Rediscovering Hope: Understanding and Working with Survivors of Trauma Susie C. Sympson
My days are phantom days, each one the shadow of a hope; My real life never was begun Nor any of my real deeds done.
Arthur Upson, "Phantom Life"
INTRODUCTION There has been increasing attention focused on the short- and long-term effects of traumatic events on individuals. In recent years, researchers have investigated the psychological sequelae of experiences as diverse as childhood sexual abuse and incest (Briere, 1992; Briere & Runtz, 1993; Brown & Finkelhor, 1986, Finkelhor, 1990), domestic violence (Herman, 1992a,1992b), rape (Foa, 1Lothbaum, R_iggs, & Murdock, 1991), combat exposure (Keane, Zimmering, & Caddell, 1985; Kulka et al., 1990), kidnapping (Terr, 1979; 1983), terrorist attacks (Brooks & McKinlay, 1992; Shalev, 1992), and natural disasters (Green, Lindy, Grace, & Leonard, 1992; Shore, Vollmer, & Tatum, 1989). Despite the recognition that many of those seeking psychotherapy have a history of trauma, few graduate programs offer formal training in this area. Although varieties of treatment modalities are available and effective in treating victims of trauma (e.g., Davidson & van der Kolk, 1996; Gersons & Carlier, 1994; Rothbaum & Foa, 1996; van der Kolk, McFarlane, & van der Hart, 1996), the diverse symptoms and associated problems may benefit from an integrative approach. Regardless of the specific therapeutic techniques employed, the argument will be made in this chapter that effective psychotherapy for survivors of trauma can be conceptualized as precipitating increases in their levels of hope. In this chapter, Handbook of Hope i~
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Posttraumatic Stress Disorder (PTSD), its etiology, symptomatology, course, and appropriate treatment will be viewed within the conceptual framework of hope theory (Snyder, 1994; Snyder, Harris et al., 1991).
POSTTRAUMATIC
STRESS DISORDER
Diagnostic Picture The existence of psychological and physical difficulties following the experience of extreme trauma and stress has been documented for many years (e.g., Archibald & Tuddenham, 1965; Burgess & Holstrom, 1974; Kardiner, 1941; Trimble, 1885). Although stress reactions have long been topics of interest to researchers and clinicians in the fields of mental health, PTSD was not recognized as an official diagnostic category until the publication of the Diagnostic and Statistical Manual (DSM-III) (American Psychiatric Association [APA], 1980). In the latest version of the D S M (IV) (APA, 1994), the essential feature of PTSD is the "development of characteristic symptoms following exposure to an extreme traumatic stressor" (p. 424). In order to diagnose PTSD, all of the following criteria must be met: 1. The person has been exposed to a traumatic event in which he or she 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, that produced intense fear, helplessness, or horror. (Childhood sexual abuse has been specifically included in this criterion.) 2. The traumatic event is persistently reexperienced in recurrent and intrusive distressing recollections or dreams of the event, flashbacks of the event, or intensification of physiological and psychological symptoms when exposed to situations similar to the traumatic event. 3. The person persistently avoids stimuli associated with the event and experiences a numbing of responsiveness to surroundings through dissociation, withdrawal, amnesia for details o f the event, restricted affect, and loss of interest in others and daily life events. 4. The person has persistent symptoms of hyperarousal that were not present prior to the traumatic event. These symptoms include sleep disturbance, irritability, inability to concentrate, hypervigilance to danger in the environment, and an exaggerated startle response. 5. These symptoms must be present for at least one month and must cause significant distress or impairment in social or occupational functioning. The onset of this pattern of symptoms in temporal relation to the initial traumatic event may be immediate or may be delayed for six months or many years. Additionally, symptoms may be acute (with duration less than three months) or chronic (lasting more than three months) and may persist for years. W h e n individuals have
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the same symptom pattern occurring and resolving within four weeks of a trauma, Acute Stress Disorder is diagnosed.
