Trauma Through the Life Cycle

O R I G I N A L P A P E R

Trauma Through the Life Cycle: A Review of Current Literature

Shulamith Lala Ashenberg Straussner •

Alexandrea Josephine Calnan

Published online: 31 May 2014

� Springer Science+Business Media New York 2014

Abstract This paper provides an overview of common

traumatic events and responses, with a specific focus on the

life cycle. It identifies selected ‘‘large T’’ and ‘‘micro’’

traumas encountered during childhood, adulthood and late

life, and the concept of resilience. It also identifies the

differences in traumatic events and reactions experienced

by men compared to women, those related to the experi-

ence of immigration, and cross generational transmission

of trauma. Descriptions of empirically-supported treatment

approaches of traumatized individuals at the different

stages of the life cycle are offered.

Keywords PTSD � Large-T and micro-traumas � Neurobiology � Gender differences � Immigrants � Treatment approaches

The past is never dead. It’s not even past.

William Faulkner

The conflict between the will to deny horrible events and the will to

proclaim them aloud is the central dialectic of psychological trauma.

Judith Lewis Herman

Introduction

As recognized by William Faulkner and Judith Herman, as

well as by many other writers and mental health profes-

sionals, trauma can take a tremendous psychological toll

that may not disappear even with the passage of time. The

term ‘‘trauma’’ comes from the Greek language meaning a

‘‘wound’’ or ‘‘hurt’’ (Oxford Dictionaries, 2013). Psycho-

logically, ‘‘trauma’’ refers to an experience that is emo-

tionally painful, distressful, or shocking, and one that often

has long-term negative mental and physical (including

neurological) consequence. An event is thought to produce

a traumatic response when the stress resulting from that

event overwhelms the individual’s psychological ability to

cope (McGinley and Varchevker 2013).

Although we often think of trauma as being synonymous

with the identified objective cause of the trauma, such as a

soldier losing his legs to a roadside bomb explosion, the

effect of the trauma is always subjective and refers to the

impact—the perceived ‘‘wound’’ or ‘‘hurt’’ as identified by

the early Greeks—that it has on the individual (Miller 2004).

Thus what might be a traumatizing, life-shattering event for

one individual might have minimal effects on another. Such

differential reaction is based on many factors, including the

individual’s age, gender identity, pre-morbid ego strength,

previous traumatic experiences, the chronicity of the trauma,

family history of trauma, current life stressors, social sup-

ports, and one’s cultural, religious or spiritual attitude

toward adversity (Amir and Lev-Wiesel, 2003; Brewin et al.

2000; Felitti et al. 1998; Foa et al. 2009; Stamm and

Friedman 2000; Straussner and Phillips 2004a).

Unfortunately, the experience of trauma is not uncommon.

Although there is a lack of recent national epidemiological

findings about trauma among adults [Centers for Disease

Control and Prevention (CDC) 2006], studies during the

S. L. A. Straussner (&) Silver School of Social Work, New York University,

1 Washington Sq. North, New York, NY 10003, USA

e-mail: sls1@nyu.edu

A. J. Calnan

Howard Center, 1 So. Prospect Street, Burlington,

VT 05401, USA

e-mail: ajcalnan@gmail.com

123

Clin Soc Work J (2014) 42:323–335

DOI 10.1007/s10615-014-0496-z

1990s found that over 60 % of men and 51 % of women in the

United States report having experienced at least one traumatic

event during their lifetime (Giaconia et al. 1995; Kessler et al.

1995). Traumatic stress can cause disorganization of thinking,

awareness, impaired judgment, altered reaction time, hyper

vigilance, and unhelpful attempts at coping. While most

people will experience time limited reactions, such as acute

stress disorder, a smaller percentage may continue to manifest

more severe and often longer lasting trauma-related impacts.

These may include panic disorders, depression, sleep disor-

ders, substance use disorders, as well as post-traumatic stress

disorder (PTSD) (Kessler et al. 1995; Leskin and Sheikh

2002; Ringel and Brandell 2012).

While trauma can impact an individual at any time in the

life cycle, from pre-natal development through old age, the

impact and the treatment approaches vary depending on the

individual’s developmental needs and the psychosocial

environment. The purpose of this article is to provide an

overview of common traumatic events and responses with

a specific focus on the life cycle—identifying selected

traumas encountered during childhood and adolescences,

adulthood and late life. The differential impact of trauma

on men and women, on immigrants, transgenerational

transmission of trauma, the concept of resilience, and the

implications for the treatment of traumatized individuals at

the different stages of the life cycle are identified.

