Self-Study Unit 1: Journalism & Trauma

A newspaper journalist, fresh out of college, arrives at the scene of a raging apartment fire at 2 a.m. to find dozens of people standing behind a police barrier. Some of these people seem to be in a daze, others are hysterical, and still others are seemingly calm and rational.

In the course of talking to a few people from emergency response and eyewitnesses, the journalist learns that several residents of the apartment building are unaccounted for. Soon a body is removed from the building on a stretcher, and the mood of the crowd turns somber. One woman in her mid- to late-fifties is sobbing uncontrollably as another person, a man about her age, tries to console her. The journalist overhears the woman crying in anguish about someone who might still be in the building. With pen and notepad in hand, and with some trepidation and uncertainty, the journalist approaches the couple to get more information.

Journalists who cover traumatic events such as violent crimes, horrific accidents, natural disasters and other situations in which they witness human pain and suffering are often required to approach and interview victims of trauma or their family members. Unfortunately the skills needed to interact with people under such stressful and unpredictable conditions do not usually come naturally. Without knowledge about traumatic stress and proper training in how to interact with potentially traumatized people, journalists may find their interviews to be awkward, uncomfortable and, in extreme cases, even re-traumatizing to their interviewees.

The goal of this module is to explain what traumatic stress is and why it is useful for journalists to know about its effects. In the building fire example above, there are many people who have just experienced a traumatic event, although not everyone responds to that event in the same way. Because human response to psychological trauma is varied, it is important for the journalist not to make unfounded assumptions about what the person who has experienced trauma is feeling. The adage, "You can't judge a book by its cover," is particularly apt when assessing the state of other people's emotions and well-being when they are under psychological stress. Seemingly "normal" and composed people may be suffering deeply but, for one reason or another, don't reflect that pain outwardly. On the other hand, someone who is crying during an interview may not necessarily want to stop talking. Indeed it may be the interviewer who is uncomfortable and decides to end the interview abruptly or prematurely, but the interviewee would actually prefer to continue. The point is, interviewing and writing about traumatized people professionally and accurately requires a degree of skill and insight. This learning module can help in that regard. Of course, this one module is not a comprehensive treatment of the subject of journalism and trauma, but it attempts to lay the essential framework for a study program that can help those interested in the subject learn about it at their own pace and enhance their basic understanding with additional resources (e.g., readings, Web sites, videos, etc.)

There are various types of traumatic response that victims and survivors of a traumatic event may experience. Acute stress disorder, posttraumatic stress disorder, and secondary traumatic stress each has its own set of criteria. A journalist who covers traumatic events and their victims would do well to recognize particular stress symptoms for accuracy and fairness in reporting. Moreover, this module also examines the role that covering traumatic events - especially after a prolonged period - has on journalists. We are only beginning to learn that prolonged coverage of traumatic events may trigger traumatic stress symptoms in journalists themselves. It is hoped that by discussing this long-overlooked subject of trauma effects on journalists, the profession as a whole will benefit by improving its understanding and response to journalists' emotional and psychological well-being.

By the end of this module, you should know:

• what traumatic stress is
• about posttraumatic stress disorder (PTSD), acute stress disorder (ASD) and the potential effects of working with traumatized individuals, including secondary traumatic stress, burnout, and vicarious traumatization
• what the effects of traumatic stress are
• why it is important for journalists to know about these effects
• how to interview people who have experienced a traumatic event
• how to cope, as a journalist, with SSD
• where to get more information for continued learning

I. What is Traumatic Stress?

Traumatic stress, as defined in this module, is the pressure, force or strain on the human mind and body from a specific event of major dimension that shocks, stuns and horrifies. The witnessing of and learning about traumatic stressors experienced by others can also be traumatizing. Common examples include witnessing or learning about the sudden death of a loved one or observing the serious injury or unnatural death of another person.

Often the victim who directly experiences traumatic stress fears for his or her life or feels imminently threatened with serious injury. Some severely traumatized individuals may dissociate during a stressor or have a blunted response, due to defensive avoidance and numbing. Often, the intense emotional response to the stressor may not occur until considerable time has elapsed after the incident has terminated.

Up to 90 percent of the general population in the United States is exposed to a traumatic stressor at some time (Breslau, Kessler, Chilcoat, Schultz, Davis, & Andreski, 1998). Common types of trauma include road traffic accidents, man-made or natural disasters, wartime combat, interpersonal violence (e.g., child abuse, sexual assault, domestic violence, other criminal violence), life-threatening medical conditions, and sudden unexpected death of a close relative or friend.

The percentage of those exposed to traumatic stressors who then develop posttraumatic stress disorder (PTSD) can vary depending on the nature of the trauma. At the time of a traumatic event, many people feel overwhelmed with fear, others feel numb or disconnected. Most trauma survivors will be upset for several weeks following an event, but recover to a variable degree without treatment. The percentage of trauma victims that will continue to have problems and develop posttraumatic stress disorder (PTSD) will depend on many factors, including the severity of trauma exposure. In one major epidemiological study of American civilians aged 15-54 (National Comorbidity Survey, Kessler et al., 1995) lifetime prevalence rates of PTSD following specific types of trauma were:

About 1 in 12 adults experiences PTSD at some time during their lifetime (women 10.4%; men = 5%; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Women are twice as likely as men to develop PTSD following exposure to traumatic events.

Although a key dimension of traumatic stress research is its effect on an individual's psychological health, there is an important underlying physiological dimension to traumatic stress. The physiological dimensions of traumatic stress are discussed at the end of Part 2.

CASE IN POINT:
Tragedy in a Houston Suburb

In June 2001, a 36-year-old woman was taken into custody after telling police that she had drowned her five children in a bathtub. Responding officers found her five children dead in her home, the youngest child only six months old. The woman's husband spoke on camera in front of their home not long after the discovery of the bodies and appeared to some observers to be calm and articulate, although not emotionless. He explained to the media about his wife's history of depression and that despite what she did he still loved her and wanted to help her.

Sometimes when we see people talking about a profoundly tragic event soon after it happens we expect them to display certain emotions — perhaps hysteria, hostility, an inability to speak coherently. When people do not respond the way we expect them to (or the way we think we would respond under the same circumstances), we may make all kinds of faulty assumptions about that person's sincerity or degree of grief and pain. The fact is, people respond to personal tragedy in their own way. Trauma experts warn us not to assume a person is "taking it well" just because he or she does not appear to be affected by a tragic event. That person could be in shock, in a stage of emotional anesthesia, or displaying a number of other emotional states that camouflage the degree of trauma that he or she is actually experiencing. This period of withdrawal or muted emotions may be helping the person to survive the unthinkable horror that has just occurred. One should never assume that psychological damage is minimal or non-existent simply by a person's outward display of emotion (or lack thereof).