Associated Features and Related P r o b l e m s The D S M - I V (APA, 1994) provides a list of features that are often associated with PTSD, and they include: . . . . Individuals with PTSD may describe painful guilt feelings. . . . Phobic avoidance of situations or activities that [represent] the original trauma may interfere with interpersonal relationships and lead t o . . . conflict or loss of job. The following constellation of symptoms may occur: impaired affect modulation; self-destructive and impulsive behavior; dissociative symptoms; somatic complaints; feelings of ineffectiveness, shame, despair, or hopelessness; feeling permanently damaged and constantly threatened; a loss of previously held beliefs; hostility; social withdrawal; impaired relationships; or a change from.., previous personality characteristics. (p. 425) Individuals with P T S D may be at increased risk for panic disorder, phobias, depression, anxiety, and substance-related disorders as well. It is of little w o n d e r that the individual suffering with P T S D experiences severe distress and substantially impaired functioning in almost every aspect of their life.
Prevalence As with many psychological disorders, it is next to impossible to k n o w exactly h o w many people are afflicted with PTSD. T h e D S M - I V (APA, 1994) estimates a lifetime prevalence for P T S D as ranging from 1 to 14%. General population studies have found that 23% of adolescents and 76% of adults have been exposed to severe traumatic stressors (Briere, 1996; Elliott & Briere, 1995); moreover, from that portion o f adolescents so confronted with profound stressors, over 20% developed PTSD. Prevalence rates ranging as high as 58% have been found w h e n studies have focused on rates in specific at-risk populations. A study by Saxe et al. (1993) found that the majority of psychiatric inpatients have histories o f severe trauma; additionally, at least 15% meet the diagnostic criteria for PTSD. Studies of Vietnam veterans indicate that 15.2% continue to suffer from P T S D m o r e than 20 years after the war (Kulka et al., 1990). O t h e r studies have found that m o r e than half of adolescent and adult prostitutes were sexually abused as children (Briere & 1Kuntz, 1987) and that half of substance abusers have histories of childhood sexual abuse (Bagley & Young, 1989). A study of victims o f the Buffalo Creek D a m collapse in 1972 (Grace, Green, Lindy, & Leonard, 1993) reveals some o f the difficulties associated with assessing the numbers of individuals with PTSD. T h e study originally included 381 victims of the flood, but only 128 (32% o f the original) participants were included in a 14-
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year follow-up. The prevalence rate of PTSD decreased from 42% in 1974 to 28% in 1986. However, it should be noted that those who refused to participate in the follow-up were significantly more distressed in 1972 than those who remained in the study (Grace et al., 1993). This suggests that the number of individuals who met the criteria for a diagnosis of PTSD is actually much higher. While those who suffered the greatest amount of trauma in the beginning were no longer included, the follow-up study revealed delayed onset cases that were not immediately identified at the time of the initial study. It has been suggested that most follow-up studies may have a bias in sampling those with less traumatic experiences (McFarlane & Yehuda, 1996), artificially depressing the actual rates of PTSD. Due to the nature of the avoidance symptoms, it is likely that all studies may share this bias, because those with the worst symptoms may be the most determined to avoid reminders of the trauma. Briere (1992) found research indicating that up to 70% of women who seek psychotherapy or other psychiatric services report histories of childhood sexual abuse. In a study of World War II (WWII) veterans attending an outpatient psychiatry clinic in Australia, 45% were found to have active PTSD (Kidson, Douglas, & Holwill, 1993). O f American W W I I veterans reporting to psychiatric services, 50% met diagnostic criteria for PTSD (Rosen, Fields, Hand, Falsettie, & van Kammen, 1989). W h e n we consider the number of combat veterans from other wars, rape victims, and the many other victims of trauma, it becomes apparent that PTSD is a relatively common psychiatric disorder. Given the numbers affected and the devastating impairment experienced, the need for effective treatment is widespread and crucial.
