trauma experience
M456
Family_Health_Care_Nursing_6e_Theory_Practice_a..._----_UNIT_2_Families_Across_the_Health_Continuum.pdf
323
C r i t i c a l C o n c e p t s
■■ Trauma is a key experience affecting the family system.
■■ Trauma-informed care (TIC) is an important part of nursing care for all clients, including families, to improve outcomes, avoid biased and inaccurate assessments and interventions, and to prevent unethical decision-making processes.
■■ Adaptive responses to trauma are more likely to become problematic when resiliency traits are underdeveloped.
■■ Post-traumatic stress disorder (PTSD), a medical diagnosis, is based on a cluster of symptoms in response to trauma that can be acute or chronic and can occur months, or even years, after a disaster or traumatic event such as war.
■■ The Ecological Systems Theory can guide nurses in applying TIC.
■■ When one or more family members are traumatized, all family members and family relationships can be affected.
■■ Perpetrators of trauma can experience trauma themselves. Nurses who focus on TIC can address the dilemmas of caring for perpetrators through mandatory reporting and family-focused care.
■■ Secondary trauma can occur whenever a family member or caring provider is exposed to victims of trauma and is impacted by their response to the traumatic event(s).
■■ The family response to trauma of one or more of its members cannot be understood or treated by focusing on individual family members alone. Family members can provide key contextual information about past traumatic events and experiences that help explain current responses.
■■ Dysregulation is the abnormality or impairment in the regulation of a metabolic, physiological, or psychological process.
■■ Community systems can prevent, treat, and measure negative outcomes to traumatic events. If community agencies are not well trained and prepared, communities will suffer.
■■ Larger political and social systems can influence and be influenced by individual, family, and community trauma in a positive or negative way.
■■ Nursing focuses on the individual, family, community, and societal reactions to trauma in order to optimize positive outcomes and prevent or treat problematic stress responses. Nurses are key in supporting health rather than focusing on the pathology of a trauma response.
Trauma and Family Nursing Deborah Padgett Coehlo, PhD, C-PNP, PMHS, CFLE
Henny Breen, PhD, RN, CNE, COI
Chapter 11
11_Rowe_Ch11.indd 323 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
324 Families Across the Health Continuum
trauma through painful memories and nightmares, hypervigilance, and emotional instability are com- mon to adults, children are more likely to react with withdrawal and mood dysregulation. These symp- toms cross ethnic groups and time. The number of individuals with PTSD in turn affects communities. Larger cultures and societies shift as the number of trauma victims grows, adding other negative con- sequences that include poor health, higher rates of other mental health disorders, and an increase in family violence.
The American Psychological Association first rec- ognized PTSD as a diagnosis and began to categorize symptoms of it in 1980. Since that time, researchers and clinicians have identified the complexity of this disorder and the lifelong, intergenerational impact of repeated and prolonged trauma experienced by individuals, families, communities, and societies. Since this publication in 1980, researchers have attempted to clarify and expand the diagnosis to cover different categories of trauma, such as combat, horrific accidents, and child abuse; different content such as domestic violence, natural disasters, and war; and different cultures such as genocide victims and victims of natural disasters across cultures and across time. The DSM-IV and DSM-IV-TR included PTSD as a subcategory under anxiety disorders, including three categories of symptoms (APA, 2000; McNally, 2004; National Center for PTSD, 2016).
1. Re-experiencing the trauma 2. Avoidance and numbing 3. Increased arousal
The DSM-5 has taken PTSD out of the category of anxiety and developed a separate category titled Trauma and Stressor Related Disorders (Friedman et al., 2011; Schmid, Petermann, & Fegert, 2013). The scope has been expanded to include both experiencing a traumatic event and witnessing or repeatedly hearing about a traumatic event. Further, the DSM-5 has included four categories of symptoms (APA, 2013):
1. Intrusion of thoughts about the trauma 2. Avoidance of discussion or other stimulus
reminding the person of the trauma 3. Increased arousal or sensory sensitivity 4. Negative cognitions and moods
Today, it is estimated that up to 10% of the general population across the world meets the criteria for a diagnosis of PTSD, with areas experiencing war
Trauma has been an increasing area of attention across the field of mental health for the past two decades. Between the advanced understanding of brain function and general physiology, as well as the mind and body response to severe and/or prolonged stress, and the increase in traumatic stress experienced by families through war, natural disasters, and family violence, the need to understand, prevent, treat, and monitor the effects of trauma on individuals and families has never been more vital. Further, the effects of trauma transcend individuals and families, but also affect communities and the broader society. Trauma influences future generations as the effects influence individual family genetics, community, and societal cultures. The negative effects of trauma are most profound during early childhood development, touching every domain of growth, with the potential of negative outcomes in adulthood, such as higher rates of mental illness, unemployment, substance abuse, and failed relationships.
The care by nurses of families experiencing traumatic stress revolves around preventing trauma when possible, supporting the development of resiliency, and, when not preventable, working toward positive outcomes. This chapter focuses on the current knowledge about trauma and nurses’ key role in the field of TIC. This care emphasizes the importance of preventing, treating early, and encouraging resilience and the ability to make meaning out of negative events. This chapter also stresses an understanding of secondary trauma, or the negative effects of witnessing trauma of others, whether that other person is a stranger, family, or fellow professional. This discussion is particularly salient for nurses, because they are some of the most likely health care providers to encounter trauma- tized victims in their everyday practice. Nurses are among the highest professional groups to experience vicarious or secondary trauma, as a consequence to their exposure to traumatized clients (Best Start Resource Center, 2012).
POST-TRAUMATIC STRESS DISORDER
The diagnosis of post-traumatic stress disorder (PTSD) has grown significantly during the past two decades, as well as the understanding of differences in symptoms across developmental ages and stages. Whereas the key symptoms of re-experiencing the
11_Rowe_Ch11.indd 324 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 325
the Substance Abuse and Mental Health Services Administration (SAMHSA)’s guide to TIC (2015), the Ecological Systems Model (Bronfenbrenner, 1984, 1995: Bronfenbrenner & Lerner, 2004), and the Family Systems Theory (Bowen, 1978) as the underlying models to guide practice.
Trauma-Informed Care TIC has emerged as a leading guideline for those health care providers, including nurses, who care for and are affected by trauma in their clients. SAMHSA (2015) has been a leader in identifying key principles guiding TIC, including:
1. “Realizing the widespread impact of trauma and understanding potential paths for recovery;
2. Recognizing the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
3. Responding by fully integrating knowledge about trauma into policies, procedures, and practices; and
4. Seeking to actively resist re-traumatization.” (SAMHSA, 2015, paragraph 2)
Further, nurses applying TIC provide safety for their clients by building safety, trust, peer support, collaboration, and empowerment, while attending to historical, cultural, and gender issues using evidence-based practices. Hobfoll et al. (2007), following a review of literature investigating inter- ventions that worked with trauma survivors across cultures, identified five essential elements of TIC immediate and long-term interventions, including:
1. Promoting a sense of safety, including building positive social support
2. Promoting calming skills 3. Promoting a sense of self-efficacy and col-
lective efficacy for families 4. Promoting “connectiveness” between fam-
ily members 5. Instilling hope: “To see a future that is
better than the trauma present” (Evans & Coccoma, 2014, p. 47)
The TIC approach is consistent with the foundational principles of the nurse-client relationship. By using these guiding principles, it is believed that victims of trauma who suffer from mental health issues, such as substance abuse, depression, anxiety, eating
or severe natural disasters experiencing the highest rates. When further divided between geographical areas, ages, and genders, the prevalence rates vary, with risks higher for women and adolescents and lower risks in Asian countries (U.S. Department of Veterans Affairs, 2007). When considering children and adolescents, it is important to note that most PTSD is caused by (1) abuse and neglect across time, (2) witnessing violence within the home and/or neighborhood, and (3) experiencing single incident traumatic events such as motor vehicle accidents and natural disasters (Salmond et al., 2011).
The number of studies on individual trauma and outcomes has increased in the past decade, as has awareness that PTSD is not limited to individuals, but rather affects individuals, families, communities, and societies. The understanding of the political and societal influences on the diagnosis, treatment, and continued research in this area explains in part the continued need to explore trauma and the relationship to family health. The extent of damage to physical and mental health caused by trauma has now been realized. This chapter uses the Ecological Systems Model (Bronfenbrenner, 2005) to explore current understanding of risk and protective fac- tors of PTSD, and uses that knowledge to further understand the multidisciplinary approach to TIC that goes beyond the medical model of diagnosis and treatment. Family nurses are in a key position to understand, recognize, prevent, and treat trauma at multiple levels. Case studies throughout this chapter illustrate the complexities of trauma and its effect on all family members, and the strong influence nursing care can have on short- and long-term outcomes.
THEORIES APPLIED TO TRAUMA
Trauma care has progressed significantly during the past two decades, with a plethora of studies published to clarify evidence-based practice across cultural groups, ages and genders, geographic areas, and types of trauma experienced. Historically, health care providers considered trauma to be a form of hysteria, meriting ineffective treatments as severe as hysterectomies. Currently, the treatment approaches recognize the modern understanding of trauma as a complex stress disorder with several applicable underlying theories. For purposes of this book, we delve into trauma understanding and care using
11_Rowe_Ch11.indd 325 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
326 Families Across the Health Continuum
Microsystem The microsystem involves the individual and the sys- tems within that individual, including physiological (i.e., respiratory, cardiovascular), developmental, and psychological (i.e., sensory perceptions, memory). The role of trauma in violating and damaging phys- ical and mental well-being and negatively affecting development of children and adults is no longer questioned. The negative impact of trauma on individuals ranges from interference with healthy development of attachment to physical and mental illness across the life span (Afifi, Boman, Fleisher, & Sareen, 2009). Although understanding the impact of trauma on individuals is important to understanding family trauma, care of these individuals in isolation is less effective than providing care within the context of the family. The microsystem provides a beginning knowledge to family trauma, but the mesosystem adds a deeper understanding.
Mesosystem The effect of trauma on any one individual within the family has a significant impact on family devel- opment and family functioning. The stress response from trauma is felt from experiencing, witnessing, or being informed about an act of violence against others. Younger children and those with intellectual disabilities who do not have the ability to process or understand the traumatic events are more vulnerable to developing problematic stress responses. This is also the case when the trauma is repeated and unpredictable (APA, 2013). This traumatic stress response is experienced by family members directly or witnessed by other family members, expanding the experience beyond the micro level to the meso level of reaction. For example, children’s reactions to trauma and their resiliency skills are shaped in part by family experiences and reactions as well as cultural experiences. The act of witnessing trauma includes direct observation as well as hearing about traumatic events repeatedly from family members. Further, how family members react to a traumatic event will have a direct impact on how other fam- ily members will respond. For example, if parents cannot regulate their own reactions and cannot support the child because of their own physical, mental, or emotional difficulties, then their child is at higher risk for developing mood dysregulation and an inability to develop healthy attachments.
disorders, and social isolation, will be better served when there is understanding of how the trauma has an impact on the trajectory of a person’s life. By working with individuals, families, and communities that have experienced trauma, health care providers can build a more collaborative approach to care. Several evidence-based approaches to working with victims of trauma include strategies for individual therapy (e.g., Eye Movement Desensitization and Reprocessing [EMDR]) and group therapy (e.g.,≈Trauma, Addiction, Mental Health, and Recovery [TAMAR]). Other approaches include changes to the treatment environment to pre- vent retraumatization (i.e., elimination of the use of restraints and isolation as punishments for individuals struggling with emotional dys- regulation; SAMSHA, 2015). TIC is a shift away from pathology of trauma to recognition of the physical, relational, and emotional changes that occur in response to trauma. The questions for clients shift from “What is wrong with you?” to “What happened to you and how is it affecting your life?” (Evans & Coccoma, 2014; SAMHSA, 2014). TIC is also one of the few models that embraces working with survivors of trauma and their families (SAMHSA, 2014).