It is important to keep in mind that discussing a traumatic event soon after exposure may have a detrimental effect on some traumatized individuals. Preliminary research in this area suggests that those individuals with heightened arousal immediately following or shortly after a trauma, may be more likely to develop long-term posttraumatic stress disorder (PTSD) (Shalev, 2001; Bryant, 2000). Therefore, overriding an individuals need for distance, avoidance of reminders of the trauma, and dissociation in the immediate phase of a trauma, may be detrimental to some individuals, particularly those with heightened arousal.

A key dimension of traumatic stress research is its effect on an individual's psychological health, which will be highlighted in the next section.

II. Effects of Traumatic Stress

In recent years, thanks to a number of researchers, educators and organizations, the role of traumatic stress and journalism has come under closer scrutiny. One of the pioneers of this work is Dr. Frank Ochberg, a Michigan-based psychiatrist who was a director of the National Institute for Mental Health and former head of the Michigan Mental Health Department. Over the years, Dr. Ochberg and the organizations that he is affiliated with, has helped increase public awareness of journalism and trauma issues — specifically what journalists should know about victims and survivors of trauma and their families, and what journalists should know about the effects (on themselves) of covering traumatic stress stories such as homicides, sexual assaults, criminal violence, natural disasters, plane crashes, and so forth.

An expert on posttraumatic stress disorder, Dr. Ochberg helped many journalists and journalism educators understand what PTSD is and what are its effects. "Whenever a reporter meets a survivor of traumatic events," he has written, "there is a chance that the journalist will witness - and may even precipitate - posttraumatic stress disorder. Therefore it is important that working journalists (including grizzled veterans) anticipate PTSD, recognize it and report it, while earning the respect of the public and those interviewed. The recognition of PTSD and related conditions enhances not only a reporter's professionalism, but also the reporter's humanitarianism."

Of course Dr. Ochberg is not suggesting that journalists "diagnose" PTSD in their interviewees but rather recognize that victims or survivors of trauma may display a wide range of responses and emotions related to the traumatic experience.

NORMAL REACTIONS
There are a number of possible reactions to a traumatic situation which are considered within the "norm" for individuals experiencing traumatic stress:

Emotional Effects

• shock
• terror
• irritability
• blame
• anger
• guilt
• grief or sadness
• emotional numbing
• helplessness
• loss of pleasure derived from familiar activities
• difficulty feeling happy
• difficulty feeling loved

Cognitive Effects

• impaired concentration
• impaired decision-making ability
• memory impairment
• disbelief
• confusion
• nightmares
• decreased self-esteem
• decreased self-efficacy
• self-blame
• intrusive thoughts, memories
• dissociation (e.g., tunnel vision, dreamlike or "spacey" feeling)

Physical Effects

• fatigue, exhaustion
• insomnia
• cardiovascular strain
• startle response
• hyperarousal
• increased physical pain
• reduced immune response
• headaches
• gastrointestinal upset
• decreased appetite
• decreased libido
• vulnerability to illness

Interpersonal Effects

• increased relational conflict
• social withdrawal
• reduced relational intimac
• alienation
• impaired work performance
• impaired school performance
• decreased satisfaction
• distrust
• externalization of blame
• externalization of vulnerability
• feeling abandoned, rejected
• overprotectiveness

Problematic Stress Responses
The following responses are less common, and indicate the likelihood of the individual's need for assistance from a medical or mental health professional:

• Severe Dissociation (feeling as if you or the world is "unreal," not feeling connected to one's own body, losing one's sense of identity or taking on a new identity, amnesia)
• Severe Intrusive Re-experiencing (flashbacks, terrifying screen memories or nightmares repetitive automatic re-enactment)
• Extreme Avoidance (agoraphobic-like social or vocational withdrawal, compulsive avoidance)
• Severe Hyperarousal (panic episodes, terrifying nightmares, difficulty controlling violent impulses, inability to concentrate)
• Debilitating Anxiety (ruminative worry, severe phobias, unshakeable obsessions, paralyzing nervousness, fear of losing control/going crazy)
• Severe Depression (lack of pleasure in life, worthlessness, self-blame, dependency, early wakenings)
• Problematic Substance Use (abuse or dependency, self-medication)
• Psychotic Symptoms (delusions, hallucinations, bizarre thoughts or images)

Some people will be more affected by a traumatic event for a longer period of time than others, depending on the nature of the event and the nature of the individual who experienced the event. One of the most debilitating effects of traumatic stress is a condition known as posttraumatic stress disorder (PTSD). The current trauma literature suggests that many factors are related to increased or decreased risk for PTSD. The likelihood of developing PTSD and the severity and chronicity of symptoms experienced, are functions of many variables, the most important being exposure to a traumatic event. It is therefore important to bear in mind that, even among vulnerable individuals, PTSD would not exist without exposure to a traumatic event.

With traumatic exposure as the foundation, other risk factors which have been shown to contribute to the development of PTSD include magnitude, duration, and type of traumatic exposure. Variables such as earlier age of onset and lower education are also associated with increased risk for developing PTSD. Additional factors related to vulnerability for developing PTSD include: severity of initial reaction, peritraumatic dissociation (i.e., feeling numb and a sense of "unreality" during and shortly following a trauma), early conduct problems, childhood adversity, family history of psychiatric disorder, education level, poor social support after a trauma, and personality traits such as hypersensitivity, pessimism, and negative reaction to stressors. Women are more likely to develop PTSD than men, independent of exposure type and level of stressor, and a history of depression in women increases the vulnerability for developing PTSD (Kessler et al., 1995; Breslau, 1990; Kulka, 1990).

SYMPTOMS OF PTSD
Posttraumatic stress disorder (PTSD) is a mental disorder resulting from exposure to an extreme traumatic stressor. PTSD has a number of unique defining features and diagnostic criteria, as published in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV, 1994). These criteria include:

Exposure to a traumatic stressor
To be diagnosed with PTSD, the person must have been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and (2) the person's response to the trauma involved intense fear, helplessness, or horror. (In children, this may be expressed instead by disorganized or agitated behavior.)

Stressful events of daily life that do not meet these criteria include divorce and financial crises, which may lead to adjustment problems, but are not sufficient to meet Criterion A for PTSD.

