriefing and refer for psychological support only those who showed signs of maladjustment over time. But orders from commanders are orders and the team convened.

The psychologist and I jumped in to smooth over the chaplain's statement. We gave a brief overview of normal reactions, self-care tips, and our confidence that all would cope well. To date, the Air Force no longer requires the CISM model, but does not explicitly condone it; a monograph published by the Association for Psychological Science debunks the utility of Mitchell's CISM and like interventions; the American Psychological Association has started a Road to Resilience campaign; and in a recent article, Lilenfeld categorized the Mitchell model as a treatment that probably produces harm in some individuals by interfering with normal recovery processes.

The above experience, combined with others as a mental health worker in military and civilian settings, set the ground work for my interest in (a) primary trauma (direct exposure to a traumatic event); and (b) secondary trauma (empathetic involvement with another's primary trauma story). My interest lead to a master's in psychology thesis project on the relationship between an individual's tendency to dissociate and be absorbed into external events (something all persons do to some extent) and the experience of secondary traumatic stress in crisis workers.

It is appropriate to ask, “Why write about a study on crisis workers in a combat oriented forum?” Primary and secondary trauma share common symptoms, so findings in one area can, cautiously, be inferred in the other. Crisis workers could theoretically be a subset of the first responder population as they are witness to stories of trauma, scenes of trauma, and often operate in environments of varying risk. More importantly, if you are in law enforcement, corrections, military, or a victim of a crime, there is likely someone or some agency that will rush in and say, “You've been traumatized and you will develop PTSD (if you don't let us help you)”.

There typically is confusion between experiencing a normal, temporary stress reaction to intense events and the development of a primary or secondary trauma disorder. Experiencing a number of symptoms does not make a disorder; the symptom cluster has to combine with a level of impairment, usually for a specified period of time. Resiliency is the norm for individuals that experience a traumatic event or are empathetically involved with the trauma of others; disorder is the exception. Most stress reactions dissipate over time and require no interventions outside a person's normal support system. Unfortunately, PTSD prevention programs are a lucrative business even though there is no good evidence they work. Sommers and Satel reported in Reason that despite a massive mental health response to the September 11, 2001 aftermath, few people utilized services and there was no widespread psychopathology outbreak. A study by Mehl and Pennebaker after 9-11 showed that people who utilized their existing social supports over the first 10 days following the attacks adjusted well.

The diathesis-stress model is currently one of the most robust models in understanding the development of a trauma disorder. It places less emphasis on the event itself and more on vulnerabilities and deficits an individual brings to the traumatic environment and how those vulnerabilities and deficits interact with the event. Most people who experience a traumatic event do not develop a disorder, those that do often have pre-existing vulnerabilities such as genetic factors, toxic pre and postnatal environments, poor early brain development due to unsupportive environments, or traumatic brain injuries. These events raise the probability of acquiring a trauma disorder, but do not directly predict disorder – nothing does.

My thesis study examined the individual traits of general dissociation and dissociation absorption. We all dissociate to some degree. To demystify it: dissociation is simply the splitting of processes that usually work together. If you drive home on a familiar route and arrive without remembering the trip, you have experienced dissociation. If you get so into a movie that you have a reaction to what is happening on screen and lose a sense of time, you have experienced dissociation absorption. A matter of frequency, intensity, and impairment separates normal dissociation from pathological dissociation. Pathological dissociation is a common symptom across a spectrum of trauma disorders to include secondary trauma.

I analyzed scores from measures of dissociation, compassion satisfaction, and secondary traumatic stress submitted by 30 crisis workers throughout the state of Maine. Eighty percent of scores reflected compassion satisfaction with 24% reporting secondary trauma. The correlation results were statistically significant for dissociation and secondary trauma. Meaning, as the reported experience of dissociation and absorption increased, so did the reported experience of secondary traumatic stress symptoms. Correlation does not prove causation and does not indicate which factor affects another factor. However, when combined with the current research literature, this type of study acts as a supporting piece of evidence. The findings support the diathesis–stress model in that an individual trait better accounted for symptoms then did exposure to another's trauma.

The stress reaction to traumatic events is real, but not always debilitating. Everyone primarily or secondarily exposed to traumatic events does not require the same degree of support or warrant professional support. It depends on the person. Self-care techniques such as diaphragmatic breathing (reduces levels of glutamate and stress hormones during event); grounding techniques (reduces absorption tendencies); operational debriefings (allows for processing and narrative building within a team), and positive use of social supports prove useful for most people. What works best in lowering risk for a trauma disorder is an area in need of further study.

Life is tough, but all have not been traumatized.

.

References:

Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2 (1), 53-70.

McNally, R. J., Bryant, R. A., & Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 4 (2), 45-79.

Mehl, M., & Pennebaker, J. W. (2003). The social dynamics of cultural upheaval: Social interactions surrounding September 11, 2001. Psychological Science, 14 (6), 579-585.

Newman, R. (2002). The road to resilience. Monitor on Psychology, 33 (9). Retrieved from http://www.apa.org.

Sommers, C. H., & Satel, S. (2005, August/September). The mental health crisis that wasn't. Reason Magazine. Retrieved from www.reason.com