Event countertransference and vicarious traumatization: Theoretically valid and clinically useful concepts?

The event countertransference and vicarious traumatization concepts have been introduced in the 1990s to describe the adverse emotional impacts that working with severely traumatized patients may have for the helping professional. These concepts are increasingly popular among trauma therapists. The present paper critically discusses the empirical evidence, theoretical validity and clinical utility of both concepts. Vulnerable trauma therapists may too eagerly embrace the event countertransference and vicarious traumatization perspectives as a cover up for their own failures. Interpersonal communication theory is suggested as a more useful conceptual framework for the analysis of countertransference reactions in therapies with severely traumatized patients.     

Life's many pieces: the identity of the group psychotherapist

The American Group Psychotherapy Association (AGPA) and its members are experiencing a trauma in response to the changes in health care imposed by the managed care industry. Although the economic threat is frightening, the threat to professionals' and AGPA's identities is even more damaging. The increasingly rapid, society-wide rate of change and factors related to the aging of AGPA's membership complicate its ability to cope with the trauma. The author recounts personal trauma and professional experiences in treating traumatized individuals, and proposes that when certain needs are met, growth can occur as part of a healing process: getting through the trauma, finding safety, self-soothing, and achieving mastery. AGPA resources for being safe, self-soothing, and achieving mastery are described. AGPA has been successful in reaching out via new accomplishments in regard to visibility, although the understandable impulse to withdraw may be impeding efforts to diversify the membership body. The author urges fighting against the pull to withdraw and expresses hope that the AGPA will cope well with the trauma by using its significant resources and will ultimately experience a beneficial change in its identity.     

Impact of traumatic incidents on family-of-origin functioning: An empirical study

This pilot study was an attempt to empirically validate some of the clinical observations made about traumatic incidents and families in the literature. The study hypothesized that there would be a significant difference in family functioning between those subjects that reported feeling traumatized and those subjects that did not report feeling traumatized, there would be a significant difference in anxiety between the identified trauma group and the identified non-trauma group, and there would be a significant difference in the breadth of support systems between the two groups. The results indicated that there were significant differences between groups of individuals who were identified as traumatized or non-traumatized. The differences included family functioning, individual feelings of anxiety, and report of familial support systems. The findings of this study were congruent with and supportive of much clinical literature on families and traumatic incidents.     

Assumptive World of Traumatized South African Adults

Abstract

One way of understanding the impact of traumatic events is through exploration of cognitive changes that confront a traumatized individual. The author investigated changes in individuals' basic assumptions after traumatic experiences. The participants were 65 people who had been traumatized by representatives of the South African apartheid government. From the total sample, 36 participants had witnessed the violent death of a close relative (sibling, mother, or father). The remaining 29 had been tortured and detained. The author administered the World Assumption Scale (R. Janoff-Bulman, 1989), a semistructured questionnaire on basic assumptions developed for the present study, and the Post-Traumatic Stress Disorder Clinical Checklist (American Psychiatric Association, 1994). Traumatic events affected the participants' basic assumptions about the meaning and benevolence of the world. The tortured and detained group and the bereaved group showed differences in their assumptions of self-worth following the trauma. Cognitive approaches can yield invaluable therapeutic insights into strategies for coping with trauma.     

On Leaving Home and the Flight From Trauma

This paper is both autobiographical and clinical—a psychoanalyst's reflections about important transitional moments in his life. Examples of such moments are the cultural blind spot regarding the affect of the Holocaust experience on the hundreds of thousands of survivors who immigrated to Israel after World War II and his own professional disavowal of that experience and his eventual finding of “shared home” in listening to the trauma discourse of Holocaust survivors and to that of other severely traumatized patients. This paper also highlights the importance for the immigrant analyst of presenting the cultural perspective stemming from his own tradition and background, and the one acquired in his new home, side by side and in dialogue with each other. Finally, the author examines how being a trauma survivor and an immigrant informs his work as a psychoanalyst.     