Qualifying stressors must induce an intense emotional response. According to DSM-IV, a qualifying stressor must not only be threatening, but it must also induce a response involving intense fear, helplessness, or horror. Some severely traumatized individuals may dissociate during a stressor or have a blunted response, due to defensive avoidance and numbing. Often, the intense emotional response to the stressor may not occur until considerable time has elapsed after the incident has terminated.

Re-experiencing symptoms
One set of PTSD symptoms involves persistent and distressing re-experiencing of the traumatic event in one or more ways. In these symptoms, the trauma comes back to the PTSD sufferer in some way, through memories, dreams, or distress in response to reminders of the trauma. A more extreme example of this is "flashbacks," where the individual feels as if he or she are reliving the traumatic experience. This is more extreme, but less common as a re-experiencing symptom. PTSD is distinguished from "normal" remembering of past events by the fact that re-experiencing memories of the trauma(s) are unwanted, occur involuntarily, elicit distressing emotions, and disrupt the functioning and quality of life of the individual.

Avoidance and numbing symptoms
A second set of PTSD symptoms involves persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness. These symptoms involve avoiding reminders of the trauma. These reminders can be internal cues, such as thoughts or feelings about the trauma, and/or external stimuli in the environment that spark unpleasant memories and feelings. To this limited extent, PTSD is not unlike a phobia, where the individual goes to considerable length to avoid stimuli that provoke emotional distress. These symptoms also involve more general symptoms of impairment, such as pervasive emotional numbness, feeling "out of sync" with others, or a lack of expectation for future goals being met, due to their trauma experiences.

Symptoms of increased arousal
This set of symptoms is represented by persistent symptoms of increased arousal not present before the trauma. These symptoms can be apparent in difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, a hypervigililant watchfulness, and an exaggerated startle response. Individuals suffering from PTSD experience heightened physiological activation, which may occur in a general way, even while at rest. More typically, this activation is evident as excessive reaction to specific stressors that are directly or symbolically reminiscent of the trauma. This set of symptoms is often, but not always, linked to reliving of the traumatic event. For example, sleep disturbance may be caused by nightmares, intrusive memories may interfere with concentration, and excessive watchfulness may reflect concerns about preventing recurrence of a traumatic event that may be similar to that previously endured.

REQUIRED DURATION OF SYMPTOMS
For a diagnosis of PTSD to be made, the symptoms must endure for at least one month.

PTSD symptoms must be clinically significant.

PTSD symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Some individuals may experience a great deal of subjective discomfort and suffering owing to their PTSD symptoms, without conspicuous impairment in their day-to-day functional status. Other individuals show clear impairment in one or more spheres of functioning, such as social relating, work efficiency, or ability to engage in and enjoy recreational or leisure activities.

Acute Traumatic Stress Reactions
Many individuals experience acute stress reactions as a result of having experienced a life-threatening event or some other sudden, uncontrollable, and frightening experience such as sexual assault, motor vehicle accident, fire, natural or man-made disaster, or domestic violence. Receiving a serious, life-threatening diagnosis (e.g., cancer or HIV) can also lead to acute stress reactions. For some trauma survivors, acute stress reactions are severe enough to meet DSM-IV criteria for Acute Stress Disorder (ASD). In addition to symptoms of reexperiencing, avoidance, and arousal, individuals with ASD show multiple symptoms of dissociation (e.g., subjective sense of numbing, reduced awareness of surroundings, depersonalization); to be so diagnosed, specific exposure, symptom, and functional impairment criteria must be met, and the disturbance must occur within 4 weeks of the trauma and last for a minimum of 2 days and a maximum of 4 weeks.

Complex PTSD
Clinicians and researchers have found that the current PTSD diagnosis often does not capture the severe psychological harm that occurs with such prolonged, repeated trauma (e.g., concentration camp and prisoner of war experiences, domestic violence, child abuse). For example, an ordinary, healthy person can experience changes in their self-concept and the way they adapt to stressful events. While not an official DSM-IV diagnosis, the term "complex PTSD," has been coined by clinicians to define the symptoms unique to long-term trauma, including:

• Alterations in emotional regulation, which may include symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger.
• Alterations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body.
• Alterations in self perception, which may include a sense of helplessness, shame, guilt, stigma, as well as a sense of complete differences from other human beings.
• Alterations in perception of perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including preoccupation with revenge.
• Alterations in relations with others, including isolation, distrust, or repeated search for a rescuer.
• Alterations in system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.

ASSOCIATED DISORDERS
In addition to PTSD and ASD, individuals who have experienced trauma are at heightened risk for developing other psychiatric disorders, including:

• Depression
• Substance abuse
• Panic disorder
• Obsessive-compulsive disorder
• Sexual dysfunction
• Eating disorders

Other Problems Individuals with a Trauma History Report
In addition to the problems listed above, patients with a trauma history are also at a heightened risk for the following problems:

• Depression, despair and hopelessness
• Difficulty trusting others
• Irritability and anger
• Intense emotions when reminded of their trauma
• Suicidal ideation
• Feeling unsafe and remaining "on guard" for possible threats in the environment
• Difficulty experiencing positive emotions such as love or happiness
• Difficulty controlling their trauma memories
• Inability to feel sadness or to cry, even with death of a family member
• "Workaholism" and/or alcohol/substance use
• Homelessness
• Revictimization (increased risk of subsequent exposure to trauma)
• Loss of important beliefs
• Aggressive behavior toward oneself, self-blame, guilt, and shame
• Problems with identity or sense of self
• Feeling permanently damaged
• Problems with self-esteem
• Physical health symptoms and problems
• Alcohol and/or drug use
• Problems in relationships with people, such as feeling detached or disconnected from others, social isolation, or getting into arguments and fights with people

For some individuals, some of the symptoms of PTSD (such as numbing, irritability, hypervigilance, or avoidance) are so ingrained as to be perceived as "part of their personality." These individuals may not appear to have any PTSD symptoms that are distressing or interfering with functioning. For some, avoidance is so ingrained that they "manage" PTSD simply by restricting their lifestyle to the degree that they have no contact with any reminders of the trauma, and therefore may appear to have relatively few symptoms. For some individuals, symptoms have been effectively managed for years by over-immersion in work or family; for others, substance abuse suppresses many of their symptoms. When such individuals retire, or stop using alcohol or drugs, they often find that their PTSD symptoms re-emerge and compromise their level of functioning in one way or another.

