June 24, 2017

Trauma and Recovery

Introducing a panel on “The Mitigation of Trauma During the Aftermath,” the panel chair, Dr. Frank Ochberg, told the audience: “The aftermath is a living thing. It isn’t just a bunch of statistics about people who died or were injured. The aftermath lives on, we are in the aftermath now.”  Opening the discussion, Danny Axsom of the Virginia Tech psychology department described research he and colleagues Heather Littleton and Amie Grills-Taquechel conducted on trauma and resilience issues — one of several post-shooting studies on that theme.

Axsom: When the shooting occurred we were in the midst of collecting data for

another project. And it dawned on me, my gosh, we have pre-data. That’s unusual because oftentimes disasters hit places where you don’t have data on the pre-trauma status of people. And we did. We were conducting a study on women’s reactions to negative sexual experiences. This was part of a three-site project and there were about 800 or so women at Virginia Tech that we had data on. So we followed up after the shootings by sending them an e-mail offering them the opportunity to complete a web-based survey related to the shooting. We had three waves of data collection, the first being two months after the shootings, and close to 300 women participated in that. We also collected data at six months and then at one year.

We asked a series of yes/no questions: Were you on campus that morning? Did you hear gunfire, did you see police, were you in any of the buildings where the shootings occurred? Based on the responses we classified people as having no direct exposure, less direct exposure or more severe direct exposure. Despite relatively low direct exposure in the sample as a whole, two months out, in terms of post-trauma symptoms, most people reported them and about 28 percent scored above a clinical cut-off that would qualify them as having PTSD. That persisted to a slightly lesser degree at six months. By that point it’s 23 percent above the clinical cutoff for PTSD. So this truly seemed to qualify as a community trauma.

The lens that we tried to use was something called conservation of resources theory. This suggests that after traumatic events, one of the things that can lead to distress is when people lose resources of one sort or another. The resources can be tangible things like a house or a car that could be lost in a flood or a tornado, but obviously in a situation like this we were talking more about intangible resources. And the idea is that if you lose them you’re at risk for distress. The kinds of resources we’re talking about are a sense of life direction, a feeling of being successful, sense of pride in oneself, things of that sort, and interpersonal resources, such as companionship, loyalty of friends. Participants were asked whether they had lost or gained these things. And the last thing is optimism, and the question would be whether they lost or gained a sense of optimism or hope.

Our results indicated that if you’re distressed beforehand you’re more likely to lose resources in the immediate aftermath, and on the other hand the more social support you have prior to the shooting, the less resource loss you have afterwards, which I think makes sense. We refer to this as a spiral model, because what people often talk about is that once you lose resources that can lead to further resource losses.

Is helping others a way to lessen distress after a traumatic event? That question, Axsom observed, has not been given the research attention it should get:

We should look more closely at how help benefits people. There are a lot of benefits for the givers of help. It gives them something to do, it structures their experience in the aftermath. It’s similar to formal rituals like wakes and funerals and memorials. Giving help is one way of addressing the existential threat that’s represented by attacks like 4-16 or 9-11. It highlights the better angels of our nature, as Lincoln said. It can be a way of reasserting control over the meaning of the event, and that corresponds to what people were saying about narrative.*

Giving help may make it easier to receive help. One of the psychological barriers to help-seeking is a reluctance to feel indebtedness to others. That’s one reason why even in situations where barriers like cost and transportation to seeking help are removed, there’s still an unwillingness, a reluctance. Some of that revolves around control and indebtedness and reciprocity, and giving help to others can create reciprocity on that balance sheet. Whether it reduces our own distress is an open question. The giver of help comes in contact with images, knowledge and sometimes people that can be distressing. So while on the one hand it may be beneficial, on the other hand it may elevate distress. But that’s not always a bad thing. There are clinical practices that elevate distress in the short term but that lead to improvement in the long run and this may be one of them.

