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Coping Strategies For Members Of The Zion Seventh-Day Adventist Church Who Experienced Multiple Losses And Complex Grief After A Major Crisis
Jean-Renaud Joseph Andrews University
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COPING STRATEGIES FOR MEMBERS OF THE ZION SEVENTH-DAY ADVENTIST CHURCH WHO EXPERIENCED MULTIPLE LOSSES AND COMPLEX GRIEF AFTER A MAJOR CRISIS
by
Jean-Renaud Joseph
Adviser: Peter Swanson ABSTRACT OF GRADUATE STUDENT RESEARCH
Project Dissertation
Andrews University
Seventh-day Adventist Theological Seminary
Title: COPING STRATEGIES FOR MEMBERS OF THE ZION SEVENTH-DAY ADVENTIST CHURCH WHO EXPERIENCED MULTIPLE LOSSES AND COMPLEX GRIEF AFTER A MAJOR CRISIS
Name of researcher: Jean-Renaud Joseph
Name and degree of faculty adviser: Peter Swanson, Ph.D.
Date completed: January 2013
Problem
This dissertation explored the prevalence of trauma exposure, complicated grief, and related symptoms among survivors and members of Zion Seventh-day Adventist
Church who had lost family members in the aftermath of the 2010 Haiti earthquake. Method
The sample included participants who were members of Zion Seventh-day
Adventist Church (n =39) who had either personally witnessed the 2010 Haiti earthquake and/or had lost family members in this traumatic event. Pearson correlation coefficients were used to explore the relations between the scale items of the IES (Impact of Event
Scale) as well as between the subscales and other variables of interest.
Results
There were no participants in the subclinical or mild range, 71.8% in the moderate range, and 28.2% in the severe range. In addition, there was a significant positive correlation between the intrusive and avoidant subscales, r (37) =.48, p=.002.
Conclusions
These findings suggest that 9 months after the Haiti 2010 earthquake, significant amounts of post-traumatic stress symptoms were observed among members of the Zion
Seventh-day Adventist Church who had lost family members in this disaster. This study also suggests that grief symptoms among this bereaved population have a significant correlation with PTSD symptoms. Further research using additional methodologies and measurement techniques is needed to determine whether or not these patterns remain consistent. Andrews University
Seventh-day Adventist Theological Seminary
COPING STRATEGIES FOR MEMBERS OF THE ZION SEVENTH-DAY ADVENTIST CHURCH WHO EXPERIENCED MULTIPLE LOSSES AND COMPLEX GRIEF AFTER A MAJOR CRISIS
A Project Dissertation
Presented in Partial Fulfillment
of the Requirements for the Degree
Doctor of Ministry
by
Jean-Renaud Joseph
January 2013 © Copyright by Jean-Renaud Joseph 2013 All Rights Reserved COPING STRATEGIES FOR MEMBERS OF THE ZION SEVENTH-DAY ADVENTIST CHURCH WHO EXPERIENCED MULTIPLE LOSSES AND COMPLEX GRIEF AFTER A MAJOR CRISIS
A project dissertation presented in partial fulfillment of the requirements for the degree Doctor of Ministry
by
Jean-Renaud Joseph
APPROVAL BY THE COMMITTEE:
Adviser, H. Peter Swanson Skip Bell
__ :______Laren Kurtz Dean, SDA Theological Seminary Denis Fortin
David Sedlacek Date approved Dedication
To my Dad, even though he didn’t live to see this work,
To the trauma survivors who inspire me with their courage and will to survive,
To the 250,000 Haitians, and some of my friends who died in the 2010 Haiti earthquake,
May they rise again.
To the survivors, in the words of Bell and Danticat (2001), may you be resilient like bamboos, bent, but not broken and able to straighten up and stand.
in TABLE OF CONTENTS
LIST OF FIGURES...... vii
LIST OF TABLES...... ,...... vii
ACKNOWLEDGMENTS...... viii
Chapter 1. INTRODUCTION...... 1
Statement of the Problem...... 1 Statement of the Task ...... 2 Justification for the Project...... 2 Description of the Dissertation Process...... 3 Expectations for the Project...... 4 Limitations...... 5 Delimitations...... 5 Definition of Terms...... 6
2. THEOLOGICAL REFLECTION...... 9
Kinds of Suffering in the Old Testament...... 10 Retributive Suffering...... 10 Educational or Disciplinary Suffering...... 11 Vicarious Suffering...... 11 Empathetic Suffering...... 12 Evidential or Testimonial Suffering...... ;...... 12 Revelational Suffering...... 12 Doxological Suffering...... 13 Eschatological or Apocalyptic Suffering...... 13 Suffering and the Biblical Creation Narrative ...... 14 The Sin of Adam and the Fall...... 16 Summary...... 19 Suffering in the Book of Job...... 19 Eliphaz’s View of Suffering...... 21 Bildad’s View of Suffering...... 21 Zophar’ s View of Suffering...... 22 Elihu’s Speeches...... 22 Job’ s Personal View of Suffering ...... 23
IV Yahweh’s View of Suffering in the Book of Job ...... 24 Summary...... 25 Suffering in the New Testament...... 26 Luke’s View of Suffering ...... 26 Summary...... 30 John’s View of Suffering...... 30 The Man Bom Blind (John 9:1-41)...... 30 Summary...... 35 God’s Mercy and Suffering in the New Testament...... 36 Spirituality and Coping with Posttraumatic Situations...... 37 Summary...... 40
3. LITERATURE REVIEW...... 42
Historical Perspectives of Posttraumatic Stress Reactions...... 46 Definition and Prevalence of PTSD According to DSM-IV...... 50 Secondary PTSD...... 53 Complex PTSD...... 54 Grief and Complicated Grief...... 55 Loss, Disaster and Complicated Grief...... 57 Avoidance...... 59 Numbing...... 59 Intense Sadness and Extreme Anxiety...... 59 Sleep Difficulties...... 60 Flashbacks and Intrusive Thoughts ...... 61 Stages of Grief...... 61 Grief and Haitian Culture...... 62 Brief History of Haiti...... 62 Haitian Cultural Values...... 66 Haitian Family’s Structure...... 66 Haitian Culture and Mental Health ...... 67 Haitian Culture and Grief...... 69 Coping and Social Support...... 71 Summary...... 72
4. METHODOLOGY...... 75 m Instrumentation...... 75 Reliability...... 77 Data Collection Procedure...... 77 Limitations...... 78 Data Analysis...... 78 Summary...... 79
v 5. RESULTS AND DATA ANALYSIS...... 80
Method of Analysis...... 80 Missing Data...... :...... 81 Sample Demographics...... 81 Scale Reliability ...... 81 Examination of Impact of Event Summary Scores...... 83 Family Members Lost and Shaken Faith ...... 85
6. RECOMMENDATIONS AND COPING STRATEGIES...... 87
Recommendations for Further Studies...... 89
7. CONCLUSION ...... 90
Appendix
1. SURVEY (ENGLISH)...... 92
2. SURVEY (HAITIAN CREOLE)...... 96
3. SEMINAR AND BROCHURE ON POSTTRAUMATIC STRESS DISORDER (HAITIAN CREOLE)...... 98
4. BROCHURE AND SEMINAR ON POSTTRAUMATIC GRIEF (FRENCH)...... 101
5. SEMINAR AND BROCHURE ON ANXIETY AND PTSD (HAITIAN CREOLE)...... 103
6. SEMINAR AND BROCHURE ON STRESS AND TRAUMA (FRENCH)...... 106
REFERENCE LIST...... 108
VITA...... 141
vi LIST OF FIGURES
1. Sin is a Broken Relationship...... 18
2. Map of Haiti...... 63
LIST OF TABLES
1. Reliability Coefficients for Impact of Event Scale Scores...... 82
2. Item-level Pearson Correlations and Descriptive Statistics...... 83
3. Descriptive Statistics for Impact of Event Scale...... 84
4. Correlations Between Impact of Event Scale, Family Members Lost, and Shaken Faith...... 86
vii ACKNOWLEDGMENTS
This dissertation is the culmination of four years of an opportunity for learning: one year at Andrews University, Berrien Springs, Michigan and 3 years at Loma Linda
University, Loma Linda, California. I wish to express my deep appreciation to the faculty and staff at Andrews University and Loma Linda University for all of the guidance that they provided over the course of the past 4 years. I would like to thank .in a special way my mentors Dr. Carla Gober, Dr. Siroj Sorajjakool who have introduced me to the theories of counseling and chaplaincy. Special thanks to Dr. Skip Bell for his enthusiasm, encouragement and professionalism. He has taken the Healthcare Chaplaincy program under his wings and has given more than expected. Special “abrazos” to Dr. Johnny
Ramirez, the coordinator of the Healthcare Chaplaincy program for his time, sacrifice, and dedication. Johnny is a role model for his students both academically and socially.
I am especially indebted to my advisor Dr. Peter Swanson under whose direction this research was conducted. I cannot thank him enough for the dedication he has shown to overseeing this project. He welcomed my rough ideas and helped me refine them through a process that felt rigorous and challenging. He went far above what was expected of an advisor.
Special thanks to Dr. David Penno, my dissertation coach. He has been a great source of guidance and support throughout the past two years. I would not have reached this point without his suggestions, help, and expertise. I would like to thank Dr. Laren
Kurtz for his help and insights throughout this process.
viii I also want to acknowledge my dissertation committee members who contributed greatly to making this study possible.
Last, but not least, I would like to extend a very special thanks to my family for their unconditional love, support, and sacrifice that made this project possible.
IX CHAPTER 1
INTRODUCTION
Statement of the Problem
Earthquake is a common, natural disaster, causing widespread destruction and the deaths of large numbers of people. Every year, an average of 939 earthquakes of magnitude 5-8 on the Richter scale occur around the world killing over a thousand people
(Ba§oglu, M., Salcioglu. E., and Livanou, M., 2002; National Earthquake Information
Center, 2010). Previous research has shown exposure to traumatic events is associated with loss of lives, loss of income, increased psychological distress (Beverley, 2007;
Chen, 2007; Wang, Gao, Shinfuku, Zhang, Zhao, & Shen, 2000), posttraumatic stress disorder and depression among survivors of disasters (Henriksen, Bolton, Sareen, 2010;
UNICEF: At a glance, Haiti, 2010).
On January 12, 2010 at 04:53:10 PM, an earthquake of magnitude 7.0 hit Port-au-
Prince, the capital of Haiti and the southern part of Haiti. Since the initial event, at least
59 aftershocks of magnitude 5.0 or greater have been recorded (USGS, 2010; Nemetly,
2010; Bailey, R.K., Bailey, T., and Akpudo, H., 2010). The country has not been subjected to a catastrophe on such a scale for more than 150 years (Eliscar, 2010).
According to official sources, more than 250,000 people lost their lives, 300,000 were injured and 1.3 million displaced. About 35 percent of the members of the Zion Seventh- day Adventist Church in Miami, Florida, including myself, experienced multiple losses to
1 their families as a result of this earthquake. Some members experienced insomnia,
nightmares, trauma, and strong emotional distress that have caused disruption in their
lives. I was the only Haitian Adventist Chaplain available in the whole Miami-Dade area
to reach out to families suffering multiple losses.
Statement of the Task
This study (a) assessed the extent to which members of the Zion Seventh-day
Adventist Church experienced posttraumatic stress reactions, (b) sought to understand the
relationship between events involving death on a massive scale, and stress, anxiety and
selected variables among members of the Zion Seventh-day Adventist Church, (c)
developed culturally appropriate coping strategies and training resources to address
different types of grief, especially complicated grief, and (d) encouraged the formation of
crisis support groups of volunteers that can provide pastoral, spiritual, and emotional
care to church members of the Zion Seventh-day Adventist Church who are dealing with
complicated grief.
Justification for the Project
Since the World Trade Center disaster of September 11, 2001 there has been
intense and ongoing concern about disasters and posttraumatic care. However, there is a
lack of literature written from a strictly Haitian perspective on this topic and there is no
research done within the Zion Seventh-day Adventist Church and the Miami Haitian
Adventist community that examines the relationship of multiple losses and unresolved
i posttraumatic difficulties.
There is a clear need for studies that are focused on the ways that the Haitian
2 community deals with extreme stress and complicated grief. The outcomes of these studies broadened the understanding of the extent and nature of traumatic events in the
Zion Seventh-day Adventist Church. As one who has experienced trauma and posttraumatic reactions, I can identify with Walt Whitman when he states, “I do not ask how the wounded one feels; I myself become the wounded one.” This is one of the reasons I undertook this project to study approximately 40 members of the Zion Seventh- day Adventist Church who were dealing with multiple losses and posttraumatic events.
Description of the Dissertation Process
Theological reflection centered on the theme of God’s justice. Justice is rooted in the very nature of God (Isa. 40:14). The word “justice” is the typical English translation of the Hebrew word “mispaF from “sapat,” which means “to judge.” Some tend to see disasters as acts of God’ s punishment. Special attention was given to biblical passages in
Luke 13:1-5 and John 9:1-9 in an attempt to understand God’s justice, punishment, destruction and the principles that applied to the situation being studied. This chapter concluded with insights about God’s view of suffering.
Current literature dealing with trauma, posttraumatic stress disorder, complicated grief, anxiety, and posttraumatic situations in books, academic journals, and media were examined. Resources related to Haitians’ view of death were considered.
Demographic data and information about Haitians living in Miami were
3 collected from the Miami-Dade Census Bureau to determine religious affiliation, and geographic distribution.
A survey was administered to people who had experienced multiple losses.
Analysis of the data collected helped to assess the extent to which members of the Zion
Seventh-day Adventist Church experienced posttraumatic stress reactions at the time the survey was administered. Study was given to the relationship between events involving death on a massive scale and stress, anxiety, and selected variables among members of the Zion Seventh-day Adventist Church. The instrument that was used is the Impact of
Event Scale (IES) developed by Mardi J. Horowitz and modified and translated into
Creole by Jean-Renaud Joseph.
Expectations for the Project
This project would raise awareness about the posttraumatic experiences of people who attend the Zion Seventh-day Adventist Church.
This project would make available a modest resource of research data for comparison purposes in future studies of stress response syndromes within the Haitian
Adventist community
This project would provide culturally appropriate educational resources in the
Haitian language to help those who are dealing with multiple losses, complex grief, and posttraumatic experiences.
This project would foster the formation of support groups, and give training to individuals in order to provide spiritual, emotional and pastoral presence to those experiencing multiple losses within the local church setting.
4 Limitations
This study used the Impact of Event scale (IES) survey. This self-report
questionnaire is short and easily administered and scored. It can also be used repeatedly to assess progress. However it is valid only for use in measuring reactions to recent traumatic events (Marren, 2005), and it is mainly a screening tool rather than a
comprehensive test (Horowitz, 2003).
Another potential limitation was that subjects may also have been influenced by a
bias for reporting more or less distress. This study did not analyze the relationship
between the avoidance component and unconscious denial (Sundin & Horowitz, 2002).
More attention should be given in future research to a more detailed analysis of the effectiveness of different types of coping strategies, and particularly to meaning-focused
coping for people experiencing multiple losses and posttraumatic stress situations.
Delimitations
This study focused on the posttraumatic experiences of situations for members of the Zion Seventh-day Adventist Church who had experienced multiple losses in their families following a catastrophic event. It did not analyze the members’ psychological disorders related to other stressors common to Haitians living in Miami such as lack of
support systems, language barriers, low level of employment, lack of medical insurance, and cultural alienation.
This study addressed only the PTSD symptomatology, including complex grief related to the specific 2010 Haiti earthquake at the time of the survey. It did not assess
information about the level of PTSD experienced by Zion Seventh-day Adventist Church members in the period preceding the event or to other causes following the event.
5 Definition of Terms
For this study, key terms were defined as follows:
Anxiety. A normal reaction to stress or inordinate adversity.
Assessment. A means of measuring the feelings of the group involved in this research.
ASD. Acute Stress Disorder which occurs after a fearful response to experiencing or witnessing a threatening event. The diagnosis of ASD requires that the individual has at least three of the following: (1) a subjective sense of numbing or detachment, (2) reduced awareness of his or her surroundings, (3) derealization, (4) depersonalization, or
(5) dissociative amnesia (Bryant, 2006).
CAPS. Clinician Administered PTSD Scale. This scale was developed by the
National Center for PTSD, and is widely used by clinicians in assessing the severity of
PTSD (Weathers, Keane, & Davidson, 2001).
CISD. Critical incident stress disorder
Depression. A persistent experience of sad or irritable mood as well as the loss of the ability to experience pleasure in nearly all activities of life.
DESNOS. Disorders of Extreme Stress Not Otherwise Specified. This is mostly a
complex disorder of extreme stress that follows upon prolonged stress exposure to
repeated traumata (Herman, 1999).
Disaster. Any event that causes great harm or damage; sudden misfortune or
calamity.
DSM-IV. Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
6 DSM-IV-R. Diagnostic and Statistical Manual of Mental Disorders Revised, fourth edition.
EDS. Excessive day sleepiness
GAD. Generalized Anxiety Disorder
IES. Impact of Event Scale. This scale was developed by Mardi Horowitz et al. It is one of the most widely used self-reporting measures to assess psychological responses to a traumatic stressor (Pratt et al., 2006).
MFMER. Mayo Foundation for Medical Education and Research
MSCR-PTSD. Mississippi Scale for Combat-Related PTSD. This 35-item scale is widely used to assess combat-related PTSD symptoms.
Posttraumatic Stress Disorder (PTSD). A natural emotional reaction that results from exposure to a deeply shocking and disturbing traumatic event or experience
(McFarlane, 2006). The presence of a traumatic situation, by itself, does not sufficiently explain why PTSD develops or persists. Risks factors must be identified that may increase the likelihood of developing chronic disorder after exposure to trauma
(DiGrande, 2007; Yehuda, 2002).
SCID-PTSD. Structured Clinical Interview for DSM-IV. This scale, designed to assess a broad range of psychiatric conditions, is intended for use only by clinicians and highly trained interviewers.
Stress. An emotional and physical response that results from an increase in tension or worry about something that is dangerous, unknown or disturbing.
Trauma. A painful emotional experience, or shock, often producing a lasting psychic effect and, sometimes, a neurosis.
7
CHAPTER 2
THEOLOGICAL REFLECTION
Our theological reflection is demanded (Hilkert, 2002) by disasters such as the tragic events of September 11, 2001, the Oklahoma Bombing, the Holocaust, tsunamis, and by major earthquakes like those in New Orleans, Haiti, Chili, Bhuj, Fiji Islands,
Indonesia, and Japan. The loss of life and the suffering during the event and in its aftermath call for explanation and meaning-making.
Some Christian and political leaders hold the idea that disease and disasters stem from human sin (Magdalene, 2003), and are “extraordinary displays of God’s anger and ire with the world.” Robertson (as cited in Macombe, 2010, p. 32) told his “700 Club” viewers (Jan. 13, 2010) that “the horrific earthquake that struck Haiti on January 12, 2010 is the country’s own fault because the Caribbean Island had made a pact with the devil.”
Others become angry at God when their suffering is unbearable and describe God as “the Cosmic Sadist” (Lewis, 1974, p. 35). Silverman, as cited in Stem (2007, p. 207) said: “If you have a God who sends in tsunamis, why in the world are you going to pray to him?” Some Christians lose their faith, and defect from Christianity because they sense that it has no answers to the problem of suffering. Others who have attempted to make sense out of a tragic situation simply subscribe to a dualist view or a deistic belief
(Webster, 1984).
9 The tenets of deism describe God’s power and personal involvement with His
creation as limited. They declareby say that “God may be a good God who is not totally powerful.” The dualists question God’s goodness by saying that “God may be a powerful
God who is not good” (Bridges, 1988). Others like Kushner propose a God who is not
omnipotent, because he is limited by the laws of nature and by the evolution of human
nature and human moral freedom (Kushner, 1989). Others simply believe that God also
suffers and that he is “the greatest companion for the fellow sufferer who understands”
(Whitehead, 1979, p.351).
Kinds of Suffering in the Old Testament
Kaiser (2009, pp.65-78) describes eight kinds of suffering in the Old Testament:
(1) retributive suffering, (2) educational or disciplinary suffering, (3) vicarious suffering,
(4) empathetic suffering, (5) evidential or testimonial suffering, (6) revelational suffering,
(7) doxological suffering, and (8) eschatological or apocalyptic suffering.