Ecological Systems Model Bronfenbrenner (1996) identifies four systems that interact together in the Ecological Systems Model: the microsystem, mesosystem, macrosystem, and exosystem. He later added the system of time, or the chronosys- tem, to describe the impact of history and time on individuals, families, communities, and societies. Time is integrated as a concept within each of the four other ecological systems. The understanding of the impact of trauma on a micro- to exosystem level helps health care providers and policy makers understand the interconnections between trauma and abuse to individuals, families, communities, and societies, and the impact of that trauma across time, generations, and geographical and cultural systems. Trauma tends to be repeated if nothing intervenes to stop the pattern. Interventions intended to stop and/or alter these patterns are much more effective when chosen and implemented with the complexity and interconnections between systems in mind. See Figure 11-1 for a visual portrayal of Bronfenbrenner’s Ecological Systems Model.
11_Rowe_Ch11.indd 326 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 327
from trauma. During the past two decades, the growing disparity between mental health and access to mental health services within a community has been well documented (Friedman, 2016). Traumatic events within schools, for example, have increased the awareness of the need for more in-depth and comprehensive mental health services to prevent these events and to be available to treat the victims and perpetrators (i.e., bullies) following these events.
Likewise, if parents lack support and positive coping strategies, they are less likely to be able to provide support to their child.
Macrosystem Trauma at the macro level includes all trauma within a community. This level of trauma not only influences individuals (micro) and families (meso), but has an impact on how a community reacts and recovers
FIGURE 11-1 Bronfenbrenner’s Ecological Systems Model
CHRONOSYSTEM
Changes in persons or environment over time U
ne xp
ec te
d de
at h
of p
ar en
t Bro ad id
eology, la ws, and customs of one’s culture, subculture, or social class
MACROSYSTEM
Extended Family EXOSYSTEM
MESOSYSTEM
MICROSYSTEM
Friends of
family
Neighbors
Mass media
Family Day-care center
Community health and
welfare services
Doctor’s office
Child
Legal services
Workplace
Church, synagogue Peers
School board
Sociohistorical conditions
D isasters W
ar s
Critical events (e.g., parental divorce)
School Neighborhood play area
Church
School
11_Rowe_Ch11.indd 327 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
328 Families Across the Health Continuum
of an individual’s health and behavioral responses on other family members, as well as other family members’ reactions and health impact on individ- uals. The metaphor of a wind chime is commonly used to describe the Family Systems Theory, with one chime, or individual family member, being struck by other chimes, or other family members, to make music or cacophony. The wind flowing through the wind chimes represents the stressors that flow through every family. The wind can be a gentle breeze, or low stress level, or higher winds, similar to high stress and less controlled stress levels. The Family Systems Theory, when considered through an ecological looking glass, can help explain the impact of trauma within and surrounding families.
The remainder of the chapter examines the types of trauma that individuals, families, communities, and societies at large currently face, along with implications for nurses.
EARLY TRAUMA
Early trauma shapes early attachment, developmental progress, and early brain development, which can be understood through the lens of the Ecological Systems Model.
Attachment Because early trauma has been shown to interfere with healthy development of attachment, attachment theories are used as a basis of research and under- standing. Failure to develop healthy attachments during childhood are commonly linked to later issues with developmental growth and physical and mental well-being. Bowlby (1973), an early researcher and theorist in the area of attachment, identified the importance of early attachment for healthy development. During healthy attachment, an infant learns to trust his or her caregivers and develops the ability to compartmentalize isolated threats or fears. When severe abuse or neglect occurs, an infant learns to mistrust his or her caregivers and views the environment as unsafe and threatening. This process destroys the infant’s ability to compartmentalize threats, leading to the inability to self-regulate emotions, behaviors, and physiological processes (i.e., sleep and elimination) (Evans & Coccoma, 2014).
Schools have been identified as key community sys- tems that can provide both prevention and treatment services. More than 60% of schools already attempt to address trauma at a community, or macrosystem, level through prevention services, community pre- paredness such as town meetings and educational programs, provision of temporary food and shelter following a disaster, counseling services, and/or behavioral programs (Taylor, Weist, & DeLoach, 2012). Using TIC when working with schools ex- periencing trauma improves outcomes, especially for traumatized youth (i.e., school bullying, school shootings, or school suicides) (Cohen et al., 2009).
Exosystem The exosystem includes the larger culture and government or laws and justice within a culture. The exosystem is touched by and touches on individuals, families, and communities. For example, the cultural reactions and legal responses to a natural disaster have grave implications for individuals, families, and communities. Consider the response by the government to Hurricane Katrina in 2005, with the delays and the disorganization during and after the disaster. These gaps in services were believed to be a contributing factor to the high rates of severe trauma reactions in survivors (Mills, Edmondson, & Park, 2007). Researchers have explored the dysregulation and hyperarousal of individuals during this time, and have found that similar processes can and do occur at a larger, systemic level. Judith Warner, in a 2010 New York Times article (Warner, 2010), observed that the large-scale dysfunction of federal regulatory systems, including the banking meltdown, collapse of the housing market, and failure of levees during Hurricane Katrina, resulted in the United States as a country struggling with symptoms of PTSD for several years after the hurricane hit the shores of Louisiana. Likewise, 16 years after the nightmare of the 9/11/2001 terrorist attacks, the United States is still engaged in war across many boundaries. The incidence of diagnosed PTSD for veterans has increased significantly during this time, from 0.7% of all military personnel diagnosed with PTSD in 2004 to 8% of all military personnel diagnosed with PTSD in 2012 IOM, 2014).
Family Systems Theory The Family Systems Theory focuses on the inter- action between family members and the impact
11_Rowe_Ch11.indd 328 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 329
interfere with healthy development. For example, whenever an individual experiences a severe threat, the sympathetic-adrenal-medullary (SAM) axis is triggered. This reaction is followed by a release of catecholamines, norepinephrine, and epinephrine, which in turn trigger the hypothalamic-pituitary adrenal (HPA) axis. The hypothalamus in the brain works during this process to regulate heart rate, respiratory rate, and blood flow, and stimulates the amygdala to store the memory and the response for quick reaction to future threats. The adrenal gland then releases cortisol, our stress hormone, that eventually allows activation of the fear extinction process, or eventual recovery from the stress (Evans & Coccoma, 2014). Refer to Figure 11-1 for an illustration of this typical physiological reaction to stress or threats. When re- peated trauma occurs, a state of constant fear develops, causing distinct physiological and psychological changes.
Research during the past 50 years has explored why prolonged or repeated trauma results in a different response in individuals compared with a typical stress response from isolated threats. Three areas of the brain have been identified as key factors in altering a healthy stress response that saves lives to a trauma-related response that causes chronic physical and mental disorders (Evans & Coccoma, 2014):
■■ Amygdala: With prolonged trauma, the amygdala becomes hyperactive, which inter- feres with the ability to appropriately process trauma memories, and decreases the function of the prefrontal cortex, causing a decreased ability to think about the response to pres- ent traumas and problem solve appropriate reactions.
■■ Hippocampus: The hippocampus is responsible for changing explicit memories, or new
Developmental Trauma Theory Heller and LaPierre (2012), in describing their Developmental Trauma Theory, categorized this early traumatic interference with attachment by describing five core areas of concern: (1) interference with connection to others, (2) lack of attunement or ability to recognize physical and emotional needs, (3) lack of trust in caregivers and the environment, (4) difficulty with boundaries between self and others, and (5) difficulty developing a sense of love and healthy sexuality. Table 11-1 illustrates the Neuroaffective Relational Model Five Core Needs developed by Heller and LaPierre (2012). More specific symptoms of failure to develop healthy attachments related to experiencing trauma include the following:
■■ Absence of self-regulation—inconsistent and unpredictable patterns of eating and sleeping, and mood regulation.
■■ Lack of response to caregivers—poor eye contact, lack of response to consoling mea- sures, withdrawal, and isolation.
■■ Lack of response to the environment— inability to pretend play, interact with toys, and/or experience shared pleasure with others (Heller & LaPierre, 2012; Joubert, Webster, & Hackett, 2012).
If untreated, children experiencing trauma struggle in cognitive, emotional, and social development (Evans & Coccoma, 2014; Heller & LaPierre, 2012; Joubert et al., 2012; Perry & Pollard, 1998). The Developmental Trauma Theory proposed by Heller and LaPierre (2012) also describes the survival strategies individuals (micro level) learn in order to cope with traumatic experiences, thereby expanding the understanding of the negative impact of trauma on attachment. These coping strategies
Table 11-1 Neuroaffective Relational Model Five Core Needs
Core Need Description
Connection Lack of ability to form healthy connection with caregivers or significant support people
Attunement Lack of ability to recognize physical and emotional needs
Trust Lack of ability to trust others
Boundaries Difficulty setting healthy boundaries
Deep sense of love and sexuality
Inability to form deep loving relationships, and, as adults, connect deep love with healthy sexuality
Source: Heller & LaPierre, 2012.
11_Rowe_Ch11.indd 329 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
330 Families Across the Health Continuum
If uninterrupted, the young child will develop secondary complications, including anxiety, shame, isolation, mood dysregulation, and uncontrolled anger or explosive outbursts (Alisic, Jongmans, Van Wesel, & Kleber, 2011; Evans & Coccoma, 2014; Salmond et al., 2011).
As a child develops into adulthood, he may try to adapt to those feelings by abusing substances or avoiding emotions (Evans & Coccoma, 2014; Heller & LaPierre, 2012). The underlying fear remains; the threat to self and to the ability to survive is not over. Symptoms emerge over time, including the following (Heller & LaPierre, 2012).
■■ Lack of affect ■■ Feelings of shame ■■ Separation from others ■■ Avoidance of emotionally disturbing situations or people
■■ Overintellectualizing and avoiding of emotions
■■ Lack of attunement or awareness of bodily and related needs
■■ Fear of being alone while at the same time feeling overwhelmed by others
■■ Fear of death and illness ■■ Fear of their own anger ■■ Fear of intimacy ■■ Strong need to control ■■ Desire for altered states and disassociation ■■ Cognitive impairments, including difficulty with auditory processing, memory, and attention
■■ Feelings of helplessness ■■ Hypovigilance or hypervigilance
Physical symptoms of prolonged and repeated trauma in childhood include the following:
■■ Disrupted sleep ■■ Eating disorders ■■ Panic disorders ■■ Obsessive-compulsive disorders ■■ Rage ■■ Depression ■■ Addiction ■■ Cardiovascular disorders ■■ Autoimmune disorders
A pattern emerges across time. Figure 11-2 illustrates the developmental pattern of maladaptation to early trauma.
memories, into implicit memories, or pat- terns (i.e., driving a car, riding a bike, or skiing change from an awkward new skill to an automatic skill that takes little conscious thought). Severe or prolonged trauma inter- feres with this process, resulting in feelings of inadequacy and doubt. Further, the hippo- campus is responsible for differentiating past experiences from present experiences. With severe and prolonged trauma, this differen- tiation is damaged, causing an individual to respond to a memory, or a similar sensory trigger (i.e., vision or sound), as if the trauma were repeating itself in the present. Finally, the hippocampus is responsible for repeated memories retrieved for a variety of cognitive, physical, and emotional functions. In the context of severe and repeated trauma, however, this process results in intrusive memories interfering with function.
■■ Prefrontal cortex: This part of our brain is responsible for cognitive processing of trau- matic memories. Without prefrontal cortex functioning, fear extinction, or the resolution of the SAM axis response, cannot occur. With hyperactive activity in the amygdala, the prefrontal cortex cannot be fully func- tional, resulting in unresolved traumatic memories.
These three areas, when affected by severe and repeated trauma, have an impact on an individual’s ability to process, store, and appropriately retrieve memories. In turn, the neurological system, in response, alerts the brain to stay in survival mode. Because this system is activated continuously when repeated trauma occurs, the individual’s ability to feel safe is threatened, resulting in a state of con- stant hyperarousal. This constant state of arousal causes an individual to become overwhelmed, leading to an abrupt shift to the parasympathetic system, and the individual shuts down, withdraws, becomes numb, disassociates, or falls into sleep. Sleep, eating, and digestive patterns are affected, and excitable behavior builds again with the next remembered or experienced trauma. Emotions range from hyperstimulated (i.e., hysteria or excessive, inconsolable crying) to numbness (no reaction to the environment). Without resolution, the individual develops a state of fear and gradually loses the abil- ity to regulate emotional and autonomic reactions.