Nature of Trauma: ‘‘Large T’’ and ‘‘Micro-Traumas’’

There are many different kinds of traumas, ranging from

what Francine Shapiro, the originator of Eye Movement

Desensitization and Reprocessing (EMDR) treatment

approach (Shapiro 1995) has termed ‘‘large- T’’ traumas to

‘‘small- t’’ or, what Straussner (2012) refers to as ‘‘micro-

traumas.’’ Large-T traumas can impact individuals, fami-

lies, groups and communities and include natural disasters,

such as hurricanes, floods, wildfires, or nuclear disasters, as

well as human-caused disasters, such as deadly car acci-

dents, individual and mass violence, and other one-time

traumatic events. Large-T traumas can also include, what

Judith Herman (1997) termed as ‘‘complex traumas,’’ and

which others refer to as Complex Traumas and Disorders of

Extreme Stress (DESNOS- disorders of extreme stress not

otherwise specified)—traumas that involve events of pro-

longed duration or multiple traumatic events (van der Kolk,

Roth, Pelcovitz, Sunday and Spinazzola, 2005). Examples

of complex, large-T traumas [also referred to as Type II

trauma by Terr (1991)], include on-going interpersonal

violence, child physical or sexual abuse spanning several

years, never-ending wars, or constant acts of terrorism.

Small-t or micro-traumas are the more common traumas

encountered by many of us. While large-T traumas are

easily identified, many micro-traumas, such as being bul-

lied in school or in the workplace (Idsoe et al. 2012;

Mishna 2012), being stalked by someone (Purcell et al.

2005), living in severe poverty (Kiser 2007), childbirth

(Kendall-Tackett 2013), or being the recipient of on-going

individual discrimination because of one’s race, religion,

gender identity, or sexual orientation, often go unrecog-

nized and unacknowledged. Yet these micro-traumas may

still cause much psychic pain and life-long damage.

Exposure to and Impact of Trauma

In her classic book Shattered assumptions: Towards a new

psychology of trauma, Janof-Bulman (1992) reflects on the

psychological shattering of one’s worldview experienced

by traumatized individuals, especially if the trauma is

caused through deliberate human acts (Straussner and

Phillips 2004a). Whereas the world was previously viewed

as being trustworthy and benevolent, this belief may

become transformed into the sense that ‘‘people will hurt

me, and I can’t trust anyone.’’ Additionally, trauma sur-

vivors might find that the world they used to perceive as

being stable and predictable, now seems unpredictable and

out of their control. Consequently, their previous sense of

empowerment and of being in control of their environment

and their lives gives way to one in which they feel dis-

empowered, helpless, and unable to predict and plan for the

future. They may even have a sense of being psychologi-

cally damaged and defective (Janof-Bulman 1992).

The idea that trauma could result in specific clusters of

symptoms first became formalized by the inclusion of the

diagnosis of PTSD in the third edition of the Diagnostic and

Statistical Manual of Mental Disorders [DSM; American

Psychiatric Association (APA) 1980]. This new diagnostic

category was precipitated by awareness of the psychological

problems experienced by returning Vietnam War veterans in

the late 1970s and the growing literature by European

writers who survived their own traumatic experiences dur-

ing the Second World War—such as Gunter Grass, Primo

Levy, and Eli Wiesel among others—and who vividly

described the profound impact of mass violence on indi-

viduals, families and communities (Straussner and Phillips

2004a). Studies of survivors of the Nazi-caused Holocaust

(Krystal and Niederland 1968) and of the Hiroshima atomic

bombing by the United States (Lifton 1968), introduced the

concept of ‘‘survivors’ guilt’’ into our vocabulary.

The more recent recognition that traumatic reactions can

result from response to events other than war, such as

sexual assault, exposure to child abuse, domestic violence,

and accidents has made PTSD a widely recognized disor-

der throughout the world (Herman 1997; van der Kolk et al.

2005). The importance of PTSD as a diagnostic category is

324 Clin Soc Work J (2014) 42:323–335

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reflected in the newly revised DSM-5 (APA, 2013), where

PTSD and related conditions are no longer listed under

Anxiety Disorders or Adjustment Disorders as previously,

but are located in a separate chapter titled ‘‘Trauma- and

Stressors-Related Disorders.’’

While the experience of trauma is common, PTSD

diagnosis is relatively rare. The estimated lifetime preva-

lence rate of PTSD in the US is thought to range between 6

and 12 %, averaging around 9 % of the population (APA

2013; Breslau et al. 1991; Kessler et al. 1995; Resnick et al.

1993). However, the initial prevalence rates among active

duty military exposed to war conditions and among survi-

vors of mass trauma, such as the September 11, 2001 World

Trade Centers in New York, can range as high as 30 % and

more (Galea et al. 2005; Susser et al. 2002). According to the

latest edition of the DSM, the ‘‘[h]ighest rates (ranging from

one-third to more than one-half of those exposed) are found

among survivors of rape, military combat and captivity, and

ethnically or politically motivated internment and geno-

cide’’ (APA2013, p. 276). Recent United States- based

studies document higher rates of PTSD among African-

Americans, Latinos and American Indians than among white

or Asian populations (APA 2013). International annual

prevalence rates are believed to be somewhat lower than

those in the US (APA 2013; Landolt et al. 2013), although

studies in areas with on-going conflict, such as in Israel and

the Palestinian territories, point to rates that are similar to

those in the US among individuals who have been or are still

exposed to combat (Dimitry 2011; Gelkopf et al. 2008;

Solomon et al. 1996).

As pointed out earlier, trauma has a differential impact

depending on age, gender, and psychosocial factors, which

are discussed below.

