In recent times here in the Philippines, the word “trauma” has been thrown about a lot. Sometimes, these so-called “traumatic” incidents and their aftermath do not warrant that label. One sees a lot of misappropriated labeling in the media and even among government agencies who are not particularly sensitive to what that term means in the Disaster Mental Health (DMH) world.
“Trauma”, in its most general form, is the collection of experiences (thoughts, feelings, and behaviors) that occurs as a response when one is overwhelmed after being exposed to a horrifying and atypical (which means that this is not seen in day-to-day, normal living) experience. Usually, only 10 to 20 percent of people exposed to traumatic situations actually develop problems later on. Majority of people exposed to trauma are able to cope and use various strategies of resilience to move forward with their lives without complications. For those 10 to 20 percent though, they may develop trauma symptoms manifesting through generalized thoughts about the world (“the world is unsafe!”) or oneself (“I was a coward! I could have done something about it!”); difficulty concentrating and focusing; repetitive feelings of anxiety, distress, and irritability; avoidance behaviors; high startle response (easily surprised and quick to retaliate aggressively); and hypervigilance (always on guard) that may interrupt sleep and rest. Collectively these symptoms may meet the criteria for a diagnosis called “Posttraumatic Stress Disorder” or PTSD.
WARNING: Only a qualified clinical psychologist or psychiatrist can diagnose PTSD. Do not diagnose yourself or your loved ones just by reading some articles on the internet or some books you bought! Self-diagnosis is a very dangerous act that can heighten anxiety and create numerous psychological concerns that can complicate whatever problems you or your loved ones may already have.
MISCONCEPTIONS OF TRAUMA
There are many misconceptions about trauma that are being perpetuated not only by non-mental health personnel (such as the media) but also by half-trained or poorly trained mental health professionals themselves! Below are some of these outdated and/or outright false information:
1. Trauma is said to occur when one’s self-esteem is damaged. This is false. Self-esteem is a separate concept from trauma, and damage to self-esteem is not recognized as an essential symptom of a traumatic experience. Low self-esteem may have existed beforehand and may predispose people to think more badly about themselves after a traumatic event, but this is not one of the primary things that clinicians watch out for. A good example for this is when the media reports about students being “traumatized” by teachers shouting at them or punishing them. This is not trauma. The students may have felt embarrassed or ashamed, but this does not constitute trauma. If parents and other adults encourage the belief in students that they were “wronged” or were “traumatized”, these students will grow up developing a vengeance mentality (“if I don’t like something, I can always claim that I was disturbed, distressed, or traumatized by something I don’t like. Therefore, I will not be forced to do or be exposed to that thing.”) and poor resiliency. However, none of these are enough to state there was trauma involved.
2. Trauma occurs if one is exposed to death. This is partly true. PTSD requires that a person witness, directly experience, or learn of something violent happening to a significant loved one. These experiences are required to be repetitive exposures to situations that involve not only death but a threat to one’s bodily integrity (for example, high chance of having your arms or hands blown off or cut off) resulting in disability, a threat of being killed or threat of loved ones being killed, and loss of freedom and quality of life (such as being held captive by terrorists). Examples of traumatic experiences are being kidnapped, being caught in the middle of a war, and struggling amidst a natural disaster such as the recent typhoon and earthquakes in the Philippines. Having a terminal illness is not considered trauma. Being shouted at by a superior such as a teacher or a boss is not considered trauma.
3. Traumatic experiences must be repetitive to qualify for PTSD. This is partly true. In diagnosing for PTSD, it is one of the requirements that the person have repetitive exposure. However, there are many different types of traumatic situations. In recent researches, some situations such as military being deployed to war zones need only one situation of highly traumatic quality to create trauma symptoms. A clinician properly trained in Trauma Psychology and Disaster Mental Health has the appropriate skill and clinical judgment to determine if there is a need for a PTSD diagnosis. If you are unsure of your clinician’s credentials, always ask. This is necessary because different situations of trauma (example, natural disasters versus war versus sexual abuse) require different sets of knowledge and skills.
