The Interplay of Different Theories of Trauma Treatment and how they are used at Danville State

Chris McNulty Bucknell University

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Abstract Psychology like any other field is always evolving and building off of itself. Theories are discussed and the ground work laid by one author is expanded on by the next. This is especially true of the expansion of the extensive ground work laid by Judith Herman in Trauma and Recovery and the expansion of that work by Dr. Bloom in the creation of her sanctuary model. After analyzing these theories a look at Danville state shows how these theories are or are not implemented.

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Psychology is an ever evolving field. One of the more unique things about psychology is that multiple theories about the same thing can exist, support and even build off each other. This is nowhere more clearly than it is in the treatment of those recovering from trauma. As we learn more and more about what causes trauma we attempt to come up with newer and better ways to treat those who have survived traumatic experiences and as a result many psychologist come up with different theories to try and aid those suffering from trauma. In this paper I will be examine the expansion of the work behind healing of trauma, the first work I look at lays an impressive ground floor for both understanding and treating trauma is Trauma and Recovery by Judith Herman. I will explore in detail how this book lays the ground work for trauma treatment. Then I will look at how these ideas were expanded on in Creating Sanctuary by Sandra Bloom which while clearly influenced by Dr. Herman expands on her ideas in interesting ways. After spending some time going into the works as individuals I will show how they bare or are not used in modern psychological study based on my observations of Danville state. To begin understanding how to treat trauma it is important to have a strong basis. One of the best books for this is found in the pages of Trauma and Recovery. The book attempts to give a very strong overview both as to the causes of trauma, the emotions often experienced by those suffering trauma as well as a potential treatments for this trauma. This book is divided into two sections Traumatic disorders and Stages of Recovery. In the first section Judith Herman gives a chilling account of the different types of trauma as well as how the trauma occurs. The very first section actually points out some of the issues with actually studying the field of trauma and how health care professionals who have looked into this field in the past have been labeled as a sort of pariah by their peers. After this the first part contains four chapters dedicated to explaining what causes the psychological competent of trauma. These chapters are Terror,

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Disconnection, Captivity and Child Abuse. Each of these sections explains how these things help to create the mindset of trauma. After this there is a chapter that explains the failing of the medical system of the time called A New Diagnosis. The chapter on Terror is used to explain that psychological trauma is the injury of those who are viewed as helpless. After going over some of the base views of how powerlessness causes trauma the chapter goes into detail about how this feeling of powerlessness prevails even after the incident causing the psychological trauma. It is broken up into four parts hyper arousal, intrusion, constriction and the dialect of those who have been traumatized. Hyper arousal is the continued excited state that those who have survived trauma, how their bodies are constantly alert for fear that the danger that once threatened them could be around any corner and strike at any time. Intrusion is the continued prevalence of the thought about what exactly happened. This can take many forms from subconscious dreams and aggression, to reliving the seen consciously over and over again sometimes altering the outcome to where the individual conquers, to the need to visit the scene of the victims trauma and confront it to even childrens play which has been altered by their experience and the child is expressing in the only way that they truly know how. Constriction is related to some part of the victim being stunted or contained. This can happen during the trauma itself or after the trauma in the forms like symptom amnesia, of drugs and narcotics in order to disassociate from their traumatic events and the inability to function by them. The dialect of trauma has nothing to do with the speech of those who have been traumatized but instead takes a look at all of the parts prior and explains how long the symptoms of these parts last before going on to describe how even years after people may still feel the terror and rage at their trauma.

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The sections on disconnection focuses on how the victim, despite attachments they had formed earlier in life often have their faith in these connections shaken to the point where they are unsure if they can trust anyone. The chapter then goes onto discuss how social support from the persons who were close to the victim prior to their trauma and the effect of the community at large. Both of these sections detail pretty much the same thing stating that it is these two groups support that will aid or worsen those suffering from trauma. Those support systems and communities that are supportive will greatly aid trauma survivors and may potentially heal some of the damage done by the trauma were as a community that shuns it survivors maybe further exasperating the damage of trauma by further destroying the individuals ability to trust and function in society as a whole. The section on captivity is more than a little terrifying. This section first explains what exactly captivity is and how this often means the victim getting repeatedly traumatized. It then goes onto describe how aside from physically controlling the environment in captivity the aggressor will often seek to psychologically dominate their victim by first dominating the way they physically control the victim such as dictating things like their eating and sleeping schedule. This has two effects of first breaking the individuals autonomy before building a sense of hope and dependence on the captor as their presence may mean a meal or the ability to rest. This is furthered when the captor gives rewards for compliance that maybe confused for affection or seen as necessary for survival. It then goes into greater detail explaining how it is that individuals in captivity may be totally broken and what that exactly means. Throughout the chapter it compares different captivity situations from terrorist holdings to domestic abuse and explains how these things can be achieved in each of these conditions. The chapter then concludes with what exactly to look for those who have been traumatized in this way.