Trauma and Children

As is recognized in the new Diagnostic and Statistical

Manual (DSM-5; APA 2013), while trauma has a profound

impact on all individuals, its impact on young children is

unique and particularly pernicious. Millions of children

throughout the world are currently growing up amidst

traumatic environments—they are being sexually and

physically abused at home, bullied at school, and trauma-

tized in their communities (Finkelhor et al. 2009). Many

lack adequate food and shelter, and some live in unsafe

communities and war zones witnessing violence occurring

to friends and family, including rape, torture and murder.

Numerous studies have shown evidence of long term

repercussions of exposure to violence at an early age (Anda

et al. 2006; Steele 2004). The implications of exposure to

trauma are now believed to have an effect on the infant

even before birth. A more detailed discussion of the impact

of trauma on children follows, starting with prenatal

impact.

Prenatal Impact

Preliminary research shows that children are impacted even

before birth by trauma that is experienced by their mothers.

Studies in New York City comparing pregnant women who

were close to Twin Towers on September 11 and suffered

‘‘post traumatic stress syndrome’’ (PTSS) with pregnant

women who were in different locations, found that new-

borns of mothers manifesting PTSS had significant smaller

head circumference at birth (Engel et al. 2005). As we

know, decrements in head circumference influence sub-

sequent neurocognitive development. More recent studies,

using modern technologies such as Functional MRI, reveal

that fetal exposure to maternal stress is significantly asso-

ciated with a variety of impacts on brain activity, endocrine

function, and on autonomic nervous system function

(Sandman and Davis 2012). While these studies have small

sample sizes and need to be validated further, we are rec-

ognizing that it is not enough to assess, when appropriate,

whether a child was born prematurely or not, or whether

the mother was malnourished during pregnancy, but also

whether she was being abused by her husband or partner, or

lived in a violent community or a war zone during her

pregnancy, and how this may be related to the some of the

problems exhibited by her children (Lieberman and Van

Horn 2008; Pine and Cohen 2002). It is also worth noting

that the biophysiological impact of paternal trauma on the

fetus and newborn child has yet to be considered as worth

studying, even though there is growing evidence that

spontaneous changes in genetic makeup in the sperms of

fathers impacts on the mental health of their children

(Kandel 2013). Whether paternal trauma impacts the

sperm, and thus the child, needs to be researched in the

future.

Impact on Young Children and Adolescents

The impact of trauma on the brain of traumatized children

continues after birth and even during adolescence and

young adulthood, as evidenced by recent studies suggesting

that the brain continues its development until age 25

(Cicchetti and Curtis 2006; Giedd 2008). Trauma, partic-

ularly complex or ongoing trauma in early life, affects

brain development, especially the development of right

hemispheric brain functions, which include among other

things, regulation of mood and social adjustment. More-

over, ‘‘[n]europsychological studies suggest an association

between child abuse and deficits in IQ, memory, working

memory, attention, response inhibition, and emotion dis-

crimination. Structural neuroimaging studies provide

Clin Soc Work J (2014) 42:323–335 325

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evidence for deficits in brain volume, gray and white

matter of several regions, most prominently the … pre- frontal cortex but also hippocampus, amygdala, and corpus

callosum (CC). Diffusion tensor imaging (DTI) studies

show evidence for deficits in structural interregional con-

nectivity between these areas, suggesting neural network

abnormalities’’ (Hart and Rubia 2012 p. 52). While the

authors acknowledge the limitations of such studies, par-

ticularly the lack of control for co-morbid psychiatric dis-

orders, which make it difficult to disentangle which of the

above effects are due to maltreatment, other researchers

have found that even indirect exposure to trauma, such as

witnessing family or community gang violence, plays an

important role in altering brain mechanisms involved in the

processing of emotions and may predispose children to

problems managing strong emotions and difficulty with

emotional regulation. Such children appear to experience

changes in stress hormonal regulatory systems and neural

patterns that are associated with heightened emotional

reactivity as well as weakened emotional resiliency,

increasing their vulnerability to problematic behaviors,

future traumas, as well as their own potential for violence

(Grasso et al. 2013; Heide and Soloman 2006).

Data from the well regarded Adverse Childhood Expe-

riences (ACE) study (Felitti et al. 1998) suggests that ACEs

are ‘‘related to a greater likelihood of developing a variety

of behavioral, health, and mental health problems, includ-

ing smoking, multiple sexual partners, heart disease, can-

cer, lung disease, liver disease, sexually transmitted

diseases, substance abuse, depression, and suicide

attempts’’ (Lu et al. 2008 p. 1018).

Various authors have identified other negative conse-

quences resulting from exposure to trauma during early

life:

• Preschool children are likely to exhibit passive reac- tions and regressive symptoms, such as enuresis,

decreased verbalizations and clinging behavior, indic-

ative of anxious attachment (APA 2013; Lieberman and

Van Horn 2008; Steele 2004).

• School age children may display both more aggression and more inhibition. They also develop somatic com-

plaints, depression, sleep disturbance, cognitive distor-

tions and learning difficulties manifested by impaired

concentration and memory problems (Steele 2004; Terr

1991).

• Adolescents exposed to trauma tend to respond by acting-out and self–destructive behavior: substance

abuse, promiscuity, delinquent behavior, and life-

threatening reenactments of violent episodes (APA

2013; Bava and Tapert 2010; Brent and Silverstein

2013; Garbarino et al. 1992; Pat-Horenczyk et al.