TRAUMA,
PTSD, A N D D E P L E T I O N
OF HOPE
Although the source of the traumatic event precipitating PTSD can vary widely, due to the necessary constraints of the brevity of this chapter, I will focus on one specific group of individuals: Vietnam combat veterans. It should be noted that while the distinct and personal nature of the individual's trauma is critically important to therapeutic work, many of the principles presented can be applied to survivors of other traumas as well. However, the person's developmental stage when the traumatic event occurs has a major impact on the eventual manifested effects. In general, the younger a person is, the more profound the physiological dysregulation (van der Kolk, 1996a). As explained throughout this book, hope theory (Snyder, 1994; Snyder, Harris et al., 1991; Snyder, Ilardi, Cheavens et al., in press) tenets tap cognitive constructs involving people's perceptions about themselves and goal-related behaviors. This model has two components: agency thoughts and pathways thoughts. Agency thoughts are self-reflective cognitions that people have about their abilities to initiate and maintain movement toward personally important goals. Pathways thoughts
15 Rediscovering Hope: Understanding and Working with Survivors of Trauma 289 are those self-referential beliefs that people have about their abilities to generate one or more viable strategies to attain their goals. Both agency and pathway thoughts are required for an individual to experience hope. Additionally, the pathways and agency components are related, but unique factors that are iterative in nature. Increases in one can spark increases in the other. Hope theory also posits that stress, negative emotions, inability to cope, and functional difficulties are the result of being unable to successfully envision and pursue strategies to a desired goal (Snyder, 1997; Snyder, Irving et al., 1996). In the following section, the development and course of PTSD will be briefly explored in terms of hope theory (Snyder, 1994; Snyder, Harris et al., 1991). Specifically, I will argue that the nature of the experienced extreme trauma dramatically restricts an individual's goals to those involving survival, both psychological and physical. The strategies that are generated toward that goal provide little reward, leading to a loss of agency and a sense of even fewer pathways.
C o m b a t Veterans
Fortunately, the majority of those reading this text will never have to experience the realities of war. Unless you have been in a combat situation, it is impossible to understand the full nature of its impact. Until recently, Hollywood has produced movies that tended to glorify war, glossing over the horrors encountered by those individuals who are thrust into battle. Internalized depictions of war as honorable and just are inadequate and maladaptive as well when the chaotic brutality of combat becomes a reality. In many ways, young male soldiers are put in a situation that is antithetical to all the beliefs and values to which they have been exposed previously. Rather than try to prepare soldiers for the inconceivable, basic training focuses on teaching them to act rather than process what is happening. At the time, this was a very adaptive strategy for survival and corresponds to the natural fight-or-flight response inherent in humans. This natural biological reaction to stress, however, was not meant to be a persistent state and leads to unwanted repercussions over time. Cole and Putnam (1992) proposed that people's core concepts of themselves are primarily defined by their ability to regulate internal states and their behavioral responses to external stressors. Additionally, they posited that lack of development or loss of self-regulation leads to problems with self-definition. These self-definitional problems include a lack of autobiographical memories, a sense of separateness, poorly modulated affect and impulse control, suspiciousness, distrust, lack of intimacy, insecurity, and isolation. Loss of self-regulation can manifest as attentional difficulties and lack of ability to focus on appropriate stimuli. This results in conditioned responses to specific stimuli being generalized to hyperarousal to any intense, yet neutral, stimulus (van der Kolk, 1996a). This lack of stimulus discrimination helps explain why traumatized people lose their ability to use feelings as guides for behavioral responses. [See Bremner, Krystal, Southwick, and Charney (1995) for a
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discussion of stress on memory and van der Kolk (1996a, 1996b, 1996c) for more general physiological reactions to stress.] Instead, arousal leads to fight-or-flight reactions which appear as automatic and immediate responses (van der Kolk, 1996a). Because the goal of the soldier was soon restricted to physical and psychological survival, the strategies to those goals were quickly learned. In their heightened state of arousal, they became aware of every sound and every movement. At times, it may have seemed that nothing they did had any affect on what happened next. Every strategy put forward failed. In addition to having their sense of being able to achieve success thwarted at every turn, they lost their sense of responsibility for outcomes. They were hypervigilant, expecting danger everywhere. As they lost their ability to self-regulate, they began to have difficulty with stimulus discrimination as well. In an attempt to compensate for the constant state of hyperarousal, they shut down through dissociation, emotional numbing, and avoidance (van der Kolk, 1996a). In the midst of death and bloodshed, "it doesn't matter" was a phrase that combat soldiers in Vietnam added to their vocabulary almost immediately. In attempts to self-regulate, many soldiers in Vietnam turned to drugs and alcohol to take the edge off. For many, this continued long after the war ended as symptoms persisted and nightmares and flashbacks refused to let them