People also filled out a coping inventory. One of the dimensions of that inventory is social contact items, including things such as: I found somebody who’s a good listener, I talked to someone about how I was feeling, I talked to someone that I was very close to, I asked a friend or relative for advice. What we found is that the more people reported using social contact coping for dealing with their reported distress, the more they reported giving help to others in that emotional way. Which suggests to me a sort of exchange that takes place. It’s not like going to a psychotherapist who’s there to give you help. It’s more a give and take. It’s less professional but there are advantages to it as well in terms of its availability, the reciprocity, the timing issue.

We asked what activities people engaged in. Did you go to the convocation? Did you attend the candlelight vigil? Place items on the memorial? Donate money to the Hokie Spirit memorial fund? And so forth. We added up the number of actions that people had taken and what we found was likewise, the more things that people had done, the more emotional help-giving they did. That makes some sense.

Some limitations: this is self-reported emotional data, with all the usual caveats. We don’t know whom our participants helped. We don’t know whether the help provided was useful from the recipients’ perspective, and we don’t know exactly how giving help and receiving help are related. That’s something we want to get into. Help-giving is a strong urge after traumas. I also think help giving may be a competence that’s worth developing in people, for their personal resilience and also for community resiliency, because the more people are engaged in giving help, the more the community is likely to have solidarity.

Psychology professor Russell Jones and sociology professor Michael Hughes described findings from a different study, drawn from a pair of surveys conducted by the Virginia Tech Center for Survey Research three and four months after the shootings. Notable in the findings was that large majorities of students, faculty and staff did not have significant mental health disorders in the immediate aftermath of the shootings.

Hughes: Our study attempted to estimate how many people at Virginia Tech had serious mental health problems following the incidents of April 16 and how many sought and received mental health services. The findings have implications for questions on the impact of traumatic experiences and loss on mental health, on the use of mental health services in the aftermath of trauma, and on the issue of whether the VT community was traumatized by the shootings. Some people were exposed to severely traumatizing events that are among the worst that human beings can experience. However, this occurred to relatively few people. At most, it appears that only 124 people out of approximately 25,000 in the VT community were directly exposed to the shootings in Norris Hall. The large majority of those were not in the rooms where the shootings actually took place. A much smaller number experienced the aftermath of the shootings that occurred earlier at the dormitory.

Russell Jones and I developed measures of direct and indirect event exposure, mental health outcomes, demographic and other background factors, and use of mental health services. Our mental health indicators were a measure of PTSD patterned after the DSM-IV diagnosis and a well-validated measure of serious mental illness (SMI) that measures severe symptoms of anxiety and depression.

So what did we find? Two months after April 16, about 15 percent of the students and nearly 10 percent of the faculty and staff had what we think would qualify for PTSD. Severe anxiety and depression (SMI) affected nearly 5 percent of students and 4 percent of faculty and staff. Eighty or more percent of the students and around 90 percent of faculty and staff did not experience any serious mental health reactions, at least not to the degree we were able to measure them. Women were two to three times more likely to have a mental health reaction.

To measure direct exposure we asked if respondents were in or near the buildings where the shootings took place, if they saw people who had been killed or injured, if they helped anyone who had been injured, if they saw people running in panic, and if they observed the actions of medical personnel, ambulances, police, and SWAT teams. We also asked a series of questions about how close respondents were to victims, whether anyone who was killed, injured, or directly endangered was a relative, close friend, acquaintance, a friend of a friend, a teacher, etc.

To measure indirect exposure we asked people if, because of their schedules, they should or might have been in Norris Hall during the shooting and if they changed campus locations between the two shooting events when it is now known that the perpetrator was walking on campus with his weapons. Also, we asked whether they tried and failed to contact their friends when there were no details about who had been killed or injured.

How important are these factors in accounting for PTSD among students? If you group all the loss factors together — that is, all degrees of relationship with someone who was killed, injured or in danger — these account for about 40 percent of the PTSD that occurred. If you look at each individual measure, the most consequential single factor turns out to be “could not contact friends to confirm their safety.” Thirty percent of the PTSDs among students in our study can be accounted for by not being able to contact people. Next highest single factor is having a friend or acquaintance that was killed, accounting for 20 percent of PTSD outcomes.