11_Rowe_Ch11.indd 330 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 331
meditation, yoga, and spiritual connection) or negative measures (e.g., drug-seeking behavior, obsessive thinking patterns, or avoidance patterns) (Evans & Coccoma, 2014). These negative pat- terns interfere with every stage of development, primarily altering cognitive, emotional, communi- cation, and social domains. Although young infants cannot consciously think about their reactions to trauma, their emotions and related autonomic re- actions are affected in a measurable way (Evans & Coccoma, 2014; Heller & LaPierre, 2012). Infants have bottom-up responses, or responses starting with brainstem or autonomic reactions to external threat, moving up toward emotional responses. Adults, in contrast, experience trauma initially from thought, or the cortex of the brain, and move down to emotional response, and finally autonomic or brainstem reaction. This is considered top- down reaction. Another important differentiation between infants and adults is that infants tend to have a broad interpretation of experiences, whereas adults are able to separate experiences and feelings between experiences. The difference in reaction is caused by the difference in development of pathways from the frontal cortex to the brainstem as the brain develops across time. The pathways are reinforced by experiences and interactions in the environment (Heller & LaPierre, 2012). Figure 11-3 illustrates bottom-up and top-down responses to trauma.
This variance in response to trauma is important to understand: Adults who experience trauma can make a distinction between different experiences in their lives, and therefore feel badly about a specific experience; infants and young children cannot dif- ferentiate between experiences and therefore, when they experience trauma, they tend to think they are bad (Heller & LaPierre, 2012). Young children and adults, however, if left untreated following a trauma, can regress back to thinking and feeling they are bad as a global response to trauma.
Early Trauma and Brain Development The understanding of the impact of early trauma on brain development has led to detailed study of the impact on brain development and plasticity, or the ability of the brain to recover from injury. When considering trauma or major stress, the body is gov- erned by two main systems: the neurological system and the endocrine system. These two systems ensure
Environmental Trauma Studies on the impact of war, terror, and unexpected natural disasters on children have resulted in the identification of the term disaster syndrome. Smith (2013) described this syndrome as a combination of symptoms of PTSD, including anxiety, dissoci- ation, and depression. The loss of people, support, routines, and assumptions regarding safety and regularity, as well as parental response, all affect the severity of a child’s response. Parental response is influenced by parents’ prior diagnosis of mental illness, prior coping strategies, and number of past traumatic experiences. Children respond to their family members’ emotional and physical changes related to trauma. When an individual (micro level) experiences trauma over time, his interaction with others (meso level) and his ability to interact in a functional manner with his community (macro level) are altered. One distinct difference between children and adults experiencing trauma through environmental events is that adults tend to have less PTSD because of the support of the community and decreased feelings of isolation, whereas children feel more isolated during these events because of profound fear of losing their supportive loved ones (Evans & Coccoma, 2014).
The human desire for regulation of the auto- nomic nervous system, with a return to balance, is strong. Individuals are highly motivated to find this balance, and will pursue strategies to achieve this goal through either positive measures (e.g., healthy patterns of sleep, eating, exercise,
FIGURE 11-2 Developmental Pattern of Maladaptation to Early Trauma
Negative coping
Dysregulation
Misattunement
Distress
Trauma
11_Rowe_Ch11.indd 331 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
332 Families Across the Health Continuum
bypassed prefrontal cortex provides the individual with the executive functions of detailed assessment, regulation of emotion or thought, inhibition of inappropriate responses, expressive speech, and problem-solving skills. Over time, an individual constantly facing threat through trauma develops a fearful identity, avoids relationships because of pre- vious threats, has uncontrolled emotional outbursts or withdrawal, disassociates from the present, and/ or experiences depression.
The hippocampus, which is key in neuroplas- ticity or the ability to generate new neurons and new neuron pathways (known as neurogenesis), is impaired. This process explains why many who experience prolonged and repeated trauma struggle with cognitive impairments, such as poor short-term memory, difficulty with concentration, difficulty learning new skills, and poor sensory in- tegration, especially auditory processing (Sherwin & Nemeroff, 2011). This process has been found to be more severe in both children and adults ex- periencing relational trauma, or trauma inflicted by people in a position of trust (meso level), than those experiencing trauma from inanimate objects (e.g., motor vehicle accidents) or environ- mental trauma (i.e., natural disasters) (Evans & Coccoma, 2014; Heller & LaPierre, 2012). This process is most damaging when the trauma experi- enced occurs early in life, and continues through- out childhood, causing an initial and prolonged damage to normal brain development (Alisic et al., 2011; Evans & Coccoma, 2014). For family nurses, it is important to assess the start and dura- tion of any family trauma occurring to a child or young adult.
survival of the individual through stimulation of the sympathetic nervous system when the individual is threatened, and the parasympathetic nervous system when the individual is safe and relaxed. Hans Selye (1976), a renowned theorist on stress, identified the connection between the hypothalamus, the pituitary gland, and the adrenal glands, now commonly re- ferred to as the HPA axis. To summarize this process, the hypothalamus links the nervous system to the pituitary system, which secretes hormones that regulate homeostasis. If homeostasis is not reached, the adrenal glands secrete the stress hormones, epinephrine and norepinephrine. These hormones stimulate the sympathetic nervous system, and the result is increased heart rate, dilation of pupils, relaxation of bronchial tubes, increased tension and circulation of blood to large muscles, and initial stimulation of the prefrontal cortex through a surge of dopamine, followed by bypassing the prefrontal cortex to the amygdala.
This bypass process encourages rapid action based on the previous experience of threats, and the assumption that the same threat has occurred and the same action for survival is needed. When this process is stimulated repeatedly and without resolution, the connection between the limbic sys- tem (where automatic actions based on emotions and repeated actions rather than thought occur) and the cortex (or the thinking part of the brain that includes judgment, creativity, and prediction of action on future consequences) is pruned (i.e., cut). When the connection is pruned, sensory perception becomes scattered and disorganized. By bypassing the prefrontal cortex, the individual exchanges accuracy, judgment, and the ability to learn for speed. The
FIGURE 11-3 Top-down and Bottom-up Reaction
Thought
Top-down response to trauma
Emotion
Thought
Bottom-up response to trauma
Emotion
11_Rowe_Ch11.indd 332 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 333
outcome of chronic illnesses in adults. Gilbert et al. (2015) analyzed 53,998 surveys from adults from 10 states and the District of Columbia using the Adverse Childhood Experiences questionnaire to measure the number of adverse effects in childhood, and the Behavioral Risk Factor Surveillance System to measure the number of chronic conditions in adulthood. The results confirmed increased risk of mental and physical chronic conditions in adult- hood for those experiencing adverse childhood experiences, with increased risk as the number of adverse events increased. This study also noted that minority groups, those living in poverty, those with lower education, and women were at higher risk for adverse childhood experiences. This study validates the need to prevent adverse childhood experiences as a key measure in improving health in adults.
Clearly, understanding early trauma and the negative impact on children and development allows health care providers to grasp better the effect of traumatic events on adults. Studies have found that resiliency is one factor that determines which adults will continue to suffer from childhood trauma versus which adults will thrive following trauma. Of interest is that the number of traumatic events is found to be consistently higher in men, but women have a higher incidence of PTSD following trauma. This is consistently true for civilian populations across geographical locations (Kilpatrick et al., 2013). One theory is that women experience sexual assault and traumatic abuse from male partners, supporting the idea that relational trauma is more traumatic and more difficult to cope with than inanimate or nonrelational trauma (Brown, Burnette, & Cerulli, 2014). Further, sexual assault is often accompanied by shame and self-blame, which increases the risk of PTSD (La Bash & Papa, 2014). More recent studies have looked at the complexity of childhood trauma leading to continued re-exposure in adults in the forms of intimate partner violence and adult sexual assault. This too is more common in women. Brown et al. (2014) studied 162 women who were seeking court-ordered restraining orders for pro- tection against abusive intimate partners. Of these 162 women, 103 (64%) exhibited symptoms of PTSD. The authors also found a significant cor- relation between the incidence of childhood trauma and the severity of PTSD in adulthood among these women.
Early Childhood Trauma The impact of early trauma and the negative long-term outcomes has led to further study of the effect of childhood trauma on adult health. The Adverse Childhood Experiences Study was conducted be- tween 1995 and 1997 (CDC, 2016) provided land- mark evidence that early trauma does indeed have negative consequences for adult health. The study was conducted as a collaboration between Kaiser Permanente and the Centers for Disease Control and Prevention (CDC), and entailed surveying 11,000 individuals across a decade, linking adverse childhood experiences with adult physical and mental health variables. The results revealed a relationship between the number of adverse childhood experiences and the number of comorbid outcomes, including adulthood depression, panic disorder, substance abuse, sexual promiscuity, relationship problems, and domestic violence (Mersky, Topitzes, & Reynolds, 2013). Figure 11-4 illustrates the relationship between adverse childhood experiences and adult comorbid conditions. The findings of this hallmark study led to a more in-depth understanding of the cumulative effect of repeated and numerous traumas experienced during childhood, and the effect on brain develop- ment. More recent studies to confirm these findings continue to support the negative impact of multiple adverse events in childhood on the occurrence and
FIGURE 11-4 Relationship Between Adverse Childhood Experiences and Comorbid Conditions. Adverse Childhood Experiences Include Verbal, Physical, or Sexual Abuse, As Well As Family Dysfunction (e.g., an incarcerated, mentally ill, or substance-abusing family member; domestic violence; or absence of a parent because of divorce or separation) (Anda, Felitti, Bremner, Walker, Whitfield, Perry, Dube, & Giles, 2006)
M ea
n n
u m
b er
o f
co m
o rb
id o
u tc
o m
es
0 1 2 3 ACE score
4 5 6 7–8
6
5
4
3
2
1
0
11_Rowe_Ch11.indd 333 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
334 Families Across the Health Continuum
(2014) studied 250 youth in an inpatient treatment program for children who had experienced sexual and physical abuse. They confirmed that those individuals with the highest vulnerability scores and the lowest resiliency scores had the highest scores for depression. Resiliency traits, therefore, should be assessed by family nurses to determine those that were present before the trauma and reinforced, versus those that are lacking and need to be taught and supported. Resiliency can buffer the negative impacts of trauma on the individual’s brain development.
Recent studies have shifted from individual traits of resiliency to family traits of resiliency, recognizing that close family support has a signif- icant influence on both the genetic influence on resiliency as well as the environmental influence on learning and using resiliency traits (Walsh, 2016). This emphasizes the strength of using Bronfenbrenner’s Ecological Systems Model when assessing and treating not only trauma, but family resiliency as well.
Resiliency has moved beyond just preventing negative outcomes following a traumatic event, but understanding why some individuals and families report growth or positive meaning after a traumatic event or events. This phenomenon was first described by Antonovsky (1987) following his research on Holocaust survivors. He identified three characteristics of those that were healthy following prolonged trauma:
1. Finding solutions to problems (engaging cognitive functioning in the prefrontal cortex)
2. Identifying supportive resources 3. Identifying capacity (engaging motivation)
Later research by Antonovsky (1993) included the development of the Sense of Coherence Scale, now commonly used to assess survivors of trauma translated into several languages. This scale measures well-being or health following trauma, rather than pathology. Shakespeare-Finch and Armstrong (2010) used this research to guide their research on post-traumatic growth (PTG). They studied survivors of motor vehicle accidents, bereavement, and sexual assault, and found that those sexually assaulted had the lowest scores for PTG compared with the other two groups. They proposed that personal trauma, such as sexual assault, is experienced in isolation and surrounded by shame, whereas other types of trauma
Resiliency Through the improved understanding of child- hood trauma and related reactions, the concept of resiliency is more fully understood, or why some who experience the same or similar event will adapt without any measure of physical or emotional dam- age or even report growth, whereas others become severely and chronically disabled. “Most contempo- rary researchers now agree that resilience refers to positive outcomes, adaptation or the attainment of developmental milestones or competencies in the face of significant risk, adversity, or stress” ( Naglieri, LeBuffe, & Ross, 2012, p. 242). Research has focused on identifying factors or characteristics that are consistently found in those individuals found to be resilient. The factors most commonly cited as resiliency qualities include the following (Afifi & MacMillan, 2011; Overland, 2011):
■■ Social connectedness and positive supportive relationships
■■ Competent parenting ■■ Absence of mental illness in caregiver(s) ■■ Easy to moderate temperament ■■ High intelligence ■■ Ego-resiliency, or the acquisition of a strong sense of self across the life span with or without trauma (Philippe, Laventure, Beaulieu-Pelletier, LeCours, & Lekes, 2011)
■■ Compassion ■■ Optimism ■■ Gratitude ■■ Determination ■■ Meaning and purpose in life ■■ Caring for self and attuning to own needs ■■ Trusting others to help ■■ Internal locus of control ■■ High self-esteem ■■ Strong self-efficacy ■■ Vicarious resiliency (Hernβndez, Gangsei, & Engstrom, 2007)
Research on resiliency continues. For example, Philippe et al. (2011) investigated 118 clients from an outpatient clinic in Canada and found that if ego-resiliency traits were present before a trau- matic event, then negative outcomes, including anxiety, depression, and self-harm, decreased by as much as 30%. Although resiliency characteristics often precede the traumatic experience, this is not always the case. Deblinger, Runyon, and Steer
11_Rowe_Ch11.indd 334 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 335
experiences trauma differently, with different symptoms, reactions, and needs for recovery. For example, both parents and children experience similar symptoms of PTSD, but adults are more likely to experience re-experiencing the event through nightmares and flashbacks, whereas children are more likely to avoid similar experiences (e.g., avoiding riding in a car after a car accident) or avoid talking about the event. Both children and adults experience hyperarousal, or the HPA axis response to stress (Evans & Coccoma, 2014; Heller & LaPierre, 2012). When this occurs, parenting often becomes overwhelming as children overreact to environmental stimuli and parents overreact to the stressors of parenting. Each family member in turn can easily be misdiagnosed as depressed, anxious, or having attention deficit-hyperactivity disorder (ADHD) and the opportunity for effective and comprehensive treatment is therefore lost. The National Center for PTSD (2016) has identified 10 key areas that affect family functioning when one or more members are diagnosed with PTSD:
1. Increased sympathy by family members, which may provide support for the family member with PTSD or prolong feelings of victimization.
