Attachment in Psychotherapy

Abstract

Basic psychotherapy techniques are necessary for trauma intervention, including the terrorist attacks that occurred on September 11, 2001. The importance of these techniques is reviewed within various settings in the New York City area immediately following the World Trade Center disaster. The purpose included debriefing of practitioners, as well as the education of trauma symptoms and assessment for client intervention. Perhaps most importantly was the therapeutic technique modeled by the social work leader in these vignettes, since she and other practitioners simultaneously experienced symptoms of trauma. The practice of creating and maintaining a therapeutic atmosphere at this time was an essential challenge for all.     

Clinicians' Experiences of Shared Trauma After the Shootings at Virginia Tech

This phenomenological study was designed to describe the shared trauma perspectives of 8 counselors who experienced the shootings at Virginia Tech and responded to community mental health needs. Shared trauma, vicarious traumatization, compassion fatigue, vicarious resilience, and posttraumatic growth were examined. Themes derived from interviews included changed perceptions of those who experienced shared trauma and the influence of the experiences on clinicians' work. Implications for practitioners and for counselor training are presented.     

Reliability and Validity of the Vicarious Trauma Organizational Readiness Guide (VT‐ORG)

The Vicarious Trauma Organizational Readiness Guide (VT‐ORG) is an assessment of an organization's readiness to address vicarious trauma (VT), which is exposure to the traumatic experiences of people served. This study reports on the psychometric properties of the VT‐ORG. Employees of first responder agencies (e.g., law enforcement, fire, emergency services) and victim assistance agencies are at a high risk for vicarious traumatization, which can lead to PTSD, substance use, and suicidal ideation, among other negative impacts. Organizations that do not address VT may see such effects as employee turnover, reduced efficiency, and negative work environments. The VT‐ORG is an assessment tool designed to help organizations complete the first step of organizational change—conducting a needs assessment. Study participants were 3,018 employees across 13 first responder and victim assistance agencies who completed the 67‐item VT‐ORG and additional measures for evaluation of its validity and reliability. The VT‐ORG was found to have excellent internal consistency (Cronbach's α = .98). A structural equation model demonstrated that the subscales of the VT‐ORG predicted criterion measures of turnover intention, compassion satisfaction, and organizational resilience, with an overall model fit of CFI = .99, RMSEA = .053. This study found the VT‐ORG to be a reliable and valid assessment of organizational responses to vicarious trauma.     

Sekundäre Traumatisierung

During the past several years there has been a growing interest in the negative effects that therapy may have on therapists. Of special interest is a phenomenon called secondary traumatization, which can arise while working with traumatized clients. As yet it has not been verified that secondary traumatization consists of posttraumatic symptoms and leads to clinically significant distress. In an exploratory study 21 therapists were interviewed who declared that they had experienced an incident of this form of work-related stress. The presented study reveals that in fact such a ?vicarious“ traumatization can arise, even without direct contact to the original trauma. It consists of post-traumatic stress disorder (PTSD)-like symptoms, but in severe cases it can also manifest itself in symptoms which are far beyond the typical PTSD spectrum. Conditions for the development of secondary traumatization are high empathic ability and dissociative processing of the trauma material by the therapist.     

New York City young adults’ psychological reactions to 9/11: findings from the Reach for Health longitudinal study

This research examines psychological distress among 955 economically disadvantaged New York City residents surveyed during high school and again after the September 11th terrorist attacks (9/11), when they were young adults. As part of the longitudinal Reach for Health study, young adult surveys were conducted from 6–19 months post-9/11 (average 8 months), providing opportunity to assess types of exposures and psychological distress, including symptoms of post-traumatic stress disorder (PTSD), depression, hopelessness, and anger. Regressions of psychological distress on 9/11 exposure were performed, controlling for high school distress, prior exposure to violence victimization, and socio-demographic characteristics. Exposure to 9/11 was positively associated with anger, hopelessness, and PTSD symptoms and a measure of global distress. The relationship was greater among women for PTSD symptoms. Although those who reported high school distress also reported more distress in young adulthood, prior psychological distress did not moderate the relationship between exposure and psychological outcomes. Greater exposure is related to distress among those who, during high school, reported lower distress, as well as among those who reported prior greater distress.     

Group therapists and AIDS groups: An exploration of traumatic stress reactions

As the AIDS epidemic continues unabated, there is growing clinical evidence that the catastrophic nature of this disease is creating a second category of trauma casualties. They are the health care practitioners who witness the narratives of those who are living with and dying from AIDS. This article examines how multiple AIDS-related deaths of group members exert a traumatizing effect on group therapists, creating vicarious traumatization. Vignettes are presented that illustrate reactions associated with traumatic stress, including death images, survivors' guilt, psychic numbing, suspicion of counterfeit nurturance, and struggle for meaning. Possible therapeutic interventions for group therapists coping with multiple deaths are also explored.The author wishes to acknowledge the endeavors of the volunteer group therapists and the Clinical Group Services staff of the Gay Men's Health Crisis of New York City, who provide group therapy to over 900 clients a week. This article is written in admiration of their extraordinary effort and dedication.     