A major conclusion of our study is that losses and social relationship factors were the most important determinants of serious mental health reactions, and that they were more important than direct physical exposure to the events and their immediate aftermath. An important remaining question is whether the community as a whole experienced trauma. A very large number of people had trouble contacting their friends in the hours immediately following the Norris Hall event. A very large number of people were shocked and saddened by the shootings. A large number experienced negative mental health reactions. However, the percentage with severe reactions was relatively small. Eighty to 90 percent did not have serious mental health reactions as of two months after the shootings. Other evidence indicates that the institution functioned well in drawing the community together. There is no evidence of social dysfunction and little evidence of individual dysfunction among large numbers of people in the aftermath of this tragedy. If the community as a whole was traumatized in a serious way, we did not detect clear evidence of this.

Policy needs to address intervention for the relatively small numbers of people who experience serious mental health reactions. Clearly we don’t know how to do this. Very few people got counseling following the events. A substantial proportion of students with SMI and PTSD did not seek or receive counseling. Very few people took the opportunity for the help the university provided all over campus. A lot of volunteers came to help people; hardly anybody took advantage of that.

Because much of the PTSD reaction, about 30 percent, was not due to direct or secondary exposure but due to not being able to contact people, an important thing we need to do is address communication problems.

Russell Jones pointed to the finding that a relatively small number of respondents had received counseling from professional therapists:

The majority of those who sought help, 60 percent, got help from a primary care doctor, 19 percent from religious counselors. Bottom line is not a lot of people sought out help. Of those who did receive mental health therapy, 28 percent were already in counseling before, and 57 percent started counseling after the shooting. The vast majority had less than 10 sessions, almost 90 percent had five or fewer sessions.

Findings and implications: we need to address gaps between available services and the actual needs of students. A number of these gaps are actually being filled and people are doing very good things. Two, we need to broaden the pool of trauma specialists trained in evidence based interventions. If you’re going to do it, if you’re going to treat people, let’s do it with a scientific backing. Three, train professionals to reflect the diversity and cultural diversity of the people in Blacksburg.

Asked if those who received therapy did in fact benefit, Jones replied that many did improve. But he added that for many people, PTSD symptoms also fade away with time. Of individuals diagnosed with PTSD following traumatic events, half will no longer meet the diagnosis after three months.

Dave Cullen: So they would’ve gotten better anyway.

Jones: Many of them would have gotten better anyway.

Examining resilience and recovery leads to the concept of solidarity — the sense, as James Hawdon put it, of pride in belonging to a group or community, trust in its other members, and identification with common values. When the community is attacked, Hawdon continued,

As Durkheim wrote over 100 years ago, everyone is attacked. Consequently not only is the reaction general, it’s collective, and this comes about in the form of solidarity.

Solidarity reaffirms that the group, while damaged, still exists. It acts as a stimulus for collective action. It provides emotional support.

His and John Ryan’s research following April 16 showed, Hawdon said, that “solidarity has a positive effect on emotional well-being. Those who expressed higher levels of solidarity later had higher levels of well-being.” Studies in New York City after the 9-11 attacks, for example, showed that solidarity was elevated at first but fell back to normal levels in six to nine months.*

What do we mean by community?  Christopher D. Campbell argues that community has three elements.* There’s geographical space. There’s sentiment, the cultural, symbolic side of community, what it means when you say I’m a New Yorker or I’m a Hokie. And there’s the social structure; the interlocking networks of social relations. These three elements make up a community. A critical incident damages either space or sentiments. When sentiment is the main thing affected, it must be reaffirmed. What we did was ask people about what they did in the week following April 16. Did you talk to family members, how often, did you talk to friends, etc. How often did you talk to media, how often did you shop at local stores, eat at local restaurants, play on a sports team, attend community meetings, etc.

Tracking solidarity over time, at nine months the drop is statistically significant. Lawsuits have been filed. Some old issues of diversity are re-emerging. And we would expect that if we do this again some time in the near future it’ll be down further.