2. Increased negative feelings about the person with PTSD. These feelings are often triggered by changes in the person with PTSD, from changes in mood regula- tion, to depression, to explosive outbursts. The person is no longer the same as the person they knew before.
3. Avoidance is a common reaction by individuals with PTSD and by family members. Family members often circum- vent talking about anything related to the trauma, and may dodge other topics hop- ing to avoid angry outbursts. Individuals with PTSD tend to avoid social situations because of fear of not fitting in or being questioned about the trauma. This, in turn, leads to social isolation of all family mem- bers as they try to support the individual with PTSD.
4. Depression is common among individuals with PTSD and their family members. The longer the symptoms of PTSD last, the more likely family members may lose hope that their family member will ever get back to normal.
are often accompanied by societal support and are without social stigma. Others have confirmed this idea, with sexual assault across the life span having higher levels of PTSD when compared with nat- ural disasters, accidents, or other types of physical abuse (Evans & Coccoma, 2014). Resiliency in war victims offers further understanding into who will develop PTSD versus who will not. Studies have shown that women and children, and those vulnerable within a population, often suffer more in a war than soldiers. Evans and Coccoma (2014), after their review of literature, felt that part of this pattern is the increased isolation and lack of support of women and children; also part of this pattern is the praise and acknowledgment of soldiers, with honorary rituals for their service, while women and children remain silent victims. Children respond differently than women. The degree that children survive trauma without negative consequences depends on the nature of the threat, the stage of development, and the degree of cognitive awareness of the event, previous trauma experience, cultural beliefs, the quality of support, the proximity to the event, and individual resiliency traits (Evans & Coccoma, 2014; Masten, 2011). These studies help nurses realize the importance of making sure that trauma survivors are not left alone and isolated, but rather supported and respected, and that care is developmentally appropriate. Masten (2011), following a review of four decades of research on resiliency, concluded that interventions that were strengths-based and competence-focused, as well as interdisciplinary and developmentally appropriate, were the most successful. For example, a multidis- ciplinary parenting class that addresses individual challenges (i.e., emotional regulation) to global challenges (i.e., finding appropriate child care) can build resiliency traits and boost protective factors in parents and children. Research is continuing on a molecular to global level and involving diverse disciplines to identify preventive factors for indi- viduals and communities across time.
FAMILY TRAUMA
Families experience trauma as a family and through individual members. This section discusses both (1) family trauma through disasters and war, and (2) individual experiences of trauma and their effect on family members. Each member of the family
11_Rowe_Ch11.indd 335 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
336 Families Across the Health Continuum
have increased to 90% of the casualties of war in the 21st century, as compared with only 5% in the early 1900s. Worldwide, the caseload of refugee children has grown from 2.4 million in 1974 to 7.2 million in the past decade (Bridging Refugee Youth and Children’s Services, 2013). In Uganda alone, an estimated 20,000 children were forced into soldier labor during a 20-year period, with related physical abuse and witnessing of severe abuse and killing of other abducted children, including siblings (Beard, 2011). In the United States, the impact of war on families, other than for refugees, is limited to wartime separation and reunion. Over time, serving in one of the branches of the U.S. military has become far less common. Since 2001, only 1.6 million veterans (or less than 0.05% of the population) have served in Afghanistan or Iraq, compared with the 16 million or 12% of the population that served in World War II (Meagher, 2007). Still, the consequences for family members of military personnel are often dire and long lasting. Death, injury, and short- and long-term disability of the veteran are stressors that can make life difficult for families, especially spouses who become the caregiver (Burland & Lundquist, 2012). For example, an increase in traumatic brain injury sustained during war is associated with phys- ical neurological problems that are made worse by PTSD (Rosenfeld et al., 2013).
The risk of suicide among Veterans is 22% higher when compared to U.S. non-Veteran adults. The rates for male Veterans is 19% higher than U.S. non-Veteran men. The risk for female Veteran suicide is 2.5 times higher when compared to U.S non-Veteran women (Office of Public and Inter- governmental Affairs, 2017).
During the most recent war that affected Americans, Operation Iraqi Freedom, thousands of family mem- bers were deployed. This war brought to light the effects of the trauma of war on families. This war resulted in 6364 causalities and 48,296 wounded U.S. troops. Two million children were affected by separation from parents, changes in health status of parents, and/or loss of parents because of this war. Forty-four percent of these children were under 6 years of age, and so were particularly prone to the effects of trauma from coexperiencing family trauma (Smith, 2013). As evidence of the difficulty these families face, the telephone calls to the 24-hour helpline Military OneSource, which provides coun- seling to veterans and their families, numbered
5. Anger is common among family members as they struggle to cope with changes in the person with PTSD and anger that expectations are not being met.
6. Guilt and shame are common for family members as they feel helpless to change negative family functioning and find them- selves feeling angry about the individual’s illness.
7. Health problems increase in individuals with PTSD and their family members, including substance abuse, reduction in healthy immune response, and negative effects of poor eating habits, poor sleep, smoking, and lack of healthy exercise.
8. Fear and worry develop as their worldview changes given the intimate knowledge that terrible things can happen. Family members may also worry about symptoms of anger and unpredictable behavior that is manifested by the person experiencing PTSD.
9. Drug and alcohol abuse occurs as a way to escape their negative feelings.
10. Sleep problems develop, especially when it is a problem for the trauma survivor.
These outcomes can leave parents feeling in- adequate and spouses feeling angry, guilty, and disillusioned. Nurses are often at the forefront of trauma care, as they encounter family members during traumatic events from war, natural disas- ters, family violence and abuse, and severe illness or unanticipated accidents. The nurses’ role with families facing PTSD in a loved one include ed- ucation of the outcomes of PTSD, support for all family members, advocacy for families, and referral for appropriate counseling and support resources for both the individual experiencing PTSD and the family members.
Families Affected by War Since the turn of the century, the nature of war has changed dramatically. Warfare in the 21st century rarely involves confrontations between professional armies. Instead, wars typically are fought as grinding struggles between military personnel and civilians, or groups of armed civilians in a city environment rather than in distant battlefields. Thus, civilian fatalities from battles fought in towns and cities
11_Rowe_Ch11.indd 336 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 337
to cause PTSD for both men (65%) and women (46%). However, less than 1% of men reported a history of rape as compared with 9% of women. Combat-related trauma was found to be the sec- ond most common cause of PTSD in men (39%), whereas no women in this study reported exposure to combat-related trauma (Peterson, Luethcke, Borah, & Young- McCaughan, 2011).
Family Violence and Trauma Family violence is generally divided into three categories: physical violence, emotional violence, and sexual abuse. The cause of family violence is well studied and is considered multifaceted, with influences ranging from multigenerational trauma (Hulette, Kaehler, & Freyd, 2011), social and cultural learning, mental disorders, and oppression (Abbassi & Aslinia, 2010).
Family violence is often both a cause and an outcome of PTSD in family members. Orcutt, King, and King (2003) examined the impact of early-life stressors, war-zone stressors, and PTSD symptom severity on partners’ reports of recent male-perpetrated intimate partner violence among 376 Vietnam veteran couples. The results indicated that several factors are directly associated with family violence, including relationship quality among the spouses, war-zone experiences of stress, and PTSD symptom severity. Experiencing PTSD symptoms because of previous trauma appears to increase an individual’s risk for perpetrating family violence. Risk for partner violence is considerably higher among veterans with PTSD when both low marital satisfaction and alcohol
more than 100,000 in the first 10 months of 2005; the calls increased by 20% in 2006. More than 200,000 antidepressant prescriptions were written for military families/service members during a 14-month period in 2005 to 2006. Moreover, unidentified and untreated PTSD presented special risks for family reintegration and put the veterans and their families at higher danger for maladaptive responses to stress, such as alcoholism, depression, and family violence (Black et al., 2004; Bremner, Southwick, Darnell, & Charney, 1996; Davis & Wood, 1999). Most soldiers have transient symptoms of stress following a trau- matic event. These symptoms resolve for most when stability and routine are restored. This is the same pattern for children. But the risk for trauma-related symptoms in children from their parents’ traumatic experiences increases with prolonged separation from parent(s) and decreased time between recovery from one traumatic event to onset of another (i.e., repeated deployment, or repeated terror associated with war) (Smith, 2013). Because of the increased understanding of the risk of trauma to family mem- bers, the military has funded numerous studies to identify effective strategies to prevent PTSD in soldiers and their family members. One program, entitled Building Resilience And Valuing Empowered Families (BRAVE Families), employs strategies used for families experiencing effects from urban violence, Hurricane Katrina, and the World Trade Center ter- rorist attack. These strategies include individual and family education and support about PTSD, art and play therapy for children, parenting guidance, and group therapy and support (Smith, 2013). The goal of programs designed to reach PTSD at the meso level is to reach more families experiencing trauma early rather than waiting for families to experience pathology first.
The National Comorbidity Survey (NCS) evaluated PTSD symptoms for 5877 individuals between the ages of 15 and 54 in the United States. The results indicated that the lifetime prevalence of PTSD in the American sample was 8%, and a higher percentage of women (10%) met PTSD criteria than men (5%). Interestingly, more men (61%) reported exposure to potentially traumatic events than women (51%). These differences suggest that other factors, such as the type of trauma, may also play an important role in the development of PTSD. For example, the NCS study found that rape was the trauma most likely © iStock.com/ejwhite
11_Rowe_Ch11.indd 337 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
338 Families Across the Health Continuum
abuse-dependence are present (Fonseca et al., 2006; Taft et al., 2005).
Domestic violence also increases the risk for PTSD and is a cause for PTSD for both the victims and witnesses of the violence. The incidence of witnessing domestic violence and related trauma continues to be a major public health problem. In 2014, it was estimated that five million children in dual-parent homes lived in a home where partner violence was present (Childhood Domestic Violence, 2014). The risk to children is great, including physical injury from getting in the “cross-fire” to psychological distress similar to children experiencing direct abuse (Kitzmann, 2012). Long-term, childhood domestic violence increases the risk for drug abuse, violent crimes, and suicide (Childhood Domestic Violence, 2014).
Other family trauma also negatively affects the individuals within the family. For example, children experiencing divorce and abuse are at particular risk for acquiring a later adult mental health illness, including PTSD and depression. In a study of 5877 individuals ages 15 to 54 years from the National Co-Morbidity Study, Affi et al. (2009) found that children exposed to both divorce and abuse had the highest rates of mental health illnesses as adults, particularly PTSD. A meta-analysis of 124 articles on long-term outcomes of children experiencing physical abuse or neglect found more depression, suicide risks, family violence, and substance abuse when compared with those not exposed to abuse and neglect (Norman et al., 2012).
