BC’sVisions Mental Health and Addictions Journal Vol. 3 No. 3 | Winter 2007

trauma& victimization experiences background perspectives& 3 Editor’s message Christina Martens 16 Why Did This Happen? Witnessing a tragedy Brian Chittock 4 Psychological Trauma: A common problem. Knowledge, myth and unanswered 17 Combat and Rescue: Breeding ground for questions Wiliam Koch PTSD Atholl Malcolm 6 Responding to Frightening Life Events 19 When the One Responding to Traumas Marilyn Laura Bowman Faces His Own: A paramedic’s story Richard Voigt 7 Critical Incident Debriefi ng: Concepts and controversy Katelin Bowes, 20 I Might Be Nothing Lara Gilbert Jill Fikowski and Melanie O’Neill 8 Victimization of People with Mental Illness: Barriers to reporting crime Liz McBratney 9 Indian Residential Schools: The aftermath alternatives Charles Brasfi eld approaches 10 Where Trauma Hides Inna Vlassev & 12 Trauma in : Red fl ags and 23 Post-Traumatic Stress Disorder: Choosing the clinical principles Claudia Maria Vargas treatment that is right for you Steven Taylor 14 —Complicated? Or not? Kay Johnson 24 Post-Traumatic Stress Disorder—and 15 : Occupational Traffi c Crashes John Vavrik hazard for helping professional 25 Connecting Virtually: Webcast on women, Michelle Srdanovic violence and substance use Nancy Poole 26 Somatic Experiencing Therapy: ‘Unfreezing’ the trauma response Amanda Sawatzky 27 The Aftermath of : Cognitive-behavioural treatment for PTSD Debra Kaysen 28 Post-Traumatic Stress in the Workplace Hans Beihl 29 Violence and Trauma in the Lives of Women with Serious Mental Illness Shanti Hadioetomo

bc partners visions

Seven provincial mental health and addictions agencies are Published quarterly, Visions is a nationally award-winning working together in a collective known as the BC Partners journal which provides a forum for the voices of people for Mental Health and Addictions Information. We represent living with a or substance use problem, the Disorders Association of BC, British Columbia their family and friends, and service providers in BC. Schizophrenia Society, Canadian Mental Health Associa- Visions is written by and for people who have used mental tion’s BC Division, Centre for Addictions Research of BC, health or addictions services (also known as consumers), FORCE Society for Kids’ Mental Health Care, Jessie’s Hope family and friends, mental health and addictions service Society and the Mood Disorders Association of BC. Our providers, providers from various other sectors, and leaders reason for coming together is that we recognize that a and decision-makers in the fi eld. It creates a place where number of groups need to have access to accurate, stand- many perspectives on mental health and addictions issues ard and timely information on mental health, mental disorders can be heard. To that end, we invite readers’ comments and and addictions, including information on evidence-based concerns regarding the articles and opinions expressed in services, supports and self-management. this journal. The BC Partners are grateful to BC Mental Health and Addiction Services, an agency of the Provincial Health Services Authority, for providing fi nancial support for the production of Visions

2 Visions Journal | Vol. 3 No. 3 | Winter 2007 editor’s message

here are two things I associate with trauma. Boxing Day 2005 watching a huge wall of water surge over people and buildings without much warning, tI wondered how the people actually living through that tsunami would ever regional be able to look at the sea again without . I also watching a documen- programs tary with Lieutenant-General Romeo Dallaire returning to Rwanda. His moving recollection of his time there and his struggles once he returned home deeply affected me. These are traumas on a population and distant level. 30 Sex for Stuff: It’s not fair trade There is also trauma on an individual scale: the recent illness of my mother Heather Miko-Kelly and close friends, the death of a couple friends of my son’s. All these things 32 VictimLINK Shanti Hadioetomo and begin to add up. For some people, there are more horrible things that affect Hazel Smith them so deeply that it takes years to overcome. I guess what I am trying to say here is that trauma affects everyone at one point or another. And as one article 33 Police Victim Services: Overseeing frontline in this issue points out, it even affects those who come in to help with trauma response Carolyn Sinclair —in a vicarious way. The question becomes then why do some people seem to 34 Complex Interactions: Women, trauma, be able to navigate traumatic experiences with not too many problems while addictions and mental health others become very affected? Susan Armstrong The articles in this issue look at the variety of theories, programs, services 36 RESOURCES and experiences that come to represent our work on trauma and victimization today. As always, there are issues and theories that we have left out, mostly because we are unable to include everything in one issue. But one thing is for sure, there is some serious food for thought and action here. As this is my penultimate issue as policy/content editor, I just want to take this chance to express my gratitude to the amazing group who works so hard to put together each issue of Visions. I knew coming in that this was a maga- web-only articles zine that presented diffi cult topics in sensitive and thoughtful ways….and this available at www.heretohelp.bc.ca/publications/visions is because there are so many people committed to each and every issue, and because there is a huge variety of dedicated people working in mental health My First—and Hopefully Last—Hospitalization and addictions in this province. But my deepest gratitude goes out to those Barbara Bawlf people who write about their lived experience. This is an act of great courage but mostly is seems it is an act of faith, faith that in telling their story things can Life After Death Troy and do change. All the rest of us have to do is listen and learn. When the Place Supposed to Help Kids Hurts Them: Dulcie McCallum on institutional at Woodlands Jake Adrian Christina Martens Kids in Control: When a parent has mental Christina is Executive Director of the Canadian Mental Health illness Kashmir Besla Association’s Mid-Island and Cowichan Valley Branches. She has Medication Treatment of Post-Traumatic an MEd in Community Rehabilitation and Disability Studies and is Stress Disorder Joseph Wang, Wei Zhang working towards her doctorate in Policy and Practice in the Faculty and Jonathan Davidson of Human and Social Development at the University of Victoria

subscriptions and contact us Tel: 1-800-661-2121 or 604-669-7600 advertising Mail: Visions Editor Fax: 604-688-3236 c/o 1200 - 1111 Melville Street E-mail: [email protected] If you have personal experience with mental health or sub- Vancouver, BC V6E 3V6 Web: www.heretohelp.bc.ca stance use problems as a consumer of services or as a family member, or provide mental health or addictions serv- editorial board | Nan Dickie, Dr. Raymond Lam, The opinions expressed in ices in the public or voluntary sector, and you reside in Victoria Schuckel, Corrine Arthur, plus representatives this journal are those of BC, you are entitled to receive Visions free of charge (one from each BC Partners member agency the writers and do not free copy per agency address). You may also be receiving editorial coordinator | Sarah Hamid-Balma necessarily refl ect the Visions as a member of one of the seven provincial agencies views of the member that make up the BC Partners. For all others, subscriptions policy editor | Christina Martens agencies of the BC are $25 (Cdn.) for four issues. Back issues are $7 for hard structural editor | Vicki McCullough Partners for Mental copies, or are freely available from our website. Contact us editorial assistant | Shanti Hadioetomo to inquire about receiving, writing for, or advertising in the Health and Addictions design/layout | Shanti Hadioetomo journal. Advertising rates and deadlines are also online. See Information or any of www.heretohelp.bc.ca/publications/visions. issn | 199-401x their branch offi ces.

Visions Journal | Vol. 3 No. 3 | Winter 2007 3 guest editorial

Psychological Trauma: A Common Problem Knowledge, myths and unanswered questions

William J. Koch his special issue of Visions on trauma and victim- abuse survivors, the event itself is associated with lit- ization discusses trauma and its results in a vari- tle psychological distress in adulthood.2 In short, the T ety of contexts (e.g., , car accidents, psychological distress associated with traumatic stress the workplace, the military and emergency workers). passes relatively quickly for most people. This does not These articles, however, barely scratch the surface of trivialize the distress suffered by chronic sufferers, but our current knowledge of trauma and its relationship illustrates that some individuals respond to trauma with to people’s mental and physical health. greater resiliency than do others. We are still learning Authors have described the consequences of trau- which factors provide resiliency or vulnerability follow- ma for centuries. It is now common knowledge that ing trauma. Such research is especially important for Dr. Koch holds adjunct people exposed to assaults, military combat, natural developing more effective treatments. appointments at the disasters and car accidents are at risk for lingering emo- What makes a trauma traumatic? There is substan- University of British tional distress. However, the characteristics of trauma tial debate about the defi nition of trauma, with some Columbia and at Simon that lead to distress and the relative contribution of the scientists arguing for a limited spectrum of life-threat- Fraser University. He co- trauma versus people’s pre-existing personalities are ening experiences and others arguing that many differ- authored Psychological still matters of debate among academics. ent life events (e.g., sexual , marital infi del- : Forensic Early research focused on the effects of large-scale ity) are potentially traumatic. Any event that is able to Assessment, Treatment, military trauma (e.g., American Civil War, ) induce an immediate state of severe fear, helplessness and Law, published in 2005 or of large-scale disasters (e.g., fl oods, fi res). Early diag- or horror can be a traumatic stressor. Types of trauma by Oxford University Press. nostic systems created a myth that severe psychologi- more likely to result in post-traumatic stress disorder Dr. Koch practices and cal distress could result only from extraordinary trau- (PTSD) include physical assault, car accidents and life- publishes extensively with mas that are not part of most people’s lives. This myth threatening illnesses (e.g., cancer). respect to the consequences has largely been discredited by modern research.1 The best predictors of PTSD are the person’s emo- of trauma. Visit his website Similarly, early writings suggested that everyone tional responses at the time of the trauma (e.g., ex- at www.drwilliamkoch.com exposed to such traumas would develop mental health treme fear, panic, shock). The next best predictor is problems. Extensive research has shown that many previous history of anxiety or . The third people are initially very distressed following trauma, predictor is stress following the trauma (e.g., fi nancial but that only a small number of people develop long- problems, low , chronic pain). Objective standing mental health problems. For example, - physical characteristics of the trauma (e.g., damage to hood sexual abuse is widely considered the most pow- vehicles) typically fi nish a distant fourth in predicting erful traumatic stressor commonly studied. It is clear, who develops PTSD. however, that for the vast majority of childhood sexual PTSD is not the only mental health problem that