get on with their lives (Kulka et al., 1990). Survival remained their goal, but now a subgoal became forgetting and alcohol and drugs were seen as the only way to achieve this goal. Although alcohol is effective at dampening PTSD symptomatology for a short time, research has found that cessation of drinking may lead to a rebound effect, with the return of insomnia, nightmares, and traumatic intrusions (Abueg & Fairbank, 1992; Keane, Gerardi, Lyons, & Wolfe, 1988). As they aged, the alcohol stopped working and their bodies began breaking down from the years of abuse. As even the strategy of self-medication began to fail, the sense of agency was depleted further. With little hope left, many of the Vietnam veterans only now are coming in for treatment after years of alcoholism and drug use. For many of these men, after years of failed relationships or social isolation, legal problems, and spotty work histories, turning to the Veterans Administration for help is their last resort. They feel betrayed by the government who sent them to war, a society that ridiculed and despised them on their return, and even themselves. Van der Kolk writes, Traumatized patients are frequently triggered by current sensory and affective stimuli into a reliving of feelings and memories of their past trauma. Being so easily propelled into feeling aroused, anxious, frightened and dissociated, they cannot count on themselves to have a stable presence in the world, and to react consistently to their environment. This inner sense of hatefulness and unpredictability will generally be expressed in social isolation or avoidance of intimate relationships. (1996a, p. 198)
As a group, they are plagued by feelings of guilt, for surviving when their friends did not; and shame, for what they did and what they were unable to do. It is not surprising that more Vietnam veterans have committed suicide since returning from
15 Rediscovering Hope: Understanding and Working with Survivors of Trauma 291 the war than were actually killed in the conflict (Kulka et al., 1990). In two separate studies (Crowson, Frueh, & Snyder, in press; Irving, Telfer, & Blake, 1997), Vietnam veterans with PTSD reported the lowest mean scores on the Hope Scale (Snyder, Harris et al., 1991) relative to any other group previously tested with this instrument. Although this model of hope (Snyder, Harris et al., 1991; Snyder, Ilardi, Cheavens, et al., in press) is proposed as a dispositional trait, it is affected by the events in our lives. If traumatic stress can deplete hope, hope theory proposes a strategy to reclaim it.
HOPE AND PSYCHOTHERAPEUTIC I N T E 1KVEN T I O N S All effective psychotherapeutic interventions share certain common processes. The theory of hope proposed by Snyder (1994) provides a framework for understanding these common factors. Hope theory predicts that appropriate and effective treatments can be formulated and applied from a variety of different psychological perspectives (Snyder, Ilardi, Michael, & Cheavens, 2000). Despite the theoretical underpinnings of particular therapeutic strategies, effective interventions share certain characteristic elements (Snyder, Ilardi, Michael, & Cheavens, in press). In the remainder of this chapter, we will explore the treatment of PTSD in various phases and attempt to explain how movement through these stages can be conceptualized in terms of hope theory. As such, we will be describing the establishment of goaldirected behavior and the generation of the agency and the pathways to reach these goals.
Phases of Therapy
Establishing the Therapeutic Alliance Exposure to traumatic events severely disturbs an individual's sense of safety and ability to trust. Establishing a working relationship and an environment in which the patient can feel safe is a primary concern in any therapeutic endeavor. H o w ever, trusting another person, in this case the therapist, is arguably more difficult for those with PTSD than with any other diagnostic group. It is likely that establishing a therapeutic alliance will require patience and negotiation. It is helpful to spell out the specifics of therapy clearlymrules, boundaries, responsibilities, contracts--in order to unintentionally avoid recreating aspects of the trauma in therapy (Herman, 1992a, 1992b). The client should participate in this exercise, with the therapist helping to formulate appropriate goals for the therapy relationship. Comments aimed at recognizing the client's participation and his or her ability to recognize possible pitfalls in the relationship can provide an initial boost to the sense of agency. The ther-
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apist can self-present as a consultant, collaborating with the client in monitoring where he or she is, what can be tolerated, and how quickly to proceed in addressing the course of various symptoms. For people who have spent a lifetime trying to forget a part of their past, the idea of intentionally accessing the pain, let alone sharing it with another, is very frightening. It is important to introduce the language of goal-directedness early in therapy. This can be an effective approach to finding out which aspects of the PTSD are causing the greatest distress and assuring the client that what you want is what the client wants for himself or herself. Reformulating the goal of forgetting the past into learning how to cope with it is a starting point. Patients need to be told that the trauma always will be a part of their past. They need to see the goal of therapy as accepting the event and learning that they can come to understand the trauma and put it in the past. There are no useful strategies and little if any agency for forgetting, but specific pathways can be generated that will help in coping with what has happened. Perhaps the biggest obstacle encountered is helping the individual see that smaller, less direct subgoals will actually help in arriving at an overall goal, which is often as global as getting better.