2007).

• Children and adolescents who witness the death of close friends or family members may experience

survivor guilt (Herman 1997; Steele 2004).

• Like many traumatized adults, children may exhibit classic symptoms of PTSD without any understanding

of what is going on with them (Derluyn et al. 2004).

• Some children exposed to severe trauma may not show many of the classical trauma symptoms until later in

life, reflecting the new DSM-5 specifier of ‘‘delayed

expression’’ (APA 2013).

• Children may exhibit traumatic bonding reflecting maladaptive attachment as well as inappropriate

modeling of the behaviors of their abusers (a behavior

also seen in adults and known as ‘‘identification with

the aggressor’’ or ‘‘the Stockholm syndrome’’) (Cohen

et al. 2006; Derluyn et al. 2004; Weierstall et al. 2012).

• Studies show that almost 100 % of those witnessing the murder or the sexual assault of a parent, and 35 % of

urban youth exposed to community violence develop

PTSD, although some of these highly traumatized

children are more resilient than others (Derluyn et al.

2004; Garbarino et al. 1992; Malmquist 1986).

These young people with a history of, or current trauma

need to be identified and treated in order to prevent life-

long physiological, cognitive, emotional, behavioral, and

social sequelae of their traumas (Anda et al. 2006).

Impact of Trauma on Adults

Ever since the tragedy of September 11, 2001 much has

been researched and written about the impact of trauma on

adults, especially in the United States. A exploration of the

literature finds a variety of specialized journals devoted to

this topic (to wit: Journal of Trauma Practice, Journal of

Loss and Trauma, Journal of Traumatic Stress, Trauma-

tology, International Journal of Emergency Mental Health,

Journal on Rehabilitation of Torture Victims and Preven-

tion of Torture, among others), as well as various textbooks

aimed at different health professions, including social work

(e.g., Courtois and Ford 2009; Foa et al. 2009; Ringel and

Brandell 2012; Straussner and Phillips 2004b, etc.). What

we would like to emphasize in this article are some of the

lesser known factors effecting millions of adults by

focusing on gender differences 1

and the impact of trauma

on immigrants and refugees.

1 While this article discusses the available research focusing on

trauma among individuals with traditional gender identities, the

authors recognize that transgender individuals experience dispropor-

tionate levels of trauma. Since a comprehensive discussion on this

topic is beyond the scope of this paper, readers are referred to Mizock

and Lewis (2008) for further information.

326 Clin Soc Work J (2014) 42:323–335

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Gender and Trauma: What Do We Know?

Studies have found that men and women experience

trauma in very different ways with somewhat different

consequences. For instance, while men are much more

likely to experience trauma, women are more likely to

develop PTSD (APA 2013): for every traumatized man,

three women have a lifetime prevalence rate of PTSD

(Foa et al. 2009). Moreover, men are two times as likely

as women to experience trauma due to physical assault,

yet women are fifteen times more likely to develop PTSD

as a result [World Health Organization (WHO), 2011a].

While there are a variety of hypothesized explanations for

these findings, ranging from the fact that women are more

likely to seek professional help than men to possible

neurobiological and hormonal differences, to women’s

greater exposure to intrusive interpersonal violence (Hien

et al. 2009), there is a lack of conclusive studies

explaining these findings. Moreover, it appears that for

men the most common factors associated with a diagnosis

of PTSD are: rape, combat exposure, childhood neglect,

and childhood physical abuse, while women are most

likely be diagnosed with PTSD that is associated with

sexual molestation, physical attack, being threatened with

a weapon, and childhood physical abuse (Janof-Bulman

1992). These differences are particularly noteworthy

among young adults. Recent data on military veterans

show that over 15 % of US women veterans returning

from the wars in Afghanistan and Iraq report being sex-

ually traumatized in the military compared to .7 % of the

men (Kimerling et al. 2010; Risen 2012).

Violence against women seems to be a growing world-

wide pandemic. According to Key Facts Regarding Inti-

mate Partner and Sexual Violence Against Women in the

World, published by the World Health Organization (WHO

2011a):

• Violence against women is a major public health problem and violation of women’s human rights.

Approximately 20 % of women report being victims

of sexual violence as children.

• The WHO multi-country study found that between 15 and 70 % of women reported experiencing physical

and/or sexual violence by an intimate partner at some

point in their lives, ranging from the extremely high

rate of 70 % of women in Ethiopia and Peru to a low

rate of 15 % among women in Japan.

• First sexual experience for many women is reported as forced, with 40 % of young women in South Africa

having such an experience. Such violence results in

physical, mental, sexual, and reproductive health prob-

lems, and may increase the vulnerability of women to

HIV/AIDS.

• Population-based studies of relationship violence among young people (i.e., ‘‘dating violence’’ or ‘‘date

rape’’) show that it affects a substantial proportion of

youth throughout the world. Moreover, worldwide, 1 in

2 female murder victims are killed by their male

partners, often during an ongoing, abusive relationship.

• Finally, situations of political conflict, post conflict and displacement may exacerbate existing violence and

present new forms of violence against women.