Retributive Suffering
This is that kind of suffering that comes as a result of sin. “When we run against
the established grain of the universe and the order that God has set in the world, God
must judge that rebellion” (Kaiser, 2009, p. 68). Retributive suffering is mostly judgment
nations or individuals brought against themselves (Lewis, 1974). Kaiser (2009) thinks
that God is the only righteous judge of the whole world (Ps 7:8-10; 58:10-11; 82:1-4;
Prov 16:10-11), and when iniquities against God piled up so that the cup of iniquity (Gen
15:16) becomes full and runs over, sin must call down God’s judgment. For Kaiser, “This
suffering comes as God’s punishment for our outright flaunting of his instructions to us,
10 to our families, and to our nations; it is our own fault and we often have only ourselves to blame” (2009, p. 70).
Examples of retributive judgment include the following: the destruction of Sodom and Gomorrah, the fall and destruction of Samaria, the capital of the northern ten tribes of
Israel, and the destruction of Jerusalem, the capital of Judah.
Educational or Disciplinary Suffering
This kind of suffering is more a teaching device that allows us to grow as
believers and contributes to the shaping of our characters. Proverbs 3:11 states, “My son,
do not despise the Lord's discipline or be weary of his reproof.” The Hebrew word musar means: “discipline,” “chastisement,” and “correction.” Its synonymyasar shows that almost one-third of its occurrences refer to God as the one bringing suffering or some type of hardship to an individual or to a nation (Kaiser, 2009; Sanders, 1955).
Vicarious Suffering
This is a psychological, mental, and emotional pain, or anguish endured by God’s
prophets in their attempt to rescue their people from an impending disaster. Some
messengers of God even experienced abuse when calling their people to repent(sub) and
come back to God to avoid destruction (See Jer 4:19-22; 8:18-21; 15:15).
Vicarious suffering is also a “substitutionary” suffering on behalf of others
(Kaiser, 2009). Isaiah 53:4-6 describes the vicarious and atoning function of suffering:
Surely he hath borne our griefs, and carried our sorrows: yet we did esteem him stricken, smitten of God, and afflicted. But he was wounded for our transgressions, he was bruised for our iniquities: the chastisement of our peace was upon him; and with his stripes we are healed.
11 Moses’ intercessory prayer on behalf of his people who sinned by worshipping the golden calf apostasy is also an example of vicarious suffering (Ex 32).
Empathetic Suffering
Empathy is sharing with another person’s emotional experience in a particular situation. Empathy is a basic emotional faculty of humankind (Vethesen, 1994) and lies at the bottom of all feelings of others (Stevenson, 1999). Hos 11:8 describes empathetic suffering in these terms:
How can I give you up, O Ephraim! How can I hand you over, O Israel! How can I make you like Admah! How can I treat you like Zeboim! My heart recoils within me, my compassion grows warm and tender.
Evidential or Testimonial Suffering
Evidential or testimonial Suffering is “the means God uses to point men and women to Himself in a way so distinct that few other kinds of evidence could match”
(Kaiser, 2009, p. 75). The book of Job (1-2) and Heb 11:25-26; 35-37 are classic examples of evidential or testimonial suffering.
Revelational Suffering
Revelational Suffering is suffering used by God to bring us into a “deeper knowledge of Himself’ (Kaiser, 2009). The prophet Hosea was asked to marry the promiscuous Gomer because the “land” had gone a-whoring, going after her Canaanite lovers. Judgment was inevitable, but the situation was not totally hopeless because God’s compassion (juesed) was great (11:8-9). God will heal their backsliding ( mesuvatan) and will take them back in love and as a result the people will know Yahweh. Revelational suffering truly reveals the love and patience of God for His wayward children.
12 Doxological Suffering
Doxological Suffering is a teaching device used by God to show His glory.
Doxological suffering has a lot to do with salvation history theology. This suffering does not come as result of our sins; it is used for God’s glory in our lives.
The life of Joseph is a magnificent example of doxological suffering. After years of trials, unfair treatment, imprisonment, suffering, and separation from his family,
Joseph finally realized that God was working behind the scene through the evil purposes and machinations of men that His glory might be worked out (See Gen 45:4-5,7; 50:20).
Doxological suffering has a “special divine purpose of lifting up the magnifying power, presence, and glory of God” (Kaiser, 2009, p. 76).
Eschatological or Apocalyptic Suffering
Eschatological thinking has generated considerable scholarly interest and
investigation. Eschatology is derived from the Greek eschatos, and it refers to the last things or eschata. Eschatology refers to a time in the future when time and history as we know it will no longer be the same (Petersen, 1992). One of the recurrent features of eschatology is between the “already and the not yet” (Dodd), God’s people will be persecuted, following a time of despair, distress, crisis and apocalyptic woes such as famines, drought, pestilence, earthquake, war, and bloodshed (Dan 12:1). God’s people or “eschatological remnant” (Larondelle, 2000) will be vindicated when God brings about closure to the present eon (Johnsson, 2000). It will be the dawn of a new age, the end of human history, the end of suffering, and the establishment of the kingdom of God.
13 Eschatological suffering is the time of distress endured by God’s people prior to the Second Advent. Things will go from bad to worse before getting better, but God’s people will be delivered from the apocalyptic woes, and out of the “furnace of affliction”
will emerge a purified people (Kaiser,2009) ready to welcome a new age in God’s
eschaton (Zee 13:9; Mai 3:3).
The first section has examined the different kinds of suffering in the Old
Testament. The next section will look at suffering from the Bible’s overall plotline
(Morgan and Peterson, 2008) of creation, and fall.
Suffering and the Biblical Creation Narrative
The Book of Genesis starts with a splendid and majestic opening: “In the
beginning God created the heavens and the earth” (Gen 1:1). This first text of the Bible
remains without parallel in the ancient world (Hasel, 1971, p. 154-167) and serves as a
sort of prologue for the whole Bible (Doukhan, 1978).
This book sets a complex but finely ordered cosmic stage (Humphreys, 2001) and
introduces the two main subjects of the whole Bible, God the Creator and man his
creature, and sets the stage for the long tale of their relationship (Wenham, 2000 ). The
Creation story also addresses itself to the intellectual questions “how” and “when” the
world was made, and speaks to the existential questions of “who” God is and “what” He
is able to do (Hasel, 1974).
In terms of subject matter, the Book of Genesis breaks up into two distinct and
unequal parts (Walton, 2009) tied together by the recurrent transitionary, and unifying
Hebrew formula 'eleh toledot: “This is the account of or These are the generations of...”
14 For Collins (2006, p. 40), the purpose of these headings is to introduce new material.
Alexander (2002, p. 102) states that these headings serve two purposes:
They are like headings or chapters in modem books. Some introduce major narrative sections, which indicate a new stage in the development of a plot. Second, thetoledot headings function like a camera zoom lens which focuses the reader’s attention on a particular individual and his immediate children.
The first 11 chapters are universal in scope and tell about creation, the flood, and the tower of Babel. The second part, chapters 12-50, presents the origins of the people of
Israel and focuses on the story of the Patriarchs and their descendants.
This section of the study will deal only with the Creation story.
Dorsey (1999), Fishbane (1979), and Doukhan (1978) see an internal movement
of thematic repetition which displays a sense of symmetry and structural orderliness:
a light
b sea and atmosphere
c dry land
a’ luminaries
b’ fish and birds
c” land animals and humans
d Sabbath
This design shows that in the first three days, God creates the three worlds of life:
(a) light, (b) sea and sky, and (c) dry land. On the next three days God returns to each of
these respective worlds and fills them (Dorsey, p. 49): (a’) luminaries, (b’) fish and birds,
(c’) land creatures, people. The seventh day is unmatched and stands as unique. On the
seventh day God rests (Fishbane, 1979).
15 Scholars have suggested that the eight acts of God in creation can all be found in the eight sections of Psalm 104, the hymn of creation (Johns, 2006, p.157).
Here, the creation of man is not an afterthought (Blazen, 2006; Hasel, 1972,
1974), as in the Babylonian tradition, Enuma Elish. For the author of Genesis, the creation of man is the goal, the apex of creation. Like other cosmogonies and theogonies of antiquity, God did not create through magical utterances (Beauchamp, 1969; Brandon,
1968), but He created simply through His commanding Word. Hasel (1974), Anderson
(1967), Beauchamp (1969), and Doukhan (1978) see a conscious and deliberate anti- mythical polemic from the author of Genesis. It is like the author of Genesis was aware of a Tiamat myth and wrote as a deliberate rejection of other cosmogonies (Hasel, 1974).
The Creation story shows that God is not a Creator who retires once his work is finished (Humphrey, 2001), He cares for His creation, He originates, designs, molds iyasar), preserves, provides, governs, and guarantees (Blazen, 2006).
The Sin of Adam and the Fall
Genesis 1 presents a cosmocentric approach and the anthropocentric approach is provided in Genesis 2. The creative task is recounted in Gen 1:1-31. Gen 2:1-3 completes this section. The remainder of this chapter presents the creation of man and woman and
3:1-4:26 narrates Adam’s sin and describes his offspring. This section picks up a topic introduced near the end of last section-“humankind”- and makes it a the new central focus (Dorsey, 1999). This technique called “pearling” (Wenham, 2000, p. 156) is also used in Genesis and the rest of the Pentateuch.
According to Gen 1:31, God uses the formula ki tov, “that it was good.” By terming the creation “very good”, this implies that the Creator was pleased with His
16 handiwork and that no evil of any type yet existed (Ury, 2001). Adam, the pinnacle of
God’s creation, was “of noble height and of beautiful symmetry, and well proportioned”
(White, 1952, p.126). Adam and Eve enjoyed a unique relationship with God, and with one another, and an idyllic life in the Garden of Eden and man ’adam had dominion over the creation.
After the Fall, the relationship with God was spoiled. It is marked by fear, shame, and alienation from God (3:6-13). Adam and Eve’s relationship with one another (3:12-
16), and with the earth was also spoiled, and they had to be expelled from the garden, had to toil to secure food and could no longer have* access to the tree of life (3:17-24).
GOD
Figure 1. Sin is a broken relationship.
17 Sin is a broken relationship. It affects relationships with God, man, nature, and
also self. After the Fall, man hid from God and attempted to evade God’s presence. He
became aware of the radical change that had taken place.
The serpent is cursed ( ’arur ’atta), the land also is cursed. However, Adam and
Eve, though their punishment was severe, are not cursed (Cotter, 2003). The woman will
suffer in her fundamental role as a wife and mother. The sentence following the curse
carries an etiological ring: “In toil you shall eat of it all the days of your life.” Man also will return to the ground (ha ’adama), from which he came. (Gen 3:19).
Ury states that “sin introduces all woes, including everything from thorns to
volcanoes, from disease to predation, from wrinkles to death. Earmarks of the fall
permeate the entire world order (2001, p. 460).”
Summary
God created Adam and Eve in His own image. The first human pair enjoyed an
unhindered relationship with God, with one another, and they had dominion over the
creation. After the Fall, they experienced alienation from God and from one another,
banishment, suffering, and ultimately death. Suffering is not a part of God’s creation but
rather a byproduct of sin, and disobedience (Morgan & Peterson, 2008). It is an intruder,
something that should not be, something that does not belong (Williams, 2005). In the
parable of the weeds among the wheat, Jesus clearly states, “An enemy has done this.”
(Matt 13:28).
Suffering in the Book of Job
The book of Job is part of the wisdom literature which includes the books of
Proverbs, Job, and Ecclesiastes, and among the Apocrypha, Ben Sira and the Wisdom of
18 Solomon (Clements, 1992; Murphy, 1981). However the book of Job does not offer wisdom instructions, and proverbs like the other wisdom books (Salapki, 2009). Some argue that there is no single classification appropriate to the literary form of the Book of
Job (Westermann, 1981). Others see in the book of Job a “comedy” (Robertson, 1977, pp.
50-54), a “disputation” (Koehler, 1956, p.149-175; Lindblom, 1945, pp.40-44), an arguing lament (Westermann, 1981), a “ritual text” (Terrien, 1969, pp. 220-235), a
“drama that ought to be acted out” (Patrick, 1977, pp.12, 13), an “historical epic”or a
“tangram, which is a puzzle that offers innumerable possible solutions” (Cooper, 1990, p.74), a “judicial process” (Scholnick, 1982, pp. 521-529) or a “lawsuit drama”
(Robertson, 1977, pp.50-54), a sapiential understanding of reality or “a didactic wisdom”
(Magdalene, 2003, p.16; Gordis, 1978, pp.41-45; Gray and Driver, 1921, pp. xxi, xxii).
In relationship with suffering, the book of Job deals with the most painful and unavoidable questions which can arise in human experience (Janzen, 1985). For Ngwa,
2009, p. 361), the book explores
“the reality of disaster not primarily through the prism of human piety, but largely through the tripartite nexus of the causal theory of suffering (with an underlying ethical uncertainty), the reality of suffering (with its overt horror and ethical crisis), and the reception theory of suffering (with its perspectival ethics).”
This section is not a running, or verse-by-verse, commentary of the book of Job. It will briefly explore the overall theology of the book in relation to suffering.
The book opens with two heavenly court scenes and trials endured by a man named Job, a patriarch who is from the land of Uz in the region of North Arabia or Edom
(Clines, 1989), a land associated with wisdom (Magdalene, 2003; Weiss, 1983). Job is a man of exemplary rectitude and piety (Pope, 1973), extraordinarily blessed with wealth and with his wife, and children. He fears God and shuns evil. Yahweh Himself
19 substantiates Job’s greatness with “a rare accolade” (Magdalene, 2003, p. 105) by stating,
“There is no one like him on the earth” (Job 1:8; 2:3).
The narrator focuses on a special meeting of the Divine council where the sons of
God have presented themselves before Yahweh and the Satan has joined them (Job 1:6).
Job’s exemplary life is called to the attention of the accuser (Satan) who doubts the disinterestedness of Job’s piety and challenges God to put Job to the test. The suffering by this patriarch seems to be “without cause” as suggested by the Hebrew word hinnam found in 1:9; 2:3. However, in spite of his trials, loss of possessions, loss of family members, loss of social standing and reputation, Job remains faithful to God. Another series of attacks struck Job’s physical life with a terrible and disgusting illness to the point that he is disfigured, and he took a potsherd with which to scrape himself, and sat among the ashes (2:8). After days of silent suffering, Job begins to complain by cursing the day of his birth (3:3-6), and the night of his conception (3:7-10).
His sufferings, and complaints pave the way for Job’s friends: Eliphaz of Teman
(4:1-5:27; 15:1-35; 22:1-30), Bildad of Shur (8:1-22; 18:1-21; 25:1-6), Zophar of
Naamath (11:1-20; 20:1-19) who speak in rotation alternately with Job in three successive series or “cycles” (Christo, 1992, p.25); and finally the intervention of Elihu
(32:1-37:24).
Eliphaz’s View of Suffering (4:1-5:27; 15:1-35; 22:1-30)
Eliphaz’s speeches comprise four chapters: (4-5; 15; 22). His speeches are a reminder of the traditional wisdom theory of retribution. He is a subscriber of the wisdom instruction that affirms the imperfect condition of human beings before God (Nam,
2000). For Eliphaz, the innocent cannot perish like the wicked (4:7-11). In that regard, he
2 0 presents a contrast between the violent fate of the wicked and the pleasant fate of the righteous (Johns, 1983). Eliphaz presents a contrast of human nature with the nature of
God (4:17). Man cannot attain purity before Eloah. God is pure and perfect, while man is
imperfect, corrupt, unjust, sinning habitually (15:14-16), and dust-bound (4:17; 15:15,
16). He associates punishment with evildoing (5:3-27), and trouble comes as a result of
man’s sinful actions. He indicates that Job has caused his own misfortune and accuses
Job of having committed sins (4:6-8; 12:12-16).
Bildad’s View of Suffering (8:1-22;18:1-21; 25:1-6)
Bildad is a “prisoner of tradition” and tends to build “his entire theology on the
premises of the doctrine of retribution” (Hartley, 1988, p. 164). For Bildad, man is unable
to avoid impurity (25:1-6). He warns Job of impeding judgment. He explains and
describes the fate of the wicked and the godless (8:13-19) in contrast to the blameless
(8:20-22). For Bildad, there is a punishment in store for the wicked (18:5-21). He did not
clearly say that Job had sinned but, but he implied it (8:20-22). For him, Job is not as
pure as he thought; otherwise things would have been different. Cox (1978, p. 118)
summarized Bildad’s speech as follows:
Bildad only veiled his conviction of Job’s guilt under hypothetical forms of speech. He was thoroughly convinced that Job was suffering as punishment for his sins. Job’s only hope was to confess his sins... In a somewhat jaunty and insincere tone promises the afflicted patriarch a happy issue out of all his trials.
Bildad was less lenient and reserved than Eliphaz but Bildad did offer a little hope (Irwin,
1933).
2 1 Zophar’s View of Suffering (11:1-20; 20:1-19)
The contribution of Zophar to the debate is modest, but makes the point within the limited perspective of traditional wisdom (Murphy, p. 29). His second speech presents
“only the negative tenet of the doctrine of retribution, the certain punishment of the wicked” (Clines, 1989, p.206). For him, Job is boasting, full of mockery, and sin (11:3-6) and his character is empty (11:11-12).
Elihu’s Speeches (32:1-37:24)
Elihu is not mentioned as Job’s friend. He is presented as the son of Barachel, the
Buzite, of the family of Ram (32:2). His four speeches are all monologues and are not directed towards Job’s friends who gave false views of God. He claims to be wise, despite his youth (32:7-10).
Elihu’s speeches play a preparatory and transitional role to the speeches of
YHWH (McCabe, 1985). Elihu used a totally different approach. He did not try to convince Job of sin, and his speeches are not as harsh as the others (Johns, 1983). Elihu has tried to identify himself with Job and speaks to him out of human solidarity (Tate,
1971). Elihu challenges Job’s statements about God which tend to attack the Creator’s integrity. For him, God speaks in a variety of ways, which include dreams (33:15-18), suffering (33:19-22), and also healing (33:23-28). Elihu does not hide the fact that the righteous do suffer (36:7-10), and the wicked are not always struck immediately by
God’s wrath. He affirms God’s justice (34:10-12), reminds Job that God’s dealings with humans is without regard to office: 34:16. His main point is that no evil can escape God’s knowledge (34:21-33). For Elihu, God is not silent (Job 33), unjust (Job 34), or uncaring
(Job 35), and he challenges Job to repent for his offensive words about God (34:16-30).
2 2 • Job’s Personal View of Suffering
Job considers his friends who came to comfort him as “inflictors of suffering
rather than comforters and sharers in his pain.” (Hartley, 1988, pp. 271, 272). Job has
tried to claim his innocence (33:8-9), and he believes that his persecution by God is a
form of abuse of judicial authority (Botavi, 1994, p. 115), and misuse of power and justice (33:10-11). He also accuses God of hiding from him (13:24), and ignoring him or
overlooking him (30:20). Job “has developed a bitter attitude toward God” (Zuck, 1978,
p. 220). He cried: “Why was I ever bom (3:20); “When will it end? (Job 6); “No matter
what I do, nothing changes” (Job 9; 10:1-7). “I can’t take it anymore!” (14:18-22).
“Nobody cares about me” (19:13-22). “What good is it to serve God?” (Job 30). Littleton
(1987) thinks that all these questions are symptoms of common depression. In 9:2a, Job
was almost willing to agree with the basic principles of justice as outlined by his friends
to harmonize his innocence (Johns, 1983; Tsevat, 1966). He thinks that God was once his
friend but now it appears that God is his enemy. He even muses on how to approach God
or even file a suit against him (Nardoni, 2004, p. 136). Job ends his arguments in a very
arrogant tone and oath (Job 31) extolling his righteousness (Waters, 2009), and
“embracing a system of anthropodicy where he was obsessed with justifying himself
rather than God” (Sauer, 1972, p. 339). Francisco (1971, p. 518) remarks that “Job was
obsessed with his own righteousness and God’s seeming injustice, so much so that Job’s
“burgeoning pride” stood between him and God.”
23 Yahweh’s View of Suffering in the Book of Job
God intervenes following Elihu’s speeches. God’s intervention in the book of Job is “the longest oration by God recorded in the Hebrew Scriptures” (Waters, 2009, p. 260).
These speeches consist of nature poems with multiple rhetorical questions which Han
(1988) coined “resumptive rhetoric”, and “challenging imperatives.”