Planning a Treatment Strategy Treatment of traumatized individuals must be paced so as to introduce and process important therapeutic material without overwhelming the internal capacities, retraumatizing, or fostering excessive patient avoidance (Briere, 1996). A thorough assessment and understanding of the prevalence of the various symptom clusters is an essential part of formulating an appropriate treatment plan. It also is important to note what the individuals may have tried in the past that has benefited them in some way. The therapist can point out that clients were using pathways to specific goals and praise them for their insights. Different approaches are required during different stages of treatment as well. Understanding the personal meaning of both the trauma and its effects on the individual is required in order to generate specific beneficial pathways. It is helpful to have a wide array of therapeutic strategies from which to draw because what may be helpful at some stages of therapy may be inappropriate and ineffective at others (van der Kolk et al., 1996). Effective treatment proceeds through the following phases: (1) stabilization of physiological and emotional reactions; (2) deconditioning of traumatic memories and responses; (3) restructuring of personal schemas; (4) establishment of secure social connections and interpersonal efficacy; and (5) accumulation of restitutive emotional experiences (Herman, 1992a; van der Kolk et al., 1996). The focus of treatment in the first phase is on mastering and controlling biological and physiological stress reactions. During the second and third phases, the focus shifts to helping the individual process and come to terms with his or her experience of the trauma. Finally, during the fourth and fifth phases of treatment, the focus is on help-
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ing individuals to reengage in their current lives (Turner, McFarlane, & van der Kolk, 1996). In many cases, the process will not be linear. The initial stabilization phase may need to be repeated often as the individual moves through different levels of processing each particular event. Often, as new details are remembered, the entire process begins over, moving through each phase until that aspect of the trauma is incorporated by the individual.
PHASES OF TREATMENT In the following sections, a more detailed discussion of each of these phases of treatment will be presented.
Phase 1: Stabilization
During this initial phase, the focus is on overcoming the intense fear and resulting defensive reactions that accompany trauma-related emotions (van der Kolk et al., 1996). Each element of the symptom pattern can be addressed as individual and measurable goals, with multiple pathways to each. Referral to a psychiatrist for psychopharmacological management is often an essential aspect of the stabilization phase. Lowering autonomic arousal may decrease nightmares and flashbacks and allow patients to sleep. I have been told by patients who started treatment that they had the first good night's sleep since Vietnam after starting in a program. The initial sense o f relief and triumph represents increases in their sense of a g e n c y m a t last, there seemed to be some hope. Any improvement in any area of functioning serves to energize individuals by sparking a sense of agency and the real possibility that pathways exist to a solution. Antidepressants are effective in improving attention and concentration levels and in decreasing ruminative thoughts (van der Kolk et al., 1996). While medication may provide some initial help, however, it is not enough by itself. Psychoeducation about the nature of PTSD and the associated symptomatology helps alleviate the patients' fears that they are going crazy. Giving a name for what they are experiencing provides a framework for understanding their reactions, as well as a belief that some relief is possible. Education about and instruction in specific techniques to control dissociation, identify and label emotions, learn to relax, recognize somatic states, and control anger are valuable and measurable pathways. Because agency and pathways are iterative in nature, each success leads to increases in both. Helping patients learn to name feelings provides a "subjective sense of mastery and a mental flexibility that facilitates comparison with other emotions and other situations" (van der Kolk et al., 1996, p. 427). This sense of mastery, with elevated agency, prompts patients to envision new pathways that lead to goals.