The Physiological Basis for Stress Responses
There is an important underlying physiological dimension to traumatic stress. In his book, Why Zebras Don't Get Ulcers: An Updated Guide to Stress, Stress-Related Diseases, and Coping, stress expert Robert M. Sapolsky, professor of biological sciences and neuroscience at Stanford University, explains in meticulous but lucid detail how the human body responds to an external threat of death or serious injury. First, two classes of hormones are released by the body's sympathetic nervous system. One class of hormones includes epinephrine (more commonly known as adrenaline) and a related hormone, norepinephrine. Another class of hormones is the glucocorticoids, which, like the others mentioned, are secreted from the adrenal gland. These hormones and others kick into action when the body is under stress and cause physiological changes in the body that could be life-saving.

Among the changes that occur are:

• "rapid mobilization of energy from storage sites and the inhibition of further storage"
• "glucose and the simplest forms of proteins and fast come pouring out of your fat cells, liver, and muscles, all to stoke whichever muscles are struggling to save your neck"
• "heart rate, blood pressure, and breathing rate increase, all to transport nutrients and oxygen at greater rates"
• "digestion is inhibited"
• "growth is inhibited"
• "reproduction.is curtailed"
• "sexual drive decreases in both sexes"
• "immunity is inhibited"
• "perception of pain can become blunted"
• "shifts occur in cognitive and sensory skills"

These changes occur to increase the organism's chance for survival when threatened and are helpful to humans when confronted by acute physical or psychological stressors. Once the danger passes, the body's physiological processes should return back to normal. A problem develops, however, when stressors are chronic, and that is largely the focus of Dr. Sapolsky's book. (More on this in section 6, "Journalists: A Self-Care Primer.")

III. Why Traumatic Stress?

Many journalists who cover "hard news" will come into contact with people who have experienced a traumatic event. At the scene of a fatal car collision, for example, or a neighborhood shooting, or an apartment fire, there are likely to be people present who are suffering from traumatic stress. These same people may also be important sources of news for their community — people who, despite their pain, can help tell the story of a tragedy as it is unfolding.

Other news stories may require contacting and interviewing survivors of trauma weeks, months or even years after a traumatic event has occurred. These contacts may be precipitated by a memorial service, developments in a case (e.g., a trial 10 months after a sexual assault), an anniversary (e.g., commemorating a school shooting or plane crash), or other reasons. This could mean picking up the phone and calling up the father of those murdered children or standing outside of a courtroom waiting for a victim of violence to emerge.

It is important for journalists to know about traumatic stress because those people they interview and write about may still be in a process of healing and recovery. A journalist knowledgeable about traumatic stress will be sensitive to a violent crime victim's need to feel humanized and respected, especially after an intentionally cruel experience. Approaching the person with genuine respect and concern reduces the perception of repeat exploitation.

As noted in Part 1, it is important to keep in mind that discussing a traumatic event soon after exposure may have a detrimental effect on some traumatized individuals. Overriding an individual's need for distance, avoidance of reminders of the trauma, and dissociation in the immediate phase of a trauma, may be associated with increased risk for developing PTSD in some individuals, particularly those with heightened arousal.

Understanding the Potential Effects of Working with Trauma Survivors
In the next section, tips for interviewing trauma victims will be offered. However, another aspect to the traumatic stress question should be addressed here. Research is beginning to show that the effects of covering traumatic events over a long period of time can actually have negative effects on journalists themselves. A number of terms have been coined to describe the changes that occur in those who regularly deal with people who have been exposed to traumatic stress events, and, as a result, become psychologically and emotionally overwhelmed by the many traumas they must bear witness to. These terms are described below as a way for journalists to better understand the changes they may have experienced in themselves as a result of both experiencing traumatic events themselves, and witnessing the effects of those events on others.

Burnout
The term "burnout" has been applied to across helping professions, and refers to the cumulative psychological strain of working with many different stressors. It often manifests as a gradual wearing down over time.

The factors contributing to burnout include:

• professional isolation
• emotional drain of empathy
• difficult client population
• long hours with few resources
• ambiguous or lack of clear success
• non-reciprocated giving and attentiveness
• failure to live up to one's own expectations for effecting positive change

The symptoms of burnout include:

• depression
• cynicism
• boredom
• loss of compassion
• discouragement

Secondary Traumatic Stress
The term "Secondary Traumatic Stress" has been coined by various authors (e.g., Stamm, 1995), to characterize subclinical or clinical signs and symptoms of PTSD mirroring those experienced by trauma clients, friends, or family members. While it is not currently recognized by the DSM-IV as a clinical disorder, many clinicians note that those who are witnesses to traumatic stress in others may develop symptoms similar to PTSD, such as:

• Hyperarousal
• Intrusive symptoms
• Avoidance, numbing
• Anxiety
• Depression

Compassion Stress
Charles Figley (1995) coined this term as a "non-clinical, non-pathological" way to characterize the stress of helping or wanting to help a trauma survivor. Similar to the common stress reactions listed in Part 2, compassion stress is seen as a natural outcome of knowing about trauma experienced by a client, friend, or family member, rather than a pathological process. It can be of sudden onset, and the symptoms include:

• Helplessness
• Confusion
• Isolation
• Secondary traumatic stress symptoms

Compassion Fatigue
Compassion fatigue, also coined by Figley, was considered a more severe example of cumulative compassion stress. It is a defined as: "a state of exhaustion and dysfunction, biologically, physiologically, and emotionally, as a result of prolonged exposure to compassion stress. (Figley, 1995, p. 34).

Vicarious Traumatization
"Vicarious traumatization" was coined by Pearlman and Saakvitne, (1995) as those permanently transformative, inevitable changes that result from doing therapeutic work with trauma survivors. In their research, they noted that a number of changes were common to those mental health workers who have trauma survivors in their case load. Those changes were considered not pathological, as described in secondary traumatic stress, but more cognitive/emotional changes in meaning and sense of self. The changes were cumulative over time with multiple trauma survivors in caseload, and pervasive in their effects on an individual's life. Vicarious traumatization changes can create detrimental effects in:

• A person's relationship with meaning, hope
• Getting ones psychological needs met
• Intelligence
• Willpower
• Sense of humor
• Ability to make self-protective judgements
• Memory/Imagery
• Existential sense of connection to others
• Self-capacities
• The enduring ability to maintain a steady sense of self
• Tolerance for a range of emotional reactions in one's self and in others
• A sense of inner connection to others
• A sense of self as viable, worth loving, deserving
• A sense of self that is grounded

There are a number of possible behavioral changes that might result from vicarious traumatization, including:

• Becoming judgemental of others
• Tuning out
• Reduced sense of connection with loved ones and colleagues
• Cynicism, anger, loss of hope, meaning
• Rescue fantasy/overinvolvement/taking on others' problems
• Developing overly rigid, strict boundaries
• Heightened protectiveness, as a result of decreased sense of the safety of loved ones
• Avoiding social contact
• Avoiding work contact

If You Recognize These Changes in Yourself
It is recommended that an individual take steps toward self-care and lifestyle balance if they are experiencing symptoms of burnout, secondary stress, or vicarious traumatization. These steps are defined in part 5: Journalists — A Self-Care Primer.