“Have you ever given orders to the morning or shown the dawn its place?”
(38:12); “Can you bind the beautiful Pleiades?” “Can you loose the cords of
Orion?”(38:31); “Can you pull the Leviathan with a fishhook or tie down his tongue with a rope?”(40:25).
The issues of God’s sovereignty and omnipotence are at the heart of God’s speeches in the book of Job. Ahn (2004) suggests that Yahweh’s speeches fall into four categories: (a) cosmology and meteorology (38:1-38), (b) animal kingdom (38:39-39:30),
(c) divine challenges (40:6-14), and (d) Behemoth and Leviathan (40:15-41-26), symbols of chaotic powers.
The creation of the earth, the sea, the sun, light and darkness, the clouds, the stars
(38:4-38), the lion, the raven, the deer, the wild donkeys, the horse, the eagle, the leviathan, the behemoth, the hippopotamus ... (Job 38-41) are used to illustrate God’s sovereignty over nature and the animate world. Job 42:2 is crucial in the understanding of
God’s monologue: “Shall a faultfinder contend with the Almighty? He who argues with
God, let him answer it.”
Job was silent and realized his nothingness, and his inability to answer God’s questions (Job 40:3-5). The ode to the behemoth and the leviathan added to Job’s silence and demonstrated God’s power versus human frailty. After listening to God, Job changes
24 his attitude toward God and withdraws his complaints (42:1-6). Now he sees God personally, not through the lens of tradition, but directly, and “understands that God is in the world with a mysterious, but powerful and loving presence, taking care of his own creatures” (Nardoni, 2004, p. 138).
Summary
Job’s three friends seem to share the common theology of the Near East (Nam,
2000), and defend the traditional view of the gods’ strict retribution. The sufferer viewed himself as a sinner in the hands of angry and capricious gods who were in total control of his life. Disease, disaster, and suffering are divine judgments for sins committed against the gods (Gray, 1970). The sufferer must have done something wrong for which he is being punished (Magdalene, 2003; Sheldon, 2002; Bloom, 1992; Christo, 1992; Fuller,
1992).
The ancient sages and patriarchs subscribed to the doctrine of retribution, the
belief that there is an exact correspondence between one’s behavior and one’s destiny
(Christo, 1992, p. 86). Job’s friends came to encourage Job and express their sympathy,
but no note of consolation was present in these speeches. Elihu shows that there are
reasons for suffering beyond the merely punitive. Yahweh’s speeches show that man
does not come to the knowledge and understanding of God on the basis of human
categories and reasoning. This comprehension of God comes only through revelation.
T. J. White, as cited in Mckenna (1986, p. 315), states,
Job recognizes that suffering is a mystery that he as a creature cannot comprehend. Before the ineffable mystery of God’s designs, he can only bow his head in adoring silence .... Knowing the answer to the question Who?, Job no longer needs to ask the question Why?
25 The book of Job shows that God does not explain the mystery of unjust suffering, but makes Job feel that he cares, and he is concerned about his suffering children. The
overall intention of the book is to show the inadequacy of the traditional theory of retribution in relationship to suffering (Murphy, 1981, p. 21).
For those who tend to equate suffering, earthquakes or trials as God’s judgment, the book of Job has taught that God is the Creator of the universe, and Fie alone has the right to do with his own as He pleases. As a sovereign God, He is unaccountable to
anyone.
Kushner (1989, p. xi) puts it well when he said, “What people going through
sorrow need most is consolation, not explanation. A warm hug and a few minutes of patient listening mend more hearts than the most learned theological lecture.”
Suffering in the New Testament
Luke’s View of Suffering (Luke 13:1-5)
In the larger literary structure of the Gospel of Luke, this pericope belongs to the
section of the great journey of Jesus from Galilee to Jerusalem (Luke 9-51-19:48). In a
shorter and immediate literary structure, this passage is set against the backdrop of the
second part of Jesus’ response to the crowds that began in 12:54-59 where Jesus laments that people know how to interpret the appearance of the sky but they do not know how to
discern the present time.
Luke 13:1 introduces a discussion with a reference to a contemporary event and
concludes with a parable on the need for repentance (13:1-9). Verse 1 states the event:”
26 There were some present at that very time who told him of the Galileans whose blood
Pilate had mingled with their sacrifices.”
The description of the incident is very brief and Luke gives no clues as to Pilate’s motivations for having them killed. It is worth noting that it was an “interjection” or just a report or an indirect account as suggested by the verb anayyeXkovxec, (Luke 13:1) which means to tell, or to report (Cholakis, 1997). Some scholars suggest that Galilee is occasionally equated with insurrectionary activity, and these Galilean worshippers may
“have come into collision with the Romans though some fanatical act of rebellion”
(Driver & Gray, 1958, p. 336). This explanation is purely hypothetical, and it is not clearly implied in this text. Others think that these Galileans seem to be simply pilgrims
from Galilee presenting their offerings and sacrifices in Jerusalem” (Bond, 1998, p. 151;
Fitzmyer, 1983, p. 1006; Marshall, 1978, p. 553). Pilate’s behavior appears cold and
insensitive. Some interpret the Greek expressionto alga tlilaxoc; sgi^sv gexa xoov 0oau»v auxcov as “gruesome” (Bond, 1998, p. 151), suggesting a barbaric slaughtering in the same way that sacrificial victims themselves have just been killed.
Pilate has been depicted by Philo and Josephus respectively as cruel, tyrannical, a
man of a very inflexible disposition, very obstinate, corrupt, insolent, careless, and
insensitive to Jewish religious conventions and mores (Stauffer, 1955, pp. 118-120;
Gatewood, 2005). Others assert that Josephus and Philo’s depictions of Pilate are not
without bias (Blinzler, 1959, pp. 182-183) and “were shaped by his theological outlook
typical of the stereotyped language of the time reserved for those who act against the
Jewish Law” (Bond, 1998, p. 36). Others have tried to present a more human, and
sensitive portrayal of Pilate. Maier thinks that Philo and Josephus are too negative
27 towards Pilate, even if he is “hardly the saint the Ethiopians would make of him” (1968, pp. 1-348). Brandon argues that these negative accolades are not correct and Pilate was neither deliberately anti-Jewish nor cruel and tyrannical. He argues that Pilate was “an efficient competent governor, trying to do his job and honor the emperor” (1968, p. 38).
Morrison (1940, pp. 83-147) and Lemonon (1981, p. 279) think that Pilate does not deserve those negative accolades and depict Pilate as relatively competent, a typical provincial governor, yet often miscalculating, impulsive, and insensitive to the mores of the governed.
Some challenge the plausibility of this incident, since it is not. referred to by the ancient writers and historians. He observes that Josephus would have known of it in his knowledge of other attacks on Jews in Palestine (Fitzmyer, 1983, pp. 1006, 1007).
However, others think that “the gruesome act of mixing human and animal blood would not have been beneath Pilate” (Cholakis, 1997, p. 120). Gatewood (2005, p. 197) remarks that “Pilate did not hesitate to exert force, even cruelty, mingling the blood of some
Galileans with their sacrifices, presumably in the interests of preserving Roman sovereignty.”
What is important in this narrative is the link between the sins of the victims and their suffering. Jesus asked, “Do you think that these Galileans were worse sinners than all the other Galileans, because they suffered thus?”(13:2)
Jesus used a second illustration of a collapse of a tower which crushed a number of citizens in the city of Jerusalem: “Or those eighteen upon whom the tower in Siloam fell and killed them, do you think that they were worse offenders than all the others who dwelt in Jerusalem?” (13:4).
28 Just remarks that “the article, with the demonstrative pronoun, suggests that these eighteen were well known to Jesus’ hearers” (Just, 1997, p. 532). The accident at the tower of Siloam “closely parallels the story of the Galileans in its grammatical structure,
showing the similarity between these two incidents” (Just, 1997, p. 534). The difference resides in the fact that the Galileans were victims of a state crime, murder while the
accident involving the death of the eighteen is a natural disaster caused by a natural cause
such as earthquake or by a mechanical failure (Talbert, 2002, p. 145; Just, 1997, p. 534).
However, in both instances, Jesus followed with a call to repentance: “I tell you, No; but
unless you repent you will all likewise perish” (13:3, 5).
Regarding the correlation between the sins of the victims and their suffering,
Jesus answered with an emphatic “no” (ovxi). Jesus rejects the notion that worse sin may
have been the cause of these tragic situations. Using a strong and emphatic tone with the
use of the adverb “cboauxcoq” (likewise, you yourselves), Jesus stresses the importance of
repentance as a means of avoiding destruction: “unless you repent (ueravoi/re), you will all
perish as they did” (13:3, 5). Here,ftsravofjTs carries the sense of changing one’s mind,
being converted, feeling remorse, feeling sorry, turning about (Temant, 1971; Dupont,
1967, pp. 48-70; Cantrell, 1991).
Schnelle (2009, p. 130) explains the double saying about the Galileans who had
been killed by Pilate and those killed in Jerusalem by the tower that collapse as follows:
Jesus intentionally lifts two individual events from an isolated cause-effect nexus and places them in a theological horizon. These events become something of a warning sign for all Israel, on whom God’s judgment will fall with unexpected terror, unless they repent. For Jesus, repentance means the acceptance of his message; the turn involved is turning to him.
29 Summary
In this pericope, Jesus uses two historical events to teach that calamities and tragic accidents can strike anyone, anywhere, and should not be seen as a sign of God’s judgment on specific people for specific sins. The death of those who perished on those two occasions does not prove that they were worse sinners than those who remained alive. Jesus’ auditors have “no grounds to pride themselves on their comparative righteousness” (La Verdiere, 1980, p. 181). For Jesus, the threat of a tragic end was present for everyone (Bock, 1996). None, including God’s people (faithful or unfaithful), are exempt (Just, 1997). Death is a common denominator for all; repentance, contrition and faith are the only alternatives to be able to escape the coming eschatological catastrophe.
John’s View of Suffering
The Man Born Blind (John 9:1-41)
The chronological timing of this event is not stated in the Gospel of John
(Stevens, 1991). However, scholars suggest that the events of John 9 may have occurred
during the Feast of Tabernacles or on the Sabbath day following the Feast of Tabernacles;
in one of three possible settings: during the Feast of Tabernacles, between the Feast of
Tabernacles and the Feast of Dedication, (Tan, 1994; Brown, 1970; Beasley-Murray,
1987; Carson, 1981); or during the Feast of Dedication, also called Hanukkah (Westcott,
1971; Schnackenburg, 1980).
30 Martyn (1979, p. 6) provides the outline for the pericope treating the chapter as a drama, and dividing it into seven scenes with two actors interacting only on the stage at one time. The scenes are delineated as follows:
1. Jesus, his disciples and the blind man verses 1-7
2. The blind man and his neighbors 8-12
3. The blind man and the Pharisees 13-17
4. The Pharisees and the blind man’s parents 18-23
5. The Pharisees and the blind man 24-34
6. Jesus and the blind man 35-38
7. Jesus and the Pharisees 39-41
This section will briefly study the passage as a whole, but special attention will be
given to the first scene: Jesus, his disciples and the blind man, especially on the verse:
“Rabbi, who sinned, this man or his parents.”
Jesus and his disciples were passing through the temple area. A congenitally blind
beggar caught the disciples’ attention. This is the only New Testament record specifying
a case of inborn blindness. However, there are other instances in the synoptics in which
blind people receive their sight (Matt 9:27-31; 12:22, 23; 15:30; 20:29-34; 21:14). Leon-
Dufour (1990) observed that the problem was obvious immediately and that the disciples
saw that it was a problem from childbirth. They asked Jesus a theological question
concerning the correlation between blindness, physical deformity and sin. Just (1997, p.
286) indicates that this question came from the disciples and not from the Pharisees. For
Dodd (1963, p. 186, 187), John 9:2 raises a question of theodicy “in terms of divine justice apportioning suffering to men.”
31 In the Hellenistic tradition, blindness was considered as death in a culture where
Phos (light) was viewed as life itself and it may have been imposed as punishment by the gods (Bemidaki-Aldous, 1985).
The disciples probably had in mind Ezek 18:2: “The parents have eaten sour grapes, and the children’s teeth are set on edge.” The Johannine community was aware of the idea of congenital sin. Ps 51:5-7 states: “Indeed, I was bom guilty a sinner when my mother conceived me.” The Jewish tradition of “the transferability of guilt” (Fishbane,
1979, p. 142) and the idea that the consequences of one’s behavior do invade the lives of following generations was not new to them (Esti, 2008). Summers (1979) says that it was a common belief in Jewish thought to relate all suffering in some way to sin.
Koester (2003, p. 104) remarks,
The disciples wanted to know what caused the man’s condition, but Jesus refused to pursue that line of questioning... Instead of trying to look back to determine what lay behind the blindness, Jesus looked ahead to what he might do with the blindness.
Jesus did not deny relationship between sin and disability. Tresmontant (1994, p.
218) thinks that Jesus abolishes the causal relationship between sin and suffering and it is
a revolution that has been long prepared centuries before by the book of Job. However, in
the healing of the paralytic in John 5, Jesus confirms the relationship between sickness
and the universal presence of sin, and the indirect consequence of the Fall (5:14). Some
scholars like Kieffer think that John 5 and John 9 are presented in almost parallel fashion
(Kieffer, 1989, p. 61). In John 9, Jesus emphasizes the sovereignty of God, instead of a
retributive cause for the man’s blindness. Using a causal and an elliptical construction
iva which often expresses purpose or may at times introduce a consecutive clause or
clause of result (Cadoux, 1941, p. 169), Jesus only states that this case is to reveal or
32 make manifest the works of God in the man’s life. Jesus makes a mixture of saliva and dirt and placed it on the man’s eyes. Some manuscripts read here¿nedrjKev, place or put upon, for EKEypiaev (anointed). Jesus gave him instructions to go wash ( viy/ai) in the pool of Siloam and the man was healed and received his sight. His skeptical neighbors questioned his identity and his explanation “the man they call Jesus had healed me” (9:8-
12) was reported to the Pharisees. For the Pharisees, the man had not really been blind at
all (9:18). Upon a line of questioning by the Pharisees, the congenital nature of the blind man affliction was later confirmed with caution by his parents: “He is really our son. He
was really blind, but how he came to see, we don’t know. He is of age, ask him” (9:19-
20), and also by the man himself (9:32). They finally concluded that this healing
constitutes a breach of the Sabbath and they argued against the person of Jesus. Since
there was no immediate danger on the man’s life to warrant Jesus performing the healing
on the Sabbath day (Stevens, 1991), the Pharisees and religious leaders asserted that
Jesus broke the law and certainly cannot come from God (9:14-16). Notice that some
rabbis argued that the Sabbath could be violated in the interest of saving human life.
R. Samuel is well known for the saying-“man shall live by the precepts of the Torah, but
he should not die in consequences of the same” (Mishnah Shabbath 7.2 as cited in
Barrett, 1978, p. 242). For the Pharisees, the blind man was not in this situation after all,
and Jesus mixture of saliva and dirt would fall into the category of kneading which is one
of the Sabbath’s prohibitions.
The Greek “para theou!\ which is the Hebrew equivalent “ min”, “me-et” or
simply “me-elohim ” indicates provenance or origin (Tresmontant, 1994, p. 220). The
Pharisees then challenged the person of Jesus, mainly his divine origin.
33 When the Pharisees challenged the blind man to give glory to God for the healing because Jesus is a sinner, he stated with conviction, “I was blind, now I see.” The formerly blind man refused to be silenced by intimidation (Sloan, 1988), and when he accused the Pharisees of wanting more information so they too could become Jesus’ disciples, he was “cast out of the synagogue”. Jesus, the light of the world gives physical
sight and the insight of faith but also passes judgment on the Pharisees for their rejection of the light and as the blind man progresses to greater and greater ability to see, the
Pharisees descend from sight into greater and greater spiritual blindness (Duke, 1985;
Brooks, 1991, p. 126). Felix Just (1997, p. 245) coined this “figurative blindness.” Just
continues,
The Johannine Jesus does connect sin and figurative blindness. That is, some people can see with their physical eyes but may not even realize that they cannot see the revelation of God manifest in Jesus, the light of the world, in Johannine terminology.
The self-imposed blindness of the Pharisees is what causes their state of blindness
(Esti, 2008, p. 105). Schnelle (2009, p. 720), thinks that “seeing” is a central feature of
the Johannine understanding of faith. He thinks that in John “know” and “see” are
structural elements of faith (p. 719). He summarizes this miracle as follows:
The Johannine concept of seeing is exemplified in the story of John chapter 9. Jesus gives sight to the man bom blind, who through faith becomes one who truly sees, while the Pharisees lapse into a crisis that subjects them to divine judgment because, persisting in unbelief, they become blind to the truth.
Fortna (as cited in Kysar, 1976, p. 73) discerns in this miracle two levels of
meaning: physical needs and spiritual needs. The physical needs function as symbols of
deeper spiritual needs. So, while Jesus heals the blind man, the overcoming of blindness
is more than a physical healing. Jesus seeks the formerly blind man and led him to a full
Christological confession of faith, and the man worshipped him{KpoasKvvrjaev). Some
34 think that the translation should not be “worshipped” but “kissed,” which reflects the eastern custom of prostrating oneself before a person and kissing his feet, especially of one viewed as belonging to the supernatural world, e.g., a deified king (Arndt &
Gingrich, 1979, p. 716). Notice the progression in the formerly blind man. He saw Jesus as a man (9:11), a prophet (9:17), and as Lord (9:38).
Summary
The question asked by the disciples is typical of the outlook of the ancient world.
The Jews believed that “A sick man does not recover from his sickness until all his sins
are forgiven.” In this passage, Jesus appeals to the sovereignty of God, and makes it clear that sin does not always cause suffering (9:3). This pericope shows that every affliction
cannot be regarded as the penalty of some wrong doing (White, 2002). This particular
case of congenital blindness is not a moral problem or punishment for some sin but an
occasion for the power of God to be revealed. Jesus makes it clear that suffering does not
always result from sin.
After this miracle, Jesus declares that the purpose of his coming is to make the
“blind” to see and to make the “seeing” blind.
God’s Mercy and Suffering in the New Testament
The New Testament use the words “KaKonaOem (kakopatheia) or KaKonadia
(kakopathia)” to express suffering. These words are also used for endurance of suffering.
However, New Testament discussions about suffering tend to focus on the questions of
the suffering of Jesus and how to understand the sufferings experienced by the early
Christians because of their allegiance to Jesus (Simundson, 1996).
35 The death of Christ was atonement for sins, and reconciled man to God (Rom
3:25; 1 John 2:2). The New Testament stresses that Christ’s death manifested the wisdom of God (Eph 3:9-11; 1 Cor 2:7, 8). Regarding Christ’s suffering, the cross has become a paradox around which the world revolves (Boyd, 2003). This ultimate sacrifice does not
appease God’s wrath; it reveals God’s love for the world (Boyd, 2003, p. 35). God suffers
for the world because of His love. Suffering teaches patience and endurance (Rom. 5:3,
4). Through suffering, believers are challenged to be sympathetic to others who are
suffering (2 Cor 1:3-7). Christians are called to share in Christ’s suffering (2 Cor 4:8-10),
to pray and give thanks in times of trouble (2 Cor 1:11; 1 Thess 5:18). Suffering can also
deepen a person spiritually (Waters, 2009) and teach humility and contentment (1 Pet 5:6,
7; 2 Cor 12:10; Phil 4:11).
Regarding suffering in the New Testament, Modica (1995, p. 22) asserts that
“persecution and martyrdom became part of what it means to be a faithful disciple of
Jesus Christ.” For De Ste Croix, as cited in Modica (1995, p. 22),
The monotheistic exclusiveness of the Christians was believed to alienate the goodwill of the gods, to endanger what the Romans called the pax deorum (the right harmonious relationship between gods and men), and to be responsible for disasters which overtook the community.
Stephen was stoned around C.E. 34 and a great persecution arose against the
Church in Jerusalem. Nero persecuted Christians and even used them as scapegoats for
the lire at Rome in A.D. 64 (Modica, 1995, p. 71). The Christians were called “notzrim ”
and were also associated with the heretics {minim) by some Jewish rabbis. The book of
Acts (Acts 4:24-31) mentions the persecution of Christians like Peter and John because of
their bold proclamation of Jesus. Others were persecuted, threatened, beaten and endured
imprisonment for the cause of Christ (Acts 9:23-25; 13:50-14:20; 20:25, 38; 22:25).