Trauma and Immigration/Migration

In 2010, some 214 million people—3 % of the world’s

population—lived outside of their country of origin (Ba-

talova and Lee 2012). While many people migrate for

positive reasons, the so called pull factors –to seek better

education or jobs, to reunite with family, and so on—more

and more people today move for negative reasons, or push

factors, i.e. they are being pushed from their home com-

munities due to natural disasters, economic situations, or

local conflicts and wars (Castex 2006). Worldwide, there

are currently over 15 million refugees uprooted from their

home countries, the highest number since the 1990s

Rwandan genocide (McClelland 2014). For many of these

individuals, trauma is compounded by grief over loss—loss

of family members and friends, loss of homes, neighbor-

hoods, language, and even familiar smells. Cultural

anchors, such as local religious and educational institu-

tions, familiar medicines, native healers and/or known

medical and psychological treatment approaches are

missing. For many, particular political refugees and those

with undocumented status, migration itself becomes trau-

matic with numerous obstacles along the way and an

uncertain future. For some, prejudice and discrimination,

lack of recognition of previously achieved economic and

personal status (the micro-traumas) compound the reac-

tions. For those whose migration status is undocumented or

illegal, seeking or obtaining help for their big T, much less

their micro-traumas is often impossible; thus their trauma

may remain unresolved and may carry over to the next

generation.

The dynamics of intergenerational transmission of

trauma was first identified in studies of adult children of

Holocaust survivors (Danieli 1998; Yehuda et al. 2001).

The growing attention in the US on what is being termed

‘‘historical trauma’’, relating mainly to Native American

populations (Heart 1999), and ‘‘Post Traumatic Slave

Syndrome’’ (DeGruy Leary 2006), which focuses on the

consequences of slavery on African Americans, point to the

increasing recognition and need to address the psycholog-

ical, social, political, and cultural impact of widespread

trauma over time. A study by Mollica et al. (1998) found

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that in a group of Cambodian survivors the impact of

trauma remains decades after the original experience and

that mental health symptoms may increase when individ-

uals experience additional traumas, findings that were

confirmed by other researchers studying refugee popula-

tions from different parts of the world (Bogic et al. 2012;

Steel et al. 2002). Thus, the frequency of traumatic events

(multiple traumatic exposures) is an important predictor of

long term mental health outcomes, especially for trauma-

tized refugee populations.

Trauma and Older Adults

The finding that cumulative trauma is more likely to

increase the risk of poor psychiatric outcomes is of par-

ticular relevance to aging populations. The global popula-

tion of people aged 60 years and older is expected to reach

about 1.2 billion in 2025, more than doubling in the last

30 years (WHO 2011b). As the world’s population ages,

the special issues of trauma among the elderly need to be

recognized more widely. The concept of ‘‘cumulative life

stressors’’ is well known in the psychosocial literature

(Dohrenwend 1998), and ‘‘cumulative trauma’’ is seen as

reflecting multiple traumas experienced by an individual in

multiple situations (Landau and Litwin 2000; Mollica et al.

1998). Thus the older an individual, the more likely he or

she is to have been exposed to a variety of traumatic sit-

uations, and the more frequent exposure to life-threatening

events has been associated with a lower capability to

handling stress and higher risks of PTSD (Brandler 2004;

Ursano et al. 1995). Moreover, the elderly are at a greater

risk for psychological distress post- disaster than middle

aged adults due to a greater risk for bodily injury, loss of

resources, and lack of social networks or supports (Mar-

sella 2008; Ursano et al. 1995). These issues play an even

greater role among disabled older adults who are dependent

on others for both physical as well as emotional support.

While the elderly may suffer trauma from the same

sources as younger people, like children they are particularly

vulnerable to being maltreated or abuse at home and even

more so in institutions aimed to protect them, such as nursing

homes and hospitals. According to the WHO (2011b), an

estimated 4–6 % of elderly people in high-income countries

have experienced some form of maltreatment at home.

Many of the abusive acts against the elderly in homes or

institutions consist of micro-traumas, such as: being physi-

cally restrained, deprived of dignity by being left in soiled

clothes, being over- or under-medicated, and emotionally

neglected and abused. One study found that more than half

the residents of intermediate care facilities were receiving

psychoactive drugs and 30 % received long-acting drugs not

recommended for elderly persons (Beers et al. 1988). Some

acts against older adults do rise up to the level of large-T

traumas of physical abuse that can be life threatening or can

result in serious, long-lasting, psychological consequences,

including depression, anxiety and PTSD.

While accurate, generalizable data are scarce (Ben Na-

tan and Lowenstein 2010), one survey of nursing-home

staff in the US, found that (Pillemer and Moore 1989):

• 36 % witnessed at least one incident of physical abuse of an elderly patient in the previous year;

• 10 % committed at least one act of physical abuse towards an elderly patient;

• 40 % admitted to psychologically abusing patients.

For those cared for at home, studies indicate that the

social isolation of both caregivers and the older adults, and

the ensuing lack of social support, is a significant risk

factor for elder maltreatment by caregivers. Thus help

needs to be provided not only to the elderly, but also to

their caregivers.