4. Debriefing is needed immediately after trauma. This is false. The American Red Cross along with other organizations such as the American Psychological Association have deemed debriefing to be potentially harmful and does not have substantial research support. Debriefing has been found in many cases to actually CREATE trauma symptoms in individuals who participated in these activities. To be fair though, the original purpose of Critical Incident Stress Debriefing (CISD, the original term for debriefing) was to prevent traumatic symptoms from occurring in first-responders (for example, police, firefighters, paramedics, military who are the first to arrive in the scene of disasters). CISD was NEVER intended to be used on trauma victims themselves! Unfortunately, the mental health world in the Philippines is not up to date or very accurate in its understanding of Trauma Psychology despite the fact that this country experiences a lot of natural disasters.
5. Art Therapy is best for children experiencing trauma. This is partly true. Art Therapy has been shown to be effective in treating not only children, but also the elderly and adults, after experiencing heavy trauma. For instance, refugees from Southeast Asia have lowered chances of developing PTSD after escaping war and terror in their countries if they are exposed to and interact with religious iconography (such as Buddhist art and statuary in temples). Art Therapy works by giving a voice to something chaotic or formless, allowing victims to give shape and structure to their experiences without having to narrate what happened to them in words. Sometimes, there are just no words strong enough to express all the anger, hate, loathing, and despair these victims felt. Art provides an outlet for all these emotions since art does not require words, mainly because art is tied to the pre-verbal expressions part of our brains (those parts that allow us to communicate even before we learned words as children). However, whether or not Art Therapy is “the best” method is dubious. Strictly speaking, cognitive-behavioral methods of therapy are still the golden standard for treating trauma. Also, there is the issue of training. It is very, VERY difficult to find someone who has been trained properly in Art Therapy in the Philippines. Art Therapy is a separate field of mental health and requires board certification with the American Art Therapy Association. Most people in the Philippines who claim to practice Art Therapy either only took up one introductory class in it, or only read books about it without being supervised or had hands-on training. Art Therapy has many dangers, one of which is opening up deeply rooted memories which can cause nervous breakdowns. Foremost in my training regarding Art Therapy is the warning that unless one has been subjected to formal training and certification in Art Therapy, do not claim to be an Art Therapist. Certain interventions using art are allowable so long as there is research support for it and one does not claim to be an Art Therapist (which is a regulated label and profession). Lastly, what passes for “Art Therapy” with children-victims of trauma is basically just a drawing session. Children are just asked to draw, without any further intervention. This is NOT Art Therapy. Again, when in doubt, always research the credentials of your mental health professional.
6. Treatment must follow quickly for trauma victims. This is false. First and foremost: Safety is always the number one priority. Victims must be placed in secure, hygienic, and safe areas/camps that have an orderly, military-like structure to prevent chaos in service delivery. People need to be reconnected to family members and loved ones. People need to know what will happen next and what to do next to get their lives back on track. These are goals for Psychological First Aid (PFA) which is not classified as “treatment”. These are practical procedures to kick-start victims’ own natural coping skills and resiliency. Second: For those who require treatment (note: part of the work of PFA is to assess those who may need extra help and who are at risk for developing PTSD), interventions can ONLY start AFTER the traumatic incident. NO treatment will be successful if the traumatic incident is still ongoing or recurrent. As an example, any psychological treatment was contraindicated during the Cebu earthquakes as even the government could not predict when the next quakes are going to happen or even if there are other quakes coming. Any treatment provided during uncertain times will be wiped out or invalidated by re-traumatization. Third: treatment for trauma cannot occur when a victim is either suicidal or homicidal (harm to self or harm to others). These must be addressed first before treatment for trauma can occur. Therefore, as noted here, there are many conditions that must be met first before psychological TREATMENT occurs. However, certain NON-TREATMENT procedures can be applied right after trauma such as PFA or a type of psychoeducational coping called diffusing (which can take place hours after the original trauma).
As trauma becomes more and more a household term in the Philippines, be sure to do thorough research to avoid misinformation and confusion. Ask your mental health professional (for a list, go to my Referral Network at the right-hand side of this site) if you have any questions regarding trauma, its symptoms, or general information which you think might benefit you or your loved ones.