John Ryan noted that solidarity tends to reflect how an event and the responses to it are framed by the community:

In the initial phase, multiple frames compete for dominance in defining what is going on here, what does it mean. By the afternoon of April 16,  there was a master frame that emerged. People agreed on what had happened — that this was a mentally ill individual who acted alone, this was senseless. We didn’t cause this, we’re not responsible for this, unlike Columbine I think. This is an attack on the whole community. A sense of solidarity, we’re all victims. And then we get the slogan we are all hokies now, quickly spreading across the country and resonating with what’s going on here. So our reading of the initial frame was that it was a frame of solidarity, of oneness.

Danny Axsom: What seems to be missing are the questions that arose pretty quickly about why weren’t we notified earlier?

Ryan: People at Virginia Tech quickly dropped that as an issue and said we’ll deal with that later, the important thing now is that we’re all hokies and we’re all victims. It was floating out there. Gun laws, actions by university officials, all those were in the papers the next morning, in the media and among people on campus and in town. But from our experience the pressure was to not criticize in that moment and in fact some faculty who did criticize in that moment were sanctioned very quickly.

Hawdon: One thing you have to remember is that at a university there is pre-existing solidarity. We have solidarity building rituals all the time. Football games, basketball games, let’s go hokies! The fact that we were a solidified group prior to April 16 immediately influences the individual frame. As hokies, we did not want to blame the institution. We wanted to feel an allegiance to it. This solidarity also helped form the collective, the master frame. There was a conscious attempt to frame this as not our fault.

Ryan: The university kicked in immediately to make sure that that was part of the master frame. They hired a PR firm the next day for three-quarters of a million dollars to brand this as not being the administration’s fault and so on. So it’s not that it emerged entirely by itself. It was cultivated, nurtured.

Hawdon: And as this master frame starts to form, it starts to filter out and repress those competing frames. On the 17th I had conversations where people would say, why didn’t they shut down campus earlier? By the 18th you didn’t hear that because the collective frame had started to form and put pressure on you to have strong character, and strong character was being a good hokie. So the power of this frame grows over time. And it has a feedback effect on solidarity; amplifies its effects.

Megan Armbruster found evidence of solidarity in the fact that none of the 26 students wounded by Seung Hui Cho left the school:

In May of 2006 we had a couple of those students graduate, and one returned to go to graduate school. No one transferred and I think that says a lot about this community. When we have commencement ceremonies I thank those parents especially because they dropped their students off twice. And they are brave people.

The 26 wounded students sought solidarity with each other, Armbruster recalled, as well as with the wider university community:

The students started to e-mail me saying that we want to meet each other and get to know each other. So we started to do things. Our first director and his wife hosted monthly dinners. They still have those every month. The help-giving we talked about, I thought was so true because these students this year have really wanted to get involved in helping other people and get involved in service.

Hawdon: You cannot downplay the importance of the convocation the next day. When Nikki Giovanni gave her speech and ended with “we are hokies, we will prevail,” and the students spontaneously stood up doing the Let’s Go Hokies chant, that was a very powerful moment. The administration knew what they were doing when they asked Nikki to give that speech. She is a powerful speaker. Another thing to remember about how powerful this frame was. When President Steger took the stand to speak at the convocation, the students gave him a standing ovation. There was already the “hey-he-messed-up” frame out there, but basically the students got up and said you’re not sticking this on us, we’re behind you. It almost brought Steger to tears.

Ryan: When we think about intervening after this kind of event — hundreds of counselors were sent to campus but people did not participate in that, which suggests that this other approach of picnics, vigils, community events and so on actually turned out to be very therapeutic for healing at the community level. Not the victims or their families but the community.

Hawdon: Let me close with a quote from Durkheim: when you see a moral scandal in a town, notice what people do. They gather together on the street and they talk, they wax indignant, and out of that individual temper comes a public temper. The moment of the convocation where the students stood up and chanted was one of the closest things to a religious experience I ever had. It said something about the group.