36 These arrests, trials, threats, beatings, imprisonments, and deaths contributed to the gospel’s being carried out to the Samaritans and Gentiles (Estridge, 1991, p. 22).
Spirituality and Coping with Posttraumatic Situations
Spirituality and religion are seen as separate phenomena (Zanowski, 2009). As for
a definition of spirituality, the viewpoints remain many. Emmons (2005, p. 731) defines
religion as “investing human existence with meaning by establishing goals and value
systems that potentially pertain to all aspects of a person’s life.”
Others see spirituality as a personal affirmation of a transcendent connectedness
to the universe while religion is the creedal, institutional, and ritual expression of
spirituality (King & Boyatzis, 2004). For Pargament (1999, p. 32), spirituality is “a
search for significant ways related to the sacred.” In the context of this study, spirituality
is considered as “a search for significance in times of stress” (Pargament, 1997, p. 90).
This psycho-spiritual definition suggests that spirituality is the heart and soul of religion
and unfolds in a religious context. Religion is then a reflection of an engagement with an
organized faith tradition. In this study, the terms spiritual coping and religious coping are
used interchangeably.
When faced with significant negative life events, many turn to God for comfort
and spirituality as a resource for effective coping (Zanowski, 2009; Cole, Benore, and
Pargament, 2004; Larson and Larson, 2003). For Fallot & Heckman (2005); Matheis,
Tusky, and Matheis (2006); and Tasker (2003), spirituality has proven to be a valuable
resource in coping with post-trauma. Zanowski (2009) suggests that spirituality and the
use of positive spiritual coping methods are related to decreased levels of distress in
response to stressful situations.
37 Pargament, Desai, and McConnell (2006) think that spirituality can be positive for some and negative for others. Spirituality can be ineffective in dealing with stressful situations when it becomes dysfunctional in using negative coping methods like pleading for direct intercession, attributing personal suffering to punishment by God, or the work of the devil (Zanowski, 2009; Pargament, Koenig, and Perez, 2000). When it is negative, it tends to be associated with greater distress (Pargament, Koenig, and Perez, 2000).
Meinsenhelder, 2002 noted that when an individual coping with a stressful event has a world-view of God as harsh, punitive, poorer outcomes are reported.
However, if God is seen in a positive perspective, spirituality may provide healing for stressful situations (Graham, Furr, Flowers, & Burke, 2001; Benn, 2001), coping resources, protection against depression, and may reduce the risk of substance abuse and suicide (Zanowski, 2009; Larson and Larson, 2003). For those who have a positive and secure view of God or a Higher Power, God is viewed as a caregiver, a source of strength, a safe haven or a secure base in times of great distress (Bellavich and
Pargament, 2002). A secure, spiritual attachment may allow individuals to feel supported by God and evoke supportive and collaborative strategies to cope with stressful events
(Cole, Benore, & Pargament, 2004, p. 63). The insecure-attachment individuals feel alienated from the sacred and do not believe that God will be there for them through tough and difficult times. This alienation can even lead to estrangement from the spiritual community (Cole, Benore, & Pargament, 2004).
For Graham (et al., 2001), the more vital one’s spiritual health, the more numerous are the coping skills. To those who are unsecurely attached, God is viewed as distant, uninterested, and these individuals tend to question their faith (Bellavich and
38 Pargament, 2002). The inability to find meaning and purpose is associated with psychological distress, doubt and uncertainty, and ineffective coping behaviors
(Zanowski, 2009; Gall, Charbonneau, Clarke, Grant, Joseph, & Shouldice, 2005). When the individual’s construct of God is positive and loving, religious comfort-seeking is usually a productive coping mechanism (Henderson, 2009; Pargament, 1999).
After the 2010 Haiti earthquake, many Haitians stated: “leave it to God.” This cry
is not a synonym of apathy, but the epitome of faith in God (West and Claude, 2003).
The New Testament proclaims that God is a God of love (1 John 4:8). Christians may suffer, but God’s steadfast love, components of which include: mercy, kindness,
lovingkindness, unfailing love, and steadfast love (Dybdahl, 2006, p. 92) is made evident
through compassion exemplified in Christ.
There are natural disasters like earthquakes, flood, hurricanes, and fires, but there
are also heinous intentional disasters committed by humans: the Armenian genocide, the
Holocaust, the bombings of Hiroshima and Nagasaki, the Rwanda massacre, suicide
bombings, the bombing of the federal building in Oklahoma City in 1995, the terrorist
attacks on the World Trade Center and the Pentagon on September 11, 2001, the Madrid
train bombing of 2004, the London bombings of 2005, the Egyptian bombings of 2005,
etc. Natural disasters are part of the consequences of the Fall and evil. Heschel states,
“There are hurricanes in the world as well as lilies” (2001, 358). Christians are caught in
the crossfire of a cosmic war (De Ste. Croix, 1963).
In the New Testament, God does not really give explanations about suffering. The
Christian is not always able to explain the “whys” of many instances of suffering. Farrer
(1961, p. 34) put it well when he said,
39 God does not give us explanations, we do not comprehend the world, and we are not going to. It is, and it remains for us, a confused mystery of bright and dark. God does not give explanations: he gives us a Son ... A Son is better than explanation.
Tupper agrees and adds that “the story of Jesus constitutes the definitive story of
God, the story that says, ‘God is love,’ the story that tells the tale of what ‘God is love’ actually means” (1995, p. 3). The cross is the climax of God’s love, and in the passion of the Son, the Father himself suffers the pain and the agony of death (Moltman, 1974, p.
274). In the world there is a universal symphony of suffering. The members of Zion
Seventh-day Adventist Church, and the Haitian community as a whole who have lost so many family members in the 2010 Haiti’s earthquake, and are experiencing complicated grief should be aware that even nature is suffering and “groaning in travail” (Rom 8:22), but the good news is that all believers are waiting for the eschaton when suffering, and death shall be no more (Rev 21:4).
Summary
The story of the Creation and the Fall gives one perspective on suffering.
Suffering is a product of disobedience. The original pair, Adam and Eve, disobeyed God and they opened the door to pain and suffering. Human beings are all vulnerable to suffering.
The book of Job is the classic biblical discussion of the problem of suffering.
Job’s friends, schooled in the moralistic teaching of the ancient Near Eastern doctrine of retributive justice, viewed suffering as punishment. The book ends with a hymn of the unfathomable greatness and power of God and the wonders and complexities of the universe. However, God offers no reasons why Job suffers.
40 Theodicy has addressed the compatibility of a good God who co-exists with various forms of suffering, pain and evil. I agree with Hume, the Scottish empiricist, who claimed that Epicurus’s old questions are yet unanswered, and with G. Mavodes who claims that they will never be. For me, suffering is a mystery that humans are unable to comprehend or control. The reasons may not be evident to the sufferer, who simply trusts
God and submits in faith.
Many members of Zion Seventh-day Adventist Church who lost so many family members were overwhelmed with a sense of emptiness. This research shows that 64.1%
of the sample population (n=39) reported that their faith was shaken by these experiences while 35.9% reported that it had not been (See chapter 5, Table 4). However, both groups turned to God for healing, and searched for meaning. The day after the disaster, many
Haitians turned to churches, and religious or spiritual beliefs to help them deal with this
tragedy. In the Haitian community, spirituality becomes especially important in providing
support and meaning in difficult and traumatic times. In their journey through grief, they
recognize that God is also the God of the valley. During these dark times, the preaching
at Zion Seventh-day Adventist Church was centered on the following Biblical passages:
“When I was in trouble, I called to the lord, and he answered me” (Jonah 2: 2):
“I was on my way to the depths below, but you restored me” (Psalm 30:3):
‘He kept me from the grave and blesses me with love and mercy” (Psalm 103:4):
“God is our refuge and strength, a very help in trouble” (Psalm 46:1):
“Though I walk through the valley of the shadow of death, I will fear no evil” (Psalm
23:4):
“Victory comes from the Lord” (Psalm 3:8).
41 During these difficult times, many members of Zion Seventh-day Adventist Church found grace, hope, faith, and a way of coping by relying on the promises of God found in
Scriptures.
42 CHAPTER 3
LITERATURE REVIEW
In order to establish the theory-based framework for this study, this chapter
discusses important literature and studies that examine (a) a brief historical perspective of posttraumatic stress reactions, (b) the DSM-IV definition of PTSD, and prevalence of
PTSD symptomatology in general, (c) an exploration of loss and complex grief/PTSD,
(d) Haitian’s views of grief, and (e) the importance of social and religious support in the
event of traumatic situations that follow a major crisis.
Several studies on the theories of PTSD, specifically, the effects of trauma and
complex grief on people experiencing multiple losses in the family after catastrophic
events, have supported this research.
Special attention will be given to McIntyre’s study (2009) on the Federal disaster
Mental Health response and compliance with best practices. This study reviewed state
disaster mental health response plans and highlighted procedures used during deployment
of disaster mental health response teams. Though that research is different from this
present dissertation, the section on PTSD predictive factors and responses, coping
strategies and survivor’s mental health were very useful in shaping my overall
understanding of PTSD.
The study by Ford (2009) on posttraumatic stress disorder, scientific and
professional dimensions, was very useful. This book gave me a framework for
43 understanding the effects of experiencing traumatic events such as terrorism, homicide, disaster, genocide, etc.
It is worth mentioning the research by Edelson (2009) on Prolonged Grief
Disorder and its relationship to attachment style and other psychological correlates. It examined the prevalence and correlates of PGD in a national web sample of bereaved adults. Even though the objectives of this study were different from that project, the section dealing with prolonged grief was a great resource when I was writing the section dealing with complicated grief.
Focusing on the emotional distress trajectories of survivors of Hurricanes Katrina and Rita, Green (2009), examines roles of pre-disaster distress, social functioning and disaster stress exposure.
Green’s study is the closest to this dissertation that I have seen so far. It provides
a review of research and theory focused on disaster, stress exposure and coping. It does
not deal specifically with complicated grief but it explores the emotional distress
trajectories of some economically-disadvantaged people who survived Hurricanes
Katrina and Rita. It shed light upon moderators and mediators of relationships between
disaster stress and Mental Health.
The study by Jamison (2008) on Primary and complex PTSD symptoms as
mediators between trauma history and schizophrenia symptomatology has also been
considered. It deals with complex PTSD symptoms and is related indirectly to this
research project. However, its objective was to test a theoretical model suggesting that
the harmful effects of trauma history on schizophrenia symptoms are mediated by PTSD
44 symptoms. The section dealing with complex PTSD and primary PTSD was very enlightening and contributes to my understanding of trauma and PTSD.
The study by Henderson (2008) on the effects of absorption and traumatic exposure on PTSD symptoms after the September 11th 2001, World Trade center attacks has provided a good historical perspective of posttraumatic reactions.
The research of Floyd (2007) investigated the psychological impact of Hurricane
Katrina on the citizens of New Orleans, Louisiana who relocated to Houston, Texas.
However, the focus is more on the influence of gender, age, marital status, educational
level and socioeconomic status on depression, Posttraumatic Stress Disorder and the
social re-engagement behaviors of relocated citizens. It used Beck’s Depression
Inventory to assess the stress levels while this present dissertation uses the Impact of
Event Scale (IES) to assess traumatic situations.
The research by DiGrande (2007) on PTSD among World Trade Center Tower
survivors of the September 11, 2001 terrorist attacks was considered. Its objective is
different from this present dissertation. DiGrande’s research is an epidemiological study
which studied the prevalence of PTSD among tower survivors and examined whether
social structure and direct exposure were PTSD risks factors. Chapter 3 entitled
“Epidemiology of PTSD” helped shape my understanding of PTSD in the general
population. It briefly mentions the relationship between disasters and PTSD.
Joseph (2006), on the effects of mass trauma in children of different
developmental stages, examines PTSD in children affected by Hurricane Ivan and
Hurricane Katrina.
45 This study presents the aftermath of natural disasters in which many individuals suffered mental health problems. In some cases, prevalence rates even doubled. The
section dealing with anxiety disorders and loss were very helpful in shedding some light on the relationship between loss and disaster. The main difference is that it targets
children affected by Hurricanes Ivan and Katrina and this present dissertation focuses on
adults (18 years and older) experiencing complicated grief after a traumatic event.
Mayfield-Schartz (2006), investigated the severity of trauma exposure and
complex Posttraumatic Stress Disorder symptomatology in women who are prostitutes
does not deal with complicated grief after exposure to a disaster, but explores the
relationship between three factors: (1) levels of trauma, (2) age at trauma onset, and (3)
the corresponding levels of complex PTSD symptoms in a non-random sample of 41 (18-
58 year old), predominantly homeless, street-walking female prostitutes. Nevertheless
this study provides some help when dealing with the mourning process after a major
crisis, particularly the stages of grief.
Historical Perspectives of Posttraumatic Stress Reactions
The original Greek use of “trauma” refers to open the skin (Ford, 2009). Garland
(1998, p. 9-11) defines psychic trauma as an event which “overwhelms existing defenses
against anxiety,” thereby inducing a “breakdown of an established way of going about
one’s life, of established beliefs about the predictability of the world,” or in more
mechanistic terms, a “breakdown in the smooth running of the machinery of the mind.”
The American Psychiatric Association defines Post-Traumatic Stress disorder (PTSD) as
an anxiety (emotional) disorder which stems from a particular incident evoking
significant stress.
46 The experience of trauma and its effect on psychological well-being have long been of interest to clinicians and researchers (Jamison, 2008). Throughout history, men and women have experienced some form of traumatic syndrome, but it was not defined as a psychiatric diagnosis. PTSD is like “a new name for an old story” (Bentley, 2005, p.
27). In 2008, the Agency for Healthcare Research and Quality estimated that collectively trauma-related disorders were the second most costly health problem in the USA, costing
$72 billion annually. Ford (2009, p. 3) states, “Posttraumatic stress disorder (PTSD)
affects one in twenty men and one in ten women at some point in their lives, about half of
whom experienced PTSD at some point in their childhood.”
Three thousand years ago, an Egyptian soldier named Hori described the feelings
he experienced before going and after returning from battle: “You determine to go
forward ... Shuddering seizes you, the hair on your head stands on end, your soul lies in
your hand” (Bentley, 2005, p. 28).
A Mesopotamian clay tablet described the case of a Babylonian king named
Gilgamesh who was terrified after the death of his closest friend, Enkidu. The tenth tablet
(www.ancienttexts.org/library/mesopotamian/gilgamesh//.) describes Gilgamesh’s
reactions:
I was terrified by his appearance. I began to fear death, and roam the wilderness. How can I stay silent, how can I be still! My friend whom I love has turned to clay! Am I not like him! Will I lie down never to get up again! ... That is why sweet sleep has not mellowed my face, through sleepless striving I am strained, my muscles are filled with pain.
Herodotus mentions the case of a commander named Leonidas, who, at the battle
of Thermopylae Pass in 480 B.C.E., dismissed some soldiers from joining the combat
because he recognized they were psychologically spent from previous battles. “They had
47 no heart for the fight and were unwilling to take their share of the danger” (Herodotus cited in Bentley, 2005, p. 27).
Homer’s Odyssey also depicts what we might term chronic PTSD when describing Odysseus as emotionally unable to return home after experiencing traumatic betrayal and loss (Ford, 2009; Shay, 2002).
A survivor of the London fire in the 1600s wrote in his diary a few months after his exposure, “It is strange to think how to this very day I cannot sleep a night without
great terrors of the fire; and this very night could not sleep until almost two in the
morning through great terrors of life” (cited in Saigh & Bremmer, 1999, p. 1).
Earlier scientific formulation of trauma was a combination of two disorders:
hysteria and hypochondria, a wear and tear syndrome resulting from stresses brought on
by living in an industrialized society (Bentley, 2005).
During the Civil War era, it was noticed that war veterans presented symptoms
including muscle weakness, tremors, fatigue, anxiety, severe palpitations, aching
sensation in the left praecordium, disturbed sleep or insomnia and depression after
returning from battle (Nemeroff, Bremmer, Foa, Mayberg, North, & Stein., 2006).
Trauma was then identified as “nostalgia, combat stress reaction, combat fatigue, combat
exhaustion, soldier’s heart, exhausted heart, effort syndrome” (Friedman, 2008, passim).
Others saw their distress as cowardice or deficit of will power (Everstine and Everstine,
2006)
In the mid-1800s, it was observed that people went through industrial accidents
without physical injury, but displayed strange behaviors days or weeks later like intense
memories of the events, severe headaches, and constant feelings of unease. It was
48 believed that psychological trauma was related to a situation or environment that tends to pose grave risks and violates the general sense of safety (Eghigian, 2011). It included the perceived inability of the modem social world to protect the victim from harm. These psychological disturbances were referred to as “railway spine,” “post concussion
syndrome”, and neurasthenia or traumatic neurosis (Hegadoren & Lasiuk, 2006; Lemer
& Micale, 2001). Trauma was also defined as a cluster of symptoms including emotional
dysregulation, and alteration of consciousness with evidence of prior traumatic
experiences (Smith, North, & McCool, 1990).
Later, people experienced a dissociative or psychic numbing at the aftermath of
traumatic events. This phenomenon was diagnosis by Pierre Janet, a French psychiatrist
as “splitting” (van der Hart, Nijenhuis, & Steele, 2005).
During and after World War I and World War II, there was evidence of different
types of battle fatigue, episodes of blindness, deafness, and periods of muteness suffered
by soldiers who came from combat situations. Some specialists, including Freud, thought
that it was the modem army unequipped to prepare soldiers for the principal burdens of
war (Shephard, 2010; Jones and Wessely, 2007). These types of traumatic situations were
diagnosed as “shell-shock,” “combat fatigue or combat exhaustion, operational fatigue”
(Henderson, 2008, p. 29). Abram Gardiner, who took time to study the effects of wartime
trauma just after World War II, concluded that these soldiers suffered from “war
neuroses,” “traumatic neuroses,” or “physioneurosis” (Benyakar, 2002; Flora, 1999;
Fullerton & Ursano, 2005; Hegadoren & Lasiuk, 2006; Linder, 2004; Henderson, 2008).
Those who survived the Holocaust exhibited some of these symptoms. Scholars in this
49 field began to advance the hypothesis that major trauma could bring about a psychological disorder (Johnston, 2008).
The Vietnam War brought awareness of Posttraumatic Stress Disorder. It was observed that Vietnam Veterans had a higher prevalence of divorce, violence, alcohol and drug abuse, and unemployment. Researchers realized that these dysfunctional behaviors are correlated with the vicissitudes of war and these psychological changes are called
“Post-Vietnam Syndrome” (Shephard, 2000). Studies of Vietnam War veterans began to
establish the field of trauma research as legitimate and significant (Smith, 2007), and the
concept PTSD (Posttraumatic Stress Disorder) was bom to describe the psychological trauma and atrocities endured by Vietnam Veterans. PTSD is also viewed as a disorder
resulting from sensitization to extreme or chronic stress.
Definition and Prevalence of PTSD According to DSM-IV
The last section was a brief overview of the historical development of the concept
of trauma. It has shown that trauma was diagnosed mainly to validate the experience of
traumatized Vietnam veterans as a normative response to the horrors of the war (Yehuda,
Keefe, Harvey, Levengood, Gerber, & Geni, 1995). However, it has become obvious that
one of the most striking consequences of experiencing trauma is Posttraumatic Stress
Disorder (PTSD). Studies on combat-related PTSD have greatly contributed to the
establishment of trauma research as legitimate (Smith, 2007).
The diagnosis of PTSD was first included in the DSM-III (Diagnostic and
Statistical Manual of Mental Disorders, third edition) in 1980. Some scholars think that
Kardiner’s work was very instrumental in the formal inclusion of PTSD in this particular
edition of DSM-III (Lasiuk & Hegadoren, 2006; Linder, 2004). Before 1980, symptoms
50 and effects of PTSD were, however, observed (Keane & Barlow, 2002). The first two editions of Diagnostic and Statistical Manual of Mental Disorders (DSM-I, 1952 and
DSM-II, 1968) did not use the term PTSD. The first edition created a category labeled
“Transient Situational Disorder” and under it, there was a sub-category called “Gross
Stress Reaction (GSR)”, defined as a psychoneurotic disorder or reaction that affected
otherwise normal individuals that originated from combat or catastrophic trauma and
stress (Linder, 2004).