Compassion Satisfaction
It is important to note that, while there are a number of risk factors involved in working with trauma survivors, there is also the possibility of a great sense of satisfaction with this work. There can be a satisfaction with this kind of work that is very powerful. Figley has coined the term "Compassion Satisfaction" to describe this process, which involves the devleopment over time of a much stronger:

• sense of strength
• self-knowledge
• confidence
• meaning
• spiritual connection
• respect for human resiliency

Stamm, B. H. (ed.). (1995). Secondary traumatic stress: self-care issues for clinicians, researchers, and educators, Lutherville, Maryland: Sidran Press.

Figley, C. R. (ed.). (1995). Compassion fatigue: coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.

Saakvitne, K. W., & Pearlman, L. A. (ed.). (1996). Transforming the pain: a workbook on vicarious traumatization. New York: Norton.

Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist: countertransference and vicarious traumatization in psychotherapy with incest survivors, pp. 295-316. New York: Norton.

Pearlman, L. A., & Mac Ian, P. S. (1995). Vicarious traumatization: an empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research and Practice, v. 26, no. 6, pp. 558-565.

IV. Tips on Interviewing

Because of the nature of news, it is likely that a journalist will have to interview trauma victims in the course of his or her work. Interviewing someone who is under psychological stress is difficult for both the interviewee and the interviewer. As interviewers, journalists can help victims and survivors tell their stories in a way that is constructive. In their book Covering Violence, Simpson and Coté suggest that the journalist consider the following questions BEFORE the "dicey moment when the city editor or the assignment editor points toward the door and tells you to get moving." The questions are:

• Is it necessary to immediately interview those who have suffered a traumatic event?
• What is the value of intruding on people when they are grieving, disoriented, shocked and frightened?
• What should you discuss with someone before that person consents to an interview?

The authors do not suggest that interviews with traumatized victims should not take place. For one thing, this is unrealistic, but further, people who are traumatized may have stories to tell that are helpful to those who hear their stories. But journalists should go about seeking interviewees in a thoughtful manner. They write:

"Each interview needs a deliberate judgment about the capacity of the other person to understand what an interview entails, including potential ramifications for the interviewee, family members, and friends. It is not enough that a person agrees to an interview. The ethical burden is not on the interview subject but on the journalist. We argue that doing the interview is not ethical unless the reporter has received what some journalists call 'informed consent, a phrase they picked up from medicine."

Psychiatrist Frank Ochberg suggests talking with interviewees about the pain that might result from remembering a traumatic event. Interviewees should also know whether their names will be used in the story. Give the interviewee an opportunity to ask the interviewer any questions before the interview begins.

Respect the other person's efforts to regain balance after a horrible experience
"Offer as much support to the interviewee as conditions will allow. Suggesting that the interviewee ask a friend, neighbor, or relative to be present may reassure her and may help the two of you talk more usefully."

Watch what you say
"At this stage your words carry a lot of weight. They can lead the victim to seek promises from you, to exaggerate what you will be able to do, and to assume that you are willing to be a friend as well as a reporter.Your manner and your first words will tell the other person whether he should trust you and how sincere you are. Those first impressions may decide whether you are ever again able to interview that person."

Set the stage for the interview
"Your first questions will provide you with two kinds of information. The first kind - details of the other person's knowledge of the situation - will help you begin to grasp what has happened. As you talk, you will be learning about the other person's capacity, or willingness, to talk to you."

Explain the ground rules
"Explain why you are there, what kind of story you are expected to write or report, when it is likely to run, and why it is important for her to speak to you. Do not promise something you cannot guarantee; the comments you are about to write down or tape may never make it into print or on the air."

Share control with the interviewee
"A person jolted by an event may need, and will certainly appreciate, a chance to decide some of the conditions of the interview. Would he like to sit or stand? Does he want to remain here or go somewhere away from the turmoil of the scene? Is there someone he would like to have present during the interview?"

Anticipate emotional responses
Referring to the words of psychiatrist Frank Ochberg: "When survivors cry during interviews, they are not necessarily reluctant to continue. They may have difficulty communicating, but they often want to tell their stories. Interrupting them may be experienced as patronizing and denying an opportunity to testify. Remember, if you terminate an interview unilaterally, because you find it upsetting, or you incorrectly assume that your subject wants to stop, you may be re-victimizing the victim."

Listen
"Good listening requires hearing not only the words that are spoken and making sense of them but also noticing gestures, facial expressions, emotions, and body language. Take the other person fully into account, then remember and make sense of what that person heard and saw."

Review with the interviewee what you have learned
"This is the time to go back over the facts, to read back statements that you may want to quote, and to arrange to obtain photographs, continue the interview, or check back for other information."

Think through what you have heard and seen
"The interview you have just completed was not a routine one. Think about what made it different. The person with whom you talked was enduring one of the most trying experiences in life. Such an interview can alter many of the assumptions journalists make about the people they talk to. Issues of trust, harm, and responsibility to others emerge from such meetings to a degree unmatched in most news interviewing. This is a time for a few moments of reflection about what you have just heard and seen."

Journalists should also think about how follow-up interviews may affect their subjects. Often traumatic events are visited and revisited, and victims and survivors are contacted for interviews and asked to talk about the past again. These could occur during anniversaries of traumatic events (school shootings, a bombing, and other violent crimes) or during criminal or civil trials. The same kind of consideration should be shown to interviewees during these times as immediately after a traumatic event (e.g., listening, sharing control, etc.). People may still be recovering from their trauma. Journalists might focus on the recovery process rather than on the event itself. In any case, they should be perceptive to the needs and responses of the interviewee. Early signs of interviewee anxiety might be a time to ask how the interviewee is doing and help make the situation more comfortable. Empathy toward the interviewee is helpful.