Moreover, when dealing with community trauma, whe-

ther natural, such as earthquakes, or man-made, such as a

terrorist attack, or individual micro-traumas, such as hav-

ing a spouse who has been diagnosed with Alzheimer’s,

older adults are particularly vulnerable to what has been

termed as ‘‘ambiguous loss’’ (Boss 2009) or ‘‘disenfran-

chised grief’’ (Doka 1989). For example, while the parents

of an adult son killed in a terrorist attack may be

acknowledged and supported by the community, the great-

aunt of the murdered young man may be totally ignored,

even though for many years he may have been her major

source of emotional support. Finally, it is important to

recognize that the nature of trauma among older adults

varies among different ethnic and racial groups, even in the

same community (Marsella 2008). For example, Higgins

and Park (2012) in a comparison of African American and

Caribbean Black older adults in New York found that

African Americans experienced more spousal abuse,

incarceration, and combat involvement, while Caribbean

Black older adults experienced more natural disasters.

Trauma and Resilience: A Strength-Based Perspective

As George Bonanno (2004) reminds us, as professional

helpers we tend to see people who have difficulties coping

with trauma. We thus forget that many people are exposed

to traumatic events at some point in their lives, and yet they

continue to have positive emotional experiences and show

only minor or transient disruptions in their ability to

function. The concept of resilience reflects the individual’s

ability to effectively use resources in the environment,

notably relationships with others, as well as their own

internal resources and potentialities (Bonanno et al. 2007;

328 Clin Soc Work J (2014) 42:323–335

123

Bonanno et al. 2011). Hauser (1999; Hauser et al. 2006)

point out that resilience is a process, not a state. Doing

longitudinal studies of youth, most of whom were physi-

cally and sexually abused at home and then put into psy-

chiatric hospitals, the authors found that those young

men, who as adults were able to achieve a satisfying life

despite horrendous childhoods, reflected three general

characteristics:

1. A belief that one can influence one’s environment (self

efficacy),

2. The ability to handle one’s thoughts and feelings

(cognitive-behavioral skills), and

3. The capacity to form caring relationships.

What is important to note is that these traumatized yet

resilient youth did not show a normative development. Their

lives had not been easy; they made seemingly unwise

choices and often got into social and legal troubles. What

characterized them was, however, an ability to learn from

experience. The authors point out is that ‘‘Resilience does

not lie in either the competence or relationship; it lies in the

development of competence or relationship where they did

not exist before’’ (Hauser et al. 2006, p. 261). It is this ability

to learn from one’s traumatic experience and to achieve what

we now refer to as Post-Traumatic Growth (PTG) (Tedeschi

and Calhoun 2004; Zoeller and Maercker 2006) that is the

ultimate goal of effective trauma treatment.

Treatment Approaches with Traumatized Individuals

The last few decades have brought extensive research and

innovative treatment approaches to helping traumatized

individuals. Since, as indicated previously, the experienc-

ing and the consequences of trauma are highly subjective,

there is no single treatment approach for helping all indi-

viduals who have experienced and suffered trauma, and

particularly those suffering from chronic PTSD. Moreover,

as trauma can occur at different ages, interventions must be

age appropriate as well as gender and culturally relevant.

Interventions with Traumatized Children

As with traumatized adults, the main goal of treatment with

traumatized children is to engage them in activities and

experiences that allow them to safely express feelings,

regulate their emotions and manage overwhelming sensa-

tions. The natural language of young children is play. Play

therapy, and related expressive arts therapies (Harris 2007),

provide a way for the child to reenact the traumatic event

through symbolic play and movement, and is an empiri-

cally-based intervention for working with traumatized

children from the age of 3–11 (Bratton et al. 2005;

Malchiodi 2008; Ryan and Needan 2001; Webb 2011).

Play therapy with a caring, empathic adult allows the

traumatized child to develop a sense of trust and provides

an opportunity to achieve a sense of control over their

trauma (Steele 2004; Webb 2011). While play therapy is

usually conducted with an individual child, other approa-

ches focus on involving the parents, and include:

Child-Parent Psychotherapy (CPP) (Lieberman and Van

Horn 2008). CPP is a psychodynamically based therapeutic

approach has shown to be very effective in treating trauma

in young children while working with parents to repair the

impact of the trauma to the family system. CPP is a flex-

ible, culturally sensitive intervention that can be utilized in

unstructured weekly session over the course of a year. It

focuses on helping the child to rebuild trust by creating a

trauma narrative where the caregiver can act out the pro-

tective role through the use of play. CPP has been sup-

ported by a number of randomized trials showing efficacy

in increasing attachment security and maternal empathy

(Berlin et al. 2008).

Parent–Child Interaction Therapy (PCIT; Eyberg and

Bussing, 2010). While not specific to traumatized children,

it is an empirically-based behavioral short term interven-

tion for children age 2–7 who are experiencing emotional

and behavioral disorders. PCIT draws on both attachment

and behavioral theories and is provided over the course of

12 1-h weekly sessions. PCIT involves the parent inter-

acting with the child with the therapist observing through a

one-way mirror and coaching through a hearing aid device.