In the DSM-II (1968, second edition), the term GSR was omitted (Flora, 2002;
Linder, 2004) and the term Transient Situational Disturbances (TSD) was introduced.
Trauma historians suggested that reactions to trauma were minimized by the introduction
of the concept Transient Situational Disturbances (TSD), since TSD is the type of
disorders that were temporary, varying in severity, occurring in individuals without
another underlying mental disorder, and an acute response to stress (American
Psychiatric Association, 1968; Linder, 2004; Henderson, 2008).
Researchers like Baldwin, Williams, and Houts (2004); Davidson, Stein, Shalev,
and Yehuda (2004); Fullerton and Ursano (2005); Lasiuk and Hegadoren (2006); and
Henderson (2008) suggested that PTSD was first identified as a separate disorder within
the anxiety disorders with the publication of the DSM-III (1980). In order to receive a
diagnosis of PTSD, a person had to report at least four symptoms from three separate
clusters of symptoms: re-experiencing the trauma, detachment and numbing responses,
and two from criteria dealing with personality or behavioral changes that were not
present before the trauma. The stressor criterion required the existence of a recognizable
stressor that would evoke symptoms of distress not only in War Veterans but also in
51 almost any person (American Psychiatric Association, 1980; Lasiuk & Hegadore, 2006;
Fullerton & Ursano, 2005; Linder, 2004; Henderson, 2008). The DSM-III is then a landmark in the history of PTSD (Lasiuk & Hegadoren, 2006; Linder, 2004) and a paramount shift in the way posttraumatic reactions were classified (Wright, 2007).
The diagnosis of PTSD has been refined and revised in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III-R, 1987). More examples of the
stressors were included. Four symptoms were also added, referring to active avoidance of thoughts, feelings, and activities as well as situations associated with or that aroused recollections of the trauma. This edition has also deleted “survivor guilt, and memory
impairment,” which were replaced by “irritability, exaggerated startle response.”
The DSM-IV (1994) identified several types of traumatic stressors or events
experienced directly or indirectly, and added more specificities that an individual must
experience, witness or confront with respect to an event that involves actual or threatened
death, serious injury, or a threat to the physical integrity of oneself or others (Fullerton &
Ursano, 2005; Linder, 2004). The elements of intense fear, helplessness, and horror were
also recognized in the diagnosis of PTSD
In the DSM-IV-TR (2000), which was the current version when this dissertation
was written, a total of six criteria must be met before a diagnosis of posttraumatic stress
disorder may be given (DSM-IV-TR (2000); Wright, 2007).
The first criterion includes: (1) direct personal experience, witness, or
confrontation with actual or threatened death or serious injury, or a threat to the physical
integrity of the person or others, (2) accompanied by a response involving intense fear,
helplessness, or horror.
52 According to the second criterion, one of the following symptoms must be present: the traumatic event must be persistently re-experienced, the recollections may be: recurrent and intrusive thoughts, images, nightmares, or flashbacks.
The third criterion addresses persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as
indicated by at least three of the following: (1) efforts to avoid thoughts or feelings
associated with the trauma, (2) efforts to avoid activities or situations that arouse
recollections of the trauma, (3) inability to recall an important aspect of the trauma
(psychological amnesia), (4) markedly diminished interest in significant activities, (5)
feeling of detachment or estrangement from others, (6) restricted range of affect,.e.g.,
unable to have loving feelings, (7) sense of foreshortened future.
The fourth criterion focuses on persistent symptoms of increased arousal (not
present before the trauma), as indicated by at least two of the following: difficulty falling
asleep, irritability or outbursts of anger, difficulty concentrating, hyper-vigilance,
exaggerated startle response.
According to the fifth criterion, the duration of the disturbance (symptoms
mentioned in second, third, and fourth criteria) should be at least one month.
According to the sixth and last criterion, the combination of symptoms causes
significant distress for the person or causes impairment in social, occupational, or other
important areas of functioning.
The present research is in line with the DSM-IV structure regarding PTSD,
however the manual definition of PTSD is incomprehensibly broad and vague (Everstine
and Everstine, 2006) and should be altered to reflect that the individual has “directly
53 experienced” a traumatic event (Spitzer, First, Wakefield, 2007, pp. 233-241). It can best be represented by four symptoms clusters: intrusion, active/passive avoidance, numbing, and arousal (Wright, 2007). The phenomenon of PTSD may occur when an individual is not provided psychological treatment following an extreme stress situation (Breslau,
2001; Briere & Elliott, 2000; Dean-Boreinstein, 2006). The experience of a catastrophic event can create many problems for its survivors (Dean-Boreinstein, 2006), including complex grief and complex PTSD.
Secondary PTSD
Secondary trauma is also called “vicarious trauma” (APA, 2000) or “remote traumatization”. DSM-II-R and DSM-III addressed direct exposure to a traumatic event to determine the prevalence of PTSD. DSM-IV has added “vicarious trauma component”
as a potential stressor. It states that “learning about unexpected or violent death, serious
harm, or threat of death or injury experienced by a family member or other close
associate “ may develop PTSD (Criterion Al, APA, 2000, p. 463).
Remote exposure, through television watching or having a friend or family
member directly experience the event, also appears to be associated with psychological
distress (Henriksen, Bolton, Sareen, 2010, p. 994). Studies by Schlenger, Caddell, Ebert
et al. (2002) Silver, Holman, McIntosh, et al. (2002) also suggest that people may
develop PTSD following direct or indirect exposure to a traumatic event. They stressed
that patients who were not directly involved with a traumatic event may still be suffering
from psychological distress following a mass-trauma, and “in some cases their distress
may be greater than those who were directly involved” (Henriksen, Bolton, & Sareen,
2010, p.999).
54 Most of the participants in this study were involved in both direct personal experience and remote exposure to a mass disaster.
Complex PTSD
Complex PTSD was not included as a separate diagnosis in the DSM-IV. It was defined as optional additional symptoms of PTSD that could be used to specify particularly severe cases (Ford, 2009). It is included in ICD-10, 2nd edition under the name “Enduring Personality Change after Catastrophic Experience” (World Health ,
Organization, 1992). However it has been proposed that Complex PTSD be included in the DSM-V.
The concept of complex PTSD is known as Disorders of Extreme Stress Not
Otherwise Specified (DESNOS). It was established in order to address the broader
adaptations of people who have histories of severe, repetitive and prolonged exposure to
trauma (Jamison, 2008; Kohlenberg, Tai, and Kohlenberg, 2006; van der Kolk, Roth,
Pelcovitz, Sunday, & Spinazzola, 2005; Briere & Elliott, 2000). Herman (1992, p. 119)
explains the difference between primary PTSD and complex PTSD in these terms: “In
survivors of prolonged, repeated trauma, the symptom picture is often far more complex.
Survivors [...] develop characteristic personality changes, including deformations of
relatedness and identity.”
Studies suggest that some Holocaust survivors suffer from the effects of trauma
even decades after the prolonged experience (Shmotkin, Blumstein, & Modan, 2003). It
is possible that some characteristics of complex PTSD may overlap with primary PTSD
(Jamison, 2008), but its critical features include:dissociation, somatization, poor self
regulation, identity or personality disturbances, including a damaged sense of self and
55 difficulties with trust and intimacy, vulnerability to repeated harm, inflicted either by the self or others (Ide & Paez, 2000). Researchers such Van der Kolk, Roth, Pelcovitz,
Sunday, and Spinazzola (2005) interpret dissociation, somatization, and affect deregulation as an attempt for the survivor to protect himself/herself from the depths of the pain, or terror associated with the trauma. However, these attempts to wall themselves off from consciousness are not the solution (Jamison, 2008).
Grief and Complicated Grief
Grief in itself is a natural and universal experience. It is a very common reaction
following a traumatic experience (Bryant, 2006). Bereavement, the process of grieving
and mourning, is a state of being experienced by an individual following the death of a
loved-one (Strada-Russo, 2006). Whether it is called “bereavement,” “grief,” or
“mourning,” it designates “the response to bereavement that generally consists of a
distressing state of unease, with yearning and longing for the person who died ...” (Shear
and Frank, 2006, p. 291). The nature of the relationship to the deceased and the
circumstances of the death play a significant role in the grief outcome (Field, Nichols,
Holen, & Horowitz, 1999; Reisman, 2001; Russac, Steighner, & Canto, 2001). Closer
and more satisfying relationships with the deceased tend to produce more grief (Bonanno
& Kaltman, 1999). Common grief reactions include physiological, psychological, and
spiritual reactions. Physiological reactions may include shortness of breath, feeling of
emptiness and heaviness, physical numbness, muscle tension, body aches, nausea,
headaches, dizziness, even gastro-intestinal problems. Other reactions may include
crying, fatigue, disturbances in sleeping and eating patterns, anorexia, weight loss, lack of
strength, and loss of sexual desire or hyper-sexuality. Some individuals experience
56 hopelessness and anger at God, and a desire to redefine one’s relationship with the deceased (Strada-Russo, 2006). There is a discrepancy among researchers on the length of time for normal grief (Strada-Russo, 2006). However, normal grief usually resolves after a variable period of time, and bereaved individuals tend to adjust to life without their loved-one (Strada-Russo, 2006).
However, there are pathological grief reactions, such as abnormal grief, unresolved grief, and complicated grief (Shear and Frank, 2006).
Complicated grief also called “traumatic grief’ is a state where a distortion or failure of one or more of the normal processes of mourning exists (Rando, 1993). It is “a chronic debilitating condition characterized by symptoms of separation distress, traumatic distress, sadness and other dysphoric affects, and social withdrawal” (Shear and Frank,
2006, p. 290). The present edition of the Diagnostic and Statistical Manual lacks a diagnostic category that would directly target the symptoms of complicated grief syndrome (Woemer, 2010). However, researchers like Bonnano (2004), Ray and
Prigerson (2006), and Horowitz (2006) have been seeking to have such category included in the DSM-V.
Following is a working definition of complicated grief (Horowitz, 2006, p. 1157):
The intensification of grief to the level where the person is overwhelmed, resorts to maladaptive behavior, or remains interminably in the state of grief without progression in the mourning process towards completion . .. (It) involves processes that do not move progressively toward assimilation or accommodation, but, instead, lead to stereotyped repetitions or extensive interruptions of healing.
Symptoms of “complicated grief’ (CG) include: thoughts of worthlessness, inability to accept the death, distressing yearning and preoccupation with the deceased, bitterness and anger about the death, shock and disbelief, unusual sleep disturbances,
57 intrusive images of the dying person, feeling excessively alone, and empty, estrangements from others, suicidal ideation, excessive avoidance of tasks reminiscent of the deceased, maladaptive levels of loss of interest in personal activities, and a general inability to function effectively (Shear and Frank, 2006, p. 293; Horowitz et al., 2003;
Provini, Everett, & Pfeffer, 2000; Prigerson & Jacobs, 2001; Rando, 1993). People experiencing CG typically feel “estranged from others and unable to feel satisfaction or
interest in daily activities” (Shear and Frank, 2006, p. 296).
Loss, Disaster and Complicated Grief
The occurrence of a disaster, by definition, is trauma-producing (Everstine and
Everstine, 2006). Studies report that individuals, who have lost all their resources and
material possessions after a disaster, experienced severe PTSD symptoms and major
depressive disorders (Nemetly, 2010; Banyard, 2009; Ford, Schnurr, Friedman, Green,
Adams, and Jex, 2004). Research by Norris, Friedman, Watson, Byrne, Diaz, and
Kanyasty (2002) suggests PTSD and also major depressive disorders (MDD) are felt to
be the most prevalent disorders arising in the post-disaster period.
Regarding personal loss, researchers like Digrande (2007); Joseph (2006); Arata,
Picou, Johnson, and McNally (2000); Thompson, Norris, and Hanacek (1993); and
Sattler, Kaiser, and Hittner (2000) have shown that more symptoms of severe PTSD were
found among people experiencing greater loss as a result of a disaster. Remote exposure
through television watching is also associated with PTSD (Silver, Holman, McIntosh, et
al. 2002). However, losing a family member or multiple members of the family as a result
of a tragic event is a “compounding factor in an individual’s reaction to traumatic stress”
(Joseph, 2006, p. 42).
58 Studies by Horowitz (2002) and Middleton, Raphael, Burnett, and Martinek
(1998) suggest that CG occurs in about 10 percent of bereaved people overall, with higher rates among individuals bereaved by disaster or violent death. Those who have
lost children or family members or close friends (Wickrama & Kaspar, 2007) have the tendency to display more severity in responses to trauma (Keese, Currier, & Neimeyer,
2008; Murphy, 2008; Joseph, 2006; Ray & Prigerson, 2006; Bowlby, 1980).
Grief is a normal human reaction. However, abnormal grief is “too little grieving
immediately after a death or too much grieving afterward” (Rosen as quoted in Gober,
2004, p. 130). For Simon, Wall, Keshaviah, Dryman, LeBlanc, and Shear (2011); Bryant
(2006); and Shear and Frank (2006), symptoms of CG (complicated grief) and related
bereavement are similar to those of Posttraumatic Stress Disorder, persistent yearning and
preoccupation with the deceased, hallucinations with the deceased, recurrent feelings of
anger and bitterness related to the death, shock and disbelief, avoidance behaviors,
anxiety, emotional numbing, intrusive thoughts, sleep difficulties, concentration deficits,
irritability, loneliness, estrangement from others, and automatic arousal in the weeks after
a traumatic experience.
Avoidance
Victims or survivors try to avoid anything that reminds them of what happened.
Avoidance tends to perpetuate PTSD, as the individual continues to struggle to keep the
traumatic memories from consciousness, the force of the traumatic memory continues to
exert stress on the individual (Jamison, 2008; Salters-Pedneault, Tull, & Roemer, 2004)
59 Numbing
Numbing is a lack of awareness and emotional detachment from what is going on
around him or her, and difficulty remembering details of the event (Doehring, 2006).
Numbing and avoidance symptoms of PTSD are the complementary symptoms of re
experiencing (Jamison, 2008). The individual’s world tends to be narrowed, and possible
buffering factors (e.g., social support) may be removed (Bonanno, 2004).
Intense Sadness and Extreme Anxiety
Anxiety disorders describe a group of conditions, including Generalized Anxiety
Disorder (GAD), Obsessive-compulsive Disorder (OCD), panic disorder, PTSD, Social
Anxiety Disorder (SAD) and other phobias (www.adaa.org).
Norris, Friedman, Watson, Byrne, Diaz, and Kaniasty (2002) and Nemetly (2010)
have reported that intense sadness is common among survivors of any major disaster,
especially among those who are bereaved. The victim’s neurological “alarm system”
seems to become too highly sensitive (Doehring, 2006, p. 79). The social, occupational,
and relational functioning of the person tends to be disrupted (Weaver, Flanelly, and
Preston, 2003). Many also present extreme anxiety and panic attack symptoms following
trauma (Nixon & Bryant, 2003). Neria, Galea, and Norris (2009) suggest that children
and the elderly have been consistently found to be at greater risk.
Sleep Difficulties
Sleep disturbance is a commonly reported symptom by trauma survivors (Morin,
2004; Kendall-Tackett, 2009). For Kendall-Hackett (2009) and Clum, Nishith, and
Resick (2001), sleep difficulties can also be related to depression and complicated grief
60 which tend to impact sleep architecture. Sleep problems may also reduce a patient’s ability to cope with pain, whether physical or emotional (Carmichael and Reis, 2005;
Smith, Perlis, Smith, Giles, and Carmody, 2000; Stepanski and Perlis, 2000).
The sleep disturbances experienced by trauma survivors can be (1) insomnia, (2)
hypersomnia, or (3) parasomnias.
Insomnia is the inability to fall asleep, or stay asleep and is often precipitated by
stress, worry, and depression (Kendall-Tackett, 2009).
Hypersommnia is the reverse of insomnia. It refers to excessive daytime
sleepiness, commonly referred to as EDS.
Parasomnias are troublesome behaviors intruding into sleep. They can be: sleep
walking, teeth grinding, and nightmares occurring during sleep (Hulme, 1989; Krakow et
al., 2000).
Flashbacks and Intrusive Thoughts
Flashbacks and intrusive thoughts are common symptoms of people experiencing
traumatic situations. When something reminds the person of the traumatic event, it is like
a trigger that draws the entire stored memory into consciousness (Everstine & Everstine,
2006). Memories of the traumatic event are encoded in the form of vivid sensations and
images that are fragmented, rigid, and disconnected from the overall context of the
individual’s life story (Jamison, 2008; Golier & Jehuda, 2002; Herman, 1992). In cases of
very severe trauma, the person may experience “flooding,” visual and auditory
flashbacks, literally reliving the traumatic event (Everstine & Everstine, 2006). Most
traumatized people are terrified when experiencing flashbacks, but the flashbacks are
obviously reminiscent of the traumatic event.
61 Stages of Grief
Grief is a common reaction following a traumatic experience (Bryant, 2006). A person who is struggling “with questions about the meaning of a past loss and is not experiencing the intense dynamics of the acute phase of grief is likely to be in the long term phase of grief’ (Doehring, 2006, p.71). There are some complicating factors that may lead to the long-term phase of grief such as the following: witnessing the death, death occurs in a tragic way, sudden, unexpected death, mutilating death, death of a child, lack of full mourning of the loss, lack of full expression of grief, and difficulties coping with the loss even after a year or more (Ibid, p. 73).
In the acute phase of grief, people experience the immediacy of their loss, the
sense of the unreality of this loss, and the disorganizing effects of grief (Doering, 2006).
Physiological and emotional symptoms include the following: sleeplessness, a sense of
chaos, numbness, anger, and intense sadness (Doehring, 2006).
Kubler-Ross (1969) described different stages of grief. The disaster process
follows a sequential pattern (Everstine & Everstine, 2006): (1) shock and disbelief, (2) \ facing the reality of the event, (3) traumatic survival mode until the event passes, (4)
adding up the losses, (5) acceptance, (6) rebuilding.
Grief and Haitian Culture
Currently in the U.S. there is a rapid rise in multi-cultural consciousness (Colin,
2001) and some ethno-cultural aspects of grief and post-traumatic stress disorders have
been identified.
62 Brief History of Haiti
Haiti means little mountain (or mountainous island) in the language of the
Tainos/Arawaks, the peaceful native inhabitants of the island (Dupuy,1989; Noailles,
2010). Haitians are from the island of Hispaniola in the West Indies, which was discovered by Christopher Columbus in 1492. Columbus named it “La Española” (“Little
Spain”) and claimed it for the Spanish crown (Katz & Boscov-Ellen, 2010). Hispaniola is
occupied by two countries: Haiti and the Dominican Republic, and has a total land area of
76,500 square kilometers. Haiti occupies the western one-third and the Dominican
Republic occupies the eastern two-thirds (Sarhan, 2006; Haggerty, 1989). Under the
Treaty of Ryswick, France officially took control of the western one-third of the island
(Haggerty, 1989).
Figure 2.Map of Haiti
63 Haiti is equivalent to the size of Maryland (Coupeau, 2008; Colin, 2001; Farmer,
2006). It is situated between Cuba and Puerto Rico, sharing its eastern border with the
Dominican Republic.
Haiti was called “The pearl of the West Indies” (Girard, 2005), the richest colony in the new world during the eighteenth century, mostly because of the production of
sugar, coffee, and cotton and it made France wealthy and was the envy of the world at that time (Goodwin, 2010; Sarhan, 2006). Farmer (2006, p. 56) notes:
St. Domingue (Haiti) was first in world production of coffee, rum, cotton, and indigo. On the eve of the American revolution, St. Domingue generated more revenue than all thirteen North American colonies combined ... and was the busiest trade center in the New world.
Haiti became independent in 1804, being the first black republic and the second
independent state in the western hemisphere, second only to the United States (Kelley,
1999; Foster, 1984; Abbott, 1998). The Haitian revolution was the first and only slave
revolution to culminate in national independence after a massive slave rebellion (Heinl,
1996; Haggerty, 1989). France, England, the United States, including the Vatican,
however, did not recognize Haiti’s sovereignty. For Katz and Boscov-Ellen (2010),
Cantave (2006), and Farmer (2004), the United States did not acknowledge the new
republic because of the importance of the slave trade to the South. In the same vein,
Clitandre (2009), Danticat (2001), and Mathewson (1996) suggest that knowledge and
recognition of the Haitian revolution would have stimulated more slave plotting and
insurrections. Thomas Jefferson even prevented American merchants from legally
participating in the Haitian trade by imposing a trade embargo (Fanning, 2008). Haiti had
to pay 150 gold francs in order to gain recognition from France. This debt was later
reduced to 90 gold francs (Farmer, 2004). The Vatican refused to recognize Haiti’s
64 independence for 56 years (Robinson, 2007). The Catholic Church did not establish a diocese in Haiti until 1860, while the United States took about six decades to acknowledge Haiti’s independence (Danticat, 2004; Rothberg, 1971). However, after so many years of political upheaval, US occupation (1915-1934), ineffective political leadership and instability (Stepick, 1998), Haiti is now the poorest, most rural and least developed country in the Western Hemisphere (United Nations Human Development
Program, 2003).