4 Visions Journal | Vol. 3 No. 3 | Winter 2007 letters

we want your feedback! If you have a comment about something you’ve read in Visions that you’d like to share, please e-mail us at [email protected] with ‘Visions Letter’ in the subject line. Or fax us at 604-688-3236. Or mail your letter to the address on page 3. Letters should be no longer than 300 words and may be edited for length and/or clarity. Please include your name and city of residence. All letters are read. Your like- lihood of being published will depend on the number of submissions we receive.

I’d like to say how consistently impressed I am with Visions magazine. It is truly an can follow trauma. Fifty per cent of individuals suf- outstanding publication. So much so that we’ve received permission to reprint fering from PTSD also suffer from depression, and as two articles from the First Responders issue for our newsletter called HIV/AIDS many as one-third of PTSD sufferers also suffer from Prevention Resources for Educators: Reaching Students with Special Learning Needs. another anxiety disorder (e.g., panic disorder, gener- We cover much more than HIV prevention—including different types of disabili- alized anxiety disorder). and drug abuse also ties and the effect on learning, innovative programs for youth with disabilities and occur frequently in PTSD sufferers. Finally, recent re- issues such as self-esteem, decision making, substance use, etc. I think the search shows that trauma, PTSD and depression change Visions articles we’ve chosen provide great information for our readers. Thanks. personal health perceptions, physical health and use of —Shelley Hourston | Director, Wellness & Disability Program/AIDS & medical care. That is to say, psychological trauma can Disability Action Program/Health Literacy Network | BC Coalition of People with Disabilities make us physically sick. Trauma not only causes many different mental Congratulation on such a fi ne fall 2006 issue of Visions. The theme “First respond- health problems, but it can also be a consequence of ers for young people” is timely and the range of content and mix of contribu- such problems. For example, alcohol intoxication is tors is admirable. I was pleased with the article by Annie Smith of the McCreary perhaps the best predictor of being a victim of sexual Centre Society and hope that it signals the beginning of greater interest by your assault. This has obvious implications for preventing partners in the rich data base and excellent reports on BC youth that the Society trauma, leading to research on rape prevention. has generated during the past decade. For your readers’ information, the issues of We sometimes learn that what we commonly do in youth mental health (suicide awareness) and substance misuse (by early adoles- clinical practice has little benefi t. Sympathy for trauma cents) are among the top priorities for our Foundation over the coming year. For survivors and misguided good intentions has some- more info on the McCreary Youth Foundation, visit www.myfoundation.ca. times led to ill-considered treatments. Although there —Roger S Tonkin | Chair, McCreary Youth Foundation, Vancouver are effective treatments for both acutely and chroni- cally distressed trauma survivors (see page 23), other interventions, such as single-session debriefi ng given shortly after the trauma incident, have failed to dem- onstrate any benefi t to patients (see page 7). I usually urge clinicians to focus less on the specifi c type of trau- ma and more on the immediate emotional experience of the trauma survivor. In summary, trauma is a very large area of research and clinical practice. Over the past 25 years we have learned a great deal about the consequences of trau- ma, about better and worse methods of with trauma and about effective treatments. However, much remains to be learned about vulnerability factors (see page 6), the prevention of trauma, early intervention for distressed trauma survivors, and effective treat- ments for chronic PTSD. footnotes 1. Norris, F.H. (1992). Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demographic groups. Journal of Consulting and Clinical , 60, 409-418.

2. Rind, B., Tromovitch, P. & Bauserman, R. (1998). Meta-analytic examination of assumed properties of child sexual abuse using college samples. Psychological Bulletin, 124(1), 22-53.

Visions Journal | Vol. 3 No. 3 | Winter 2007 5 background

Responding to Frightening Life Events

Marilyn Laura hen an event threat- individuals are more easily or travel. Yet others may creased arousal, and efforts Bowman, PhD ens our safety or that upset than others. conclude that their own to avoid stimuli related to W of our loved ones, It is important to rec- best response is a kind of the trauma. If a person has Dr. Bowman is a Professor our inner psychological re- ognize that these individu- deliberate suppression. these symptoms so severe- Emerita at Simon sources are called upon as al variations are authentic For some, this suppression ly that he or she is highly Fraser University. Her we try to cope. Contrary and naturally occurring. may indeed be best, be- distressed, or is unable to research and clinical to popular thinking, there An absence of vivid emo- cause we know that “avoid- function adequately in nor- interests have focused is no one “best” way to tional symptoms should ance” can be an effective mal life tasks, then the dis- on neuropsychological cope, and people don’t all not be regarded as some strategy after an event with order may be diagnosed. effects of brain trauma, go through a set series of sort of abnormal condition consequences that cannot The percentage of and psychological effects “stages” of coping. The re- that needs intervention. be changed, such as sud- people who develop a of diverse traumas. She ality of responding to stress- Most people who expe- den bereavement. turbulent and persistent retired last year from SFU’s ful events is more complex rience even very frightening Keeping these individ- emotional response to a Psychology department than that. and dangerous events do ual differences in , dangerous event is about and a consulting practice in Different individuals not develop mental disor- there are, however, some 15%, with some variations clinical neuropsychology will respond differently to ders and do not seek treat- responses after a frighten- in different groups. any given situation. Some ment from mental health ing event that may repre- People show amazing people will respond with professionals. Instead, they sent a mental disorder. resilience through experi- strong emotional changes work through their fear, re- When a person’s - ences of war, rape, assault that may include anxiety, lief, or other turbulent al turmoil is so great that it and terrible accidents, us- fear, anger or depression. , using habits they interferes with normal ac- ing their own coping styles. Others may experience have developed throughout tivities, formal treatment Humans are social animals. little change in their emo- their lives. may be required. In the Most of us fi nd comfort in tional condition. Some individuals may mental health professions our family and friends once How individual people talk about the event—with we differentiate between we are returned to a situa- respond tends to be typical family members, a reli- two main stress-related tion of safety—and, we can of the way each has faced gious leader, a friend or mental disorders: “acute help others by quiet offers other challenging or dan- a counsellor on a public stress” disorder and “post- of support. In daily life we gerous events in the past. “crisis line.” Others may traumatic stress” disorder help each other through One factor in how we re- not wish to talk, prefer- (PTSD). fearful situations by rec- spond is a lifetime of learn- ring to think about their ognizing and respecting ing how to think about experience and put it into consists of strongly in- the different coping tactics creased emotions of anxi- that we and others use, and People don’t all go through a set series of “stages” of coping. ety and fear that are so by not imposing any rigid severe they impair func- model of ‘how people are The reality of stressful events is more complex than that tioning in everyday life for supposed to react.’ a time, but resolve within Whether our role is life’s challenges and learn- a longer perspective of four weeks after the event. that of a family mem- ing how to regulate our how they or others have PTSD is an event-attrib- ber or a professional, we emotions. Another factor handled tough situations uted anxiety disorder that should be sensitive to indi- that affects an individual’s in the past. lasts more than one month vidual needs and styles, so response is his or her typi- Some may seek com- after exposure to a danger- that recovery of emotional cal “background” emotion- fort in distracting activi- ous event. It includes pow- well-being can arise natu- al style or temperament, ties that have given them erful symptoms of intrusive rally out of the person’s which has a signifi cant ge- pleasure in the past, such memories or dreams of own unique being. netic component—some as running, music, reading the event, episodes of in-

related resource Bowman, M. (1997). Individual differences in posttraumatic response: Problems with the adversity–distress connection. Mahwah, NJ: Lawrence Erlbaum.