The Shattering of the Stimulus Barrier: The Case for an Integrative Approach in Short-Term Treatment of Psychological Trauma

The paper argues that the integrative psychotherapy approach is ideally suited to the treatment of psychological trauma. A brief term intervention model, devised by psychotherapists working with trauma in the South African context, is presented to illustrate this premise. It is asserted that posttraumatic stress represents a disorder in which dysfunction occurs both internally and externally, according to Freud at the interface of these two aspects of psychological functioning, i.e., at the ego boundary. Disturbance manifests in recognizable cognitive, behavioral, and somatic symptoms and in addition carries unconscious associations and anxieties. The ideal approach to treatment thus appears to be to draw on the relative strengths of both the psychodynamic and cognitive-behavioral schools. Existing trauma intervention models reflect the centrality of integration in many respects, although this does not seem to be explicitly recognized. The five components of the model referred to above are outlined and each component is explored in terms of its efficacy within both a cognitive-behavioral and a psychodynamic framework. Illustrative case material is provided to demonstrate the mechanisms at work in each case. The paper argues that the clinical success of the model lies in its integrative perspective and that psychotherapy integration should be recognized as the approach of choice in the treatment of traumatized individuals.     

The effect of persistent posttraumatic stress disorder symptoms on executive functions in preadolescent children witnessing a single incident of death

We compared executive functions (EFs) of traumatized preadolescent children with and without marked posttraumatic stress disorder (PTSD) symptoms to the performance of a nontraumatized control group, and examined the relationships between EF deficits and functional status in traumatized preadolescent children. Fifty-one preadolescent children who had witnessed a death at school 30 months prior (26 with marked PTSD symptoms and 25 without) and 30 healthy controls who had not been traumatized participated. EFs were examined using the Comprehensive Attention Test (CAT). The functional state of traumatized children was measured by the Parent Report Form-Children's Health and Illness Profile-Children's Edition (PRF-CHIP-CE). The traumatized children, regardless of status of PTSD symptomatology, showed poorer working memory performance than nontraumatized healthy controls. The traumatized children with marked PTSD symptoms performed more poorly on measures of interference control compared to those children without marked PTSD symptoms. Lower levels of EFs were associated with lower risk avoidance and diminished academic achievement in traumatized children. These results indicate that an inhibitory control deficit is specifically associated with the current PTSD symptoms but not with trauma exposure per se.     

Group Therapy as an Ecological Bridge to New Community for Trauma Survivors

Abstract

Group therapy counteracts the isolating effects of interpersonal trauma and enables survivors to connect with sources of resilience within themselves and others. By providing an alternative relational experience in which the survivor and her safety are valued, groups empower members to establish self-affirming and supportive relationships in their outside lives. The current paper reviews the psychological impact of chronic interpersonal violence and the relevant literature regarding group therapy for trauma survivors. We describe an approach to group treatment for complexly traumatized patients developed at the Victims of Violence Program, and through a clinical vignette, illustrate some of the ways in which group therapy can expand the relational world of survivors.     

The cost of caring–the impact of secondary trauma on assumptions,values and beliefs

The aim of this paper is to look at the impact of working with distressed and traumatized clients. The paper describes a survey involving 430 care workers who regularly work with distressed or traumatized clients. The survey involved the participants completing a 21-item beliefs inventory describing their supervision or support and recording whether they had any spiritual or religious beliefs. A factor analysis of the results of the inventory found four factors, three of which involved the negative impact of the work on beliefs while the fourth gave an indication of the positive beliefs or post trauma growth that comes from working in this area. The results showed that while doing a good job and experiencing fulfilment were higher in carers who experienced lower levels of distressing experiences and beliefs, an increase in competence and improved learning opportunities were associated with higher levels of challenge. A review of the information provided on supervision and support showed that there was a wide variation in the sources of support for the different professions. While around 46% of the carers had spiritual beliefs only 29% were members of a religious group. The discussion looked at the implication of the results of the survey including the possible benefit of using the carer belief inventory to identify carers who may be vulnerable to secondary trauma or compassion fatigue. The need to provide support to all professions undertaking caring work with distressed or traumatized clients was highlighted.     

The role of early care and education in addressing early childhood trauma

Young children's experience of trauma is associated with a wide range of adverse events and circumstances, including abuse and neglect, domestic violence, loss of a parent, and community violence. Policymakers and practitioners are increasingly aware that trauma during the first few years of life is especially widespread, and there is growing interest in new ways to support these young children and their families. Many young children who experience trauma attend early care and education (ECE) programs, and these settings offer important opportunities to promote their well‐being. This paper examines strategies currently being implemented in ECE to address early childhood trauma. The paper first examines research on how trauma affects young children's development, ECE environments, and society. We then describe the unique needs of young, traumatized children and features of trauma‐informed care that can address their needs, along with emerging interventions and supports that can be incorporated into or linked with ECE settings as part of a trauma‐informed approach. We conclude with a discussion of future directions for ECE and trauma research, policy, and practice, bearing in mind both the promise of new approaches and a limited evidence base to date.     