An inclination to "over-empathize," however, may not be professional. Simpson and Coté write that "some reporters eagerly identify with those who survive violence because of a personal history of abuse, sexual assault, or other traumas. That identification becomes so strong that the reporter ignores professional boundaries in order to become a confidant and even advocate. A skilled reporter needs to concentrate on understanding and reporting events accurately; deep emotional connections to people in those stories can undermine those goals. Yet we would agree with those who say a reporter sometimes can be very helpful to a victim or family member. But we believe that the best results for everyone occurs when the reporter understands his own needs and is sensitive to signs of trauma and growing distress in others."

The bottom line is that a journalist needs to be both self-aware and aware of the impact that trauma has on others. This understanding can help the journalist tell a traumatic story knowledgeably and with appropriate sensitivity.

Basic Empathy Skills for Post-Traumatic Interviewing Situations
Empathy is the capacity to participate in another's sensations, feelings, thoughts, and movements. The first and foremost requirements for skilled empathic interviewing are:

• Interest
• Attentiveness
• Caring
• Self-containment
• Freedom from expectations or judgments
• Respect

Possible Empathic Responses
Sometimes it is helpful to have cues to work from in learning empathic responding, which may be very different from general interviewing strategies. The following cues are offered to give examples of empathic interviewing strategies:

• "From what you're saying, I can see how you would be.."
• "So what you're saying is.."
• "Let me just check something. Do you mean you're."
• "It sounds like you're saying.."
• "You seem really.."

Supportive Comments:

• "You must be."
• "I can understand you feeling.."
• "It sounds really hard."
• "It sounds like you're being hard on yourself."
• "I would imagine you'd be feeling really ____ right now."

Comments on Emotional Tone:

• "It seems like it's hard for you to have feelings about this.."
• "It seems like you are pretty numb right now."

Asking for Details or Clarification (gets the person to slow down and stay with the situation or the feelings):

• "So let's go back a minute.."
• "I noticed that you are rushing through this a bit."
• "It seems hard to stay with this."
• "I don't get it. What do you mean they..?"
• "Could it be."
• "I wonder if.."

Moving into End of Interviewing Session:

• "It is such a tough thing to go through something like this."
• "I'm really sorry this is such a tough time for you."
• "I know of a website that might be helpful for you."

Purposes of Empathic Responding

• Some individuals are deep within themselves and need to be drawn out by asking for clarification, gently mirroring and reflecting what has been said.
• Some individuals are overly expressive and needy, and may need to have you establish a working distance by remaining neutral, not getting drawn into "rescuing," making "it sounds like." statements. You cannot help if you are engulfed.
• Shows you care and that you understood the other person. Not to pry, but to increase the person's sense of themselves in the present moment.
• If you have misunderstood, the talker can immediately correct your impressions. You learn more about people.
• It lets the talker know that you (the listener) accept him/her invites him/her to tell his/her story.

V. Self-Care Primer

Similar to police, firefighters, and first responders to critical incidents, journalists are often exposed to highly stressful, traumatic situations, and required to bear witness to others who have been overwhelmed by traumatic events. While emergency workers have, particularly in the last decade, recognized the need for self-care and organizational safe-guards, journalists may not yet have been recognized as potential candidates for employee safeguards and increased support.

While journalists are increasingly feeling more comfortable talking about the effects that covering violence and other traumatic events has had on them, this was not always the case. In the past, many journalists chose not to talk about their feelings of fear, anxiety, depression, anger and other emotions because those expressions might be construed by others as a sign of weakness and inability to do the job. Today, even nationally prominent journalists such as the New York Times' Rick Bragg, CNN's Christiane Amanpour and retired veteran broadcast journalist Bernard Shaw have spoken publicly about the emotional and psychological difficulty of covering certain kinds of news stories.

At a conference at the University of Washington several years ago, one journalist talked about the difficulties of covering an adult-child sex ring case that dragged on for two years and other emotionally taxing stories. "Everyday I get up and there's this river, this wild raging river," she said, "and I take a deep breath, and I dive in and at the end of the day I claw out, and the next day I jump back in. I don't feel that I ever have time to think about what I'm doing."

What journalists need to remember is that there may be a number of potential stress reactions they may have when they write about particularly stressful or traumatic topics — murders, car accidents, sexual assaults and other violence. It is also possible that they may experience traumatic stress symptoms themselves after covering these kinds of stories over a long period of time.

As described in parts 2 and 4, people who are regularly exposed to traumatic stress may experience reactions that are adverse to their mental and physical health, such as cynicism, isolation, excessive smoking or drinking, compulsive behavior like overeating or illicit drug use, anger, anxiety, avoidance, depression, and so forth.

Coping Strategies

There are a number of common strategies that individuals utilize when coping with extraordinary stress in their lives. These strategies, while effective at manageable levels of stress, can become unproductive or detrimental when stress reaches overwhelming or traumatic levels. Common coping mechanisms have been grouped into six types of categories:

Reappraisal

• I challenge the thought's validity
• I analyse the thought rationally
• I try to reinterpret the thought
• I try a different way of thinking about it
• I question the reasons for having the thought

Punishment

• I tell myself not to be so stupid
• I punish myself for thinking the thought
• I get angry at myself for having the thought
• I shout at myself for having the thought
• I slap or pinch myself to stop the thought
• I tell myself that something bad will happen if I think the thought

Worry

• I replace the thought with a more trivial thought
• I dwell on other worriesI worry about more minor things instead
• I think about the more minor problems I have
• I think about past worries instead
• I focus on different negative thoughts

Distraction (Cognitive)

• I call to mind positive images instead
• I focus on the thought
• I think pleasant thoughts instead
• I think about something else

Social Control

• I do not talk about the thought to anyone
• I keep the thought to myselfI avoid discussing the thought
• I find out how my friends deal with these thoughts
• I ask my friends if they have similar thoughts
• I talk to a friend about the thought

Distraction (Behavioral)

• I occupy myself with work instead
• I keep myself busy
• I do something that I enjoy

Of the above coping strategies, research has shown that:

• Punishment is associated with depression and anxiety
• Use of punishment decreases with recovery
• Worry is associated with anxiety
• People who recovered used less worry
• Distraction increases with recovery, and remains the same in those who do not recover
• Reappraisal reduces depression and intrusions, but depression may reduce the ability to reappraise (which is one of the most effortful strategies)
• Recovery was associated with increased use of reappraisal (Reynolds and Wells, 1999)