6 Visions Journal | Vol. 3 No. 3 | Winter 2007 background

Critical Debriefi ng Concepts and Controversy

eople involved with, or lowing the traumatic event “natural emotional process- Katelin Bowes, Jill Fikowski and exposed to, modern- and can last three to fi ve ing” that follows a traumatic Melanie O’Neill, PhD P day traumas can expe- hours. Debriefi ng responses event.8 CISD may also unin- rience a range of emotional are now recommended as tentionally lead trauma survi- Katelin is a fourth-year responses. Concern for vic- standard practice in many vors to rely heavily on health undergraduate student at tims of workplace and disas- schools, workplaces and gov- professionals and, conse- Malaspina University-College, doing ter-related trauma has led to ernment organizations. For quently, bypass the support a double major in psychology and increased popularity of early example, people witnessing of family and friends.8 The sociology. She plans to pursue intervention and prevention or experiencing workplace- fact is, many trauma survi- a master’s degree in speech strategies. or school-based violence will vors, despite the initial range pathology Critical incident stress often receive a debriefi ng in- of stress reactions, have their debriefi ng (CISD) is one such tervention. symptoms completely re- Jill is a third-year undergrad at strategy. CISD was originally Controversy between solved within three months of Malaspina. Currently a research developed by Dr. Jeffrey debriefi ng and more clini- the event, without any inter- assistant, she plans to do graduate Mitchell to ease the acute cally established therapies, vention at all.9 work in clinical psychology, stress responses of emer- such as cognitive-behaviour- At present, personal tes- specializing in substance use and gency workers.1 A critical in- al therapy, has been widely timonies are largely promot- co-occurring disorders cident is any event faced by debated. Because it is diffi - ing the use and popularity of emergency service personnel cult to demonstrate the ef- CISD.10-11 In order to support Melanie is a Registered that may cause strong emo- fectiveness of CISD, the de- its continued use, researchers and Professor at Malaspina, with tional reactions that could bate is likely to be ongoing.3 must scientifi cally examine clinical and research interest in interfere with their ability to There is limited scien- the effectiveness of CISD. They post-traumatic stress disorder and function.1 CISD hopes that tifi c evidence for the effec- need to use adequate control obsessive-compulsive disorder immediate intervention fol- tiveness of CISD. The un- groups (a comparison group lowing a traumatic event will tested thinking behind CISD of participants who do not eliminate or at least reduce is that early intervention for receive the treatment being 1 delayed stress reactions. trauma may reduce more studied, often referred to as a footnotes CISD is an intervention chronic psychological disor- placebo group or “sugar pill”). visit www.heretohelp.bc.ca/ 4 conducted by trained mental ders. While some fi ndings They need to follow-up and publications/visions for Katelin, Jill health professionals, in ei- support the use of CISD after to look at the impact of CISD and Melanie’s complete footnotes ther group or individual for- a traumatic event and sug- with different groups of trau- or contact us by phone, fax or e- mat. CISD encourages trau- gest it may be an effective matized people. Objectives for mail (see page 3). matized individuals to share tool of crisis intervention,5 the use of CISD must also be their thoughts and feelings there is little direct evidence re-examined,10 to ensure that about the critical incident, supporting its use to reduce the long-term psychological with the goal of making or prevent future psychologi- and emotional recovery of the of the trauma.2 Aside from cal symptoms. traumatized individual is the the reassurance and support However, there is evi- fi rst priority. provided by the health care dence from studies that show professional, resources and individuals receiving CISD ac- information regarding prac- tually fared worse than those tical coping skills are also receiving no intervention.6-7 offered.1 What might account for these Debriefi ng typically oc- fi ndings? One criticism of curs two to three days fol- CISD is that it may prevent the

Visions Journal | Vol. 3 No. 3 | Winter 2007 7 background

Victimization of People with Mental Illness Barriers to Reporting Crime

Liz McBratney orking in the for a variety of reasons. and energy for the victim ought to be performed by a Wcriminal court A multitude of barriers to follow through with all government agency associ- Liz is a Court Services system has pro- come in to play, including the follow-up requirements. ated with court, or by a non- Supervisor and Advocate for vided me with a great , accessibil- Required practical tasks, profi t service contracted to the Motivation, Power and deal of experience assist- ity, fear of retaliation and such as fi lling in victim im- provide victims services. Achievement Society ing mental health con- the potentially intimidat- pact statement forms and However, funding to victim- sumers who are charged ing court process. providing medical informa- related resources has been with criminal offences. I tion, also create barriers to cut in recent years. have also had many cli- Discrimination accessing support in the ents with mental illness Stigma and discrimination criminal justice system. Fear of retaliation who have suffered vio- are common barriers to Forms require an indi- A common barrier for vic- lence and discrimination reporting crime. Many vic- vidual to have an address timized individuals when at the hands of others. tims with mental disorders or contact number for fol- reporting offences is the People with mental fear they are perceived as low-up, as well as a certain fear of retaliation. Offend- illness frequently become not being credible because level of literacy. Also, these ers may deliberately target vulnerable and easy tar- they suffer from delusions. documents can be invasive people with mental illness gets of physical and men- They fear this is thought to and may require informa- because they see them as tal . This is particu- impair their ability to re- tion and documentation vulnerable and less likely larly evident on the streets count events accurately. from a physician. to go to the police. in Vancouver’s Downtown Victims often suffer Medical examinations If street drugs play a Eastside. Many of these in- from shock, , an- can be included as part part in the situation, the cidents don’t get reported ger, and guilt, evidence for charge ap- likelihood of someone re- which can be intensifi ed by proval. But many mental porting violations is further a mental health condition. health consumers don’t decreased. The individual people with mental An interviewer may feel want to seek medical at- may not want to disclose illness—victimized more that a victim who is expe- tention, because they’ve the fact that they have ad- riencing these symptoms had negative experiences diction issues. As well, they People with mental illness are more likely to be is exaggerating details. Fil- involving hospital certifi - don’t want to be subject to victimized than the general population—on average tering what is fact and what cations or clinical care. further harmful violations. 11.8 times more often for violent crimes: is fi ction is diffi cult, and the There is little support court has to ensure that wit- available to help people Daunting Violent crimes nesses are reliable. maintain mental health and court process | Rape and attempted rape: 22.5x more It is my experience, in self-care throughout the The court process itself is | : 15x more working with individuals in court process. More often, intimidating and anxiety | Aggravated assault (attack for the purpose of the courts who have past they need to access com- producing. Anxiety and infl icting severe bodily ): 13.1x more experience with abuse munity mental health care fear is further complicated | Robbery with injury: 7.3x more and violence, that they through their physician or by the fact that the person tend not to trust that the mental health team. who has been victimized Other crimes system will work in their In my capacity as a must once again see the | Theft of property from a person: 140.4x more favour. As a result, these mental health court worker accused in the law court. | Household burglary: 4.9x more victims are less likely to with the Motivation, Power Also, the mentally ill per- | Theft of property from a place: 3.6x more rely on the court system and Achievement Society son must deal with sher- | Motor vehicle theft: 2.5x more to fi ght their battles. (MPA), I have assisted peo- iffs and police in uniform, ple who have been victims which can be diffi cult for source Teplin, L.A., McClelland, G.M., Abram, K.M. et al. (2005). Crime victimiza- Accessing support by accompanying them to those with negative past tion in adults with severe mental illness: Comparison with the National Once a crime has been court or by helping them histories with authority, or Crime Victimization Survey. Archives of General , 62(8), 911-921. reported, it can take a sig- fi le documents, as per a delusions or paranoia re- nifi cant amount of time judge’s requests. This role lated to authority systems.

8 Visions Journal | Vol. 3 No. 3 | Winter 2007 background

As an advocate, I have It is important to rec- ance should be identifi ed people; and the provincial also witnessed homeless ognize that all individu- and made available to government Victim Safety people attempting to come als, including those with the victim. These may in- Unit, which attempts to into the building, but hav- mental illness, should be clude women’s groups, in contact victims when of- ing nowhere to put their treated with respect and the case of spousal abuse; fenders will be released in worldly possessions while compassion while they mental health teams, for the community. At MPA, attending court. This situ- cope with situations of vi- counselling and treatment; we will assist, however we ation reduces the accessi- olation. They should know the Native Courtworker can, by providing addition- bility of the court process that they are not alone. and Counselling Associa- al referrals to appropriate for these individuals. Resources for assist- tion, to assist Aboriginal community services. responding to someone with a mental illness who has been victimized source Remember that: Offi ce for Victims of Crime. | Being a victim of, or witness to, a crime is often | Introduce yourself and your role (2000). Victim empowerment: traumatic and may trigger symptoms of mental illness | Remove victims from noisy environments (like crowds) Bridging the systems—Mental | Victims with mental illness might not disclose their | Include victims in all conversations health and victim service providers condition. Therefore, some signs to watch for: | Explain your actions before proceeding (student material). Washington, DC: author. www.ojp.usdoj. | accelerated speech or unintelligible conversation | Be calm, reassuring, patient and honest gov/ovc/publications/ | delusions, hallucinations, paranoia | Contact someone in their support network infores/student/student.pdf. | depression | Find out what they need to feel safer Offi ce for Victims of Crime. | inappropriate emotional responses | Keep interviews one-on-one, simple and brief (2002). First response to victims of | memory loss | Remember that despite paranoia or delusions, a crime who have a disability. Wash- | unfounded anxiety, panic or fright person with serious mental illness may still be able ington, DC: author. www.ovc. | Approach from the front and maintain eye contact to provide accurate details of the crime gov/publications/infores/ fi rstrep/2002/NCJ195500.pdf.