Not all critical incidents give rise to solidarity. Under the pressure of a disastrous and damaging event, fault lines in institutions and in society can widen, instead of narrowing. Jeff Stern gave a vivid illustration of the contrast between Virginia Tech after the shootings and New Orleans after Katrina:

Here you had this hokie solidarity. And in New Orleans –  I’m getting a tour a couple days after the Superdome has been evacuated. We come to a 12-foot wall that’s been bulldozed between New Orleans and one of the parishes. The police captain was there and I said, was that to keep the flood waters out? And he said no, that was to keep the people from going into the parish. That’s the fracture that you talk about, where it’s a very divided community.

Dave Cullen noted that an event can be framed one way within an institution or community and another way in the larger public:

There’s the local frame and the national frame. With Columbine, those were completely at odds. There was the same kind of solidarity within the school but that was at odds with the national frame. Here you weren’t necessarily competing with the national narrative, but it was two different narratives.

A paradox of solidarity is that even while it unifies, it can also divide. Defining “us” can also define “them,” perhaps particularly when a community has suffered damage or loss in a critical incident. The result can be ambiguous: strengthening bonds of identity and common beliefs and values within the community may assist recovery, but fissures between the group and those outside its boundaries may widen.  This happens when identity, solidarity and mutual aid  develop around themes of scapegoating and revenge. Gerard Fromm, director of the Erikson Institute at the Austen Riggs Center in Stockbridge, Mass., noted that different dynamics come into play when a critical incident is manmade rather than natural:

Collective trauma from intentional human disasters is different because it introduces dynamics having to do with human motivation and violence.  It attacks people’s symbolic, sense-making functioning, individually and collectively, and leaves them vulnerable to massive regression. Societal trauma often leads to an interruption of usual mourning processes in favor of psychic numbing, a sense of overwhelming pain, and indiscriminate rage.  Because the natural tendency of the mind is to turn something experienced passively into active mastery, vengeance is sought as a form of recovery. This is why trauma begets trauma, and is also one of the ways trauma is transmitted to the next generation.

Even after incidents of deliberate human violence, a cycle of division and vengeance is not inevitable. The Virginia Tech community’s coming together after the April 16shootings illustrated, Fromm observed, “that recovery indeed involves an active relation to trauma but not necessarily a vengeful one.” He also noted that a connection between recovery and togetherness is made in the very word “therapy”:

Traumatic dreams are an aspect of the mind’s effort at recovery, an attempt to experience, bit by bit, what could not be endured at the time. They represent an effort to become a whole person again, with all of one’s history, including its most painful parts.  But this return to the scene must be experienced in the company of others. The word therapist comes from ancient Greek, one of its original meanings being “the second in combat” — the people just behind the front line, who  support the soldiers  and serve as witnesses to the horrific experience.

Richard Curtis, chair of anthropology at John Jay College, saw the Virginia Tech experience as evidence that people may be more resilient after a traumatic event than we commonly think. He also suggested that critical incident analysts and other researchers should give more attention to cultural as well as individual factors that influence people’s resilience and ability to recover. And, consistent with the derivation of the word (and with the fact that social expressions of solidarity seem to have benefited many more people than the trauma counselors who flocked to the campus) Curtis pointed out that therapy does not have to be exclusively the province of professionally trained mental health practitioners, even if American culture views it that way:

You found that 85 percent of the people didn’t have PTSD, and that says something. This subject of successfully managing trauma is an understudied area, because we typically study people who are traumatized rather than the people who emerge unscathed,  so to speak. Researchers have paid little attention to social and cultural factors. But there’s every reason to believe that trauma and recovery are mediated by culture. And it’s something we need to look at more closely.

Researchers and individuals in psychology have long believed that resilience is pretty fixed. You either have it or you don’t. I think that some psychologists have come to realize that resilience is something that you can develop. It can be developed over time. You can build it. It’s a finding that I don’t think is surprising to cultural anthropologists and perhaps others in the room who have looked at this.