Haiti is situated on the mountainous half of the island of Hispaniola with slopes exceeding 20 percent grade covering nearly two-thirds of the country. The likelihood of landslide occurrence is extremely high if natural resources are degraded (Styles, 2010;
Eichler, 2010). Styles (2010, p. 54) remarks that the western half of Hispaniola has been completely stripped of its trees for fuel and construction and this deforestation has already led to severe landslides in recent years.
During the Duvalier’s regime (1957-1986), the Haitian economy and environmental conditions (continuing erosion) worsened in rural areas. In addition, the
Haitian governement’s acts of torture and violence were either experienced or witnessed by those who opposed the Duvalier’s regime (Colin, 2001; Bibb & Casimir, 1996, p. 96).
The Haitian peasantry began to head to Port-au-Prince, the Haitian capital, making the capital overcrowded and contributing to the creation of slums breeding disease and violence (Mission of Hope, 2007; Eberlee, 1999).
In the 1960’s a large majority of Haitians, including writers, journalists, politicians and professionals of the elite emigrated to escape state-sanctioned persecution and violence (Zimra, 1993).
65 Following the ousting of Duvalier in February 1986, and until December 1990,
Haiti experienced four military coups d’état (Bohming, 1991) that added to the country’s political instability. Conditions of poverty and economic crisis also forced the Haitian urban middle class to immigrate to the U.S. (Mooney, 2005; Catanese, 1999; Eberlee,
1999; Wucker, 1999; Dewind and Kinley, 1988).
The “Kennebunkport order” (Executive Order No. 12,807,57; Federal Regulation
23,133 as cited in Louis-Quist, 1997, p. 33) signed by President G. W. Bush in 1992,
which requires the U.S. Coast Guard to search and intercept in open water all Haitian
vessels and return them to Haiti has slowed the Haitian immigration (Louis-Linquist,
1997).
The Haitian Bureau of Statistics and Information projected that by the year 2010,
Haiti should have a population of 10,085,214 inhabitants (IHSI, 2003). Lentschner (2004)
reported that about 2 million Haitians immigrated to the United States for various reasons
from 1960 to 2004.The Haitian community abroad is widely spread throughout the Unites
States: New York, New Jersey, Massachusetts, Miami, Texas, Illinois and other areas as
well.
Creole is the language spoken by 100 percent of the population whereas French is
spoken by 10 percent of the population (Colin, 2011). Some speak of Haitian
“francophilia” which is ingrained in the social formation, for it is linked to access to
education (Segal, 1984, pp. 315-324; Fleischmann, 1984, pp. 101-118).
Haitians have high levels of religious observances, both in Haiti and abroad (Rey,
1999; Stepick, 1998). The primary religions practiced by Haitians are Catholicism and
Protestantism. The peasant masses participate in the worship of ancestral spirits through
66 voodoo rituals that are essentially derived from a hybrid, African-derived cult (Colin,
2001; Charles, 1990; Buchanan, 1980; Greene, 1993), Aleman and Ortega, 2001). In
2003, voodoo was formally recognized as a religion in Haiti (Nicolas, Schwartz, and
Pierre, 2010; Bellegarde-Smith, 2003).
Bibb and Casimir (1996) and Nicolas, Schwartz, and Pierre (2010) suggest that in times of psychological distress, religion provides individuals with a sense of community and a spiritual support network.
Haitian Cultural Values
Haitian culture is strongly rooted in African traditions. The artistic and musical
Haitian expressions are unique. The musical style is called “Kompa” which is “a mixture
of music and dance through the application of African drumming, guitars, saxophones,
horns, and Creole lyrics” (Nicolas, Schwartz, and Pierre, 2010, p. 100).
The Haitian cuisine is very well known. It includes rice and beans, “griyo”, which
is a special fried pork, “mayi moulen” (cornmeal), mixed with special spices and herbs.
Haitian Family’s Structure
The Haitian family system tends to be predominantly nuclear but may be
extended (Colderbank, 2009) to include blood relatives and in-laws, most of whom live
under the same roof (Rasambleman, 1976). The oldest man is the leader of the family, a
patriarch to whom all members owe reverence and respect. In some Haitian suburbs,
some members of the family, including sons, grandson, nephews and others live within a
short distance of the main “house” called “caille” or “lakou.” They cultivate the land
owned by the extended family members (Herskovits, 1959). Children are taught to
67 respect elders in the Haitian culture in order to have a successful future (Charles, 1986).
Physical punishment is an accepted and frequent method of disciplining children in Haiti
(Golderbank, 2009; Alvarex and Murray, 1981).
The Haitian family provides the fundamental foundation of Haitian life (Nicolas,
Schwartz, & Pierre, 2010). Haitians living in the Diaspora regularly send money to their parents and friends in times of natural disasters. The Haitian family system is a strong,
supportive mechanism for those who face adverse situations. Belonging to a family or a
community, maintaining traditions and cultures, and having a strong religious belief are
examples of protective factors (Grimaud, 2010, p. 24).
Haitian Culture and Mental Health
Jeanne Philippe (1979) and Boursiquot (2001) caution that it is impossible to
understand Haitian mental health through the lens of western psychiatry. Haitian mental
illness is a social illness and cannot be understood and treated without considerations of
culture or the interaction between cultural, familial, and individual characteristics as
factors in the development of personalities and pathologies. For Mars (1947), Bijoux
(1965), and Boursiquot (2001), ignoring the Haitian folklore and the cultural aspect of
Haitian mental illness greatly diminishes the chances of success and effective treatment.
It is one of the reasons, says Boursiquot (2001, pp. 1, 2) that “Haiti has been a source of
curiosity and misconceptions on the part of researchers and scientists.” In 1946 and 1993,
Price-Mars, the pioneer of Haitian psychiatry cautioned against the zeal to classify
Haitian mental disorders, based on the ICD and the DSM classifications.
68 Haiti as a whole endures a social ambivalence about acceptance of its true African ethnic background versus the view of the self as “colored or black French” (Boursiquot,
2001, p. 3)
In the past, people suffering from mental illness were arrested and incarcerated
(Boursiquot, 2001; Bordes, 1992). Others were taken to the local folk healers and voodoo priests and treated with beatings accompanied with songs and incantations (Bordes, 1980, p. 161; Bordes, 1992, p. 305). Even after the influence and efforts of pioneers like Price-
Mars, Jeanne Philippe, Chavannes, Lamarque Douyon, Haiti has made a little progress regarding mental illness and there is a lack of mental health professionals and institutions
in the country that can provide mental health services. McShane (2011, pp. 8-10)
describes Haiti’s lack of mental health structure in the following terms:
Haiti lacks a coordinated mental health care system. There are two psychiatric hospitals in the country: Defile de Beudet in Croix des Bouquet is the sole hospital for the chronically mental ill, Mars and Kline Psychiatric Center in Port-au-Prince is the only hospital for acute mental illness. It is a 52-year-old dilapidated facility which is severely understaffed and under-resourced.
Boursiquot (2001) questioned the use of the sophisticated western mental health
tests that are not adjusted to the culture of this illiterate population. Barry A. Hong (2010)
states,
It would be a mistake to look at the situation in Haiti through a traditional Western lens, because to the Haitians and their culture, family structures, communities, and religious resources will give a different substance and meaning to how. they cope.
Jaimes, Lecomte, and Raphael (2010) suggest that those who want to intervene in
Haiti must be brought to rethink practices in psychiatry and mental health according to a
vision of integration between Creole and Western medicine in clinical interventions.
According to Charles (1986, p. 185), a therapist may encounter three types of Haitian
69 clients: (1) those who come in the normal process of family reunification to rejoin relatives (they have a natural support system), (2), those without relatives who have been
encouraged by close friends to come, and (3) those who come on their own.
For Charles (1986, p. 196), Haitians have a tendency to ignore the problem,
thinking that they are able to deal with issues of depression within the family circle.
Chassagne (as cited in Bibb and Casimir, 1996) said that Haitians appear to be
unresponsive to therapy, and they tend to minimize, intellectualize, or relegate the
problem to God. The refusal to talk one on one does not necessarily equate with denial.
Bibb and Casimir (1996) note that Haitians tend to show non-verbal clues such as the
folding of arms across one’s chest with eyes looking at the ceiling, deep sighs, and eye
rolling that may convey a sense of boredom, embarrassment and dissatisfaction.
Haitian Culture and Grief
Each culture has its way of coping with grief and expresses mourning in its own
traditions, rituals and ways. Grief is the most available untapped emotional resource for
personal transformation (Prashant, 2010).
Grief is the cognitive and emotional process of working through a significant loss
(Larsen, 1999). Kubler-Ross (1969) has outlined five stages of grief reactions: denial and
isolation, anger, bargaining, depression, and acceptance/decathexis. Bowlby (1980)
identifies three phases: the urge to recover the lost object, disorganization and despair,
and reorganization. Parkes (as cited in Gober , 2004, p. 120) has rearranged Bowlby’s
phases in four phases or stages: shock and numbness, searching and yearning,
disorganization and despair, and reorganization.
70 The disaster process follows a sequential pattern (Everstine & Everstine, 2006):
(1) shock and disbelief, (2) facing the reality of the event, (3) traumatic survival mode until the event passes, (4) adding up the losses, (5) acceptance, (6) rebuilding.
The Haitians go through these stages like people in every other culture. After the
2010 Haitian earthquake, Haitians embraced church amid tragedy (Kaleen, 2010) and use
faith to cope with their grief (griefspeak.com/id90html). Kirmayer as cited in Grimaud
(2010, p. 23) states that “religion in Haiti offers a sense of purpose, consolation,
belonging and discipline. Religion can increase self-esteem, alleviate despair and provide
hope in very difficult and trying circumstances.” Nicolas, Schwartz, and Pierre (2010)
also think that in the case of Haiti, religion has also been shown to be associated with
coping and dealing with poverty, illness, and death. A. Money (as cited in Grimaud,
2010, p. 23) comments,
Haitians frequently exclaim Bon dye Bon (God is good) when something bad happens .. .believing that God is good, affirming that one’s dignity cannot be taken away by material deprivation or tragedy, and trusting that God answers prayers are further religious sources of resilience.
According to Money, Haitian’s beliefs and religious rituals generate cognitive
processes of self-efficacy and hope that even the worst tragedy can be endured.
Grief unites Haitians and is for them the most untapped emotional resource
available for their transformation (Prashant, 2010). According to the views presented on
the web site griefspeak.com/id90html, Haitians share the following pattern in the
aftermath of a death: (1) close family members and relatives make arrangements for the
funeral and church services, (2) family members and close friends visit the home of the
deceased to offer prayers and support, (3) a nightly wake is held at the home of the
deceased from the time of the death to the time of burial. This wake generally includes:
71 chat, food, drink, sharing of jokes, playing cards, and dominoes, (4) close family members and friends dress in black or white or dark colors for the funeral as a way of expressing their grief, (5) many Haitians express grief with the physical manifestations of great emotion. However, Haitian men are more reserved in their expression of grief and tend to contain their grief. (6) After the burial, family members and friends return to the home of the deceased or to the church fellowship hall for a reception where tea, coffee,
and foods are served.
The 2010 Haitian earthquake was very hard for Haitians living in the Diaspora.
Through radio, CNN, and other television networks, they heard the news that 200,000
people were dead and more than 300,000 injured. They had a sense of hopelessness when
they saw people burying their loved ones, and when they viewed onlookers digging their
friends, neighbors and family members out of collapsed buildings. Those who live in the
U.S. and abroad went through anticipatory grief when they had not heard from their
family members for one or two weeks. At Zion Seventh-day Adventist Church in Miami,
some church members lost 14 members in their family, others lost 2, 4 or 6.
This project studied the extent to which these members experienced complicated
grief.
Coping and Social Support
Families experiencing grief following a traumatic situation tend to think they can
handle it on their own with help of families, friends, and their religious faith (Smith,
Killpatrick, Falsetti, & Best, 2002). Some may even think that accessing mental health
counseling would be a sign of weakness or stigma, or they would not admit to having a
problem (Smith, Killpatrick, Falsetti, & Best, 2002). Research suggests that there is a
72 need for strong social support for people who have experienced personal or vicarious trauma in order to counteract the chronic long-term effects on psychological and physical health (Philipsen, 2003; McFarlane, 2006). Benight (2004) reports that when disaster survivors received strong social support, they tend to experience less distress. On the other hand, studies by Brewin, Andrews, and Valentine (2000) also suggest that perceived lack of social support can be a risk factor for PTSD.
A study by Tucker, Pfefferbaum, Nixon, and Dickson (2000) on Oklahoma City bombing concluded that counseling was helpful in assisting individuals at risk for PTSD.
Literature reviewed in this study suggests that group interventions among Haitians
appear to be more effective than individual counseling. It helps the survivors feel
understood, reduces social isolation, and helps them address embarrassment, fear of
negative reactions, and the worries associated with traumas that are particularly difficult
to talk about with family and friends. Foy (2008) indicates that group treatment is
beneficial for those with chronic PTSD, and group psycho-education of persons affected
by a common event facilitates the verbal sharing of experiences, helps change complex
behaviors, mobilizes social support, and gives information about available services.
Summary
This chapter is an overview of the history and development of the term
Posttraumatic Stress disorder (PTSD) and how it is used in relationship to trauma. The
concept of PTSD refers to a psychological disorder resulting from exposure to a
traumatic event. It was shown that trauma was diagnosed to validate the experiences of
traumatized Vietnam veterans as a normative response to the horrors of the war. The
diagnosis of PTSD was first included in the DSM-III in 1980, although its symptoms and
73 effects have been observed for much longer.
In order for an individual to receive a full DSM-IV diagnosis of PTSD, at least one symptom within Criterion B, at least three within criterion C, and at least two within criterion D must be present, and these symptoms should last at least one month (Criterion
E). Also included are symptoms that involve intense fear, helplessness, or horror and the belief that they or someone close to them might die or be seriously injured or permanently disabled, and criterion F, the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
PTSD is a debilitating condition that can occur in people who have experienced or witnessed a traumatic situation, such as disaster, terrorist incident, war, personal assault, or sudden death of a loved one. It is characterized by symptoms such as the following: intrusive distressing recollections of the traumatic event, flashbacks, chronic, unrelenting,
intrusive memories, flashbacks, nightmares, emotional numbness and avoidance of
situations that are reminders of the trauma. After a natural disaster, survivors may
experience recurrent anger, jumpiness, insomnia, and lack of concentration.
This chapter has discussed complicated grief involving difficulty accepting the
loss, longing for the deceased, dreaming, yearning, sadness, and avoidance.
0 Considering that cross-cultural factors play a significant role in the grieving
process and that ethno-racial minority groups are more exposed and less protected from
traumatic stressors (Ford, 2009, p. 317; Beverley, 2007), this chapter attempted to
highlight the Haitian cultural aspects of distress. It has shown that Haitians’ views of
grief and mass trauma are very complex, culturally influenced and that providing mental
health help to them requires particular sensitivity.
74 This literature review suggests that natural disaster creates physical, financial and emotional challenges to individuals and communities. In the aftermath of a disaster or a major crisis, various humanitarian organizations helping the Haitian communities tended to focus more on the financial and physical aspects of the disaster, such as shelter, food, water, and medicine. However, traumatic occurrences have the potential to impact dramatically the functioning of families, individuals and communities, and significant posttraumatic symptoms may develop weeks and months after the disaster. There was a lack of adequate disaster mental health response to this calamity within this particular population.
It is difficult to conduct mental health research among the Haitian community, because Haitians in general do not want to disclose intimate problems to strangers or professionals. They consider solving personal and intimate problems as family or
religious matters, and this refusal to talk does not equate denial. This study is a modest
effort to create awareness and to help members of Zion Seventh-day Adventist Church
view trauma as a serious mental health challenge.
The next chapter will address the methodology used to conduct this research by
considering Haitian language and cultural factors in addressing PTSD and complicated
grief after a major crisis.
75 CHAPTER IV
METHODOLOGY
Instrumentation
The Impact of Event Scale (IES) questionnaire was used to collect pertinent information for this study. The Impact of Event Scale is an instrument developed by M.
Horowitz, M. Wilner, and W. Alvarez in 1979 to measure the current degree of subjective impact experienced as a result of a specific event (Horowitz, Wilner, & Alvarez, 1979).
After evaluating the Impact of Event Scale following 20 years of use, Sundin and
Horowitz (2002) concluded that events such as natural and technological disaster, bereavement and loss, violence, sexual abuse, and war exposure are strong predictors of levels of intrusive and avoidant symptoms after a traumatic event, and that the Impact of
Event Scale is a good instrument to assess different individuals and populations exposed to life stress situations.
This instrument was chosen because it is (a) an appropriate instrument to measure the subjective response to stress in older adults (Horowitz, 2002); (b) a reliable and valid instrument for assessing post-traumatic stress disorder in particular populations
(Horowitz, 2003; Horowitz, 2002; Horowitz, Wilner, & Alvarez, 1979); and (c) it is short and easily self-administered and scored (Marren, 2005)
The Impact of Event Scale (IES) contains 15 items that assess the PTSD symptoms, and it takes approximately 10-12 minutes to complete. The various items are
76 divided into two subscales: intrusion and avoidance. Intrusion is characterized by unwanted memories of the event, nightmares, unbidden thoughts and images of the trauma or its aftermath, troubled dreams, strong waves of feelings, and repetitive behavior (Vassar, Knaup, Hale, & Hale, 2011, p. 9; Weiss, 2007; Amdur & Liberzon,
2001). Avoidance is typified by denial of the condition of the event, avoidance of reminders of the event, impaired sensation, behavioral inhibition, and awareness of emotional numbness (Weiss, 2007; Joseph, 2000).
This 15-item questionnaire uses a 4-point scale (i.e. 0= not at all, l=rarely,
3=sometimes, and 5=often) with a scoring range of 0 to 75. It mostly measures the
Intrusive, and Avoidance sub-scales. The questions that measure the Intrusive sub-scale are: #1,4,5,6,10,11,14 = 0 to 35 points and those measuring the Avoidance subscale are:
#2,3,7,8,9,12,13,15 = 0 to 40 points (Horowitz, Wilner, & Alvarez, 1979).
The interpretation of the stress score is as follows:
0-8 Subclinical range
9-25 Mild range
26-43 Moderate range
44 + Severe range
The total score = Avoidance subscale + Intrusive subscale = 0 to 75 points
(Sundin & Horowitz, 2003; Horowitz, 2002; Horowitz, Wilner, & Alvarez, 1979;
National Center for Posttraumatic Stress Disorder, hyperlink http://www.ncpts.org/).
There is also the IES-R which is an expanded 22-item version of the Impact of
Event Scale. However, the shorter version was used in this study.
77 Reliability
The IES is the most widely used self-report measure of posttraumatic stress. Its psychometric properties are satisfactory and it is a viable alternative for assessing PTSD
(Vassar, Knaup, Hale, & Hale, 2011,'p. 12). It is reliably researched and is probably the most popular trauma-specific questionnaire (Joseph, 2000; Sundin & Horowitz, 2002).
Schwarzwald, Solomon, Weisenberg, & Mikulincer (1987, p. 849) report that the IES has high internal consistency, test-retest reliability; it discriminates among different populations and symptom levels, and has been supported by factor analytic studies. There is a strong correlation between Impact of Event Scale scores and observer-diagnosed
PTSD (Sundin & Horowitz, 2002).
Data Collection Procedure
All pertinent information required by the Institutional Review Board (IRB) was provided. Once approval was received, the research study was initiated. Contact was made with Zion Seventh-day Adventist Board members explaining the nature of the research project. The Church Board gave written permission to the researcher to conduct this study. Participants were considered eligible for this study if they were 18 years of age and older and had lost one or multiple family members in the earthquake. The questionnaire was translated into Haitian Creole using the back-translation method. The investigator translated the English text into Creole and a Creole text was translated back into English by an independent bilingual person and compared with the original text. The
Creole translation was verified with 2 native Creole-speaking persons.