Indian Residential Schools The Aftermath

he last Indian residential school (IRS) closed in being forced to attend an IRS away from their home Charles Brasfi eld, 1984. That ended a period of time in which the community. Upon arrival, he or she is separated from MD, PhD, FRCPC T government of Canada had attempted to elimi- opposite sex siblings, punished for speaking in a native nate Aboriginal cultures, languages and social struc- language and, in many of the schools, required to at- Charles is doubly qualifi ed tures. The attempt failed. tend religious services foreign to them. In my view, this as a psychiatrist and clinical I am a medical doctor who has been especially in- all constitutes . psychologist. He is the terested in Aboriginal mental health. Over the last two Director of the North Shore decades, I have treated many survivors of residential Sexual abuse Stress and Anxiety Clinic, was schools. It became clear to me that their lives had been Many children attending an IRS were subjected to sexual a Clinical Associate Professor dramatically changed by their attendance at an IRS. abuse. For the most part, this consisted of anal rape of in Psychiatry at UBC, and Other doctors who also treated many of those survivors boys and vaginal rape of girls, although there was also has been on staff at Lions labelled them as alcoholic, criminal or drug addicted. some coerced oral sex. Most of the perpetrators were male Gate Hospital. Charles has Often, those other doctors had not asked about attend- members of the staff of the IRS. But it also happened that long been active in Aboriginal ance at residential school. older students would sexually assault younger students. mental health Most strikingly, these assaults occurred not once or twice, Inherent psychological abuse but for some children, continued every few days or weeks I noticed that many people’s IRS experiences were and over a period of years. One survivor reported to me similar. The pattern of experience begins with a child an estimated 3,000 separate episodes of anal rape.

Visions Journal | Vol. 3 No. 3 | Winter 2007 9 background

While most of the perpetrators were male homo- sexual pedophiles, many young girls were also assault- ed by male heterosexual pedophiles. In some cases, the continued sexual assaults lasted into adolescence and resulted in pregnancy. Some of the pregnant girls were sent home and some were simply discharged from the school in disgrace. With lesser frequency, I have also heard reports of female heterosexual and ho- Where Trauma Hides mosexual pedophiles who instructed children in tech- niques of masturbation (manual genital stimulation of Inna Vlassev, PhD anada is a multicul- self or another) and oral sex. Usually, the children se- tural nation. Our lected for such instruction were preadolescent and not Inna is a Psychologist in Vancouver C neighbours, col- themselves sexually active. Usually, the children were who specializes in trauma and leagues, spouses and par- very distressed by their experiences. collaborates with the Cross ents have diverse ethnic Cultural Clinic located at Vancouver and racial backgrounds. In General Hospital the last decade the psychi- Much of the discipline of the residential schools was atric literature has been full physical. That is, children were struck, beaten or oth- of research and scholarly erwise physically punished for misbehaving. A typical work devoted to the sig- punishment story is of being beaten with razor straps, nifi cance of transcultural rulers and yardsticks. Several people who attended one issues.1 particular school told me of a female supervisor who Health care practi- had a special stick for inserting vaginally into little girls. tioners must be increas- Some people had signifi cant scarring, damaged eyes ingly sensitive to cross- and dental damage. cultural concerns. This The classic story, which has been repeated to me article explores the chal- many times, is of a young girl punished for speaking lenges presented by the her own language. She was forced to kneel on broken crossing point of trauma glass in front of a cross, with her arms spread and with and culture. a needle propped under her tongue. No one has told me that they were that very little girl, but many people The competent have told me the story. cultural assessment Consider the following The aftermath clinical scenario. A Bosnian In their late teens, the IRS children were sent home woman in her young for- from the residential schools. In most cases, they had ties, previously a science had no training in parenting, minimal training in any teacher in her home coun- employable skill and no support for their disturbed psy- try, has , low self- chological functioning. esteem, anxiety, feelings They had, however, been sexualized. They married of guilt and marital stress. and had their own children. Not surprisingly, they had She uses alcohol to keep diffi culty parenting those children. They tended to par- her anxiety under control. ent as they had been parented in the IRS. That is, they footnotes She arrived in Canada 13 punished their own children physically for misbehaving, 1. de Silva, P. (2006). The years ago with her husband and in many cases, treated them as sexual objects. tsunami and its aftermath in Sri Lanka: and small child, when eth- Unlike the IRS staff, this new generation of parents Explorations of a Buddhist perspective. International Review of Psychiatry, nic war was ravaging the was genuinely fond of their children. It upset them to 18(3), 281-287. former Yugoslavia. The see their children upset, and they often consoled them- family was sponsored by a selves with alcohol. So did their children. Physical vio- 2. deVries, M.W. (1996). Trauma in cultural perspective. In B.A. van relative in Canada. The cou- lence and assault became commonplace. der Kolk, A.C. McFarlane & L. ple left reluctantly, mostly This whole pattern was repeated for generations. Weisaeth (Eds.). Traumatic stress: The for the sake of their child. Today, most women on reserves have been sexu- effects of overwhelming experience on The family appears to have ally assaulted. Most people of both sexes have been mind, body and society (pp. 398-416). integrated into the new cul- physically assaulted. And nobody talks about it. New York: Guilford Press. ture: both adults have pro- Only just now is the damage of the IRS system be- 3. Herman, J. (1992). Trauma and fessional jobs and a small ing recognized. Only just now are signifi cant numbers recovery: The aftermath of violence—from number of friends, and of individuals beginning to talk about their traumatic domestic abuse to political terror. New York: BasicBooks. their teenager is function- experiences. Only now is some healing evident.

10 Visions Journal | Vol. 3 No. 3 | Winter 2007 background

ing relatively well at school. and the intense heart-to- toms. Your fi ndings on that talks in circles. 4. van der Kolk, B.A. As a capable clinician, heart conversations with are negative. Furthermore, She has trouble speak- (1996). The body keeps you have completed a de- friends, to name just a few your client’s immediate ing when she tries to revis- the score: Approaches to cent assessment of men- of the customs she took family and relatives have it some experiences from the psychobiology of post- tal status. You have been for granted. not been involved directly the fi nal days with her stu- traumatic stress disorder. In B.A. van der Kolk, A.C. mindful that this woman Indeed, you have done in the war, and no one has dents in Bosnia. She avoids McFarlane & L. Weisaeth has had a life history in a an impressive amount of been harmed. You have in- eye contact; her narrative (Eds.). Traumatic stress: The different social context. reading on the history and quired whether faith plays becomes confusing—it’s effects of overwhelming experi- You have explored with her complexity of the ethnic a role in the client’s life, hard to keep the chronol- ence on mind, body and society the meaning of her physi- structure in the Balkans. as this is a way of evaluat- ogy of events clear. She re- (pp. 214-241). New York: Guilford Press. cal and psychological com- You have consulted with ing strengths and coping fers to atrocities she didn’t plaints from the point of colleagues on their experi- skills. witness but knows her stu- 5. Briere, J. (2002). Treat- view of her native culture. ence with refugees and im- The plan is to offer dents and friends suffered. ing adult survivors of severe childhood abuse and ne- The client expresses herself migrants from that region. treatment for depression She presents them with glect: Further development well in English, but, never- It is important, in this related to grief from losing such blandness and lack of an integrative model. In theless, you check in with case, to screen for post- her native land and cou- of emotion that you feel an J.E.B. Myers, L. Berliner, J. her for misunderstandings. traumatic stress disorder ples work to assess the se- urge to change the topic, to Briere et al (Eds.). The APSAC Handbook on Child Maltreat- You have taken the (PTSD)—a condition that verity of marital confl ict. fi nd material that is more ment (2nd ed.) (pp. 175-204). time to evaluate how the may develop after the ex- Generally, you relate understandable. Thousand Oaks, CA: Sage uprooting affected her, perience of a life-threaten- with ease to this woman— Obviously, it is time to Publications. what it is like to cope with ing event. PTSD involves she is well-spoken and reconsider the diagnosis. 6. Chu, J. (1998). Rebuilding daily stress away from the a response of intense impassioned when pre- shattered lives: The responsible protective powers of one’s fear or horror, helpless- senting her issues. Yet, as Complex PTSD treatment of complex post- culture.2 The client readily ness, re living the event treatment begins, you fi nd PTSD is a diagnosis de- traumatic and dissociative disor- talks about her sadness through persistent memo- yourself feeling frustrated. rived primarily from sin- ders. New York: that she has no immediate ries, dreams or intrusive It is diffi cult to keep gle isolated incidents. John Wiley & Sons, Inc. family. She misses drink- thoughts, and emotional the focus in the sessions— Resuming life after fl ee- ing the infamous black numbing or extreme irrita- the client brings up seem- ing a traumatized society, coffee with her parents bility, among other symp- ingly unrelated issues and however, is much more

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War Trauma in Refugees Red fl ags and clinical principles