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Phase 2: Deconditioning Traumatic Memories and Responses For a majority of Vietnam veterans and many others with severe PTSD, the idea of examining the trauma is terrifying. They often have tried for years to escape the intrusive memories and flashbacks, the intense emotional reactions, the sights, the sounds, and even the smells. For them, the trauma is not in the past, but rather a constant replay of events in the present. In attempts to understand this experience, many researchers have offered theories as to how and why this occurs. It is thought that intense arousal and the concomitant oversecretion of hormones interferes with information processing and the storage of information in narrative, or explicit, memory. The failure of explicit memory leaves the traumatized person without words to describe what happened. In his state of speechless terror, unable to produce a coherent narrative, the implicit memory is activated. The traumatic memories are dissociated from consciousness and become stored as sensory perceptions, obsessional ruminations, or behavioral reenactments (van der Kolk, 1996c). Recent neuroimaging studies support this. During provocation of traumatic memories, individuals with PTSD showed decreases in activity in Broca's area, the part of the brain thought to be responsible for transforming subjective experience into speech (Rauch, van der Kolk, Fisler, & Alport et al., 1996). At the same time, increased activity was observed in areas in the right hemisphere thought to be responsible for processing intense emotions and visual images (van der Kolk, 1996c). The increased arousal associated with PTSD can trigger these trauma-related memories. In turn, it is likely that this reliving of traumatic events in flashbacks and nightmares causes the stress hormones to be released again, creating a kindling effect which strengthens the memory trace (van der Kolk, 1996a). Prior to beginning this stage of therapy, the patient must feel safe and report relative stability outside the session. Education about the rationale behind deconditioning is effective in that it helps to instill agency in the efficacy of the work required. Patients have been dealing with the pain of these vivid memories for years; they generally are willing to undergo the process again, with someone else, if they feel they are safe. Again, the hardest part may be convincing them to have this goal; they will access the agency and the pathways with the therapist's assistance. Learning to tolerate the memories of intense emotional experiences is a critical aspect of recovery (van der Kolk et al., 1996). Treatment consists of helping a person find ways to acknowledge the reality of what has happened without reexperiencing the trauma again. Merely uncovering the memories in not enough, however; they need to be modified and transformed by being placed in the proper context and integrated into a meaningful narrative (van der Kolk et al., 1996). All the fragmented pieces of implicit memory must be reconstructed into an explicit autobiographical memory. By understanding the nature of the trauma, the therapist can support and aid patients through this painful process (1) by staying with
15 Rediscovering Hope: Understanding and Working with Survivors of Trauma 295 them through the suffering, (2) by labeling the suffering as meaningful and bearable, and (3) by helping them master the trauma by encouraging them to put the experience into a symbolic, communicable form (van der Kolk et al., 1996b). Controlled exposure to the traumatic memories can reactivate and modify the intensely emotional experience. Regardless of the method employed, two conditions are essential for effective treatment (Foa & Kozak, 1985; 1Lothbaum & Foa, 1996). First, the trauma-related information must activate the patients' own traumatic memories. In order to be modified, the affects associated with the initial trauma must be experienced. The decrease in fear and anxiety is thought to be dependent upon the controlled and coordinated evocation of the stimulus components, the physiological response components, and the meaning elements, including emotional components, of the traumatic memory (Foa & Rothbaum, 1989). Second, new information that is inconsistent with the original memory must be provided in order to form a new, nontraumatic structure (Rothbaum & Foa, 1996). Without the necessary transformation, the sense of agency actually can be depleted by reinforcing the person's feelings of incompetence and inability to effect change. There are many approaches to this end, including imaginal flooding, systematic desensitization, stress inoculation training, implosion therapy, hypnotherapy, eye movement desensitization and reprocessing, alpha-theta EEG biofeedback, and psychodynamic therapy. Although this is a critical step in helping someone cope with intrusive memories, it is important to recognize the dangers involved with this approach. Small steps must be seen as the goal, and the pathways should be direct and facilitate the recognition of movement toward the goal. Each goal achieved will impact on agency thoughts and act as a catalyst for the setting of larger goals, as well as facilitate the generation of identified pathways. It is important that the therapist does not allow clients to set themselves up to fail. Some individuals, especially those with active thought disorders or serious suicidal ideations, are likely to decompensate and experience serious adverse reactions. Timing is critical, with special attention paid to the persons' ongoing capacities to tolerate the process. Careful attention to providing appropriate replacement information can initiate movement into the next phase of treatment, restructuring beliefs about the self and the trauma.