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The next chapter is based on child abuse. In this chapter the type of environment that often are seen with abused children. It then goes onto describe how some children are able to disassociate from the trauma and make it seem like it happened to someone else. Those not able to disassociate form a much more fractured mind and seem to be unable to cope with their situation taking on the thought that they are either evil incarnate as it is their fault there parent is acting this way or that they are the martyr to be offered up for the good of all. Neither of these are very healthy frames of mind to have in a growing child and often damages the child. Then the study goes onto describe how the children then grow into adults with the hope of once they are older being free which more often than not turns out to be untrue as they unable to fully cope on their own due to their adverse environments it also points out that while only a small percentage there are some children who will grow up to be abusers themselves as they view it as normal. The last chapter in the first part of the book is the section that details the medical system of the time and its tendency to blame the victim. It explains that in the past beaten wives were seen as masochistic and her husbands violence being her fault so they focused on treating her masochistic tendencies which took the form of resting her husband and once she was compliant she was viewed as cured. It then went on to call for a new system of describing trauma being necessary before looking towards part two. Part one successfully lays a pretty effective ground work for what exactly causes trauma. Part two is the stages of recovery. These three stages are safety, remembrance and morning and reconnection. Before going into the stages Herman does an excellent job expelling what exactly a healing relationship should be. She explains that the key to recovery from trauma is restoring and individuals faith in themselves as well as empowering the victim to make choices about their life. This

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section then goes on to explain the difficulties that may occur both with patient transference and counter transference. Transference is when the victim either sees the therapist as either in the same league as the perpetrator and just as likely to hurt them and thus do not trust them or as some kind of miracle healer and rescuer that can do no wrong and then they get mad or angry when this ideal is violated. Counter transference is the issue that occurs when therapists begin to share in the trauma of their patients experiencing similar thoughts and feelings to those that they are trying to aid. A therapists faith can be shaken and the therapists need to be aware of this as it can take the form of losing faith in oneself or seeing on self as some kind of divine healer. Neither attitude helps the victim. To avoid this it is described that the contract between the victim and therapist should be clearly defined so as to know what the boundaries are on both sides and sticking to them create the healthiest alliance between caregiver and patient. The first important step to recovering from trauma is safety. This often overlooked step is making sure that the victim is first medically safe and that they are physically fully recovered from their trauma. Then it is important to make sure that they feel safe were they are living both physically and with those they are with. It is very easy to overlook this step either as friends or family of the victim or as a therapist but it is key that the victim has the ability to create safety for themselves even if that means not reporting their crime. Forcing them to or to not report it only makes the trauma worse. It is also important in this stage for the therapist to be available but not overly so, so as to not create a dependence on the therapist from the patients side. Another part of this is helping the victim reestablish healthy living habits and it was suggested that medications be used if called for. The second step is both remembering and mourning the event and the death of who the victim was before the trauma. The way that the remembrance work is that first the therapist works on

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memories before the trauma which tells them who the victim was before the trauma before working on recreating and putting words to the event itself. After this is completed therapist use a variety of methods, such as emotional flooding where the person is exposed to a sort of relieving of the trauma equipped with anti-anxiety techniques as well as a script of what happened in the present tense again and again, over the course of weeks, while being encouraged to allow their emotions to flow. The reason behind this is that by doing so it helps the patient fully accept what has happened and helps them categorize it as another memory. After this has been accomplished its time to mourn for who the victim used to be. Trauma inevitably changes a person in major ways, effectively killing who they were so only in mourning for both what happened and who they used to be will the victim eventually be able to find peace. There are issues with this as sometimes victims refuse to mourn either because it seems too big a task, pride, or the victim fantasies both positive (such as forgiveness fantasies) and negative (such as revenge based fantasies) may hinder the healing of the patients. The final step is Reconnection. This isnt as much with the community as it is with ones self and their new freedom. As stated earlier a key part of trauma is the helplessness the individual feels so when choices are added back into the persons life and it can be intimidating. In this stage the person actually fully takes back control of their lives and of themselves as a major part of this stage is finding peace with ones self as well as reconnecting with the community. There is one last point the Judith Herman makes in this chapter and that is one never truly recovers from trauma but instead are able to focus on living their lives instead of ruminating on their trauma. There is one final chapter to The theories presented by Judith Herman are quite good and I find myself agreeing with them quite a bit. I understood the point of flooding and while I had heard about it before never has it been as clear as to how this method was actually supposed to work then in this