Assumptive world of traumatized South African adults

One way of understanding the impact of traumatic events is through exploration of cognitive changes that confront a traumatized individual. The author investigated changes in individuals' basic assumptions after traumatic experiences. The participants were 65 people who had been traumatized by representatives of the South African apartheid government. From the total sample, 36 participants had witnessed the violent death of a close relative (sibling, mother, or father). The remaining 29 had been tortured and detained. The author administered the World Assumption Scale (R. Janoff-Bulman, 1989), a semistructured questionnaire on basic assumptions developed for the present study, and the Post-Traumatic Stress Disorder Clinical Checklist (American Psychiatric Association, 1994). Traumatic events affected the participants' basic assumptions about the meaning and benevolence of the world. The tortured and detained group and the bereaved group showed differences in their assumptions of self-worth following the trauma. Cognitive approaches can yield invaluable therapeutic insights into strategies for coping with trauma.     

Psychological Trauma in Adolescence: Familial Disillusionment and Loss of Personal Identity

This article presents trauma theory and characteristics of traumatized adolescents. A case vignette demonstrates the considerations regarding assessment and treatment strategies in clinical work with an adolescent girl who suffered profound trauma, loss of personal identity, and self-esteem due to familial disillusionment. In contrast, the author presents the case of a female Holocaust survivor, documenting catastrophic loss, also during adolescence. Irrespective of the nature and magnitude of trauma, the single most outstanding predictor of future positive adjustment and resilience was the nature of the parent-child tie.     

Going Beyond Certain Limits Together: How Ferenczi's Notion of Elasticity Informs Group Treatment of Traumatized Patients

This paper explores Ferenczi's elasticity techniques, ideas about mutuality, and analyst self-disclosure. It describes the application of Ferenczi's theory of working with traumatized patients to a group comprised of six patients. By exploring Ferenczi's techniques in working with his patients individually, the author hopes to guide clinicians in applying and recognizing the special value of Ferenczi's theory in a group setting. The author's emphasis on promoting an atmosphere of tenderness in the group led members to reveal their experiences of trauma after they had developed sufficient feelings of safety and freedom in the group.     

Dealing with trauma at work—the employee's story

This paper describes the responses of employees to traumatic incidents at work. Although organizational policies and procedures have a strong influence on employee behaviours at times of trauma, the psychological contract formed between the employee and the organization is an equally powerful influence. The employee's responses to trauma are described in a three phase model; this model separates the responses at the time of the trauma from the acute responses following the trauma and the chronic responses, some of which may last for many years. Typical employee responses at each trauma phase are illustrated with case material taken from workplace settings. Finally, the paper returns to the importance of the psychological contract and describes how the organizational care programmes can be enhanced or damaged by the way the organization deals with the aftermath of the trauma and its traumatized employees.     

The “Second Injury” to Victims of Violent Acts

This paper, originally published in 1980, is a significant contribution to the study of psychological trauma and its treatment; particularly countertransference aspects of that treatment. Initially it was widely cited but then became little known, largely because of the inaccessibility of the original publication. The three major concepts in Symond's approach are: (1) self-hate and shame are the key dynamics in post traumatic distress; (2) ordinary professional attitudes of those who are supposed to help often intensify the traumatized person's self-hate and shame. Martin Symonds called this is the second injury; and (3) to counteract the self-hate and the shame, the professional must adopt a much more active attitude and behavior—in contrast to the previous experience the traumatized individual has had with the world of helpers (including family and friends). Here, Symonds addresses the analysts’ vulnerability and shame and their role as active instruments against self-hate and shame.     

Hertzmann,Leezah & Newbigin,Juliet (Eds.). Sexuality and Gender Now: Moving Beyond Heteronormativity. The Tavistock Clinic Series. London: Routledge. 2019. Pp. 358. Pbk. £29.99.