The experience of trauma, especially repeated traumas, increases the risk of long-term negative outcomes for children and adults. Each family mem- ber exposed to abuse, neglect, and major transitions and loss, such as divorce, is at risk for PTSD, as well as continuing the cycle of violence within families, with repeated events increasing that risk (Hulette, Kaehler, & Freyd, 2011). As noted earlier, family resiliency traits can alter these outcomes signifi- cantly, with the result that, for most individuals who experience negative and traumatic events and have strong personal and family resiliency traits, these families do not develop negative health outcomes or repeat the family pattern of PTSD (Walsh, 2016). These findings clearly support the need for trauma-focused family care and interventions by nurses and other health care providers to prevent family-centered trauma. © iStock.com/PickStock
Families Affected by Disasters Disasters are events that cause widespread destruction of property, dislocation of people, and immediate suffering through death or injury. Disasters interrupt basic daily needs, such as obtaining food and shelter, for an extended period, making recovery difficult.
During the past three decades there were a total of 372,634 deaths, 995,219 injuries, and more than 61 million people negatively affected by earthquakes. The majority of deaths were related to collapsing buildings and other structures. The most vulnerable citizens were the very young and the very old, or those not able to escape without assistance from others. Earthquakes occurring in low-income countries have had the highest mortality rate largely because of the lack of protective infrastructure, as well as poor recovery following the disasters (Doocy, Daniels, Murray, & Kirsch, 2013).
Disasters are classified as either natural or human caused. Natural disasters include weather and seismic events such as floods, hurricanes, and earthquakes. Human-caused disasters include events such as fires, building collapse, explosions, acts of terrorism, or war.
Natural disasters are the most frequently occurring type of disaster. In the last 10 years, the Interna- tional Red Cross reported that 1.1 million people across the world were killed by natural disasters (e.g. hurricanes, tornadoes, earthquakes, storms, tsunamis, and volcanic eruptions) (International Federation of Red Cross and Red Crescent Societies, 2012; UNISDR, 2012). An additional 100,000 people were killed worldwide from technological disasters, ranging from industrial accidents to transportation
11_Rowe_Ch11.indd 338 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 339
parent-child relationships (Samper, Taft, King, & King, 2004). Among Iraq and Afghanistan veterans, trauma symptoms such as sleep problems, dissoci- ation, and severe sexual problems predicted lower marital satisfaction for both the veteran and his partner (Blow et al., 2015; Goff, Crow, Reisbig, & Hamilton, 2007).
Gorman, Eide, and Hisle-Gorman (2010) determined that parental wartime deployments affect the children of deployed parents in multiple ways, but the clinical significance of those effects is still unknown. They concluded that there was an 11% increase in mental and behavioral health services sought during a parent’s deployment. In addition, services for behavioral disorders grew by 19% and services for stress disorders grew by 18%. Although the need for mental and behavioral health increased, the need for other outpatient services decreased. Furthermore, incident rates for children were particularly higher when they were older than 8, both parents were on active duty and married, or when the male parent was deployed.
Secondary Traumatization The impact of trauma is not limited to the traumatized persons themselves. Spouses of the injured persons seem particularly susceptible to a phenomenon called secondary traumatization (Dirkzwager, Bramsen, Ader, & Van der Ploeg, 2005). Secondary traumatization has only recently been described and is not yet a diagnostic category in the DSM-V (APA, 2013). In a study of Dutch peacekeeping soldiers and their families (Dirkzwager et al., 2005), it was found that partners of peacekeepers with PTSD symptoms reported more sleeping and somatic problems, more negative social support, and judged the marital relationship as less favorable when compared with the general population. Another study in Israel found that spouses of veterans with PTSD suffered from higher levels of emotional distress and a lower level of marital adjustment than the general population (Dekel, Solomon, & Bleich, 2005). In a qualitative study of wives of Israeli veterans with PTSD, Dekel et al. (2005) noted that the wives were carrying a heavy burden supporting and caring for their husbands and families; all of them identified personal symptoms of PTSD from hearing about their partner’s trauma and experiencing the negative
accidents (International Federation of Red Cross and Red Crescent Societies, 2016). During the years 2004 to 2005, natural disasters killed 336,540 people in the world and more than 300 million people were directly or indirectly affected by those disasters ( International Strategy for Disaster Reduction, 2006). In the United States alone during 2007, tornadoes killed 80 people, and thunderstorms and accompanying floods, lightning, winds, and hail caused another 157 deaths (National Severe Storms Laboratory, 2007). In 2011 the Disaster Relief Fund requested $1.95 billion in aid for families and indi- viduals affected by such disasters (U.S. Department of Homeland Security, 2011).
Regardless of the type of event, families are affected in multiple ways when disasters strike. Some of the many stressors that occur include loss of significant others, injuries to self or family, separation from family, or extensive loss of property. These losses result in heightened feelings of stress, with many families experiencing symptoms of PTSD. The most vulnerable suffer the most. For example, children often display sleep disturbances, depression, and anxiety, with symptoms increas- ing the closer the child is to the disaster and the perceived threat to self and loved ones (Evans & Coccoma, 2014).
Family Functioning and Post-Traumatic Stress Disorder Trauma-related reactions have a negative impact on family functioning. In a study of current relationship functioning among World War II ex-prisoners of war, more than 30% of those with PTSD reported relationship problems compared with only 11% of those without PTSD (Cook, Riggs, Thompson, Coyne, & Sheikh, 2004). In Vietnam veterans, PTSD symptoms have been significantly associated with poor family functioning (Evans, McHugh, Hopwood, & Watt, 2003) and problems with marital adjust- ment, parenting satisfaction, and psychological abuse (Gold et al., 2007). In a review of literature related to family relationships and PTSD, Blow, Curtis, Wittenborn, and Gorman (2015) reported a similar pattern for veterans returning from Iraq and Afghanistan, with the added negative effects of traumatic brain injuries and multiple deployments. The PTSD symptoms of avoidance and emotional numbing in particular have deleterious effects on
11_Rowe_Ch11.indd 339 12/21/17 5:04 PM
.
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
340 Families Across the Health Continuum
The community has a key role in the prevention and treatment of trauma. Child welfare services often respond to threats of trauma from abuse and neglect, and police services often respond to threats of domestic or community violence. Nurses as a professional group are mandatory reporters. Every state in the United States and province in Canada has enacted legislation governing the reporting of child abuse and elder abuse. Reporting requirements across countries can differ, and each health care provider is responsible for knowing which condi- tions require reporting to appropriate authorities. Coohey, Renner, Hua, Zhang, and Whitney (2011) identified mandatory reporting as an intervention that facilitates engagement with services that can promote resilience.
It is incumbent on all agencies that work with victims of trauma to become well versed in TIC. Agencies that work with trauma victims have a responsibility to be trained for their role in trauma care. For example, if child welfare workers are not properly trained on trauma, they may not support foster parents in appropriate reactions to chil- dren with trauma-related behaviors. This lack of support may lead to placement failure and result in children being retraumatized by multiple inter- ruptions in attachment, initiating a dangerous cycle (Richardson, Coryn, Henry, Black-Pond, & Unrau, 2012). Box 11-1 presents responses to questions regarding exposure to trauma as a training guide for health care providers.
Consider the following scenario: A 13-year-old child, who has been sexually abused by her father, is placed into foster care. During counseling, she is encouraged to retreat to a quiet place when chaos from the crowded foster care becomes too much. Because of lack of training and poor
effects on their partner’s health. Partners of veterans with combat-related PTSD experience significant levels of emotional distress (Manguno-Mire et al., 2007).
This pattern is not limited to family members caring for veterans with PTSD (Devilly, Wright, & Varker, 2009). Other studies have looked at non- family members. Thomas and Wilson (2004) re- ported that 7% of health care providers working with traumatized victims experience symptoms consistent with PTSD. Other researchers have attempted to define this phenomenon, using terms including compassion fatigue, professional burnout, and secondary traumatic stress (Meadors, Lamson, Swanson, White, & Sira, 2009; Newell & MacNeil, 2010). Each definition describes the psychological and physical response to caring for victims but not directly experiencing trauma. Meadors et al. (2009) studied 167 health care providers working in pediatric intensive care units. They found a sig- nificant correlation between compassion fatigue, or secondary traumatization, and symptoms of PTSD. Nurses, physicians, social workers, and chaplains described the difficulty of caring for families who had a child severely ill, injured, or dying. These professionals not only heard about the traumatic event repeatedly from families, but witnessed the traumatic events over and over as they cared for families across time. This witnessing of trauma led to secondary traumatization.
COMMUNITY AND TRAUMA
The community response to trauma can have a major impact on the degree of traumatic stress experienced by individuals, families, and the community as a whole.
Have you ever attended workshops or trainings about how people are affected by extremely frightening or traumatic events?
Never: 85.9% <1 day: 7.7% <2 days: 1.3% 2 days: 1.3% 2 + days: 3.8%
Have you ever listened to radio programs/read literature about how people are affected by extremely frightening or violent events?
Never: 19.2% 1 –2 times: 16.7% 3 –4 times: 39.7% 4 –7 times: 15.4% 7 + times: 9.0%
BOX 11-1 Responses to Questions Regarding Exposure to Western Trauma Discourse
11_Rowe_Ch11.indd 340 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 341
children in the United States will experience or witness a traumatic event before they reach age 4 years (SAMSHA, 2011). These statistics show symptoms of a country experiencing dysregulation from systemic trauma.
The high obesity rate in the United States is a clear example of a nation experiencing dysregulation and fear. Obesity is growing the fastest in our poor and crowded neighborhoods. The lack of healthy foods, safe neighborhoods that support outdoor activity, high levels of stress, and presence of early and repeated trauma are key factors in causing obesity and related chronic health conditions (Karr-Morse & Wiley, 2012). Yet, the response to obesity is not centered on trauma-focused inter- ventions, but instead on unsuccessful dieting and major surgeries.
Another indicator that the United States as a nation is struggling with high levels of trauma and related stress symptoms is the increasing rate of substance abuse. Although nicotine addiction is at an all-time low, addiction to other substances, such as alcohol and opiates, is increasing at an alarming rate (National Institute on Drug Abuse, 2012). Researchers have found that those struggling with food cravings leading to obesity and those struggling with drug addiction both exhibit decreased dopamine levels. Overeating and drug use temporarily raise dopamine levels. A lack of dopamine, particularly in the frontal cortex, is caused by early trauma more often than genetics (Karr-Morse & Wiley, 2012). A country experiencing repeated trauma without resolution quickly fills with individuals, families, and communities that are highly stressed and traumatized, with resulting increase in stress-related illnesses.
Chronic stress is toxic stress. Toxic stress, as defined by the Center on the Developing Child at Harvard University, is when an individual experi- ences strong, frequent, and prolonged stress such as chronic child abuse or neglect without adequate support (Center on the Developing Child, 2012). Toxic stress interferes with the ability to learn, be creative, stay healthy, and have joy. Countries that experience toxic stress through natural disasters, war, or dysregulation of major systems also experience a drop in the ability to learn, be creative, have healthy citizens, and have joyous outcomes. Robin Karr- Morse and Meredith Wiley, the authors of Scared Sick: The Roles of Childhood Trauma in Adult Disease (2012), compared our body’s response to stress with the U.S. Department of Homeland Security.
communication with the counselor, her foster mother scolds her for “being too isolated.” When she goes to school, she becomes overwhelmed by fear and retreats to the library to regain her ho- meostasis. Because her teachers are untrained and unaware of her needs, she is again punished. She begins to distrust her counselor, foster parent, and teachers, and relapses into fear, disconnection, and dysregulation. She retreats into rigid boundaries. This short vignette illustrates the importance of educating community-based service providers to understand TIC and to integrate and collaborate services to promote positive rather than dangerous and negative outcomes.