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book. What I somewhat disagreed with was that Dr. Herman seemed to be focused on more large scale traumas such as rape or prolonged child abuse, there was little to know mention of what about people who have suffered what might be society be considered lesser traumas but that still have a unique and lasting impact on the victim such as a bad car accident? This is where Sandra Blooms sanctuary model builds on the ground work laid by Dr. Herman. Blooms model of sanctuary really has no limit to what could be the cause of trauma and in fact spends the first chapter of her book talking about lesser types of trauma such as every day toxic stress and a bad break up. Bloom also focuses more on what societal factors such as loss of justice that may contribute to trauma rather than any specific instance of trauma such as rape. Blooms book also builds on the importance of attachments with a few additions. Whereas Herman just talked about how these attachments maybe disrupted as a result of trauma, Bloom acknowledges attachment theory on the whole, looking at what different types of attachment can mean for adults. Bloom then continues to point out why attachment is important in children and discuss what effect trauma can have on already established attachment The first thing that Bloom outlines to do is to create a safe space. It is the very first thing mentioned in the Creating Sanctuary section of Blooms book Creating Sanctuary in this part of the chapter Bloom outlines that in order to effectively create sanctuary the first thing that was needed was safety. To achieve this Bloom and her team set out to create an environment that was psychologically and socially safe. The final safety Bloom seeks to create is the management of self-destructive behavior of those they are trying to help such as self-mutilation and suicidal tendencies. This is clearly in arrogance with Dr. Hermans idea of safety being the key to being able to effectively create sanctuary.

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In truth most of Dr. Blooms sanctuary model is very similar to the themes suggested by Dr. Herman. She just made it into a community of healing made up of both those injured and those dedicated to their aid. Specifically Dr. Bloom again mentions ideas of reconstructing the trauma and grieving for what was lost as a result of suffering the trauma before attempting to reconnect both internally and with the others in the community. Bloom added several things to this however. This included the idea of changing the idea that the victims needed to blame someone usually those not at all involved. Dr. Bloom also added the idea that the physical damage done is more than just the damage seen at first treatment and made sure that those in the program worked on repairing their bodies as much as possible and making sure that those in the program were healthy. Finally Dr. Bloom made sure to help the people in her program learned how to play again. As Dr. Bloom and her colleagues were constantly living with those they were treating caring for one another became essential. While Dr. Herman makes sure to mention ways for therapists to take care of themselves, Dr. Bloom and her team were at far more risk and as a result more drastic steps were needed to make sure that the crew did not burn out. To do this she mentions how the crew needed to learn to let their guard down with each other just like they encouraged their patients to do. From there they had support groups and worked on sharing their burdens both their own and those they shared with their patients with one another. The final way was being able to maintain their ability to laugh with one another. The really big section that Dr. Bloom added was the last chapter of her book which was all about how to avoid creating trauma in the first place. In this chapter Bloom looked at how popular media such as violent television and games. She then listed several staggering statistics which suggest very heavily