Phase 3: Restructuring Personal Schemes Throughout our lives we organize our experiences and conceptions of the self and of the world into cognitive schemes that allow us to function without being overwhelmed by our stimulus-filled world. These schemes help to assimilate and accommodate new information and experiences. When experiencing trauma, the person's view of the world, the self, and others may be seriously altered to reflect the event. Ideas such as "I am helpless," "I deserve to be punished," or "the world is a horri-
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ble place" may dominate every aspect of daily life. It is important to pay special attention to how trauma has affected people's sense of self-worth and self-efficacy, their capacity for trust and intimacy, their ability to feel empathy, and their ability to meet their personal needs (Herman, 1992b).
Phase 4: Establishing Social Connections and Interpersonal Efficacy The final focus in therapy with traumatized individuals is helping them to reintegrate with others and society. It generally is accepted that perceived social support relates positively to increased levels of psychological functioning and overall wellbeing. In a previous study, perceived social support was significantly correlated with higher levels of hope in those with PTSD (Irving et al., 1997). Yet most individuals with PTSD generally have few social connections and often experience strained relations with family members. As patients learn to self-regulate their internal physiological and emotional states, they become more willing to interact with others because they have less fear of their own unpredictability. Their ability to process the trauma and restructure related cognitions about the world and themselves also opens the real possibility that they can have meaningful relationships with others without risking too much of themselves. They have regained a sense of control of their lives and the belief that they are effective agents in their own futures. The iterative benefits of the increased pathways feelings and the increased sense of agency have prepared them to broaden their goals. There has been a lot written about the benefits of group therapy with trauma survivors (Briere, 1996; Herman, 1992a, 1992b; Parsons, 1985). The group can provide a sense of community because the members share an understanding of what it is like to survive a traumatic experience. Members learn that they are not alone, and often, secure bonds are formed in a short period of time. The group provides a forum to explore issues of safety and trust without fear of rejection or danger. This helps decrease stigmatization, lessen feelings of isolation, and reduce shame (Briere, 1996). Additionally, being in a group provides additional pathways when the members discuss strategies that have helped them to deal with issues they share. Members in a group also provide support and assistance to others. This increases their feelings of agency and improves self-esteem (Briere, 1996). Regardless of the structure of the group or the varying degrees of emphasis on stabilization, processing of trauma, bonding, or interpersonal support, aH traumarelated groups share certain goals. Effective groups help members stabilize trauma reactions, explore and validate emotions, understand the effects that trauma has on current affects and behaviors, and learn new strategies for coping with interpersonal relationships (van der Kolk et al., 1996). What members learn in the group also can be gradually extended to other situations outside the therapeutic arena.
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Phase 5: Accumulation o f Restitutive Emotional Experiences In many ways, the final phase of therapy is an extension of those that came before. As the individual is no longer consumed with avoiding reactions to the traumatic memories, he or she begins to have time and energy to focus on living. Developing a social network provides many more avenues to grow and experience new activities and interests. Often, the patient will discover gratifying opportunities that act as reparations for past injuries (van der Kolk et al., 1996). As mastery gains occur in a variety of areas, the person can generate more goals, along with the necessary strategies to attain them.
CONCLUSION As noted previously, traumatic stress can have devastating and far-reaching effects. Exposure to trauma, especially ongoing trauma, alters individuals on a biological and physiological level, on an emotional level, on a cognitive level, and on a characterological level. This chapter has attempted to offer hope theory as a framework for understanding how human responses to a traumatic event can lead to the development of PTSD and the accompanying problems associated with this clinical picture. Although victims of PTSD provide immense challenges to psychotherapists and other mental health workers, working with this population also offers tremendous rewards. W h e n persons have lost hope, they have little else. Any improvements that are attained can stimulate the process of reclaiming hope. The ability to see the future returns, and with that, meaningful personal goals and the belief in one's ability to attain these goals as well as the strategies for doing so. Granted, it sometimes is a long road to travel to see a glimmer of light; the steps also may be slow and cumbersome, but the trip is worth the effort for those who are willing to take the first step.
ACKNOWLEDGMENT The author wishes to thank Peggy Kennerley and Christine Gerety for their comments on an earlier draft of this manuscript.
REFERENCES Abueg, E R., & Fairbank, J. A. (1992). Behavioral treatment of posttraumatic stress disorder and cooccurring substance abuse. In P. A. Saigh (Ed.), Posttraumatic stress disorder: A behavioral approach to assessment and treatment (pp.111-146). Boston: Allyn & Bacon.
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