SYSTEMIC TRAUMA
The symptoms of post-traumatic stress (PTS) cross individual, family, and community boundaries. Many argue that the United States of America is suffering from PTS from repeated traumatic events such as wars, natural disasters, and economic traumas across time without resolution or intervention. This has resulted in a nation with trauma symptoms, including depression, intrusion of unwanted and negative thinking patterns, hyperarousal especially to perceived threats from others, and related health decline. One clear symptom of this premise is the decline in the general health of U.S. citizens, not unlike the health of individuals suffering from PTSD. Americans possess the shortest life span of any industrialized nation, with almost half of American adults struggling with hypertension, high cholesterol, diabetes, or all three. Further, more than one-third of adults and children are obese (U.S. Department of Health and Human Services, 2012). An increasing number suffer from stress- related illnesses, stemming from or causing mental illness, substance abuse, and domestic violence, as well as several different physical illnesses. Infant mortality is dismally high, with the United States ranking highest among the top seven industrialized countries of the world (U.S. Department of Health and Human Services, 2012). Child abuse rates are equally high when compared with other nations (U.S. Department of Health and Human Services, 2012). One-quarter of our nation’s children take prescription medications. One-fifth of our nation’s children have been diagnosed with a mental health illness (Hensley, 2010). Twenty-six percent of all
11_Rowe_Ch11.indd 341 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
342 Families Across the Health Continuum
help throughout the healing process renders nurses important members of the interdisciplinary team that prevents, treats, and evaluates care for individuals and families affected by trauma-related illnesses. This section outlines the nurse’s role in the prevention, identification, and treatment of these conditions as part of an interdisciplinary team.
Trauma-Informed Nursing Assessment and Intervention Trauma-related illnesses, including PTSD, can develop after a traumatic event or events at any age. To be diagnosed with PTSD, certain conditions must exist. The person has to have been exposed to a traumatic event; experience intense feelings of fear, helplessness, or horror (for preverbal children, the feelings of helplessness are commonly seen as withdrawal, and feelings of fear are commonly seen as intense emotional arousal); re-experience the event through flashbacks, dreams, or disturbing memories; avoid any stimuli associated with the event; avoid any reminders, thoughts, or feelings about the event; be hypervigilant; have difficulty falling or staying asleep; possess an exaggerated startle response; and have symptoms that last lon- ger than 1 month and cause significant distress or impairment in functioning (APA, 2013; National Center for PTSD, 2010).
It is the role of nurses to assess for symptoms of PTSD. There are simple methods to screen patients who may have undetected PTSD. One easy to use tool is the Primary Care PTSD Screen (Prins et al., 2016), which consists of five questions preceded by an introductory question (referenced below).
Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:
■■ A serious accident or fire ■■ A physical or sexual assault or abuse ■■ An earthquake or flood ■■ A war ■■ Seeing someone be killed or seriously injured ■■ Having a loved one die through homicide or suicide
Have you ever experienced this kind of event? YES/NO If no, screen total = 0. Please stop here. If yes, please answer the following questions.
Both systems are aimed at a complex and inte- grated system that maintains safety. When part of that system is overtaxed or disconnected, safety is threatened. Threats to the larger system, whether real or imagined, can further overwhelm the system and lead to disease.
The greater culture and societal laws and policies can influence the incidence and the treatment of trauma. Countries riddled with war, poverty, and disease have higher incidents of stress-related symptoms, whereas countries that support policies that decrease violent solutions to problems, provide broad access to preventive and primary health care, and decrease poverty have lower incidences of stress-related symptoms. For example, the incidence of PTSD in New Zealand is estimated to be 6.1% of the population (U.S. Department of Veterans Affairs, 2007), whereas the incidence of PTSD in the Gaza Strip was found to be 77% of 9- to 18-year-olds exposed to the ongoing Israeli-Palestinian conflict (Fasfous, Peralta-Ramírez, & Pérez-García, 2013). The extent that countries can prevent and/or treat the causes of post-traumatic stress early clearly influences the health of the citizens in every country.
Many argue that the traumatic events experienced over the course of the last two decades in the United States were too rapid to resolve and caused a chronic state of fear in the country. For example, in 2005 the United States experienced Hurricane Katrina, continued involvement in the Iraq war, economic collapse, raging wildfires in California, a severe snowstorm in New England, and a school shooting. U.S. citizens watched these disasters unfold with little support or education on how to process these events to avoid post-traumatic stress symptoms. Today, many individuals talk about feeling numb to the disasters watched on television, and have increased fear related to travel, economics, and routine activities, such as attending school. The management of trauma symptoms need to expand beyond individuals, families, and communities, and include national and international traumas and the impact on a nation as a whole.
NURSES AND TRAUMA
Nurses are key to helping with the diagnosis and treatment of trauma-related illnesses in individ- uals and families. Their presence at the forefront of emergency care of victims of trauma and their
11_Rowe_Ch11.indd 342 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 343
characteristics (Friedman, 2006; Warner, 2010). See Box 11-2 on vicarious trauma.
Risks Associated With Trauma There are several risks and risk factors associated with both adults and children exposed to traumatic events of which nurses should be aware:
■■ Suicidal risk: because of feelings of numbness, disconnection from support people, chronic fear and anxiety, and feelings of hopelessness and helplessness.
■■ Danger to others: ask about firearms or weapons, aggressive intentions, feelings of persecution.
■■ Ongoing stressors: such as changes that have occurred at home, marital discord, problems at work.
■■ Risky behaviors: such as risky sexual adven- tures, nonadherence to medical treatment, substance use and misuse.
■■ Personal characteristics: past trauma history, coping skills, relationship attachment.
■■ Limited social support: the individual’s lack of willingness to accept help and inclination to isolate.
■■ Comorbidity: coexisting psychiatric or medi- cal problems such as depression and chronic widespread pain (CWP).
In the past month, have you. . . .
1. Had nightmares about the event(s) or thought about the event(s) when you did not want to? YES/NO
2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? YES/NO
3. Been constantly on guard, watchful, or easily startled? YES/NO
4. Felt numb or detached from people, activities, or your surroundings? YES/NO
5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? YES/NO
(Prins, A., Bovin, M. J., Kimerling, R., Kaloupek, D. G., Marx, B. P., Pless Kaiser, A., & Schnurr, P. P. (2016). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). [Measurement instrument]).
The screen is positive if the patient answers yes to any three items.
It is also important for nurses to assess risk factors and provide families with protector factors or posi- tive coping strategies and enhancement of resiliency
Trauma clearly transcends individuals, families, communi- ties, and greater societies across time and across cultures. Nurses are often the front-line health care providers to identify and intervene when acute and chronic trauma occurs.
A real risk for nurses is the development of the attunement survival style described by Heller and LaPierre (2012). This style of coping is characterized by attuning to others’ needs and neglecting one’s own needs, which is an apt description of the lived experiences of many nurses. If nurses identify themselves as givers, yet neglect their own needs, they are at a high risk for vicarious trauma, or the development of PTSD symptoms from caring for or witnessing trauma in others. This condition is also referred to as compassion fatigue and secondary trauma in the literature (Afifi et al., 2009).
This term has evolved as helping health care providers were identified as being at high risk for negative psychological reactions to their job, with early descriptions of burnout. Symptoms of burnout include feeling overwhelmed, hopeless, helpless, and unappreciated. Motivation is lost, and if unrecognized and untreated, it may lead to depression, loss of job, and, in the long term, early death (Smith, Segal, & Segal, 2012). Although burnout can be caused by repetitious and uninspiring work, it can also be caused by vicarious trauma. Prevention of vicarious trauma is possible through education, avoiding professional burnout, and professional and peer support during and after caring for traumatized patients (Pearson, 2012).
BOX 11-2 Vicarious Trauma
11_Rowe_Ch11.indd 343 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
344 Families Across the Health Continuum
Once symptoms develop, outcomes improve with a combination of individual and family therapy, along with appropriate medication management of symptoms when needed. For example, in a study of seven children following a bus accident, the combination of individual and family ther- apy with selective serotonin reuptake inhibitors ( SSRIs) resulted in a remission of PTSD symp- toms, whereas the control group that only received medication without family therapy still had symp- toms 3 months later (Stankovi et al., 2013). In the cases where medication and family therapy were used, researchers used systematic family therapy (SFT), a structured family therapy protocol, to facilitate family involvement and family-directed interventions. It proved effective in preventing chronic PTSD in victims.
Secondary Family Traumatization Assessment and Intervention To help the traumatized family, the nurse should first realize that traumatized families rarely seek family-focused intervention. Instead, they often present with problems that are not immediately related to the traumatic events they have experienced (Figley & Barnes, 2005). Nurses should learn the parallel processes of individual and systemic stress reactions that follow a traumatic event. Figley and Barnes (2005) offer suggestions to help clinicians recognize family responses to traumatic events and offer some interventions to help patients and families affected by these events. For example, families are affected by the individual’s symptoms of PTSD. They know the story of the trauma, witness the symptoms, and want to help in some way. Therefore, the family spends more and more time caring for the trau- matized member. Moreover, while the traumatic event is being persistently re-experienced by the exposed family member, the other family mem- bers are responding to this individual’s expressed need for support. As the primary affected family member tries to avoid stimuli and reminders of the trauma, the other family members must de- vote increased time, energy, and problem solving to avoid conversations, people, places, and things that might stimulate memories. They have to cope with withdrawal and numbing that goes along with the primary affected family member’s diminished interest in usual activities, refusals to see friends,
Child risks associated with PTSD include the following:
■■ Dysregulation: unpredictable or irregular sleep and eating patterns, and difficulty regulating moods and emotional responses.
■■ Poor connection: difficulty forming or main- taining relationships, with a tendency to be alone, have poor eye contact, and resist con- nection with others.
■■ Poor cognitive development: difficulty with attention, short-term memory, problem solving, creativity, and play. High incidence of learning disabilities, particularly auditory processing disability.
■■ Poor attunement skills: difficulty recognizing and asking for needs.
■■ Inability to trust: difficulty forming relation- ships, oppositional behavior, sleep problems.
■■ Hyperarousal: increased response to environ- mental stressors or memories, with rage, anger, or severe anxiety.
The best evidence-based nursing treatments for the individual with PTSD include both psychothera- peutic interventions—such as cognitive-behavioral therapy (CBT) and family therapy—and education and monitoring of medications, primarily SSRIs (Friedman, 2006; Herbert & Sageman, 2004; Sautter et al., 2006; U.S. Department of Veterans Affairs, 2016). CBT is one type of counseling. Research shows it is the most effective type of counseling for PTSD. The U.S. Department of Veterans Affairs (VA) is providing two forms of CBT to veterans with PTSD: cognitive pro- cessing therapy (CPT) and prolonged exposure (PE) therapy. Prevention is the goal with primary treatment of potential post-traumatic stress re- sponse; several programs start interventions at the time of the traumatic event rather than waiting for symptoms to develop. Sufficient evidence for psychological first aid is widely supported by available objective observations and expert opinion and best fits the category of “evidence informed” but without proof of effectiveness. An intervention provided by volunteers without professional mental health training for people who have experienced a traumatic event offers an acceptable option. Further outcome research is recommended (Fox et al., 2012).
11_Rowe_Ch11.indd 344 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 345
and inability to express love and caring. The family becomes increasingly more isolated. Family members have to manage problems with sleep, outbursts of anger and rage, exaggerated startle responses, and hypervigilance about safety. These factors increase the risk of secondary traumatization or symptoms of trauma reaction in family members from witnessing the traumatic stories and the negative impact on the primary family member.
Nurses applying TIC using the Ecological Systems Theory Approach to Trauma Treatment begin the treatment by correcting interrupted trust and attachment (Heller & LaPierre, 2012). Infants and young children who experience rejec- tion and abuse early in life often expect that same experience from present and future caregivers. A trusting and therapeutic relationship must form. This process is slow, as the child or adult who has learned to avoid feelings and relationships will first resist, and then struggle with moderating those feelings and relationships, and then, if successful, learn to trust. The initial steps of treatment are as follows:
1. Move slowly: building connections can be terrifying to a traumatized individual.
2. Build trust: building a therapeutic rela- tionship depends on being predictable and trustworthy.
3. Be empathetic: you may be the first kind person in their lives.
4. Help children and adults listen to and explore their new skills at identifying emotions, organizing thoughts and emo- tions, and learning different reactions and responses to their emotions.
5. Help build self-esteem through teaching top-down thinking. For example, if an adult has always felt he was bad because of traumatic events in his life, help him rethink about the events being bad instead.
6. Gradually support and encourage connec- tion with their own feelings, then their body responses and reactions, and finally connection to other people. The connec- tion to other people should also be gradual, starting with close caregivers or family members, and advancing as tolerated to outside peers and associates.