Claudia María Vargas, e know that the wounds from war are not con- clinging to their mothers, trembling and uncalled for PhD fi ned to the battle fi eld. Refugees from confl ict crying. They may also show their trauma through play W zones often continue to experience trauma and inappropriate behaviours for their age like thumb- Claudia is an Adjunct from , imprisonment, and resettle- sucking, nail-biting, bedwetting, frightened facial ex- Associate Professor in the ment for a long time. Thus, it is important to under- pressions, fear of darkness or sleeping alone, and little Pediatrics department at stand the challenges of families and communi- social interaction.13-14 According to the research, par- Oregon Health and Science ties.2 This piece identifi es some red fl ags for post-trau- ents may not recognize possible trauma, because they University. Dr. Vargas has matic stress disorder (PTSD) according to age, gender mistakenly assume “the child wasn’t looking when it worked and done research and culture, and provides some guiding principles for happened” or “was too little to know.”9 on refugee services and mental health workers in caring for refugees.* • Six to 11 years. Children at this age may become disabilities in Canada and Psychological distress from war is harmful to refu- anxious, depressed, angry, unable to concentrate or the United States gee children and adults regardless of racial or cultural socialize with peers, and may refuse to go to school. background. Refugees may experience a sense of help- Others may experience sleeping diffi culties, night- lessness and despair. The most common mental health mares, fear of the dark, and physical ailments like issue for refugees is post-traumatic stress disorder and vomiting, headaches or stomach aches. This age related symptoms of depression, anxiety, inattention, group is three times more likely to suffer from PTSD sleeping diffi culties, , and survival guilt.3-12 than adolescents, because they are at a younger stage of development.15-16 Red Flags • Adolescents. Adolescents may be affected for a long Age time.13 They can feel as if they are frozen in the past, Trauma can look very different across the develop- with no prospect of a future.17 Their trauma shows mental stages. Here are some of what we know are in school diffi culties, eating disorders, alcohol abuse, danger signs: teenage pregnancy, thoughts about suicide, or gen- • Birth to fi ve years. Young children have diffi culty eral ‘acting out.’ Most at risk are those who have lost explaining their trauma, but display their trauma by family and community connections.18

12 Visions Journal | Vol. 3 No. 3 | Winter 2007 background

• Adults. Traumatized adults tend to suffer from hyper- Complementary therapies vigilance, emotional numbing and fl ashbacks or re-ex- Survivors of torture have been shown to suffer intense periencing the trauma.1 They may startle easily, show and prolonged pain, and they have a greater risk of the fi ght-or-fl ight response or a heightened sense of developing chronic pain and other health problems.28 awareness, and suffer from nightmares, emotional de- Treatment of chronic pain from injuries that damaged tachment from oneself and others, and distorted emo- nerves, muscles or bones may need more than one type tions and perceptions.19-21 They may abuse drugs or of therapy, starting with medical care. Complementary alcohol, and become depressed, hostile and suicidal. therapies such as and body work appear to help the emotional and physical healing process.28-29 Gender Girls tend to internalize the trauma and become anx- Family-centred care ious, withdrawn and depressed. Boys tend to external- Since PTSD affects the whole family, it is important to ize trauma and are more likely to and be inattentive, learn its effects on all family members. Professionals impulsive and hyperactive, or to engage in violent ac- who are family-centred are sensitive to the different tivities.19 However, fi ndings are inconclusive regarding ways families cope with loss and sorrow, and to their gender differences. need to maintain their culture and language. These footnotes

More important than gender, however, for young- practitioners value cultural diversity and uniqueness visit www.heretohelp.bc.ca/ sters is family separation, the murder of a parent (more across families and explore the need for community publications/visions likely to be the father, since more refugee men are mur- supports and reconnecting families with their cultural for Claudia’s complete dered than women), parents’ emotional well-being, ex- communities.1,28-31 footnotes or contact us by perience of torture by a family member, or the number phone, fax or e-mail (see page 3). and intensity of traumas.15-16,19,22 Strengths model Refugees face many challenges—a different language, Culture culture and world view—but they also bring with them * The essay is based on Findings point to commonalities in the human expe- many strengths. As survivors of persecution and cul- a review of international rience of emotional and physical pain and suffering tural and family losses, they are motivated to succeed studies on PTSD in refugee across cultures.23-25 The expression of trauma may dif- and create a better life for themselves and their chil- children, complemented fer: e.g., Soviets tend toward alcohol abuse,26 while dren. Amidst the pain and trauma, clinicians need to with interview data of Ethiopians describe physical symptoms such as “burn- recognize their strengths.32 service providers in Canada ing all over, a tight feeling in the neck, and ‘insects and the United States. crawling under the skin.’”27 Vietnamese have the think- Cultural responsiveness The information gathered too-much problem, and Latin Americans have “nerv- War trauma can affect future generations, as illustrated has been shared with ios” (nerves).26 However, we need to be careful about by the suffering of Indigenous and persecuted groups.33-34 respondents. stereotyping. The suffering is universal. There is a need for cultural competence based on re- spect, trust, empathy, care and understanding of the ** The Vancouver Some Principles of Care** socio-political and historical forces that led refugees Association of Survivors Multidisciplinary care into exile.26,28-29,33 A culturally welcoming and safe en- of Torture developed the Refugees may have faced many health challenges, vironment is essential. Culture-sensitive care embraces VAST Therapeutic Principles physical injuries, hunger, and emotional trau- cultural healing practices, including the role of spiritual- of Care. See footnote ma. It is essential to provide medical and mental health ity and the mind–body–spirit connection. reference 17. care, as well as the housing, schooling, and employ- ment needs essential to life in their new homeland.

Visions Journal | Vol. 3 No. 3 | Winter 2007 13 background

Grief—Complicated? Or Not?

Kay Johnson, MA, BHSc s a mental health What is the medical view • much slower thinking to feel like they can get go- (Psychiatric Nursing), RN worker and as a be- of “complicated grief”? and physical abilities ing with life again. a reavement consult- The medical community • unable to do the usual People with mental Kay is the Director of ant, I have struggled to clear- views complicated grief tasks of daily living or health or addiction issues Griefworks BC, a provincial ly understand if a griever is as a major depressive job requirements have usually had many bereavement resource experiencing complicated episode.1 The bereaved • hallucinatory experienc- losses including secondary and referral centre housed grief—recognized by the person may think the sad- es other than transiently losses related to their ill- in the Children’s and medical community as a ness is ‘normal,’ but seeks hearing the voice of, or ness: (e.g., loss of income, Women’s Health Centre psychiatric condition1—or professional help for relief seeing the image of, the relationships, employment, of BC. She has many years not. Is it complicated grief of associated symptoms deceased person status, self-esteem and/or of experience working with already-present men- such as insomnia. A diag- control, and losses due to in mental health and in tal health and/or addiction nosis of major depressive Symptoms of avoidance, discrimination and/or vic- palliative care and now issues? Or is it the natural disorder is generally not numbing, increased arous- timization). Often, in this focuses on bereavement expression of grief exagger- given unless symptoms al, depressed mood, somat- population, I have seen un- program development ated by these issues? are still present after two ic or sexual dysfunction, supported, unresolved loss months.1 guilt or obsession, addiction through death early in life. When does The duration and ex- or other related symptoms Not dealing with this early complicated grief occur? pression of ‘normal’ be- may also be present. grief is frequently the main I believe that complicat- reavement varies consid- reason there is a mental ed grief occurs when the erably among individuals Is it? Yes or no? health condition and/or in- death has added emotion- and/or cultural groups. I’ve seen all of these behav- creased use/misuse of alco- al trauma. However, the presence iours in people who didn’t hol and other drugs. According to Dr. of certain symptoms, not have a mental illness before 2 footnotes Therese Rando, probably characteristic of a natural the death and who didn’t NOT necessarily the leader on complicated response, may point to a experience a complicated complicated grief 1. American Psychiat- grief, three situations can grief situation. Corporate Dr. Rando created a list ric Association. (2000). . 1 Diagnostic and statistical manual complicate grief when These symptoms include: presidents and school-age of symptoms that are of- of mental disorders (DSM-IV-TR) someone close dies: • guilt about things other children fi nd themselves ten mistaken for compli- (4th ed., text revision). Washing- • the death threatened than actions taken or unable to remember how cated grief, or incorrectly ton, DC: Author. Note: their own survival not taken at the time of to use the telephone. Those thought of as abnormal See under Bereavement • the death is sudden and usually meticulous about responses to loss.2 (CodeV62.82); it is referred the death to as “Major Depressive shocking, with mutila- • thoughts of death other their appearance wear dirty, • Feelings or unresolved Disorder.” tion of people other than feeling that he or wrinkled clothes. Some confl icts coming up than a loved one she would be better off may say this is a major de- from past losses that 2. Rando, T.A. (1993). Treat- ment of complicated mourning. • the death is the trau- dead or should have pressive disorder if it lasts have or haven’t been Champaign, IL: Research matic and/or mutilating died with the deceased longer than two months, dealt with. This is a nat- Press. death of a loved one • feeling that everything as noted above. However, ural response for any bad happened because I know that sometimes it griever. Often, a small the survivor deserves it takes months for a griever loss triggers the feelings