Individuals with strong coping skills often choose to:

• focus on brief time intervals when in a problem-solving mode (e.g., thinking only about what to do next) or focus on extended time intervals to obtain a less devastating picture of the trauma (e.g., as one tragic event in a full and meaingful life)
• maintain a view of the self as competent and of others as willing and able to provide support
• focus on the current implications of the trauma and avoid regretting past decisions and actions (Horowitz, 1986)

The process of "converting" traumas into growth experiences has the following characteristics:

• It is a cognitive process
• It is usually done by the individual alone, but confidants can also suggest new interpretations
• It usually occurs between 2 weeks and 4 months following the stressor
• It can enhance coping with subsequent stressors
• It usually depends more on individual's psychological resources than on the characteristics of the stressor event
• It is intuitive, rapid, and sudden, rather than an extended logical thinking process ("sudden insight," "flash," "revelation.") (Finkel and Jacobsen, 1977)

There are also healthy coping mechanisms that have been suggested by journalists and editors themselves and tried out in newsrooms across the country. Debriefing opportunities after a community tragedy has been shown to be helpful, as well as making mental health services readily available for those who need them. The act of seeking mental health counseling needs to be de-stigmatized in the newsroom culture so that journalists will feel comfortable accessing those kinds of services. Peer support is also beneficial. Often there is one or more individuals in a newsroom who a troubled employee can seek out for empathy and friendly counsel. The person or persons providing this counsel, however, needs to be careful not to become too overwhelmed by others' emotional pain.

Editors and other newsroom managers can take a leading role in letting journalists know they work in a caring newsroom. Hosting a workshop on journalism and trauma can help prepare journalists to deal with potential problems related to covering traumatic events. Calling the newsroom together to discuss problems and concerns during or after a traumatic event shows concern not only for the journalists but for the community that the journalists are reporting on.

A potentially harmful coping mechanism to both the journalist and community is the effect of desensitization to others' emotional pain and psychological distress. While it is often necessary to compartmentalize one's emotions temporarily to get through a difficult period and do what it takes to get a story written, it is harmful to stop feeling altogether. The inability to empathize in the process of getting a story could cause the journalist to add trauma to an already traumatized victim. Journalists need time and encouragement to process their emotions, to deal with their feelings of sadness or anger or horror or confusion, and not repress them.

A good internal and external support system is critical. Some people meditate, take long walks, listen to relaxing music, enjoy quiet baths, seek spiritual retreat or sustenance, and treat themselves to massages and other extravagances when they are feeling "stressed out." This, coupled with a network of caring family, friends and health professionals, provide constructive relief to a stressful work life.

Reducing stress in one's life, especially when one has a busy and stressful job, usually requires thoughtful planning and deliberate action. Work can be all-consuming, leaving little time to think about how to rest, relax and enjoy life. Unfortunately this self-neglect can lead to physical and mental deterioration. Countless studies have by now established a clear link between stress and sickness. Journalists, like all people who work at stressful jobs, need to create a wellness program for themselves that takes into account healthy eating, exercise, recreation, relaxation and, if necessary, physical and mental treatment.

Practice Lifestyle Balance

Besides being more aware of coping strategies, there are many ways to restore lifestyle balance, and keeping track of and making progress with as many of the following changes is a good way to regain balance after having been exposed to or witnessed cumalative traumatic experiences:

Physical Self-Care

• Eat regularly (e.g. breakfast, lunch, dinner)
• Eat healthily
• Exercise
• Get regular medical care for prevention
• Get regular medical care when needed
• Take time off when sick
• Get massages
• Dance, swim, walk, run, play sports, sing, or do some other physical activity that is fun
• Take time to be sexual—with yourself, with a partner
• Get enough sleep
• Wear clothes you like
• Take vacations
• Take day trips or mini-vacations
• Make time away from telephones

Psychological Self-Care

• Make time for self-reflection
• Have your own personal psychotherapy
• Write in a journal
• Read literature that is unrelated to work
• Do something at which you are not expert or in charge
• Decrease stress in your life
• Notice your inner experiences — listen to your thoughts, judgements, beliefs, attitudes, and feelings
• Let others know different aspects of you
• Engage your intelligence in a new area, e.g., go to an art museum, history exhibit,sports event, auction, theater performance
• Practice receiving from others
• Be curious
• Say no to extra responsibilities sometimes

Emotional Self-Care

• Spend time with others whose company you enjoy
• Stay in contact with important people in your life
• Give yourself affirmations, praise yourself
• Find ways to increase your sense of self-esteem
• Reread favorite books, re-view favorite movies
• Identify comforting activities, objects, people, relationships, places, and seek them out
• Allow yourself to cry
• Find things to make you laugh
• Express your outrage in social action, letters, donations, marches, protests
• Play with children

Spiritual Self-Care

• Make time for reflection
• Spend time with nature
• Find a spiritual connection or community
• Be open to inspiration
• Cherish your optimism and hope
• Be aware of nonmaterial aspects of life
• Try at times not to be in charge or the expert
• Be open to not knowing
• Identify what is meaningful to you and notice its place in your life
• Meditate
• Pray
• Sing
• Spend time with children
• Have experiences of awe
• Contribute to causes in which you believe
• Read inspirational literature (talks, music, etc.)

When to Seek Help

There may be times when the above self-help strategies are not effective in reducing the effects of exposure to traumatic stress. Research has shown that some changes associated with exposure to trauma may involve a change in brain chemistry and function, and that the use of antidepressants is effective in reducing both PTSD and depressive symptoms in individuals who are unable to manage their symptoms behaviorally. Individuals have also shown partial or full relief from post-traumatic stress symptoms through certain types of cognitive-behavioral treatment. As stated in Part 2, seeking assistance from your medical doctor or a mental health professional who is skilled in trauma is recommended if:

• you are experiencing any symptoms that are causing distress, significant changes in relationships, or are impairing functioning at work
• you are self-medicating with alcohol or drugs
• you are unable to find relief with the strategies listed above

VI. Best Practices

Each year the Dart Center for Journalism and Trauma recognizes outstanding newspaper coverage of victims and their experiences with the The Dart Award for Excellence in Reporting on Victims of Violence. A panel of judges from across the country convenes to select the winner of each year's award. Judges look for entries that go beyond the ordinary in reporting on victims of violence, taking into account all aspects of an entry. The reporting, photography and layout (headlines, cutlines, artwork and graphics) should:

• Portray victims of violence and their experiences with accuracy, insight and sensitivity.
• Be clear and engaging, with a strong theme or focus.
• Inform readers about the ways individuals react to and cope with emotional trauma, as well as the process of recovery.
• Avoid sensationalism, melodrama, and portrayal of victims as tragic or pathetic figures.
• Emphasize the victim's experience rather than the brutality or cruelty of perpetrators.