Reliability and validity of the Social Cognition and Object Relations Scale (SCORS) in the assessment of dream narratives

In this study, we aimed to investigate the application of an externally rated measure of interpersonal representations (Social Cognition and Object Relations Scale [SCORS]; Westen, 1995) to dream narratives. A total of 80 student participants enrolled at a private university in the New York City metropolitan area completed a Dream Log and affect adjective checklist (Wellman, 2002) based on a recalled dream at both 1 month and 3 months following the September 11, 2001, terrorist attacks. Using the dreams provided in this study we examined the interrater reliability of SCORS ratings, the relationship of SCORS variables to an independently rated measure of dream distortion, and the relationship of SCORS variables to participants' own ratings of dream affect. Results indicated that dreams were reliably rated using the SCORS, 3 cognitive SCORS variables were significantly related to dream distortion, and affective SCORS variables were meaningfully related to participants' own ratings of affect in their dreams. Findings from this study provide support for the application of SCORS ratings to dream narratives. We discuss implications for further research and clinical application.     

Integration of Test Results with Clinical Observations A Diagnostic Case Study

In this study, we aimed to investigate the application of an externally rated measure of interpersonal representations (Social Cognition and Object Relations Scale [SCORS]; Westen, 1995) to dream narratives. A total of 80 student participants enrolled at a private university in the New York City metropolitan area completed a Dream Log and affect adjective checklist (Wellman, 2002) based on a recalled dream at both 1 month and 3 months following the September 11, 2001, terrorist attacks. Using the dreams provided in this study we examined the interrater reliability of SCORS ratings, the relationship of SCORS variables to an independently rated measure of dream distortion, and the relationship of SCORS variables to participants' own ratings of dream affect. Results indicated that dreams were reliably rated using the SCORS, 3 cognitive SCORS variables were significantly related to dream distortion, and affective SCORS variables were meaningfully related to participants' own ratings of affect in their dreams. Findings from this study provide support for the application of SCORS ratings to dream narratives. We discuss implications for further research and clinical application.     

The effect of constant threat of terror on Israeli Jewish and Arab adolescents

The effect on Israeli Jewish and Arab adolescents of living under constant threat of terrorist attacks was assessed in a sample of 346 adolescents. The study probed their direct and indirect exposure to terrorist attacks, avoidance of public centers, sharing feelings with significant others, and stress reaction symptoms. The adolescents showed mild to low levels of stress symptoms in reaction to terrorist attacks in Israel, with no significant differences between Jews and Arabs. The Jewish adolescents reported knowing more people involved in terror attacks and being more informed by their parents about them. Demographic and exposure variables explained 39% of the variance of stress reaction symptoms. Being female, knowing someone injured, having parents who discuss terrorist attacks or forbid going out, and more sharing of feelings were significantly related to higher stress symptoms. For Jewish adolescents, greater levels of sharing of feelings were related to higher distress. Jewish and Arab adolescents proved to be similarly affected by the threat of terror but were also resilient even in highly unusual circumstances.     

A prospective investigation of the relationship between just-world beliefs and the desire for revenge after September 11, 2001

We prospectively examined the relationship between individuals' belief in a just world and their desire for revenge against the perpetrators of the September 11 terrorist attacks against the United States. Eighty-three undergraduate students who had completed a measure of just-world beliefs prior to the terrorist attacks were assessed approximately 2 months following the attacks. The more strongly they had endorsed just-world beliefs prior to the attacks, the more distressed they felt about the attacks and the more they desired revenge. Furthermore, the relationship between belief in a just world and the desire for revenge was mediated by feelings of distress in response to the terrorist attacks. The results point to the importance of justice beliefs in understanding responses to the terrorist attacks.     

Anxiety, depressed mood, self-esteem, and traumatic stress symptoms among distant witnesses of the 9/11 terrorist attacks: transitory responses and psychological resilience

Posttraumatic stress related to the September 11, 2001 terrorist attacks and general psychological distress were examined in six cohorts of college students (N=5412) enrolled at an American public university between Spring 2000 and Fall 2002 some 2,500 miles from New York. Consistent with data from Schuster et al.'s (2001) national survey, which used a very low threshold criterion, our findings revealed that 44% of women and 32% of men experienced at least one symptom of posttraumatic stress 6-17 days after the attacks. In contrast to these results, depression levels showed only small differences, and self-esteem and trait anxiety showed no changes. Findings indicate that 9/11-related stress responses among distant witnesses were very mild, transitory and focused in scope, suggesting resilience with respect to broader psychological and psychopathological reactions. Findings are discussed with respect to the role of physical and psychological proximity on the reactions to traumatic events in the general population.     

Reply to Panel Follow-up Questions

When both therapist and client share a traumatic event, there are multiple levels of vulnerability to traumatization for the therapist. Our personal vulnerability is not only a backdrop for our clinical work but also an acknowledged fact in many therapeutic relationships, a situation that changes the frame of the work. In addition to clinical challenges, shared trauma increases a therapist's vulnerability to vicarious traumatization; VT is defined as the negative transformation of the therapist's inner experience as a result of his or her empathic engagement with and responsibility for a traumatized client. Emphasizing the importance of awareness, self-care, meaning, and community, the article summarizes important steps to anticipate, address, and transform the therapist's experience of vicarious traumatization.     