14 Visions Journal | Vol. 3 No. 3 | Winter 2007 background

of past losses. son who died, or seem- er loved ones may die. A Challenge • Sadness is not the strong- ing to continue the rela- Or being resentful that The challenge of support- est emotion. Instead, it tionship by, for exam- a bad person didn’t die ing a griever with a mental could be anger, guilt or ple, talking about the instead of this good per- health issue and/or addic- frustration. There may deceased in the present son. They may get angry tion is to be able to recog- also be physical reactions, tense. Again, these are if they believe others are nize the natural grief proc- such as sleep problems; natural reactions. not grieving enough. ess for what it is. And to social reactions, such as • Keeping parts of the These are common re- avoid enabling the griever wanting to be alone a lot; home as it was before the actions in grieving. to use their grief as an ex- or behavioural reactions, death to keep the mem- • Experiencing tempo- cuse for unacceptable be- like sobbing frequently or ory alive. The bereaved rary periods of intense, haviour. In the period after constantly checking that person may continuously fresh grief long after the the death, the griever often the environment is safe. say or do things so that death. This is natural. has diffi culty concentrating, • Feeling like a part of them others will not forget the Those with complicated gets frustrated more easily, died with their loved one person who died. They grief, however, may ex- and feels a loss of personal or that something is miss- may resist changing perience some aspects power or control. It’s im- ing from themselves. This things that were in place of mourning for many portant to fi nd ways to in- may be more exagger- before the person died, years, if not forever. They crease the griever’s feelings ated if the loss had trau- such as not wanting to may also have a course of of regaining control, but it’s matic circumstances. move or take a new job. mourning that does not also important to maintain • Feeling sorrier for them- • Worrying about the decline with time. the healthy boundaries of selves than for the per- chance that they or oth- responsibility for actions.

Vicarious Traumatization An occupational hazard for helping professionals

y fi rst job was at a transition house for women changeably, despite their differences. Michelle Srdanovic fl eeing abuse. A co-worker shared that after years Researchers identifi ed in the Mof working in the anti-violence fi eld, she could no 1970s by looking at emergency services workers who Michelle has seven years longer stand to watch violence on the news. I thought of were repeatedly exposed to victims of trauma. The work- professional experience her years later, when my husband and I were taking a walk ers began to experience symptoms of post-traumatic supporting victims and around Stanley Park. My husband pointed out a man sit- stress disorder, such as nightmares and fl ashbacks.1 In survivors of trauma. She ting alone in an area jam-packed with children and men- 1995, the term was proposed to bet- is pursuing an MA in tioned that he must be a kind grandfather. I had noticed ter described the “cost of caring” that counsellors paid.2 Counselling Psychology at the same man moments earlier, but I had targeted him The concept of vicarious trauma developed through Simon Fraser University as a sex offender. In that moment I grasped the extent to studying therapists who worked with victims of sexual and works as a research which my work with victims of sexual and relationship violence. Researchers Pearlmann and Saakvitne believe assistant on a project violence had infl uenced the way I see the world. that when we listen to the traumatic stories shared by addressing vicarious clients, our view of ourselves and the world is perma- traumatization. Michelle Different names, similar experiences nently transformed.3 plans to research how It seems that Freud may have been on to something transition house workers when he fi rst identifi ed countertransference. He viewed How do we change? manage vicarious trauma it as a condition that develops when therapists transfer The constructivist self-development theory aims to give a their own unresolved issues onto their patients. Today, deeper understanding of the impact of vicarious trauma. this term is more commonly used to describe the gen- The theory is rooted in the idea that reality is not some- eral emotional reaction a therapist has to a client. thing that is simply ‘out there.’ Instead, we construct our For helping professionals who work with victims of own reality based on our experiences. Thus, when we trauma, their reaction to a client can be similar to the repeatedly experience exposure to traumatic material, footnotes post-traumatic stress symptoms of a victim. it can change our perception of reality. Generally, these Researchers generally agree that these post-trau- changes will occur in the following areas: 4 visit www.heretohelp.bc.ca/ ma-like reactions exist. There is, however, debate about • the framework (‘lens’) through which we see the world publications/visions for Michelle’s complete naming and describing the experience. The terms sec- • our self capacities, including our sense of self as footnotes or contact us by ondary trauma, compassion fatigue, vicarious trauma worth loving phone, fax or e-mail (see and countertransference have all been used inter- • our ability to get emotional needs met in relationships page 3).

Visions Journal | Vol. 3 No. 3 | Winter 2007 15 experiences and perspectives

Why Did This Happen? Witnessing tragedy

Brian Chittock, DBA, CFRE ancouver’s Celebra- and planned to watch the ing and our group of friends the roof, ran to Timmy tion of Light fi re- Italy’s fi reworks demon- to watch China’s fi reworks and held him tight. I was V works festival will stration that night from the display. I had heard that in a daze. I continued to Brian is the Executive Director of Jessie’s Hope never be the same for me rooftop terrace. Most of the Timmy and Jun had arrived hold onto Timmy, who at Society, which is a member again. The memories I have people knew each other. and were on the roof with this point was in shock. He of the BC Partners for of July 29, 2006, when Timmy came later that us, but I hadn’t seen them. was crying and mumbling Mental Health and China put on a spectacular night and brought his new At the end of the show, that Jun had pulled away Addictions Information fi reworks demonstration, boyfriend Jun, whom he there was a lot of commo- from him forcibly, run up are of chaos, screams, si- had met a couple of weeks tion, with people trying to to the edge of the roof and rens wailing—and the life- earlier. Jun, a handsome get down from the roof. jumped to his death less body of a young man smiling young guy, joked Suddenly I heard my Everyone was yelling I had just met a few nights around with all of us that friend Kirk screaming and screaming. Police, before. He was lying in a night. He had only been in for someone to call 911, ambulance and fi re sirens pool of his own blood after Canada for a few months screaming that someone blared. Helicopters circled jumping off the 18th-fl oor studying English. He was had jumped off the roof. above with their search- rooftop of my friend Alex’s from Brazil, which is where He then yelled, “Brian, get lights focused right on us. apartment building in Van- Timmy was from as well. over here now and take It was as if we were all in couver’s West End. The fi reworks were amaz- care of Timmy!” a movie, or a dream; as if It all began on Wednes- ing; we all had a lot of fun. Timmy was on the none of it was real. All I day, July 26, 2006. A few On Saturday the rooftop ground quivering and could feel was horror. How friends had assembled at was packed with people crying uncontrollably. I could anyone jump off of Alex’s apartment for drinks from the apartment build- jumped over the fence on an 18-storey building?

vicarious trauma | continued from previous page lack of boundaries and rescuing others For example, if we hear many stories about violence, • abandoning spiritual beliefs we may begin to see the world as unsafe. We may even feel fearful of trusting others, and this can affect our The emerging research suggests that those with a histo- relationships. ry of trauma are more likely to experience the greatest impact. Newer, less experienced counsellors, are also related resource How can you recognize vicarious trauma? more vulnerable.5 National Clearinghouse Visible changes include: on Family Violence. (2001). • becoming cynical or losing hope Working toward solutions Guidebook on vicarious trauma: • avoiding social or work contact The consensus is that vicarious traumatization is in- Recommended solutions for anti-violence workers. www.phac- • becoming fearful and overprotective because the world evitable for those who work with trauma survivors. aspc.gc.ca/ncfv-cnivf/family- is seen to be dangerous Yet we can address it and sometimes even prevent it violence/pdfs/trauma_e.pdf • setting rigid boundaries in relationships or, displaying a by paying attention to our ABCs:6 • Awareness of our needs, emotions and limits • Balance between our work, leisure time and rest | “I was terrifi ed when my daughter asked to sleep over at her friend’s house. • Connection to ourselves, to others and to something Many of the children I support were sexually abused at a sleepover. I greater (i.e.,spirituality) couldn’t let her go.”—Victim Services Worker

| “I wanted to work with women who have been abused, because I thought I Research shows that the most infl uential resource is a could make a difference. Some days I lose hope—especially when I realize that group of peers that we can talk to about our trauma- nothing has changed in the fi ve years I’ve worked here.”—Transition House Worker related work.7 So, how can we become involved in the | “I just look at the world differently. When I see a mother who is critical of support offered by our organizations? Clinical super- her children, I get upset and wonder if the child is abused. If I see a woman vision, team meetings and chances to debrief are all wearing sunglasses indoors, I think that she is hiding bruises from being valuable in helping counsellors stay connected. beaten. This is stuff I never used to consider.”—Transition House Worker Our clients change us forever; to honour them and ourselves, we must practice self-care.