Participants were individuals recruited from Zion Seventh-day Adventist Church,
Miami, Florida. Fifty questionnaires were distributed to survivors of the 2010 Haiti
78 earthquake who were living in Miami and members of the Zion Seventh-day Adventist
Church. Some of them were on vacation in Haiti during the earthquake and witnessed the traumatic event. To ensure anonymity and confidentiality, participants were not asked to supply identifying information like: name, gender, age, or other personal characteristics, and they did not have direct contact with the researcher. A drop box was provided for the return of the questionnaires. A week later 39 completed questionnaires were retrieved from the drop box.
Participants were not compensated for their involvement in this study. They did not have to complete informed consent procedures, however they were informed that the return of the survey implied consent.
Limitations
The Impact of Event Scale is a screening instrument, not a comprehensive test,
and has a nonclinical focus (Marren, 2005). Its greatest value is realized when it is
administered repeatedly to track individuals’ progress. In this study it was administered
once.
Data Analysis
Descriptive statistics and correlation techniques were used to analyze the data. All
analyses were done using the Statistical Package for Social Sciences (SPSS) version 12.0
Revised (version 2.8.1) statistical programs. The qualitative responses were thematically
categorized into two sub-scales: Intrusive sub-scale and Avoidance sub-scale. The
influence of the following additional variables was assessed: number of family lost and
whether or not the earthquake and the events that followed had shaken their faith.
79 Summary
This chapter presented the general design used to implement this study. The original Impact of Event Scale (IES) translated into Creole was the primary instrument used to collect the data in order to assess PTSD. This scale assesses two clusters of
experiences occurring in response to a traumatic situation—avoidance behaviors
(attempts to avoid reminders of the event), and intrusive thoughts (unwanted memories).
The inter-correlations between the Impact of Event Scale scores, the number of family
members lost, and their faith in God were also analyzed. In the following chapter, the
data analysis and results of this survey are presented.
80 CHAPTER V
RESULTS AND DATA ANALYSIS
Method of Analysis
The analyses were done using the Statistical Package for Social Sciences (SPSS) version 12.0 Revised (version 2.8.1) statistical programs. Alpha coefficients were used to
assess the internal reliability of the total and subscale scores of the Impact of Event Scale.
If the items on a scale are all measuring the same underlying construct, then we would
expect them to be positively correlated with each other. Alpha reliability coefficients are
a way to assess how strong the inter-item correlations are among the items. Alpha
coefficients range from 0-1, and in general, alpha coefficients greater than .70 are
considered adequate (Tabachnik & Fiddel, 2001).
Pearson correlation coefficients were used to explore the relations between the
scale items as well as between the subscales and other variables of interest. A Pearson
correlation is a measure of the linear association between two variables. Pearson
correlations range from -1.0 to +1.0, with values closer to the end points indicating
stronger effects. If a correlation is negative, it means that as one variable increases the
other variable decreases. If a correlation is positive, it means that as one variable
increases the other variable increases as well.
81 Missing Data
One participant left question 11 blank when filling out the survey. This missing value was addressed with imputation (Little and Rubin, 2002) that is enabled by the
Amelia package in the Revised version ( 2.8.1). The imputation process involves
estimating a value for the missing data by using all of the other information in the data
set. The total useable sample size for this analysis is N=39.
Sample Demographics
Demographics variables were not considered. However, all participants were
members of Zion Seventh-day Adventist Church who had either personally witnessed the
2010 Haiti earthquake and/or had lost family members in this traumatic event.
Scale Reliability
Table 1 shows the reliability analysis results for the Impact of Event scale. The
alpha reliability measures for the total scale score and intrusive subscale were within the
acceptable range. However, the Avoidant subscale showed substantially lower reliability.
Table 2 shows the correlations between each of the items on the scale. Given the
definition of the alpha coefficient described above, it follows that the low reliability
coefficient for the Avoidant subscale is due to small or potentially negative correlations
between the items making up this subscale. Examination of the correlations between the
items on the Avoidant subscale (Q2, Q3, Q7, Q8, Q9, Q12, Q13, Q15) revealed several
very small correlations with, one substantial negative correlation between Q9 and Q12
82 (see Table 2). This pattern of correlations is responsible for the lower reliability for this
subscale. The Intrusive subscale reliability was very close to that reported by Horowitz
(2003) although the Avoidant subscale reliability was substantially lower.
Table 1
Reliability Coefficients for Impact of Event Scale Scores
Average Inter-item Scale Alpha Correlation
Total Score .74 .16
Intrusive Subscale .72 .27
Avoidant Subscale .50 .11
83 Table 2
Item-level Pearson Correlations and Descriptive Statistics
01 Q2 Q3 04 Q5 Q6 Q7 Q8 Q9 Q10 Qll Q12 Q13 Q14 QI5 Qi 1 Q2 .20 1 Q3 .52** .06 1 Q4 ,25 .34* ,49** 1 Q5 .40* .23 .32* .23 1 Q6 .18 .35* .08 .40* .33* 1 Q7 .02 -.05 .06 -.02 .08 -.25 1 Q8 .15 .16 .14 -.09 ,40* -.03 .09 1 Q9 .13 .22 .001 .03 .20 .08 .17 .37* 1 Q]0 .06 -.10 .07 .13 .33* .17 - .07 .10 .32 1 Qll .24 .26 -.04 .18 .34* .10 -.003 .04 .10 .38* 1 Q12 .07 -.01 -.05 .12 .44** .53** .07 .13 -.24 .18 .30 1 QI 3 .39* .22 .05 .05 -.07 -.02 .11 .10 .17 -.007 -.07 -.02 1 Q14 .31 .20 .06 .31 .23 .32* .02 .005 .38* .22 .49** .09 -.02 1 Q15 .34* .06 -.04 .02 .25 .02 .32 .21 .36* .04 .19 .15 .33* .56** 1
Mean 3.15 2.31 2.87 2.38 2.41 1.90 2.44 2.79 2.62 2.62 2.15 2.23 2.44 3.05 2.90 SD 1.33 1.20 1.56 1.58 1.55 1.57. 1.50 1.75 1.60 1.41 1.46 1.33 1.19 1.26 1.21 Min 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 Max 5 5 - 5 5 5 5 5 5 5 5 5 5 5 5 5 N 39 39 39 39 39 39 39 39 39 39 39 39 39 39 39
Note: *p < .05, **p < .01. The Pearson correlations between each item are displayed in the triangular matrix. Each entry in the correlation matrix can be identified by looking at the corresponding column and row label of that entry. The descriptive statistics for each of the items are displayed at the bottom of the table. Included is the mean value across all participants (i.e., the average score), the standard deviation (SD; a measure of how much the scores vary within the sample), the minimum score, the maximum score, and the sample size (N).
Examination of Impact of Event Summary Scores
The total and subscale scores are created by adding together the scores for the
appropriate items for each individual in the sample. Thus, the total score is composed of
84 all 15 items on the scale. The Intrusive subscale score is composed of items 1, 4, 5, 6, 10,
11, and 14. The Avoidant subscale score is composed of items 2, 3, 7, 8, 9, 12, 13, and
15. Once the total and subscale scores for each individual are calculated, descriptive statistics are calculated on these scores to get summary values for the sample as a whole.
Table 3 shows the descriptive statistics for the total and subscale Impact of Event Scale scores.
The total score is interpreted in the following manner: 0-8 subclinical, 9-25 Mild range, 26-43 Moderate range, and 44 + Severe range. The mean total score across the
sample was 38.25, squarely in the moderate range. There were 0 participants in the
subclinical or mild range, 71.8% in the moderate range, and 28.2% in the severe range.
In addition, there was a significant positive correlation between the Intrusive and
Avoidant subscales, r(37)=.48, p=.002, such that as intrusive thoughts and behaviors
increased, avoidant thoughts and behaviors increased as well. This correlation between
the subscales was very close to that reported by Horowitz (1979; r=.42).
Tabled
Descriptive Statistics for Impact of Event Scale
Standard Scale Mean Minimum Maximum Deviation Total Impact Event Scale 38.25 9.96 26.76 65.00
Intrusive Subscale 17.66 6.19 9.00 33.00
Avoidant Subscale 20.59 5.38 10.00 36.00
85 Family Members Lost and Shaken Faith
Participants also answered two additional questions about the number of family members lost and whether or not the earthquake and the events that followed had shaken their faith. Eleven participants lost one family member, 19 lost two members, 5 lost three members, and 4 lost four family members. Twenty-five (64.1%) participants reported that their faith had been shaken by these experiences, while 14 (35.9%) reported that it had not.
Table 4 shows the inter-correlations between the Impact of Event Scale summary
scores, the number of family members lost and shaken faith. The number of family members lost was significantly related to both the total impact score and the avoidant
subscales, such that as the number of family members lost increased so did the impact of
the event. The number of family members lost was also correlated with the shaken faith
question. Participants that reported that their faith was shaken tended to have more family
members lost.
86 Table 4
Correlations Between Impact of Event Scale, Family Members Lost, and Shaken Faith
Faith Total Intrusive Avoidant # Lost Shaken Total Impact Score 1 Intrusive Subscale .82** 1 Avoidant subscale .85** .45** 1 # of family members lost .31* .18 .36* 1 Faith Shaken (yes/no) .02 .01 -.05 .46** 1 Note: *p < .05, **p < .01. The Pearson correlations between each item are displayed in the triangular matrix. Each entry in the correlation matrix can be identified by looking at the corresponding column and row label of that entry. Since the shaken faith variable is binary (l=yes, 0=no), the correlation between it and the other variables are point bi-serial correlations. These correlations are interpreted in the same way discussed above.
87 CHAPTER VI
RECOMMENDATIONS AND COPING STRATEGIES
The author was not able to find any other research that investigated the prevalence of trauma, PTSD and complicated grief among members of Zion Church who experienced multiples losses in their families in the aftermath of the 2010 Haitian earthquake.
A major finding that emerged from this study is that 71.8% of respondents scored
in the moderate range, 28.2% in the severe range, and that there were no scores in the
subclinical or mild range. There was also a significant positive correlation between the
Intrusive and Avoidant subscales. As intrusive thoughts and behaviors increased,
avoidant thoughts and behaviors increased as well. This means that there were a lot of
flashbacks and distressing dreams associated with this traumatic event. During a
flashback a person may relive the traumatic event and completely lose touch with reality,
believing that the traumatizing event is actually happening all over again (Floyd, 2007;
Longe, 2006).
This study also finds that participants tried to avoid thoughts, feelings, and
activities associated with the trauma. Studies by Boelen, van den Hout, and Reynolds
(2008) on the role of threatening misinterpretations and avoidance in emotional problems
after loss, and Shear and Shair (2005) on the attachment-based model of complicated
88 grief and the role of avoidance confirm that avoidance is the key element in assessing
Complicated Grief (GC).
The data presented in this research have profound clinical implications for the respondents, and highlight the need for disaster mental health responses that address the needs of disaster survivors in the local church.
Based on the findings obtained from the results of this study, the following recommendations are being offered as ways of coping. By coping, we mean any effort that makes a hardship easier to bear (Rosenbloom, Williams, & Watkins, 2010) and skills to adjust to the stress and to the changes it has created.
First, for the 28.2% who are in the severe range, it is recommended that all
participants see a Mental Health Professional who is aware of the cultural practices and
biaises with respect to the expression of grief in the Haitian community to determine
whether or not they are experiencing PTSD. Second, it is recommended that the local
church educate survivors on the psychological effects of trauma: depression, Generalized
Anxiety Disorder, Posttraumatic Stress Disorder, eating and sleeping disorders, grief,
complicated grief, remembrance and mourning, reconnection, how to say good-bye,
connecting thoughts and feelings, building connection and meaning, distress tolerance,
self-care, how to transform traumatic memories (Some sample seminars and educational
materials in French and Haitian Creole are available at the appendix). The goal of these
seminars is to create awareness, and teach people that after exposure to traumatic events,
some individuals presented a specific array of symptoms that may affect their normal
lives, self-definition, and interpersonal functioning.
89 These educational materials regarding traumatic reactions and grief processes will help people to validate their feelings, grieve appropriately, think about and process their losses, and normalize their experiences.
Third, this study recommends that the local church should provide social and spiritual support by organizing more social activities for members who have lost multiple family members. Spiritual support includes: prayer breakfasts, organization of support groups, and pastoral visitation groups. Seminars on the difference between a normal visit and a pastoral visit need to be presented to volunteers who are willing to visit, to teach them how to establish a pastoral presence, and how to conduct an interview using open- ended non- threatening questions.
Social programs could include: Sundays and holidays at parks and beaches in
Miami, Miami Beach and Key Biscayne, Florida, etc. It is also recommended that the
church organize concerts, recreational trips to Orlando, Tampa, and places like Freeport,
Grand Bahamas, Cozumel, Mexico, Cayman Island, Ocho Rios, Jamaica, and Haiti, etc.
for church members. Fund-raising events could be organized to help those who need
financial assistance.
Recommendations for Further Studies
1. A follow-up over a larger geographical area would provide additional data for
other intervention methodologies.
2. It is recommended that this study be extended to include the (IES-R, Impact of
Event Revised and the Inventory of Complicated Grief (ICG), which is a scale designed
to measure maladaptive symptoms of loss. This would help optimize sensitivity and
90 specificity for identification of Complicated Grief (GC) among members of the Zion
Seventh-day Adventist Church.
3. Further study should be conducted in the Greater Miami area to stimulate clinically useful research among the Haitian communities.
4. Following the disaster, pastoral support to the members of the congregation was presented in the form of a small-group ministry. The congregation was divided into small groups of 6 or 8 to allow everyone to share and express their emotions. This particular ethnic group seems to be more willing to express their feelings in a small-group setting rather than on a one on one basis.
Further studies should be conducted in other communities to determine whether or not this particular approach could benefit individuals faced by similar trauma.
91 CHAPTER VII
CONCLUSION
This research explored the prevalence of trauma exposure, complicated grief,
PTSD and related symptoms among the members of the Zion Seventh-day Adventist
Church who experienced multiple losses in their families in the aftermath of the 2010
Haiti earthquake. Our findings of increased intrusion and avoidance phenomena among
survivors of the Haiti 2010 earthquake are consistent with previous research that has
shown an increase in depression and mood disorders following a major disaster (Nandi,
Galea, Ahem, & Vlahov, 2005). This study also suggests that grief symptoms among this
population have a strong correlation with PTSD symptoms. The prevalence of traumatic
grief among this bereaved population makes it necessary for helpers, volunteers, and
religious organizations to be aware of the special needs of this ethnic group. Thus, PTSD
treatment may need to include a grief component as well, but more research is needed to
test this observation.
The results of this study should be interpreted with caution, as there are important
limitations to the extent to which these findings can be generalized.
The first limitation stems from the fact that this research project is limited in
scope. A much deeper understanding would be gained by including a wider sample.
Second, prior personal trauma history, socio-demographic variables such as
gender differences, age, marital status, education level, income; and effects associated
92 with trauma and PTSD were not considered in this project. Future work is needed to determine potential gender differences in trauma and PTSD exposure among this particular ethnic group.
Third, due to the nature of the survey instrument used in this study, we were only able to examine the Intrusive and Avoidance subscales. In this regard, this study is not
100% consistent with the DSM-IV and the proposed DSM-V classifications. Future work would benefit from replicating and expanding the current findings using additional
methodologies and measurement techniques like CAPS (Clinician Administered PTSD
Scale), SIDES (Self-Report Inventory for Disorders of Extreme Stress-SR), the ICG
(Inventory of Complicated grief), or IES-R (Impact of Event Scale Revised), which
closely parallel DSM-IY and proposed DSM-V criteria for PTSD. This would also
determine whether or not the patterns remain consistent.
Finally, as with all post-disaster research, there is potential for respondent
inaccuracies either accidental or deliberate. This could include over-reporting of the
amount of grief, trauma exposure or PTSD they experienced as time passed or as
symptoms changed.
In summary, the current findings indicated that individuals experiencing multiple
losses in their families after a major crisis tend to experience complicated grief and PTSD
symptoms, particularly avoidance, intrusion, and re-experiencing symptoms.
However, despite the above limitations that warrant attention, this study offers a
baseline for future studies of traumatic grief, and PTSD among the Haitian communities
in Haiti or in the Diaspora.
93 APPENDIX 1
SURVEY (ENGLISH)
Impact of Event Scale (IES) Questionnaire of Mardi J. Horowitz
Modified by Jean-Renaud Joseph- format restructured, question 1 added, question 2 added: "catastrophe," question 3 added: "what happened," questions 10,11,16-19 added, test date added
Test Date:_____
N.B. The return of this survey serves as a form of implied consent
1. How many family members have you lost 1 2 3 4-up
in the 2010 Haitian earthquake. Q Q Q Q
2 .1 thought about this catastrophe Not at all Rarely Sometimes Often when I didn't intend to: Q o Q o
3 .1 avoided letting myself get upset Not at all Rarely Sometimes Often when I thought about it or was Q Q Q Q reminded of it.
4 .1 tried to remove what happened Not at all Rarely Sometimes Often from my memory. o Q o o
94 5.1 had trouble falling asleep or Not at all Rarely Sometimes Often staying asleep because of pictures Q o Q Q or thoughts about it that came to my mind.
6.1 had waves of strong feelings Not at all Rarely Sometimes Often about it o Q Q o
7.1 had dreams about it Not at all Rarely Sometimes Often
Q o Q Q
8.1 stayed away from reminders Not at all Rarely Sometimes Often about it. Q o Q . Q
9.1 felt as if it hadn't happened Not at all Rarely Sometimes Often or it was unreal. o O o o
10.1 wondered why God would allow Not at all Rarely Sometimes Often something like that. o o o o
11. My faith in God was Not at all Rarely Sometimes Often shaken after this event. Q o o Q
95 12.1 tried not to talk about it. Not at all Rarely Sometimes Often o Q o o
13. Pictures about it popped Not at all Rarely Sometimes Often into my mind. Q o Q o
14. Other things kept making me Not at all Rarely Sometimes Often think about it. o o o o
15.1 was aware that I still had feelings Not at all Rarely Sometimes Often about it, but I didn't deal with them. Q Q o Q
16. I felt scared when I thought Not at all Rarely Sometimes Often about it o o Q o
17.1 had feelings of irritability and anger Not at all Rarely Sometimes Often when thinking about it. o o o Q
18. I had less interest in Church activities Not at all Rarely Sometimes Often since it happened. o o o o
19.1 felt more comfortable staying Not at all Rarely Sometimes Often
away from people or avoiding them. Q o o o
2 0 .1 tried not to think about it. Not at all Rarely Sometimes Often o o o o
96 21. Any reminder brought back Not at all Rarely Sometimes Often feelings about it. Q Q Q Q
22. My feelings about it were Not at all Rarely Sometimes Often kind of numb. Q o o Q
Contact Information: In the event that I have any questions or concerns with regard to my participation in this research project, I understand that I may contact Jean-Renaud Joseph at ieani(5)andrews.edu (Tel: [954] 504-3489).
97 APPENDIX 2
SURVEY (HAITIAN CREOLE)
Kesyone Mardi J. Horowitz Pou We Impotans TranblemanTé 2010 La An Ayiti
Jean-Renaud Joseph meté chanjman fom nan; H ajouté keksyon 1 ak 2:katastwof;
keksyon 3: sa k' pase; keksyon 10,11,16-19; epi, dat tés la.
Dat tés la:______/______/______
N.B. Si ou ranpli epi remet kesyone a, ou tou bay konsantman ou.