The aftermath of 9/11: effect of intensity and recency of trauma on outcome

Does trauma exposure have a long-term impact on the brain and behavior of healthy individuals? The authors used functional magnetic resonance imaging to assess the impact of proximity to the disaster of September 11, 2001, on amygdala function in 22 healthy adults. More than three years after the terrorist attacks, bilateral amygdala activity in response to viewing fearful faces compared to calm ones was higher in people who were within 1.5 miles of the World Trade Center on 9/11, relative to those who were living more than 200 miles away (all were living in the New York metropolitan area at time of scan). This activity mediated the relationship between group status and current symptoms of posttraumatic stress disorder. In turn, the effect of group status on both amygdala activation (fearful vs. calm faces) and current symptoms was statistically explained by time since worst trauma in lifetime and intensity of worst trauma, as indicated by reported symptoms at time of the trauma. These data are consistent with a model of heightened amygdala reactivity following high-intensity trauma exposure, with relatively slow recovery.     

Cognitive complexity in response to traumatic experiences

Two studies examined how personality motives influence the perception of traumatic events in memory and how such perception may be linked to psychological distress. Participants completed implicit and explicit measures of agentic and communal motives. In Study 1, participants living in New York City at the time of the terrorist attacks wrote their thoughts and feelings about the events of September 11th. In Study 2, participants wrote about a personally traumatic experience. In both studies, they also completed questionnaires on psychological symptoms and stress-related growth. The memories were then scored for differentiation and integration. Agentic motives correlated with differentiated perceptions and differentiation was linked to dissociative symptoms in Study 2. Communal motives related to integrated perceptions, and integration related to stress-related growth in both studies. Findings suggest that motives play a significant role in the perception of traumatic and difficult experiences and that these perceptions may be differentially linked to psychological impact.     

Treating survivors of the World Trade Center terrorist attacks of September 11, 2001

As part of an established traumatic stress research and treatment program located in New York City, we experienced the September 11, 2001, terrorist attacks on the World Trade Center first as New Yorkers, but also as professionals with an interest in both treating the survivors and furthering scientific knowledge regarding the neurobiology and treatment of traumatic stress. This paper gives vignettes of calls to our program and the treatment of World Trade Center terrorist attack survivors.     

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.     

In the belly of the beast: traumatic countertransference

The authors discuss their work together in a consultation process. One author led many groups that were created to facilitate recovery for persons directly impacted by the terrorist attacks on September 11, 2001; the other acted as consultant to the therapist/leader. The leader was a resident of New York City at the time of the attacks; the consultant lived in a distant Midwestern city and the two had never met prior to the work. They describe their experience of working together and the role of this collaboration in the lives of the leader and the groups. Well aware that little exists in the literature about groups led by leaders having experienced the same trauma as group members, the authors pay special attention to the countertransference that each underwent and raise questions about the effects of that on the group process.     

School Entry After a Community-Wide Trauma: Challenges and Lessons Learned from September 11th, 2001

The purpose of this paper is to describe the implementation of a school-based trauma-specific mental health program in New York City following the terrorist attacks on September 11, 2001. This program aimed to serve children most at risk for developing mental health problems as a result of physical proximity (e.g., evacuation from schools surrounding the World Trade Center) to the trauma. As we present the components of the program, we will review the literature that guided our decision making. The ongoing struggle between searching for answers from established science and immediate needs in a crisis is highlighted. Lastly, a discussion of the lessons learned and recommended next steps is presented.     

Caring for Carers in the Aftermath of Trauma

The potential impact on psychological well-being of working in the caring professions in the aftermath of trauma and disaster has been recognized for many years, with terms such as burnout, compassion fatigue, and vicarious traumatization coined to describe stress-related conditions. Although prevalent, these conditions do not affect all workers in the field. Various studies have investigated potential risk and protective factors. It is argued that the outcomes of this research should be used to guide practical interventions in the workplace designed to minimize stress-related problems. A framework that incorporates interventions at the primary, secondary, and tertiary prevention levels is outlined, and research investigating the efficacy of interventions at each of these levels is recommended.     

Memories of the terrorist attacks of September 11, 2001: a study of the consistency and phenomenal characteristics of flashbulb memories

In this study, I investigated students' memories of the terrorist attacks of September 11, 2001, carried out by Al Qaeda terrorists against the World Trade Center in New York and the Pentagon in Washington. Participants completed on two occasions (2 weeks and 8 months after the events took place) a memory questionnaire that included an assessment of the phenomenal richness of their memories. The results showed that the participants remembered very well the circumstances in which they first heard about the terrorist attacks, that they were very confident about this information, and that these memories were characterized by a high phenomenal richness. Over time, there was a decrease in all of these variables, but people's ratings of phenomenology and confidence were still very high.