The final judges consist of three journalists chosen from outside Washington state, a victim/survivor representative, and the president-elect of the International Society for Traumatic Stress Studies.

Two previous winners for the Dart Award illustrate some of the concepts discussed in this curriculum module.

"Who Killed John McCloskey," The Roanoke Times (Roanoke, Va.). A compelling series on the the suspicious death of an 18-year-old man arrested and placed in the care of a mental institution, the cover-up that followed, and the family's on-going grief and confusion (2000 Dart Award winner).

"A Stolen Soul," The Portland Press Herald (Portland, Maine). For the sensitive and thorough portrayal of Yong Jones' struggle to bring her son's murderer to justice against the backdrop of her cultural beliefs (1999 Dart Award winner).

Conclusion

By now, having completed this module, you should know what traumatic stress is; what PTSD, ASD and secondary traumatic stress effects are; what the effects of traumatic stress are; why it is important for journalists to know about these effects; how to interview people who have experienced a traumatic event; how journalists can deal with a stressful work life; and where to get more information for continued learning.

Interviewing trauma victims, as would be the case with any difficult interpersonal task, should improve with practice. In journalism school, sometimes students practice these interviews using role-playing and interactive drama. (See the Resources section for more information.)

Conceivably, media organizations could arrange for similar training for their employees, perhaps working with a local journalism program.

Generally speaking, the rules for interviewing trauma victims resemble the rules for being a good friend. Be respectful. Tell the truth. Be empathetic. Be responsive. Be accurate and fair.

Families often clip and save news articles about a murdered or injured loved one. It is disturbing to them if a name is misspelled or a statement of fact is inaccurate. Remember that after someone has died, artifacts that remind the survivors of their deceased loved one take on much greater significance. Treat photographs with special care if a survivor entrusts you with them. Keep in mind that news stories about the deceased person may become part of an important body of memorabilia for the family.

When approaching the parent of a murdered child, journalists should avoid asking banal questions like, "How do you feel?" or even "I know how you feel" (even if they think they do). A better way of starting interaction might be to say, "I'm very sorry about what happened to your daughter." Also, journalists should be wary of asking questions that might sound unintentionally accusatory.

Victims of violence and their loved ones have had the shock of human cruelty inflicted upon them. One of the goals of the Dart Center is to help train journalists not to add any further trauma to the lives of people who have already suffered enough.

Journalists can also suffer from extended coverage of traumatic events and need to be aware of the effects that such work may have on them mentally and physically. It is neither in the best interest of the journalist nor his or her subject for the journalist to be completely desensitized to other people's suffering. On the other hand, too much empathy can be debilitating. Like good news stories, balance is key.

Human cruelty is a sad fact of life and occurs both where you expect it and don't expect it. Sharing stories of trauma and tragedy can be helpful to those who are victimized as well as to society as a whole. The Dart Center attempts to help journalists tell these important stories with sensitivity and professionalism.

Sources and Resources

ON THE INTERNET

International Society for Traumatic Stress Studies
Dart Award for Excellence In Reporting on Victims of Violence
PTSD 101 by Frank Ochberg
Role-playing and Interactive Drama in Teaching and Learning
National Center for PTSD

BOOKS & ARTICLES

Coté, William and Roger Simpson, Covering Violence: A Guide to Ethical Reporting About Victims and Trauma. New York: Columbia University Press, 2000.

Bloom, Sandra L., M.D., and Michael Reichert, Ph.D. Bearing Witness: Violence and Collective Responsibility. New York: Haworth, 1998.

Bloom, Sandra L., M.D. Creating Sanctuary. New York: Routledge, 1997.

Sapolsky, Robert M. Why Zebras Don't Get Ulcers: An Updated Guide To Stress, Stress-related Diseases And Coping.

Nieman Reports, "Violence," Vol. L, No. 3, Fall 1998, pages 4-38.

Allen, Jon (1995). Coping with Trauma: A Guide to Self-Understanding (American Psychiatric Press, 1995). Dr. Allen, a clinical psychologist at the Menninger Clinic, explains the effects of traumatic experience on the survivor's personality, physiological functioning, and social relationships. He discusses the symptoms of PTSD, dissociative disorders, and other recognized psychiatric disorders associated with trauma, and describes treatment approaches and self-help techniques.

Herman, Judith. Trauma and Recovery (1992, Basic Books). This book offers a feminist perspective linking sexual and domestic violence with combat and political terror. These have a common effect on survivors: disempowerment and denial. Drawing upon published research and her own clinical work, Harvard psychiatrist Judith Herman asserts that just as "traumatic syndromes have basic features in common, the recovery process also follows a common pathway." Trauma and Recovery explores ways in which the treatment process can empower the survivor.

Van Der Kolk, Bessel A. (Editor), Alexander C. McFarlane (Editor), and Lars Weisaeth (Editor), (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. This book presents a comprehensive synthesis of research and clinical knowledge on traumatic stress and its treatment. The book examines the history of individual and societal responses to trauma, acute traumatic reactions, adaptations to trauma, mechanisms and processes of memory, developmental and cultural issues, and treatment issues. Controversies in the field are addressed, such as the role of memory, the relationships between biological and psychological processes, and legal issues.

Matsakis, Aphrodite. (1992). I Can't Get Over it: A Handbook for Trauma Survivors (New Harbinger Publications). A psychotherapist specializing in PTSD who has worked extensively with Vietnam veterans and survivors of child sexual abuse, the author explains in detail the symptoms of PTSD, and suggests a wide variety of techniques for coping with them. A new edition of her 1988 book Vietnam Wives: Facing the Challenges of Life with Veterans Suffering Post Traumatic Stress (Sidran Press, 1996) deals with the additional stresses brought arising from midlife as well as those stemming from the experience of combat.

Shengold, Leonard. Soul Murder: The Effects of Childhood Abuse and Deprivation. (Yale University Press, 1989) examines the adult lives of child abuse survivors from a psychoanalytic perspective. Drawing from the lives and works of Chekhov, Dickens, Kipling, and Orwell, he demonstrates the ubiquity of deliberate abuse and its devastating effects.