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that society itself works towards the prevalence to trauma. So she then explores how different social issues could be tackled in order to work towards a saner society. Now that Ive explained how the Sanctuary model has built off of the theories discussed by Dr. Herman it would be beneficial to see how these models are actually implemented in practical settings. Based on observations it is clear to me that Danville state hospital does in some ways follow the model set forth by Dr. Herman. First and foremost is their attempt to provide safety for their patients. Several patients have stated that they feel safe in the hospital. As this is the first essential thing in both the sanctuary model and in Dr. Hermans theory it is a definite boon to Danville. Second they have psychologist who clearly care and who seem to have clearly defined boundaries with their patients and that their patients seem to trust. Danville even goes a step further by adhering to some of the principles of the sanctuary model presented by Dr. Bloom. First a lot of patients are living together and while they are not as well screened as they take anyone with any kind of disorder it could potentially have a similar effect. Second there is a gym on sight at Danville that I know patients are encouraged to use in order to stay physically healthy. Finally I know that most of the psychologists tend to get together every Friday night to both bitch about work and to unwind from the week. This is very similar to what Dr. Bloom said that her group did in order to stay sane while helping their patients. That said in a lot of ways Danville does not follow the sanctuary model. While there is a lot of comradely amongst the psychologists I got the feeling that this was the only group that really looked out for one another. Almost every time I was there I either heard about or witnessed some discontent between some of the staff. One way I witnessed this was in the form of either the psychiatrist either talking down to the others or trying, and sometimes succeeding, in making changes that the other staff did not want nor did they understand why he was attempting to make the changes, which lead to some

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resentment of him. Another was that there seemed to be a lot of drama with the nurses both between shifts and on shifts. During most morning reports there was a complaint about how either second or third shift wasnt doing what they were supposed to be doing and trying to hoist their responsibilities onto treatment team or the first shift staff. Then while on shift it was quite common to hear the nurses gossip about either each other or other staff members when those staff members werent around to hear. Whats worse is the relationship that the nurses seemed to have with the patients. It seems like the nurse was good with most of the patients but there was always one or two that each nurse disliked. This caused a problem as often the nurses would antagonize the patients they didnt like which cause problems for their recovery. In two separate instances privileges were denied one patient and another patients release meeting was hindered due to the nurses prejudice. Beyond not being up to the standards of the sanctuary model I would argue that Danville is not even up to the standards as suggested in Dr. Hermans book. The thing that Dr. Herman said that patients need when recovering from trauma is the ability of choice. By and large those at Danville have no choice in anything that they do. Every day they are told what groups to go to, when to eat meals, when to shower and roughly when they should go to bed. They cant even go outside without an out card which is provided to those who have been doing well and been on their best behavior for two weeks. Then it can be just as easily taken away. In some ways this sounds more like captivity then treatment. That said I will be fair to Danville they do have programs that are meant to aid people in adjusting back to the world as a whole but even these seem to be given as rewards to patients who seem to be doing well. While I wouldnt suggest giving every patient a work program right away perhaps it should be easier to obtain rather than requiring an entire treatment teams agreement. It is also worth

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mentioning that not everyone there is a trauma survivor, in fact more are there for non-trauma related illnesses. Even so I do not think these conditions are helpful to anyones recovery and with the amount of people who either have to spend huge amounts of time in the hospital or the large number of those who get discharged just to be brought back does not inspire confidence for whatever model Danville is using to treat its patients. There is still a lot we dont know about how people think and interact. This is especially true when it comes to the treating of those who have suffered trauma either in their past. Instead it is important to continue to build on prior theories. Dr. Herman does a fantastic job of laying the ground work for trauma treatment even though her view of what causes trauma maybe a little narrow. Dr. Bloom then expands on Dr. Hermans work accepting a wider range of things that may cause trauma as well as taking the individual method of treating trauma and adding it to a group setting with a fair amount of success and even goes onto suggest changes that could be made in society to prevent the continued causing of trauma. What is really interesting is to see how Danville State hospital, one of the last mental hospitals uses some of both theories while missing key components of both. Yes they have the community down but it seems to be lacking the community feeling that made the sanctuary model so effective and yes the provide safety but they seem to be missing the enabling of patients choice, even most patients stay there is not by choice but is instead court ordered. It will be interesting to see what the next expansion of trauma treatment is as well as to see how it will be implemented.

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Reference Bloom, S. (2013) Creating Sanctuary: Towards the Evolution of Sane Societies. New York and London: Routledge Taylor and Francis group Herman, J. (1997) Trauma and Recovery: The aftermath of violencefrom domestic abuse to political terror. New York: Basic Books Rivard, J.C., Bloom, S.L., McCorkle, D. Abramovitz, R. (2005) Preliminary results of a study examining the implementation and effects of a trauma recovery framework for youths in residential treatment. Therapeutic Community: The International Journal for Therapeutic and Supportive Organizations 26(1): 83-96.