The coaching consists of helping the parents to utilize two

sets of skills: a. Child Directed Interaction, which teaches

parents to use traditional play therapy techniques, and b.

Parent Directed Interaction, which teaches the parents

skills to address disruptive behaviors while increasing

compliance by the child. These skills include establishing

rules, praising compliance, using time-out chair for non-

compliance, and so on (Ware et al. 2008).

Trauma-Focused Cognitive Behavioral Therapy (TF-

CBT; Cohen and Mannarino 2008).

TF-CBT is a psychosocial intervention found to be

effective in treating PTSD and other behavioral and emo-

tional problems related to a variety of traumatic experiences

in children and adolescents. It can be used with children and

parents in individual and conjoined sessions, as well as in

multi-family groups. TF-CBT usually lasts from 12 to 16

sessions. The treatment model focuses on applying the

acronym PRACTICE, which summarizes the nine compo-

nents of this model: Psychoeducation and parenting skills;

Relaxation skills; Affect expression and regulation skills;

Cognitive coping skills and processing; Trauma narrative;

In-vivo exposure (when needed); Conjoint parent–child

sessions; and Enhancing safety and future development

(Cohen and Mannarino 2008; Cohen et al. 2006).

Clin Soc Work J (2014) 42:323–335 329

123

Intervention with Traumatized Adults

Many different treatment approaches have been shown to

be effective for traumatized adults. They include: Psy-

choeducation, cognitive behavioral therapy, exposure

therapy, desensitization and imaginal flooding, Eye

Movement Desensitization and Reprocessing (EMDR),

narrative therapy, group therapy and medications.

Psychoeducation

Psychoeducation is the ‘‘process of teaching clients with

mental illness and their family members about the nature of

the illness, including its etiology, progression, conse-

quences, prognosis, treatment and alternatives’’ (Barker

2003, p. 347). While there has been limited empirical

evidence proving the importance of psychoeducation (Lu-

kens and McFarlane 2004), clinical experience has shown

that understanding the physiological responses to trauma

can help individuals develop new coping strategies in

dealing with others and learning to calm oneself physically

(Creamer and Forbes 2004). It has also been shown to

improve the quality of life for family members traumatized

by others or to better understand the sometimes irrational

behaviors of their traumatized loved one (Solomon et al.

2005).

Cognitive Behavioral Therapy [CBT]

CBT has been shown to be very effective at helping indi-

viduals who have experienced trauma by dealing with their

thoughts and beliefs, as well as with their behavior pat-

terns. Among the various empirically-based CB treatments

are:

1. Exposure/Desensitization, which consists of direct

confrontation with trauma by having individuals

visualize the event, talk about it, and expose them-

selves gradually to stimuli which reminds them of the

trauma. This is repeated several times until the person

becomes accustomed or desensitized to these thoughts

and images. Through these repeated exercises, the

traumatic memory becomes just a regular memory,

allowing the individual to have a sense of control

rather than feeling helpless over the past traumatic

event. One particular approach is known as ‘‘Prolonged

Exposure’’ (PE; Foa et al. 2007), and is rooted in the

tradition of exposure therapy for anxiety disorders and

emotional processing for PTSD. PE uses both imaginal

exposure (confront feared trauma memories and

thoughts via imagining the feared object, event, or

situation), and in vivo (experience/confront feared

objects, places, events, and situations in real world

settings). Individuals also are provided with psycho-

education on trauma reactions and on the use of PE to

reduce symptoms, as well as breathing training to

manage their anxiety. PE may not be appropriate for

individual who have a history of multiple traumas

(particularly in childhood), those with anger problems,

and those who dissociate (Foa et al. 2007, 2009).

2. Another empirically supported cognitive-behavioral

treatment for PTSD is Dialectical Behavior Therapy

(DBT) (Linehan 1993), which was developed for

individuals diagnosed with borderline personality

disorder (BPD). The emotional dysregulation that is

the hallmark of BPD is also associated with symptoms

of complex-PTSD (DESNOS). The treatment com-

bines group skill training sessions, individual psycho-

therapy, and phone coaching. It is designed to help

individuals label and regulate arousal, tolerate emo-

tional distress, and trust their emotional reactions.

Emotional regulation, interpersonal effectiveness, and

self-management skills, including mindfulness and

meditation skills are core skills in DBT. Validation

and dialectical strategies are used to balance accep-

tance and change during treatment.

3. A different treatment model found to be effective in

treating traumatized adults is Eye Movement Desen-

sitization and Reprocessing (EMDR) (Shapiro 1995).

For many traumatized individuals, remembering an

event can feel as real as if it were happening again

before their eyes. EMDR uses the person’s eye

movements to help the natural processing and relax-

ation mechanisms available in the brain. During

treatment, people are asked to think of a picture,

emotion or thought relating to their trauma and at the

same time to watch the therapist’s moving finger or

listen to a repeating sound of a drum or a bell, leading

to cognitive dissonance and a diminished power of the

intrusive traumatic memory. EMDR can be delivered

in a short series of sessions and does not involve

detailed narrative of the traumatic event.