7. Be available to help the child or adult explore feelings of rejection, anger, aban- donment, and fear. Many individuals who have experienced trauma have survived by becoming numb. As this numbness fades, survival feels threatened. During this transition from numbness to feeling, many may withdraw for varying periods of time. A therapeutic nurse will rec- ognize this pattern and avoid judging the traumatized individual during these phases.
8. Help children and adults connect with oth- ers, as support has been found to be a key factor in successful treatment of trauma (Evans & Coccoma, 2014).
The nurse working with a traumatized family needs to explore each family member’s perception of what happened both before and after the event. The family may block the telling of trauma if the family was the cause of that trauma. Listening to individuals and observing for signs of secondary trauma can be critical to getting help for all family members. The nurse needs to recognize that the family’s worldview will have been altered by the traumatizing events and that its attitudes and beliefs may shift from safety to suspicious, distrustful attri- bution regarding the motivations of others, including helping health care providers. Hypervigilance and controlling behaviors may actually interfere with the family getting the help it needs. In addition, if the stressors impinging on the family go unattended, a pattern of poor communication and blaming may become the central family dynamic. Also, the roles in the family may shift, with some members becoming more enmeshed with the traumatized member and others withdrawing from the family system. Children may have to take on the role of emotional caretaker for the parents and thus be compelled to hide their own feelings and fears, while other siblings act out to express anger, leading to more parenting stress. Most emerging trauma treatment has as its main shortcoming the focus on the individual rather than the family system. Careful implementation of interviewing techniques and the exploration of the family life experience through ecomaps will assist nurses in accessing the complex relationships and characteristics of families living with trauma or post-traumatic complications. Nurses are also key
11_Rowe_Ch11.indd 345 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
346 Families Across the Health Continuum
This case study offers an example of a family that experienced trauma, and the impact of individual trauma and family trauma on all family members. The events that occurred within this family illustrate the complexities of prolonged and repeated trauma, as well as resiliency characteristics touching the individual, family, community, and nation.
Family Members: • Mother: Laura (age 45) • Father: Victor (age 46) • Oldest daughter: Natalie (age 24 years) • Middle daughter: Kimberly (age 23 years) • Youngest daughter: Taylor (age 22 years)
Figure 11-5 shows the Knoll family genogram. The Knoll family initially sought care at a multidisciplinary clinic because of increasing concerns about their youngest daugh-
ter, Taylor. They started this care when Taylor was 15 years of age, and complained that Taylor was refusing to attend school, using marijuana and alcohol on a daily basis, and was currently dating a man who was 20 years older. When they threatened to call the police, Taylor stated she would “run away and never return.”
Family Development: The mother, Laura, has a history of intimate partner violence from her husband, causing her to escape across the country when her daughters were ages 3, 4, and 6, respectively. She remarried when her daughters were ages 8, 9, and 11, respectively. All three girls did well until adolescence, with participation in sports, family activities, and school. Her youngest daughter abruptly stopped all participation in school and sports at age 13 years, and began befriending peers that were involved in drugs. Her mother sought treatment through her primary care physician, who recommended residential care. In spite of 3 months’ residential treatment, the same problems continued. When Laura’s oldest daughter disclosed memories of sexual abuse from her biological father when she was in preschool, Laura became overwhelmed. She had just asked her ex-husband to take care of her younger daughter as she did not know how to help her. In spite of her ex-husband being an active alcoholic with a history of physical violence and now under suspicion of sexual abuse of her oldest daughter, this decision brought more guilt and shame to Laura. However, Taylor insisted on going to live with Laura’s ex-husband and did not believe he sexually abused her sister. Taylor came back after 6 months. Laura tried other resources and agonized as she watched her youngest daughter struggle through years of methamphetamine and heroin addiction. Her ex- husband moved to town when her daughters were 18, 19, and 21, respectively. This added to her stress, as he demanded participation in family activities and celebrations, and demanded rides from all family members as he did not have a driver’s license. This caused strain in her current marriage. Today, Laura works full time and cares for her four grandchildren on a regular basis. She has recently started counseling because of feelings of depression and being overwhelmed with family responsibilities.
The father, Victor, lived across the country from his family from the point of divorce until 5 years ago. Divorce occurred against his will when his three daughters were ages 3, 4, and 6, respectively. Although he has had other partners, he continued
Case Study: Knoll Family
in finding resources for families that use a family approach to trauma care.
The nursing role also includes looking at com- munity actions and societal responses to trauma at a personal, family, community, and societal level, and how that trauma affects health. Becoming involved with prevention strategies, such as community preparedness for disaster, can lead to improved community health. Working with national orga- nizations to provide organized community-based interventions for traumas can be an important step to preventing negative long-term consequences.
Participating in research and implementing research findings that demonstrate the impact of trauma on all ecological levels can help improve treatment plans and outcomes. Finally, shaping policies at the national level that support families in need, by decreasing poverty, improving access to health care, supporting parents with improved child-care options and improved parenting education and support, and reducing environmental stress, can be an important step to reducing the impact of trauma in children, adults, families, communities, and nations.
11_Rowe_Ch11.indd 346 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 347
to try to get back together with his ex-wife, trying to convince her that the domestic violence was only caused by his heavy drinking. He denied any sexual abuse of his daughter. He continued drinking alcohol in spite of being diagnosed with hepatitis C and cirrhosis of the liver. He was agreeable to having his youngest daughter come live with him when she was 14 years of age, which lasted 6 months. Taylor left her father’s home because of his “constant drinking.” Two years later Victor moved to the same town as his children and ex-wife. He currently joins the family for all family events and celebrations. He maintains employment off and on, and relies on his daughters for transportation to his job as he does not have a driver’s license because of repeated citations for driving under the influence (DUIs).
Natalie grew up with her mother and two sisters from the time of her parents’ divorce to her mother’s remarriage when Natalie was 10 years old. She then lived with her mother, stepfather, and two sisters. She did well in school and participated in activities throughout her school years. When she was 17 years old, she disclosed memories of sexual abuse. She was distraught to learn that her siblings did not believe her, and her mother told her to “forgive your father; that was a long time ago.” She sought counseling on her own, but now notes that she continues to pick abusive men as partners. She has two children from different fathers, and both fathers are incarcerated for drug sales. She is completing her college degree in counseling.
Kimberly, the middle daughter, grew up with her mother and sisters until her mother remarried when she was 8 years of age. She then lived with her mother, stepfather, and two sisters. She did well until high school, when she developed inca- pacitating panic disorder. This caused her to avoid school. She received antianxiety medications for approximately 1 year and reported feeling better. She received her general equivalency diploma (GED) when she was 20 years of age, and now works as a housecleaner. She has had the same partner for the past 4 years, and they have one daughter together. Her partner is concerned about her alcohol abuse and has threatened to leave if she does not seek treatment.
Taylor, as the identified patient, stated she did well in school and with peers until she was 13 years of age. She states she then became very depressed and lost interest in all that she previously cared about. She remembers being in residential care and being diagnosed with bipolar disorder. She was given medications, but she refused to take any of the medications once she left the treatment facility. Upon return home, she returned to using drugs as a strategy to “feel something” and “have the energy to do anything.” Taylor spent 6 months with her father at age 14 years, but returned stating he “drank too much.” Taylor then went back to residential care for 6 months, followed by 3 years of methamphetamine and heroin addiction.
Case Study: Knoll Family (cont.)
(continued)
Taylor
Victor 46 yr
Laura 46 yr
Porche 2 yr
Kim Natalie 24 yr
FIGURE 11-5 Knoll Family Genogram
11_Rowe_Ch11.indd 347 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
348 Families Across the Health Continuum
She earned her GED, and has been fully employed in computer technical help for the past 5 years. She gave birth to her daughter, Porche, 2 years ago. Because Porche’s father was trying to get custody because of Taylor’s drug use, she re-entered drug treatment. During this treatment time, she experienced a flooding of memories of her father sexually abusing her during her preschool years. She stated she remembered her father getting drunk and sexually abusing her in a closet in their old home. She stated she felt shame and extreme guilt that she did not believe her sister when her sister disclosed the same abuse. She stated she did not know how to set boundaries with her father to this day, and requested help keeping her father out of her life. Currently, her father calls her almost daily, and demands help with transportation three to five times per week.
Function: Communication within the family started out as avoidant, with each family member feeling unable to share thoughts and feelings with other family members. Boundaries were blurred and unclear (i.e., mother being unable to say no to having her daughter live with a suspected sexual abuser, and Taylor being unable to say no to seeing her father in spite of memories of sexual abuse). Through intensive counseling and parent coaching within the clinic and through home visits, the family now participates in healthier communication patterns, nonviolent problem solving, and shared positive experiences. Each family member, however, continues to show signs of chronic PTSD, caused by repeated and severe traumas within the family. When asked about traumatic events, the family summarized the following:
• Intimate partner violence • Alcohol addiction of father • Sexual abuse of two daughters by father; father denies this • Drug addiction by Taylor
Laura was asked about resiliency skills for both herself and her daughters. She felt she had positive support through her parents, a strong religious affiliation including daily prayer, the absence of any substance abuse, and the ability to adapt to the many changes and traumatic events occurring across time. She noted that her daughters were her support as well as her burden. She stated that they were very adaptable at times to big changes. Resiliency areas where this family lacked included: optimism, self-efficacy, and poor ability to set healthy boundaries.
Nursing Interventions:
Microsystem: The individuals within this family needed a thorough and comprehensive assessment of symptoms of trauma- related health concerns given the history of repeated and prolonged trauma. The mechanism of prolonged stress for Taylor started in early childhood, given her symptoms of mood dysregulation, attention deficit disorder, depression, and drug addiction. Likewise, her older sister, Natalie, experienced early childhood trauma, but her symptoms and outcome were different. She struggled more with relationship struggles, choosing men who would abuse her and desert her, similar to her biological father. Taylor’s middle sister, Kimberly, denied any memories of sexual abuse. She did, however, show signs of trauma through her panic disorder and alcohol dependency. Given that two out of three daughters remembered being abused, it is likely Kimberly experienced abuse, too. Laura struggled with her own abuse. She suffered from intimate partner violence, which is often accompanied by sexual assault (Evans & Coccoma, 2014). She also witnessed her daughters all struggle through adolescence and young adulthood because of their past abuse and her difficulty setting boundaries.
The understanding of each of the individual’s experiences and related traumas helps the nurse identify the need for individ- ual care for each family member. The daughters and mother started family care with individual counseling. They soon built a trusting relationship with the therapist and learned across time to become more attuned to each of their own needs, learned to ask for their needs appropriately, and discovered how to regulate their responses to emotions.
Mesosystem: Family-centered care was instituted after 3 months of individual counseling to improve family development and functioning. Family self-care strategies were initially implemented to stabilize and organize the family, followed by family meetings to address communication and problem-solving skills, as well as ways to build positive connections between and among family members. During the family meetings, the family also discussed the effects of trauma on the family, especially the difficulty all family members had in setting healthy boundaries with Victor. The family is now currently preparing to meet with Victor and enforce clear boundaries to prevent further trauma.
Case Study: Knoll Family (cont.)
11_Rowe_Ch11.indd 348 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 349
Macrosystem: This family struggled with finding supportive community resources. See Figure 11-6, the Knoll family ecomap, which depicts the subsystems. This family experienced trauma care at a time when addiction services were separated from TIC. Therefore, Taylor did not address her own trauma until early adulthood. Likewise, her siblings and mother did not receive TIC until almost two decades after the trauma occurred.
Exosystem: This family was affected by societal rules, culture, and policies. The availability of health care through the state allowed services to this family, but limited those services to weekly contacts with specified providers rather than the family being able to pursue professionals skilled in TIC.
Outcome Following Treatment: Following 1 year of TIC, this family is no longer demonstrating symptoms of PTSD. Each family member is experiencing positive connections within and outside the family. During this treatment period, the family worked with the same nurse, with interven- tions focused on ongoing family assessments, care coordination to facilitate better relationships across the family care–provider ecology, improving family communication and closeness through the use of rituals and routines, and individually targeted de- velopment of resiliency characteristics. All family members, except the biological father, are sober, and all members report more energy, ability to express emotions, and decreased hyperarousal toward their biological father/ex-husband.
Case Study: Knoll Family (cont.)