1. Konbyen moun ou pédi nan tranbleman té a. 1 2 3 4-plis O o o o
2. Katastwof la té vinn nan tet mwen sanzatann. me Raman Pafwa Souvan O Q o o
3. Mwen té éseyé reté posem le m sonjé l¡. me Raman Pafwa Souvan 0 o Q Q
4. Mwen té chaché vag sou sa. me Raman Pafwa Souvan O o o o
5. M pa té kab domi byen paské lespri m té troublé. me Raman Pafwa Souvan O Q o o
6. Sa té konn sakajé lespri m ampil. me Raman Pafwa Souvan O o Q o
7. Mwen té fe rev sou sa. me Raman Pafwa Souvan O o Q o
8. M té chaché bliyé bagay sa a. me Raman Pafwa Souvan O Q Q o
9. M té santi kom si sa pat pasé vré. me Raman Pafwa Souvan O Q Q o
10. M té mandé pouki Bondyé ta kité sa rivé. me Raman Pafwa Souvan O ■
a 98oc o o O 11. M té v'inn gen dout sou Bondyé apré sa té rivé. me Raman Pafwa Souvan O Q Q Q
12. Mwen té bat poum pat palé sou sa. me Raman Pafwa Souvan Q Q Q Q
13. Foto ak vidéo sou li té tripoté m. me Raman Pafwa Souvan O Q o Q
14. Gen lot bagay ki té maré lespri m ak li. me Raman Pafwa Souvan Q Q o o
15. M té konnen m té sansib sou sa, men m té vag sou li. me Raman Pafwa Souvan O o o Q
16. Mwen té santi m pè lè mwen sonjé sa. me Raman Pafwa Souvan O Q o Q
17. Mwen té santi m fâché, épi m té fè kolè le'm sonjé sa me Raman Pafwa Souvan O Q o Q
18. M té entéresé mwens nan afè Légliz apré sa té pasé. me Raman Pafwa Souvan O o o Q
19. M té santi m pi alez lè m pa té bokoté moun. me Raman Pafwa Souvan O Q Q o
20. Mwen té éseyé pa réfléchi sou sa. me Raman Pafwa Souvan O o o o
21. Chak fwa m té sonjé sa, menm vyé lldé yo té retounen. me Raman Pafwa Souvan O o o Q
22. M té santi m krazé lè lesprim té vinn sou sa. me Raman Pafwa Souvan O Q Q o
Kontak Infomasyion: anka ou-m ta gen kesiyon sou rechech sa, m-konprann ke map kontakte Jean-Renaud Joseph nan iea ni (S) a ndrews.edu (Tel: [954] 504-3489).
99 APPENDIX 3
SEMINAR AND BROCHURE ON POSTTRAUMATIC STRESS DISORDER (HAITIAN CREOLE)
PTSD (Post-Traumatic Stress Disorder), se yon non nouvo pou yon ansyen malady. Li te konn gen plizyè lot non. An 1670, doctè milité peyi Lasuis te wè li tankou se te yon afè ak sonje la-kay. Nan
19eme syèk, sou Napoleyon, chirijyen lage yo te komanse rele li "fatig" epi, nan Lage Sivil ameriken, yo te rele li "ke solda" oublyen "sendwom efô" paske yo santi se te yon kesyon fè twop éfo. Nan Lage Mondyal 1 an, tout moun te rele I' "che chok"; nan Lage Mondyal 2 a, se te
"fatig lage", ansuit "fatig goumen". Lè peryôd lagè Vyetnam nan t'ap kalme, nan komansman
1970 yo, non li, se te "Sendrôm Apre-Vyetnam" pou di stress pandan ak aprè lagè nan sides Azi a kit e lakôz pwoblèm say o. Finalman, an 1980-epi jis jounen Jodi a- 3em edisyon Diagnostic and
Statistical manual of mental Disorders (DSM-III) bali non "Post-Traumatic Stress Disorder".
Kisa PTSD (Post-Traumatic Disorder) a ye?
Se yon pwoblém ké-sote paret apre ou viv yon evenman ki danjere anpil, ki sakaje lespri epi ou pa te kap kontwole, tankou lagé, vyól, kidnaping, atak terrorist, oubyen dezas natirel tankou tonedo, inondasyon, gwo siklon, oubyen tranbleman te. Se pa tout moun ki ekspoze nan sitiyasyon say o ki merite tretman. Poutan, san tretman, PTSD a ki rive lakoz moun pa ka reyalize aktivite chak jou yo byen anko. La, gen risk pou yo ap chache trete pwop tet yo, tonbe nan alkól, dwóg, goumen anndan kay, chomaj ak travay ki pa rapóte anyen diplis, rete san kay pou domi, prizon ak tiye pwop tet yo. Rechyach montre PTSD kapab ede Mennen malady ko tankou doulé ki difisil pou dokte trete, tansyon-wo, pwoblém pou dorni ak malady kea p konpayel li.
100 Koman pou rekonét PTSD?
PTSD pote chanjman tét-chaje k¡ komanse byen boné apre evenman ki sakaje lespri a pase, menmsi yo paret vreman apre semen, mwa, petét men mane. PTSD pote kat kategori chanjman:
(1) fé-tankou (pwoblém memwa, chache dekonekte, sa pa twó touché ou, louvri je ou byen gran ap veye, mete konpótman ou anba kontwol, ep¡ izóle ou), (2) Reviv evenman an nan lespri ou
(reviv moso nan evenman an detanzantan, pwoblem somey, santiman sa vin twop ato, ep reyaji piplis pase ou ta dwe); (3) Tounen victim evenman an (pedi konfyans nan lot moun, atitid ko- lage, pedi kapasite pou ede tet ou, ak pe chanjman); (4) maledyksyon (santi ou koupap, santi tet ou pa koret, santi PTSD a konn nan yon depresyon ki bezwen tretman pou tét pa li.
Le PTSD a fasil pout rete a, chanjman yo dire, nómalman, yonn a twa mwa apre evenman tét- chaje a. nan peryód rekalsitran an, chanjman yo dire twa oubyen plis, avék piplis tan pou li manifesté, omwen sis mwa depi evenman an. Si ou santi pwoblém yo vreman anbetan, ale dirék-dirék lopital.
Si ou remake nenpót nan pwoblém sa yo, ou pa sél; éd ap tann ou. Ou pa responsab. Aji anfavé santé ou. Chache éd.
Ki tretman ki genyen ppóu PTSD?
Erezman, reyalite a montre genyen tretman pou PTSD. Spesyalis kapab ede ou remonte evenman an, konsa, ede ou korije sa k' merite korije. Yon löt metöd kapab ede ou rezoud pwoblém pé ak ké-sote ou yo, konsa reprann aktivite nömal ankö. Genyen medikaman tou ki ka ede. Ou kapab diskite avék docté a sou medikaman ki pi bon pou ou.
101 Kote m'a twouve èd pou PTSD
Oganizasyon say o kapab bay asistans oubyen oryente ou avek PTSD.
Vet Centers- Vet centers kay konsèy ak sévis pou tout vétéran, kelkeswa zôn konba kote yo te sévi a. genyen sévis tou pou mann fanmi ki gen pwoblem ki mare avèk travay milité yo.
Ou ap twouve anplwaye Vet Center yo nan le bisnis némal nan nimewo gratis 800-905-4675
(Lès) ak 866-496-8838 (Pasifik). Pou trouve Vet Center ki pi pre ou a, ale nan www.va.gov/directory.
102 APPENDIX 4
BROCHURE AND SEMINAR ON POSTTRAUMATIC GRIEF (FRENCH)
Deuil Post-traumatique
Le deuil traumatique exprime la chagrin ou la souffrance traumatique consécutive à une perte.
Nous devons remarquer que la perte a tendance à déclencher une sorte de dépréssion majeure avec des risques à tendance suicidaire.
La perte traumatique présente aussi des difficultés au niveau de la réadaptation, ce qui complique le processus de l'endeuillement de vivre des séparations.
Qu'arrive-t-il donc au traumatisé? Le traumatisé tend à revivre la scène de la mort comme un film mnésique (Bacqué, 2003, p. 112) qui se repasse jour et nuit. Ces images mentales sont nocives à la santé mentale de l'individu et a des conséquentes néfastes sur la famille et le milieu ambiant.
Suivant le DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), il a lieu de noter quatre domains importants relatifs au deuil post-traumatique; (a) le syndrome de répétition, (b) l'enlèvement de l'angoisse et de la souffrance, (c) les réactions neuro-végétatives, (d) la perturbation des relations à soi-même et au monde.
Lorsqu'une personne pert un proche dans des circonstances traumatisantes, la symptomatologie du deuil est compliquée et prolongée.
Pour l'Association Psychiatrique Américaine, l'évènement traumatique est constamment revécu, de l'une ou plusieurs manières: (1) Souvenirs répétitifs et envahissants de l'évènement provoquant un sentiment de détresse et comprenant des images, des pensées ou des
103 perceptions, (2) Rêves répétitifs de l'évènement provoquant un sentiment de détresse, (3)
Impression ou agissements soudains, comme si l'évènement traumatique allait se produire
(incluant le sentiment de revivre l'évènement, des illusions, des hallucinations et des épisodes dissociatifs, y compris ceux qui surviennent au réveil au ou au cours d'une intoxication), (4)
Sentiment intense de détresse psychique lors de l'exposition à des indices internes ou externes pouvant évoquer ou ressembler à un aspect de l'évènement traumatique en cause, (5)
Réactivité physiologique lors de l'exposition à des indices internes ou externes pouvant évoquer ou ressembler à un aspect de l'évènement traumatique .
En ce qui a trait à l'évitement, il doit y avoir la présence au moins de trois des manifestations suivantes: (1) Efforts pour éviter les pensées ou les conversations associées au traumatisme, (2)
Efforts pour éviter les activités, les endroits ou les gens qui éveillent des souvenirs du traumatisme, (3) Incapacité de se rappeler d'un aspect important du traumatisme, (4) Réduction nette de l'intérêt pour des activités importantes ou bien réduction de la participation à ces mêmes activités, (5) sentiment de détachement, (6) Restriction des affects, incluant l'incapacité
à éprouver des sentiments par rapport aux autres, (7) sentiment d'amour bouché (par exemple, penser ne pas pouvoir faire carrière, se marier, avoir d'enfants ou vivre une vie normale)
D'autres symptômes peuvent aussi se manifester: (a) Difficultés d'endormissement ou sommeil interrompu, (b) Irritabilité ou accès de colère, (c) Difficultés de concentration, (d) Hyper- vigilance, (e) Réactions de sursaut exagéré
Prière de consulter un spécialiste de santé pour aider à limiter les deuils post-traumatiques.
104 APPENDIX 5
SEMINAR AND BROCHURE ON ANXIETY AND PTSD (HAITIAN CREOLE)
Problem Anksyete
Anksyete nan la vi nou se yon fason pou ko a reyaji, pou li di gen bagay ki pa mache dwat. Li pwoteje nou e prepare nou pou aji rapid le nou an danje. Men, pou kek moun, anksyete a kapab dire, li pa rezonab, epi li kab chofe tet ou. Li kab melanje avek aktivite odine yo e, menm, ran yo enposib. Le sa a, anksyete a tounen pwoblem.
Anksyete pote plizye kalite pwoblem.
GAD (Generalized Anxiety Disorder). Ou gen ke-sote pou tout bagay. Sa dire. Li gwo neg. Li pa chita sou reyalite a.
OCD (Obsessive-Compulsive Disorder). Ou pa chache lide say o, ou pa vie yo, men yo rantre kareman nan tet ou. Ou pran tout mwayen ki pase nan tet ou pou pouse yo ale. Yo la pired.
Pwoblem Panik. Sanzatann, ou santi ou panike e ou pe pou li pa kontinye konsa.
PTSD (PostTraumatic Stress disorder). Se yon gwo evenman out e viv oubyen out e asiste ki sakaje lespri ou e ki Mennen pwoblem anksyete sa a.
Pwoblem pe sosyete a. Pe pou moun pa rantre nan la vi prive ou. Pe pou moun pa diminye vale ou.
Lot kalite laperéz. Tél bagay, tel kote oubyen tel sitiyasyon kapab pote gwo laperéz. Yon pé sansatann, gwonég, ki pa chita sou anyen.
105 Plis pase 40 milyon granmoun ki genyen 18 an oubyen plis soufri avék omwen yon kalite pwoblem anksyete, nan Etazini. Bo kote timoun, se kalite pwóblem nan tét nou rankontre pi plis.
Rechéch komanse montre pwoblem anksyete chita nan mitán fanmiy yo, epi yo mare avek ko nou menmjan avék aléji, dyabét al lot malady ankó.
Si ou kwé ou-menn oubyen you moun pa ou ka byen genyen you pwóblem anksyete, li ti liv sa a pou twouve tretman. Pou plis enfómasyon sou pwoblem anksyete, vizite www.adaa.org.
Anksyete ak Pwoblem Ki mare Avek Li
Se pa difisil pou twouve moun ki genyen pwoblem anksyete epi ki soufri tou ave plizie lot malady mantal tankou depresyon, pwoblem bipole, bwe alkol twop, pwoblem somey, menmjan avek sendwom vant-fé-mal, fibromyaji (ki pote gwo doulé nan jwenti zo oak anpil z oak anpil lot kote nan ko a), menmjam avek lot pwoblem k oak kapab genyen.
Kék moun ka komanse avék yon premye pwoblém. Li mande tretman, anpremye. Pa egzanp, si yon moun santi depresyon paske yon pwoblém pé sosyete anpeche li fonksyone byen avek zanmi akfanmi li, pwoblem anksyete a riske bakop depresyon an, donk, se li dabó ki pout rete.
Oubyen si yon moun genye depresyon ki anpeche tretman pwoblem anksyete a (sa mande anpil volonte ak fós), depresyon an ka byen bezwen trete anpremye:
Checke yon dokté oubyen yon terapis pou twouve pwoblem ou a e di ou ki tretman ki posib, tan l'ap dire, ki pwoblem tretman an la lakoz, konbyen tan yo ap angaje avek ou, epi lot pwoblém santé. Konsa y ova ede ou deside tretman ki pi bon pou ou a.
Tretman an kapab genyen medikaman ou terapi ladan li; toulede bay bon ranman. Toulede ansanm ta dwe bon tou. Desisyon an va chita sou bezwen al preferans ou. Setenman, y ova diskite avek youn pwofesyonel ki abitye avek pwoblem lan ak eta santé ou.
106 Laplipa moun ki gen pwoblem anksyete twouve ed nan men pwofesyonel santé. Rezilta a pa toujou menm; seten moun bon apre kek mwa pandan lot moun bezwen plis tan. Tretman an kapab konplike si ou genyen plis pase yon pwoblem anksyete oubyen si ou ap soufri avek lot kondisyon tankou depresyon ou dyabet. Se pou sa, tretman an dwe fet sou mezi chak moun.
Kote Ki Pay tretman
Plizyè kalite pwofesyonel santé antrene pou chache epi trete pwoblem ansyete: doktè (nan yo genyen sikyat, entenis, dokte malady fi, doktè lafanmiy), sikolog, tavaye sosyal, spesyalis santé pou konpotman, terapis pou maryaj ak lafanmi, enfimye, enfimye pratiksyone ak asistan doktè.
Dirijan legliz ak konseye lekol ka byen ede tou. Moun ki viv pwoblem nan deja kabab ede tou.
Kob pou sevis yo, ranbousman kobo u depanse, diferan selon djob ou, asirans santé ou ka ak regleman stet la.
Ale nan www.adaa.org pou twouve terapis ki nan zôn ou a. moun ki nan lis la se manm ADAA
9Anxiety Disorders Association of America) ki spesyalize nan pwoblem Anksyete. Egzijans pou pratike sikoterapi chanje selon stet yoo. Anvan ou kômanse yon tretman avek yon terapis, poze kesyon sou fomasyon ak kalifikasyon li.
Lot kote ou kapab tcheke: (1) Konpanyi asirans sante, (2) Depatman sikyatri lekol medsin ki nan zon nan, (3) depatman sikoloji nan inivèsite, (4) Klinik mantal oubyen sikyat nan lopital ki nan zon nan, (5) Ajans santé mantal oubyen VA (Veterans Administration) ki nan stet la oubyen nan zon na, (6) Sevis konsey anndan kolèj ki nan zon nan.
107 APPENDIX 6
SEMINAR AND BROCHURE ON STRESS AND TRAUMA (FRENCH)
Le stress posttraumatique est une réaction psychologique normale à la suite d'un évènement traumatique intense, surtout lorsque la vie est menacée (American Psychiatrie Association).
Plusieurs réactions ou symptômes peuvent se développer à la suite d'un évènement traumatique, surtout si l'individu a vécu, avait été témoin ou a été confronté à un traumatisme.
En général l'évènement traumatique suscite une peur intense, un sentiment d'impuissance ou d'horreur et qui a provoqué la mort ou de sérieuses blessures.
Le traumatisme psychique a toujours existé. Cependant il faut attendre la découverte de la réalité clinique pour faire un diagnostic scientifique. Le phénomène était surtout confiné dans le cercle étreint des psychiatres militaires.
C'est au cours de l'année 1980 que le diagnostic de stress post-traumatique a été officiellement reconnu. A l'époque on le considérait comme une réaction à long terme à l'exposition à des zones de combat ou de conflits.
De nos jours, les spécialistes reconnaissent que la quasi-totalité des cas de réaction au stress de combat on tendance à déveloper le syndrome de stress post-traumatique. Les évènements tels que viols, agressions, attentats, guerres, catastrophes naturelles, catastrophes industrielles, incendies, et accidents sont aussi reconnus comme étant des évènements traumatogènes.
L'individu affecté se trouve dans l'incapacité de foentionner normalement, et ceci met en danger sa proper vie et aussi celle des autres membres de sa famille (Lalumiere, 2003).
108 Pour poser un diagnostic de stress post-traumatique, les condition suivantes doivent être réunies: (a) la ré-expérience du traumatisme, (b) l'évitement, (c) L'hypervigilance.
Il doit y avoir la présence d'une ré-expérience du traumatisme pour être mesure de diagnostiquer le stress post-traumatique. Par re-expérience du traumatisme, nous pouvons citer: (1) les cauchemars, (2) le flash-back qui est une forme de revivre de manière persistante
V l'évènement traumatique.
L'individu a des souvenirs ou des rêves répétitifs. Ces souvenirs hantent l'individu et provoquent en lui un sentiment de détresse.
Ensuite on doit aussi remarquer souvent l'évitement des situations tandant à rappeler l'évènement en question avec un émoussement des réactions générales, telles que l'engourdissement et l'anesthésie émotionelle.
Enfin, l'individu doit présenter des symptômes persistants d'activation neuro-végétative pouvant se refleter par des difficulties de sommeil, de l'irritabilité, des difficultés de concentration, de l'hypervigilance, une réaction de sursaut ou de l'agitation motrice (Lalumière,
2003).
Si les symptômes persistent pendant un mois et provoquent une profonde détresse qui nuit au fonctionnement du sujet. Prière de consulter le médecin de famille qui pourra recourir de façon complémentaire aux services spécialisés d'un psychologue ou d'un psychiatre.
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142 VITA
Name: Jean-Renaud Joseph Date o f birth: April 1, 1955 Place of Birth: Port-au-Prince, Haiti Married: September 23, 1983 to Claudie Alexis Children: Jonelle (1986), Regine (1988), and Schubert (1991)
Education:
1975-1978 Bachelor of Arts in Sociology, School of Human Sciences, State University of Haiti 1978- 1979 Diploma in European Civilization From German School o f International Development, Berlin, Germany 1979- 1980 Student Intern on scholarship at European Economic Community, Brussels, Belgium 1980- 1983 Bachelor of Arts in Theology from Adventist University of Haiti 1983-1985 Master of Arts in Religion from Andrews University 2005-2008 Doctor of Theology from Colorado Theological Seminary, (graduated summa cum laude) 2009-2010 Clinical Pastoral Education from Vitas Innovative Hospice, Miami Florida Clinical chaplaincy internship at Northshore Hospital, Miami, Florida 2009-Present Working on a Doctor of Ministry in Clinical Healthcare Chaplaincy at Andrews University
Ordination:
1992 Ordained to the Seventh-day Adventist Gospel Ministry
Experience:
2006- Senior Pastor of Zion Seventh-day Adventist Church, Miami, Florida 1997-2006 Senior Pastor of Sinai Seventh-day Adventist Church, Plantation, Florida 1995-1997 Pastor of Beracah Seventh-day Adventist Church, Queens, New York 1990-1995 Pastor of Stamford Seventh-day Adventist Church, Stamford, CT 1987-1990 Pastor of Sinai Seventh-day Adventist Church, Spring Valley, NY
Publications:
Joseph, J. R. (1995). La catastrophe corinthienne [The Corinthian Catastrophe]. Brushton, NY: Teach Services. ______. (2005). La loi, le Sabbat, et le dimanche: une relecturehistorique et prophétique [The law, the Sabbath, and Sunday: a new historical and prophetic reading], Montréal, Canada: Librairie SE Wilson.
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