Narrative Therapy

This approach is based on the belief that trauma disrupts

the normal narrative processing of everyday experiences by

interfering with psychophysiological coordination, cogni-

tive processes, and social connections, and such incomplete

narrative leads to symptoms of posttraumatic distress

(Wigren 1994). Narrative therapy thus allows for the

completion and reframing of the traumatic event. While

there is some evidence showing the effectiveness of this

approach (Amir et al. 1998; Schaal et al. 2009), there

seems to be no single narrative treatment model. Further

330 Clin Soc Work J (2014) 42:323–335

123

research is needed in order to identify the best narrative

approaches.

Group Therapy

While group therapy has been found to be effective at

providing support for individuals in many circumstances,

the use of certain group approaches, such as Critical

Incidence Stress Debriefing (CISD) has been shown to

have the potential for retraumatization. This is a particular

danger for some individuals who are mandated to par-

ticipate in such a group and listen to other people’s stories

of their traumatic events before they had a chance to

process their own trauma (Rose et al. 2002). Thus caution

must be taken when utilizing any group approaches to

trauma treatment.

One highly effective treatment model, used mainly in

group settings, is Seeking Safety, developed by Lisa Na-

javitis (2006), The Seeking Safety Model is a present-

focused therapy to help people attain safety from both

trauma/PTSD and substance abuse. Treatment is flexible

and utilizes 25 different topics that focus on both cognitive

and behavioral areas. Seeking Safety is based on five

central ideas: Safety as the priority of treatment; integrated

treatment of trauma and substance use; a focus on ideals;

content addressing cognitive, behavioral, interpersonal

skills and case management; and attention to the clinician.

Originally developed as an empowerment model for

women, it is now recognized as being an effective and

widely used approach for many others, including trauma-

tized US veterans (Boden et al. 2012). The program

focuses on teaching traumatized individuals to view

themselves in more positive ways and helping clients build

their self-esteem and self-confidence.

Medications

While there are no medications specific for trauma or

PTSD, some medications have been shown to be effective

at treating certain symptoms of PTSD, such as depression,

anxiety or sleeping disorders. Currently the US Federal

Drug Administration (FDA) has approved only two anti-

depression medications for use with patients diagnosed

with PTSD: sertraline (Zoloft) and paroxetine (Paxil),

although other medications are being used off-label (Jeff-

reys 2013). It is worth noting that some medications have

been found to be dangerous for those using or recovering

from a substance use disorder, or those who are potentially

suicidal (for a full review of medication use for those with

PTSD, see Jeffreys 2013).

In general, when working with traumatized adults, the

most important task is the establishment and maintenance

of a physical and emotional sense of safety. It is critical to

determine if the individual is at risk for imminent inter-

personal violence or other maltreatment in their psycho-

social environment, if they are suicidal or homicidal, and if

they are psychologically stable and capable of caring for

themselves (Briere and Scott 2012).

Interventions with Older Adults

While there is a growing acknowledgement of the need for

psychosocial interventions with this population, the litera-

ture tends to focus more on programs and policies devoted

to identification and reporting of elder abuse than actual

clinical interventions (Brandler 2004, Donovan and Regehr

2010). Literature on empirically supported interventions

with traumatized older adults seems to be almost non-

existent, although some believe that CBT may be effective

(Foa et al. 2009). Obviously, more needs to be done to

identify effective clinical approaches to this growing

population.

Conclusion

Unfortunately, traumatized children and adults comprise a

significant number of individuals in our communities and

will continue to be with us in the foreseeable future.

Many remain untreated. It is therefore critical for clini-

cians to be familiar with the various traumas encountered

by individuals, families and communities, and to become

knowledgeable about the most effective treatment

approaches for a given population. Despite the growing

research that is providing us with a base of scientific

knowledge regarding promising interventions, there is

much to be learned about effective interventions with

traumatized children and adults—to make sure that we

‘‘do no harm.’’ Particularly important is research focusing

on the resilience that many traumatized individuals’

exhibit and learning how best to encourage clients to

access their strengths and abilities both in and out of the

treatment process. Finally, because of the risk of experi-

encing secondary trauma, clinicians also need to be aware

of the risk of working with high caseloads of traumatized

individuals and to learn to take care of themselves so that

they do not become part of the problem, but are an

effective part of the solution.

Acknowledgments This paper is based on a keynote presentation by the senior author at the international conference on Trauma

Through The Life Cycle From a Strengths Perspective: An Interna-

tional Dialogue, Hebrew University, Jerusalem, January 8, 2012. The

authors would like to thank Drs. April Naturale, Miriam Schiff and

Shlomo Einstein for their helpful critiques of an earlier draft of this

paper.

Clin Soc Work J (2014) 42:323–335 331

123

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Dr. Shulamith Lala Ashenberg Straussner is Professor and Chair of Social Work Practice Area and Director, Post-Master’s Program in

Addictions at the NYU Silver School of Social Work She is the

Founding Editor, Journal of Social Work Practice in the Addictions

and was the 2013 Fulbright Distinguish Chair, Masaryk University,

Brno, Czech Republic.

Alexandrea Josephine Calnan is Mental Health and Substance Abuse Clinician at Howard Center in Burlington, VT. She graduated

from New York University Silver School of Social Work in 2013 and

attended the international trauma course and conference in Jerusalem

in January, 2012.

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