Strongly attached
Moderately attached
Slightly attached
Tension
Direction of energy flow
Natalie’s counselor
Kim’s counselor
Natalie’s addiction support group
Family nurse
Laura’s addiction support group
Taylor’s counselor
Taylor’s addiction support group
Kim’s addiction support group
Laura’s counselor
Taylor
Laura
KimNatalie
Victor
FIGURE 11-6 Knoll Family Ecomap
11_Rowe_Ch11.indd 349 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
350 Families Across the Health Continuum
Mr. Caldwell, a 47-year-old National Guard soldier who is in the hospital for a hernia repair, had returned home from a 12-month deployment to Iraq, where he had his first exposure to combat in his 18 years of National Guard duty. Before deployment, he worked successfully as a fireman paramedic and was a happily married father with two children. He and his wife were socially outgoing with a large circle of friends from the same rural area in which they both grew up. They have been married since high school. See a genogram and ecomap for the Caldwell family in Figures 11-7 and 11-8.
While in Iraq recently, Mr. Caldwell had extensive exposure to other soldiers’ combat injuries as the noncommissioned officer in charge of the battlefield medical aide station. His unit treated the severe, crippling injuries of soldiers en route to the trauma hospital. The aide station was often overrun with multiple casualties. He treated soldiers from patrols and convoys in which improvised exploding devices destroyed vehicles and wounded or killed people. Although he did not have to kill enemy combatants, he agonized that he may also have been responsible for the deaths of some soldiers because he simply did not have enough men or resources to treat all the casualties adequately. When asked about the worst moment during his deploy- ment, he readily stated it was when he was unable to intercede while a Humvee with a bleeding soldier draped over the hood and several wounded soldiers in the back drove by the aid station, because the driver’s view was blocked by blood gushing on the windshield and the driver could not see him waving the Humvee to safety.
When he first returned home, things seemed to be okay. But more than 2 years after coming home, he has had more and more difficulty relating to his wife. He reports feeling angry all the time, and that no one will listen to him. Sleep has become difficult. He has to sleep on the recliner in the living room because his back hurts so badly that he cannot lay flat. When he does sleep, he has a recurring, vivid nightmare about turning a corner outside of a building in Baghdad where he encounters an insur- gent with a rifle who shoots him. His daughter complains that he has become so overprotective that he will not let her go out with any friends, much less any boys. His wife reported that he has been emotionally distant since his return. His employer, who initially supported him, has reported that his work at the fire department has suffered dramatically. During a recent burning motor vehicle extradition drill, one of the car’s tires exploded. The unexpected explosion rattled him so much that he became unable to go to work anymore. Mr. Caldwell says that since his deployment, he no longer has an identity—he cannot work, and he no longer feels like he can fulfill his obligations as a husband and a father. He reports that he sometimes experiences strong surges of anger, panic, guilt, and despair and that at other times he has felt emotionally dead, unable to return the love and warmth of
Case Study: Caldwell Family
Eileen 43 yr
Secondary PTSD
Paul 47 yr
• Currently unemployed • National Guard was
deployed to Iraq; now home
• Insomnia • Back pain • PTSD
John 14 yr
Kira 16 yr
High school Secondary PTSD
High school Secondary PTSD
FIGURE 11-7 Caldwell Family Genogram
11_Rowe_Ch11.indd 350 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 351
family and friends. He does not want to get a divorce, but fears this will happen. Although he has not been actively suicidal, he reported that he sometimes thinks everyone would be better off if he had not survived his tour in Iraq. He is currently on several medications for back pain from his on-the-job injury at the fire department. He is complaining of a lot of postoperative pain.
This composite case illustrates several kinds of war-zone stressors. Mr. Caldwell felt helpless to prevent several deaths. In addition to that feeling of helplessness, he had to witness the horror of many people dying, and had to respond to emergen- cies on a very unpredictable basis. Nurses, who are taking care of patients who have had a difficult return to civilian life need to be aware of the complicated nature of readjustment. As this case illustrates, the prevalence of PTSD may increase considerably during the 2 to 6 years after veterans have returned from combat duty (Hermes, Fontana, & Rosenheck, 2015).
This family is dealing with the chronic problems that occur when a veteran returns home with significant PTSD. The care for this family, when delivered from a Family Systems Theory perspective, will need to address Mr. Caldwell’s PTSD, as well as the family’s ever increasing secondary traumatization from his stress responses.
Theoretical Perspective: Using a family systems theoretical approach, the plan of care for Mr. Caldwell includes referral for his PTSD and providing the family members with education and resources about what they can do to address their own secondary trauma, as well as
Case Study: Caldwell Family (cont.)
(continued)
FIGURE 11-8 Caldwell Family Ecomap
Friends
Friends
Kara John
Paul Eileen
Church
Kara’s teachers
John’s teachers
Eileen’s work
Fire department
VA medical services
Family friend
Strongly attached
Moderately attached
Slightly attached
Tension
Direction of energy flow
11_Rowe_Ch11.indd 351 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
352 Families Across the Health Continuum
Case Study: Caldwell Family (cont.)
support his recovery. As part of the plan, the nurse can help the Caldwell family by drawing a family ecomap that shows re- sources currently being used.
Because Mr. Caldwell has been traumatized by his experience with war, ultimately all his family members and family rela- tionships are affected. Mr. Caldwell’s war experience was his alone, but his wife is being affected by the symptoms he is expe- riencing, symptoms that will get worse as she takes on even more of a caregiving role following his surgery. The children are baffled by the changes in their father, and do not know quite what to do. Because Mrs. Caldwell is so involved with caring for him, the children do not feel like they can go to her with their problems. In addition to their parents not being available to them emotionally, both children have had to take on family roles that their parents used to manage. For example, the daughter, Kira, now must do more of the family meal preparation and house cleaning. The son, John, has to do all the yard work, which has made it harder to spend time with his friends. Both teenagers are starting not to do as well in school because of the constant tension in the home and their fears that their parents may divorce. Because Mr. Caldwell’s trauma is so severe, it is highly likely the other members of the family will suffer secondary traumatization.
This family’s response to the trauma of Mr. Caldwell from war cannot be understood or treated by focusing on just his care (microsystem). His family members (mesosystem) can provide key contextual information about past traumatic events and experiences that can explain current responses. In fact, they are a central reason why Mr. Caldwell wants to get better and resume more of his leadership roles within the family. As he has been spiraling downward, the rest of the family has followed and all now report deteriorating mental health.
The boundaries or borders for this family may both be protective and act as a barrier to seeking help. It may be that Mrs. Caldwell feels it is disloyal to talk about her husband’s problems with an outsider. Mr. Caldwell has many fears about admitting his difficulties and feels ashamed about how his problems have affected his wife. Mrs. Caldwell is afraid to ask for help because she does not want her husband to feel any more embarrassment than he does already. They are both suffering in silence, reluctant to talk to each other, or to anyone else. The nurse will have to create a trusting relationship to overcome this natural reluctance to share family secrets. One of the things that may help is to explain how providing this information may enhance the medical team’s ability to provide quality care.
In this case, the spousal relationship has suffered because of Mr. Caldwell’s trauma. Wartime separation and reunion, and then later problems with PTSD from combat, have created some marital dysfunction that was not there before. In this situation, the marital rela- tionship as a subset within this family is the most problematic area. By helping this family improve this one area of its family functioning through appropriate referral, the nurse could have a great impact on the rest of the family subsystems. Because this is a new experi- ence for Mr. and Mrs. Caldwell, they are not quite sure how to deal with it, plus they are reluctant to seek outside help at this time.
Assessment and Intervention Considerations: The assessment and intervention for the Caldwell family focuses on PTSD and secondary trauma. As we can see clearly from this case, although Mr. Caldwell’s traumatic exposure occurred some time ago, undiagnosed or inadequately treated PTSD could complicate his surgical recovery. PTSD is associated with more physical health problems and somatic symptom severity (Hoge, Terhakopian, Castro, Messer, & Engel, 2007). Although CWP—defined as pain in various parts of the body and fatigue that lasts for 3 months or longer—has thus far been documented only in veterans from the first Gulf War, the potential for this phenomenon to emerge in current combat veterans is high. CWP is associated with greater health care utilization and a lower quality of life (Forman-Hoffman et al., 2007). Researchers working for the Veterans Administration have documented that a substantial percentage of Iraq and Afghanistan veterans experience ongoing or new pain, of which 28% is reported to be severe (Gironda, Clark, Massengale, & Walker, 2006).
In this instance, postoperatively Mr. Caldwell may be having more problems with pain perception, pain tolerance, and other kinds of untreated chronic pain. In addition, PTSD symptoms may make it difficult for the nurse to communicate with the patient, may reduce the patient’s active collaboration in evaluation and treatment, and reduce patient adherence to medical regimens.
Assessment: Because trauma is underrecognized, patients with PTSD are not properly identified and are not offered education, counseling, or referrals for mental health evaluation. There are simple methods to screen patients who may have undetected PTSD. As noted, one easy to use tool is the Primary Care PTSD Screen (Prins et al., 2004).
11_Rowe_Ch11.indd 352 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
Trauma and Family Nursing 353
Case Study: Caldwell Family (cont.)
Next, assess the family for possible symptoms of secondary traumatization. How are Mr. Caldwell’s wife and children responding to his symptoms? What symptoms are they experiencing because of his difficulties? Identify how roles may have shifted for this family given Mr. Caldwell’s current circumstances. Is the family still functioning as a strong cohesive unit? How have things changed? How open is this family to working with the nurse? What might help facilitate this?
Nursing Interventions: Provide education about PTSD and secondary trauma. Because the family’s participation is essential in identifying symptoms of PTSD and planning treatment, the nurse must create an environment that is supportive and inclusive of family members in order to work in partnership with the family. There are several sites on the Internet that can help the nurse develop educational fact sheets that can be shared with patients and families. The Veterans Affairs National Center for PTSD and the Defense Department’s Walter Reed Army Medical Center collaborated to develop the Iraq War Clinician Guide https://www.ptsd.va.gov/ professional/materials/manuals/iraq-war-clinician-guide.asp). The next step that the nurse should take in intervening with the Caldwell family is referring all family members for further care. Set up a plan for referring to a PTSD specialist those patients who show signs of potential PTSD and who are amenable to receiving additional evaluation or counseling. In this instance, the nurse could provide the family with a list of possible options. Many local areas have lists of returning veterans’ counseling services that include counseling for couples and families. Involve the family in the plan of follow-up care.
SUMMARY
In this chapter, we discussed trauma and how TIC may be employed with patients by family nurses. Key points include the following:
■■ Trauma affects the entire family system. ■■ Trauma-related illnesses are more likely to develop when resiliency traits are lacking either before or after the trauma.
■■ Trauma-related illnesses can occur months, or even years, after a disaster or traumatic event such as war occurs. Trauma-related illnesses, particularly PTSD, affect both children and adults, with adults more likely to have flashbacks of the incident and children more likely to develop hypersensitivity and avoidance of similar situations (e.g., avoiding cars after a motor vehicle accident).
■■ The Ecological Systems Theory can guide nursing assessment and interventions to help families cope effectively with trauma.
■■ When one or more family members are trau- matized by an experience, all family members and family relationships are affected.
■■ The more severe the trauma an individual family member suffers, the more likely the other members of the family are at risk for secondary trauma.
■■ The family response to trauma of one or more of its members cannot be understood or treated by focusing on individual family members alone. Family members can provide key contextual information about past traumatic events and ex- periences that help explain current responses.
■■ Community systems can prevent, treat, and measure negative outcomes to traumatic events. If community agencies are not well trained and prepared, the risks for undetected and untreated trauma-related illnesses increase.
■■ Larger political and social systems can influence and be influenced by individual, family, and community trauma. If nations experience severe trauma, they, as a whole, show signs of trauma response.
■■ Nursing focuses on the individual, fam- ily, community, and societal reactions to trauma in order to optimize positive outcomes and prevent or treat negative implications.
For additional resources and information, visit http://davisplus.fadavis.com. References can be found on DavisPlus.
11_Rowe_Ch11.indd 353 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
11_Rowe_Ch11.indd 354 12/21/17 5:04 PM
Kaakinen, J. R., & Coehlo, D. P. (2018). Family health care nursing, 6e : Theory, practice, and research. F. A. Davis Company. Created from mnsu on 2024-09-09 03:45:34.
C op
yr ig
ht ©
2 01
8. F
. A . D
av is
C om
pa ny
. A ll
rig ht
s re
se rv
ed .