The “grief industry” has become institutionalized in America, especially after 9-11. But as trauma mitigation becomes more professionalized, what are the pluses and minuses for members of our society? Could this need to provide help to victims of trauma and to do this trauma debriefing actually create more problems by blocking natural family and neighborhood contacts and reducing the traditional role and function of communities? Some researchers now realize that more research should be focused on the particular effects of people’s worldviews. If people who share certain worldviews are more resilient than others, we need to understand what those are.

Different cultures, Curtis argued, have different ways to help people manage trauma, grief and loss. Professional mental health counseling as practiced in our society is only one of them, and even within our society should be recognized as not the only alternative:

Some clinicians now hesitate to automatically provide counseling following a traumatic event. Rather, they recognize that people should share what they want with people they know well: “close friends, relatives, familiar clergy… our social networks – they are what help people create a sense of meaning and safety in their lives.”* While it is refreshing to hear that some clinicians do not endorse the “daddy knows best” approach to trauma mitigation, the recognition that different people have different ways of coping with trauma simply begs the question of what those ways are. It is here that some of the methods and techniques employed by anthropologists can be usefully applied. In my own work, among drug users with AIDS, for example, where premature death in this highly stigmatized “community” is a fairly frequent occurrence, there are extensive formal and informal support networks that assist individuals as they cope with loss and grief. Understanding the structure, role and composition of these various networks is essential to being able to offer the kinds of emotional and material assistance that makes a real difference in their ability to successfully cope with grief and loss.

Richard Schwester, ACIA’s associate director and archive director, spoke about questions for further study in relation to trauma and post-traumatic stress:

I want to tease out some avenues to pursue. For example, if you can enhance safety — objective safety, subjective safety, physical and mental safety — does that decrease the risk or the onset of PTSD and other related disorders? If you increase and build efficacy, does that reduce the risk? If you have greater social connectedness, does that reduce it? And if you instill hope, does that reduce the risk of PTSD and other mental health problems? One thing to look at is differences in media coverage, how the media cover an event and what the effect of the coverage is.  Does media coverage matter in terms of perceptions of safety and PTSD?

On the notion of efficacy: in the context of post-traumatic stress, from what I’ve learned, trauma inhibits your confidence about dealing with emotions or constructive problem-solving. You lose that confidence in terms of how to handle things. There are cognitive behavioral therapy and other tools for promoting efficacy. But it’s something that individuals build themselves and impart to others. The real caveat about building efficacy among individuals who have gone through some traumatic incident is that they have to know inside themselves that they have this ability to be efficacious. And that’s a pretty big presumption. So one thing I thought about was how do students feel about their ability to be efficacious? Do they have this inside them? It would be interesting to craft a survey instrument that would measure perceptions of self-efficacy.

On social connectedness — greater networks, greater social supports, less problems. At least that’s what I’ve gotten out of the literature. What do universities do institutionally? What kinds of programs and best practices have been developed? What works? And the importance of families. I wrote “examine the loved ones link.” During a traumatic event, is it better to send students home? Did the students who went home to their moms and dads fare better? Jim?

Hawdon: The ones who stayed here fared better.

Schwester: And finally the notion of hope. Hope is socially constructed; it can mean a lot of things to a lot of people, but in the context of trauma mitigation it means getting your life back into place. What does that look like on a college campus after this kind of event? What is a return to normalcy, so to speak? Was it a good idea to cancel finals? Or would it have been better to force people back to class and then give them that sense about the future, that we have to plan for our future and part of that is finishing the task at hand and getting back to class. That might be an avenue of future research.

* Randall Collins, “Rituals of Solidarity and Security in the Wake of Terrorist Attack,”   Sociological Theory, 22:1 (2004) pp. 53-87

* C.D. Campbell, “Social structure, space, and sentiment: searching for common ground in sociological conception of community,” in D.A. Chekki, ed., Community Structure and Dynamics at the Dawn of the New Millennium, Research in Community Sociology, Volume 10,  Bingley, UK: Emerald Group Publishing (2001)

* Jerome Groopman, “The Grief Industry,” The New Yorker, Jan. 26, 2004