16 Visions Journal | Vol. 3 No. 3 | Winter 2007 experiences and perspectives

How could Jun decide to fused and angry. that Jun had left a note at die in such a violent way? No one could under- Timmy’s apartment. He Slowly we got up and stand what drove Jun to had recently come out. I took Timmy downstairs such a tragic act. He was He wrote about how be- to fi nd the police. Over the so young, vibrant and alive ing gay was causing him a next two hours, in Alex’s on the Wednesday when I lot of turmoil. He was un- apartment, we all gave fi rst met him. How could sure how to deal with his our statements to the po- he have done this to all of feelings—toward himself, lice. They seemed unsure us? How could he have left toward Timmy. He didn’t of what to do. There was us with this sadness, with know how to deal with his so much chaos. And they all the unanswered ques- family back in Brazil. seemed to be treating it tions? How could he have I felt so sad that he as a homicide. We were suffered so deeply and so felt he had to endure this stunned. We were even alone, without trying to torture alone. I, too, have more stunned when they fi nd a solution to whatever had some tough times and I think I will always have told us they couldn’t pro- demons were inside him? many times didn’t feel a helpless feeling when I vide us with counselling. What a tragic situation this I could go to anyone for think of him, because he We would have to deal was for us, Timmy, Jun’s support or help. never gave any of us a with this horror on our friends and, especially, Today, Jun is still in my chance to help him. I can own. Everyone was upset, Jun’s family. thoughts, but they are not only hope that he’s in a crying, questioning, con- We later found out sad thoughts any more. better, safer place.

SAFER (Suicide Attempt Follow-up, Education and Research) is a BC-wide service that works to reduce suicide risk among those in crisis, assist family and friends who care about them, and promote healing among those bereaved by suicide. People with concerns relating to suicide can receive crisis related resource intervention by telephone, and anyone bereaved by a suicide death can access one-on-one counselling or support groups. Call 604-879-9251.

Combat and Rescue Breeding Grounds for PTSD

rom 1964 to the early and Rescue Squadron. In were getting ready to sort Atholl Malcolm, F ’80s, I was an air navi- those days, emergency loca- out the mess, place body CD1, PhD, RPsych gator/tactical offi cer in tor beacons were not very parts into body bags, and so the Canadian Forces. I was accurate. We would spend on. Then word came to wait Atholl is a clinical and consulting one of a large number of air several weeks at a time look- until the coroner arrived on psychologist in private practice. crew trained and contracted ing for lost aircraft in British the scene. They had a long Formerly the department chair to serve for fi ve years. My Columbia’s unforgiving ter- wait, guarding the scene and of Psychology and Applied goal was to fi nish this term, rain and mountain weather. keeping bears away. When Leadership at Royal Roads get my discharge gratuity and I was taking a course in the coroner arrived, he took Military College, he is currently go to university. abnormal psychology at this one look, threw up and left, an Adjunct Associate Professor at In the middle of my time, and was particularly telling our team to get on the University of Victoria. Visit his stint, the rules changed and struck by a textbook chapter with it. A coroner had dif- website at www.drmalcolm.ca we were all offered a perma- on traumatic stress and its fi culty dealing with a scene nent commission. I accept- effects. It seemed to apply that was commonplace to ed, but soon realized that a to our environment and, es- the Rescue Specialists. degree would help career ad- pecially, to the Rescue Spe- vancement. Getting a degree cialists, whose job included Old-Fashioned ‘Therapy’ in psychology seemed easi- parachuting into what can After a long day of search- est to manage while being only be described as human ing, we would relax with posted in different locations carnage. a few drinks. If the search around the country—and I recall one tragedy when ended successfully, with I was interested in under- fi ve lives were lost in the lives saved, we celebrated; standing human nature. crash of a light plane. While if there were fatalities, we While taking this degree, we were circling above, our drowned our sorrows. I was fl ying with 442 Search specialists on the ground Over time, it became ap-

Visions Journal | Vol. 3 No. 3 | Winter 2007 17 experiences and perspectives

parent that many of us were second component can in- is not memorized in the true more comfortable around clude re-experiencing the ini- sense of the word. To explain: each other than at home with tial event when a reminder if we think of something that our families. Our crewmates triggers a traumatic reaction. happened in the past, even understood why we stood I treated one soldier who was an unpleasant event, we talk around telling war stories, triggered by the sight of a lo- our way through the memo- avoiding personal issues. We cal soccer pitch, because an ry as we visualize the event, had a great sense of ‘gallows’ area of vegetation around and we can choose at any humour. Looking back, it is it was similar to vegetation time to distract ourselves. A easy to see why there was around a mine fi eld in Bos- traumatic memory lacks the high rate of family break- nia. Other forms of re-experi- cognitive or self-talk compo- down and other diffi culties. encing include nightmares. nent, because there was a The third component is lack of cognitive processing A Second Career a strong desire to avoid any- in the fi rst place. In the fi ght- After completing my doctor- thing that is a reminder of or-fl ight response, our reac- ate in Clinical Psychology and the event. So the PTSD suf- tion is physical and more or 20-plus years in the military, I ferer will avoid social interac- less instantaneous: we either began a new career as a psy- tion in case someone brings fi ght back or run away. chologist in private practice. up a topic of conversation Brain scans have shown Regarding my 442 that may trigger a reaction. that when a person is sub- Squadron days, the circle is Avoidance may also include jected to something that trig- completed, as the old text- avoiding or pushing away gers the original memory, the book predicted. In the last family members, because the sites of the brain where ver- two or three years, my prac- heightened arousal causes bal material is processed are tice has assessed several of inappropriate emotional re- relatively quiet compared to my former squadron col- actions. This causes guilt and when someone thinks about leagues for post-traumatic shame. So the sufferer, in an a non-traumatic event. So, in stress disorder (PTSD). These attempt to avoid hurting the therapy, by gently and gradu- people are now retired, but people he or she loves, will ally re-exposing a PTSD victim due to the traumatic sights spend hours in isolation—in to the original trauma and they were exposed to, some the basement on the compu- helping the person stay with are badly affected. Fortunate- ter, for example. Or, they will it while talking about it, we ly, they are entitled to, and spend excessive time with build the verbal component. are receiving, much-needed the colleagues who under- Once the verbal compo- therapeutic assistance from stand them because they are nent is built, the person has Veterans Affairs Canada. in the same boat—and it is an option to choose not to often over a drink. think about it. In this way, What is Trauma? PTSD is an anxiety dis- the instantaneous startle In my military day, Canada’s order. Alcohol, other drugs, reaction is less likely to hap- involvement in peacekeeping gambling, sex and pornogra- pen, and the person now has was extensive, but active en- phy are common avoidance some control over it. A major gagement in combat opera- behaviours, because they fear in PTSD sufferers is lack tions was rare. Now, a large represent means of distract- of control, because that was number of Canadian troops ing from the anxiety. De- inevitably a signifi cant factor are exposed to highly trau- pression is also a common in the original trauma. matic events. However, PTSD side effect of PTSD. More than 50% of PTSD is not just a soldier’s disorder. sufferers develop chemi- It also applies to assault vic- Treatment of the cal or other dependencies. tims and relief workers and Traumatic Memory From a treatment point of police offi cers, and to anyone Treatment can take several view, it is absolutely neces- who is involved with others forms. All involve exposure sary to treat these co-occur- who have been traumatized. to the original trauma and ring problems together. There are three major learning to cope with it. components to PTSD. The When a person is ex- Optimism for the Future related resource fi rst is increased arousal, posed to a physical threat, it The good news is that follow- National Centre for PTSD, which involves, for example, is the “fi ght-or-fl ight” centres ing treatment, my friends US Veteran Affairs: a heightened startle response of the brain that are activat- from air force days are cop- www.ncptsd.va.gov and sleep diffi culties. The ed. In this context, the event ing and their family life is

18 Visions Journal | Vol. 3 No. 3 | Winter 2007 experiences and perspectives improving. There is now a long—in the trash can. to take the fi rst step. I have much greater understand- We can now provide seen many clients who came ing of brain chemistry and therapies that work. It is my only because their marriage this very real disorder. “Shell experience, however, that was on the line if they did shock” and “lack of moral many PTSD sufferers are re- not. Nevertheless, they en- fi bre” are terms that have luctant to seek help. So it of- tered the therapeutic door, been placed where they be- ten up to a family member and that is a major step.