In this paper the author argues that trans-identification and its associated medical treatment can constitute an attempt to evade experiences of psychological distress. This occurs on three levels. Firstly, the trans person themselves may seek to evade dysregulated affects associated with such experiences as attachment trauma, childhood abuse, and ego-alien sexual feelings. Secondly, therapists may attempt to evade feelings, such as fear and hatred, evoked by engaging with these dysregulated affects. Thirdly, we, as a society, may wish to evade acknowledging the reality of such trauma, abuse and sexual distress by hypothesizing that trans-identification is a biological issue, best treated medically. The author argues that the quality of evidence supporting the biomedical approach is extremely poor. This puts young trans people at risk of receiving potentially damaging medical treatment they may later seek to reverse or come to regret, while their underlying psychological issues remain unaddressed.     

Rorschach content interpretation in post-traumatic stress disorders: a reply to Carr

In traumatized patients, Rorschach responses draw from a variety of sources, including the traumatic event itself, past and current experiences, and internal fantasy. As complex and highly condensed mental constructions, these responses often serve to reveal the meaning of the trauma in terms of the patient's prevailing personality conflicts. In many cases, this meaning may be hidden in the response's distortion of or elaboration on images drawn from the actual event.     

Acute stress disorder: a synthesis and critique

The diagnosis of acute stress disorder (ASD) was introduced to describe initial trauma reactions that predict chronic posttraumatic stress disorder (PTSD). This review outlines and critiques the rationales underpinning the ASD diagnosis and highlights conceptual and empirical problems inherent in this diagnosis. The authors conclude that there is little justification for the ASD diagnosis in its present form. The evidence for and against the current emphasis on peritraumatic dissociation is discussed, and the range of biological and cognitive mechanisms that potentially mediate acute trauma response are reviewed. The available evidence indicates that alternative means of conceptualizing acute trauma reactions and identifying acutely traumatized people who are at risk of developing PTSD need to be considered.     

Evidence-based mental health interventions for traumatized youth: a statewide dissemination project

Psychological trauma in childhood has been shown to increase a variety of psychological disturbances and psychiatric disorders. Although evidence-based treatments for children who have been traumatized exist, they are infrequently used by clinicians treating children. The present paper describes the creation of the Treatment Collaborative for Traumatized Youth (TCTY) which is a statewide partnership in North Dakota designed to disseminate efficacious treatments for traumatized children and monitor outcomes across a broad, rural, geographic expanse. The paper reviews the dissemination strategy developed by the TCTY, reports outcomes regarding both clinicians and child participants, and highlights problems identified in the project and solutions that were generated.     

Dialectical Behavior Therapy With Prolonged Exposure for Adolescents: Rationale and Review of the Research

Among adolescents, interpersonal trauma has been associated with severe post-traumatic stress disorder (PTSD) and impairments across multiple domains of functioning (e.g., Derosa, Amaya-Jackson & Layne, 2013; Ford, Courtois, Steele, van der Hart, & Nijenhuis, 2005; van der Kolk, 2005). Such difficulties can include high-risk behaviors such as active suicidality (Middlebrooks & Audage, 2008) and nonsuicidal self-injurious behavior (NSSI; Hu, Taylor, Li, & Glauert, 2017). While there have been many advances in the treatment of trauma, treatment dropout for adolescents seeking trauma-informed treatment is predicted by diagnostic comorbidity and complexity (Sprang et al., 2013), as well as the number of traumatic events endorsed (Wamser-Nanney & Steinzor, 2016). Many traumatized adolescents with high-risk behaviors are referred to Dialectical Behavior Therapy (DBT-A). However, DBT-A does not yet include a specific, evidence-based protocol for treating PTSD, without which treatment gains may not be sustained for traumatized adolescents (Harned, Korslund, & Linehan, 2014). While Prolonged Exposure (PE) is indicated as the gold-standard treatment for PTSD and has proven effective for adolescents (PE-A; Foa, McLean, Capaldi, & Rosenfield, 2013), it has not yet been validated with adolescents who are actively suicidal. However, PE has successfully been integrated within DBT for adults with co-occurring Borderline Personality Disorder and PTSD (e.g., DBT-PE; Harned et al., 2014). Based upon this model, the current paper proposes the integration of DBT-A and PE-A to treat adolescents with interpersonal trauma who also present with high-risk behaviors. The paper discusses anticipated complications related to adapting this model for adolescents and provides direction for future research.