When the One Responding to Traumas Faces His Own A Paramedic’s Story

Surreal Paramedic ‘real’ Richard Voigt My journey into the world of mental illness started in Having been a paramedic for 12 years, I had seen some February 2000 with an ambulance call that should have horrifi c calls. Calls involving children stand out: I found it Richard is a former been a routine affair: a patient was in cardiac arrest. hard to accept or make sense of a child dying. Also, wit- paramedic There was something different, for me, about the nessing someone realize that their life has been altered way I took in the scene as we arrived. The patient was is not pleasant, even when you’ve seen it a few times. lying in a crosswalk and a fi shing rod and tackle box Thankfully, I can still count on my hands the number were sitting by the curb, some distance from a river. of really disturbing calls. Contrary to what one sees on But things seemed oddly out of place… television, our days are generally quiet. Really intense My shift partner and I started to work on the patient calls happen just a few times a year, but the rest tend to footnotes immediately and were quickly backed up by the Ad- be calls in which you know what to expect. 1. Workers’ Compensa- vanced Life Support (ALS) team. As we worked, the scene However, 1999 had been a stressful year, with a tion Board of BC changed became surreal. It was like I was watching everything higher number of critical incident calls than usual. I its operational name to WorkSafeBC in July 2005; from above—and I still couldn’t make sense of what I had attended to a fi reman and three police offi cers. I however, the legal name saw. When it came time to defi brillate the patient, I just had also attended to two co-workers and had resus- remains the Workers’ Com- kept on ventilating him—registering the call to clear, but citated a friend’s daughter. When the case is close to pensation Board of BC. unable to act. My partner had to get me to stop. home, it is particularly diffi cult emotionally. 2. Canadian Mental Health The ALS attendants took me with them to the hospi- I had an extremely upsetting experience in Septem- Association, BC Division. tal, which wasn’t usual; I was the driver and usually drove ber 1999. My partner and I were trapped on a call at a (2003). Navigating workplace the ambulance to the hospital… When they spoke to me domestic scene where weapons were involved, and at disability insurance: Helping after the call was completed, I felt like a robot replying, the same time I was hearing over the radio about my people with mental illness fi nd the way. See cmha.bc.ca/ and the sensation of exhaustion was overwhelming. A friend and co-worker being attacked on the job. And advocacy/insurance for hospital doctor that I knew told me to see my physician. it brought back memories from almost 20 years prior, more detail of Richard’s My family doctor sent me to a counsellor, but it was of dispatching taxis while a cab driver was being mur- WCB journey (under the clear I needed more help. My coping mechanisms weren’t dered. I really began to feel out of sorts after that day. pseudonym, Peter). working. I was getting angrier and dwelling on calls I had Prior to the ‘fi sherman’ call, I had increasingly been done. My union representative suggested I see a psychia- having problems sleeping and had pain trist specializing in post-traumatic stress disorder (PTSD). from clenching my jaw. My mood was The psychiatrist gave me good news and bad news. changing. I got angry when driving. I felt The good news was that he was able to verify and explain wound up all the time. I didn’t want to why I had PTSD; it was a relief to have some understand- go to work any more. But my employer ing of what was going on. Then the bad news: he said I hadn’t provided training in recognizing the shouldn’t return to my job, as my stress was work related. signs of job-related stress. My wife and I I was devastated. On the advice of a co-worker I fi led a had separated; I thought it was the stress Workers’ Compensation Board (WCB) claim.1 of the separation that was getting to me.

Visions Journal | Vol. 3 No. 3 | Winter 2007 19 experiences and perspectives

3. Voight vs. Her Maj- WCB: Compounding the stress arguing that my attempts to gain justice removed re- 4 esty the Queen in Right Once I had fi led with WCB, things quickly went really bad. sponsibility from their jurisdiction. In November 2005 I of the Province of British WCB denied my claim, saying that trauma from my time fi led a Notice to Admit in BC Supreme Court, presenting Columbia and the Workers as a ward of the Alberta government was the cause all the facts of the case.3 WCB made no reply within the Compensation Board of requisite 14 days, so my statements are legally deemed British Columbia [et al], of my mental health condition. And any possibility of 2005, Notice to Admit, case working in any form in health care was denied me by a to be the truth. And in April 2006 the BCHRT denied 4 no. L94497, fi led in the psychologist I had never spoken with. WCB’s bid for dismissal of the case. New Westminster Supreme I had been taken into care at age 12, because my WorkSafeBC (what WCB is now called) still fails to Court of BC registry. adoptive parents became ill. It was a trying time, and acknowledge that the evidence—which their counsel 4. Voight vs. Work- I did become very rebellious; consequently, I was mal- did not oppose—supports my claims of mismanage- ers’ Compensation treated. But I never suffered any mental health issues. ment and failing to consider my safety. And they con- Board, 2006 BCHRT 190, WCB had no evidence that my time as a ward had af- tinue to force me to drive truck. RSBC 1996, c.210 (as Fighting this worker compensation claim has been amended). www.bchrt. fected my job. And the psychiatrist’s opinion was that bc.ca/decisions/2006/pdf/ the PTSD was job-related. incredibly stressful. Seeking help can, it seems, actually april/190_Voigt_v_Work- The WCB Review Board determined that I had sus- cause more harm than the original injury. ers_Compensation_Board_ tained injury from my employment as a paramedic and It really affected my psychological frame of mind 2006_BCHRT_190_pdf. awarded permanent partial disability and retraining. I to have my doctors say one thing (that my stress injury fi led a complaint with the BC Human Rights Tribunal was work related) and WorkSafeBC say the opposite (BCHRT) in 2003, alleging discrimination based on fam- (that it wasn’t work related). Being forced to work in ily status and type of injury.2 This, however, began a an inappropriate vocation by the agency charged with whole new struggle—and what I believe was retaliatory the protection of workers was too much for me. I got action on WCB’s part. to the point where I was not only suicidal, I believed I was inappropriately retrained and placed in a truck- WorkSafeBC was trying to kill me. That they refuse to driving job. I had been showing signs of road rage and, correct their errors I fi nd unbelievable. with minimal training, was expected to drive a semi-trail- When my back injury got to the point where I need- er through the Lower Mainland. And the prolonged sitting ed medication for the pain, my doctor’ locum wanted and heavy lifting aggravated previously documented back me committed; she thought I was delusional, because injuries (two herniated discs that were also later confi rmed I said that WorkSafeBC forced me, with my history of by a CT scan).3 I’ve also been forced (threatened with loss back injuries, to work in this vocation they had chosen of income) to drive when experiencing problematic reac- for me. No, they would never do that! tions to psychiatric medication (Moclobemide). Now I’m dealing with the BC Ombudsman. On and WCB responded by trying to have the case dismissed, on it goes…

of our existence—I mean in some way to society. I might be nothing existence in a collective All I’ve been doing is tak- sense—us as a species, ing, taking, and here I am Journal writing as a planet, as a solar sys- again in the hospital, tak- tem, as a/the universe. In- ing up a bed and nurses’ nocence is a delusion, but and doctors’ time and a necessary one. Maybe causing worry and pain Lara Gilbert July 18th, 1993 and anal intercourse with my eyes are wide open to for my mom. I’d be better ’ve heard the opin- him, and that my father everything, but the effect off dead, and I wish my Lara was educated in ion, in general and fondled and raped me of this has been to inca- family would understand Vancouver, British Columbia, I with regard to myself until I got the guts up to pacitate me. Instead of this so that when I am suc- receiving her BSc (Honours personally, that people move in with my mom— facing the challenges life cessful with my suicide, I Biochemistry) from the abused as children often these events pretty well presents, I’ve lost motiva- won’t have caused them University of BC in 1995. develop depression as ad- tore those rose-coloured tion and energy and inter- even more problems… Lara took her own life in olescents or adults. I don’t glasses off me and al- est, while still being aware […] 1995 and her journals were argue with that theory at lowed me to see the real that those challenges are published nearly a decade all, but I think my ideas world, early on. there. I feel guilty for not December 16,1993 after her death about depression fi t in Some people speak of even putting the effort Age 21 perfectly with this cause- lost innocence, but if any- into the small things—I I am so enraged at the effect hypothesis. The thing was lost, it was the can’t even do the laundry people with power, usu- fact that my grandfather ability to close my eyes and cook, let alone organ- ally male, who get away forced me to have oral sex to the negative aspects ize my life and contribute with anything; and at the

20 Visions Journal | Vol. 3 No. 3 | Winter 2007 experiences and perspectives

Excerpts are reprinted with permission from I might be nothing: Journal writing by Lara Gilbert. Abridged and edited by Lara’s mother, Carole Itter, 2004. The book is available from Trafford Publishing at www.trafford. com or from Carole directly at [email protected] justice system that turns a to help however he could; prostitution. The Crown insisting that they remain blind eye while other peo- he wanted to be my big prosecutor has warned me outside the room. I said I ple suffer. brother. He couldn’t make that this will defi nitely be would be more nervous I wonder what to ex- the choice of whose story brought up, and his objec- if I saw anyone in there I pect will happen next to believe, but he feels for tions may be overruled so knew. month at the sexual as- how I’ve suffered, and I must be ready to go into If my boyfriend and sault hearing involving he says his relationship the “story.” best girlfriend fi nd out that male nurse. Even with our father has been The way the male what a slut I’ve been, I without my full medical strained for the last fi ve nurse asked me to have don’t think I’ll be able to records documenting my years. My father makes it intercourse with him stand the humiliation. I’ll dissociative experiences, hard not to believe him, and later to give him “a feel like less than a real post-traumatic stress dis- my half-brother says. blow”—I felt like I was a person. And if in court I’m order and my brush with I can imagine; he’s a prostitute whose services asked why I tried prostitu- prostitution—which gives natural arguer. It’s good to were being requested. It tion, I’ll just have to admit the defence plenty of ma- know that my half-brother was so demeaning. So I that no, it wasn’t for the terial to come up with rea- is supportive of me any- told him that I’d had ex- money—I wasn’t penni- sons I might not be telling way. But it still boggles periences in the past in- less or wired on drugs—it the truth—even without my mind how most of volving unethical sexual was because I longed for a all my previous allegations that family is trying to ig- relations and that it was sense of power and control Offering myself to men for a price gave me a feeling of worth and importance, and an exchange that was business-like and for me, unemotional. “Safe” sex. The power and worth, of course, are illusions. of my grandfather, father, nore the issue. Grandma damaging. I was hoping that was lacking in my life. and the rape of last No- practically admitted to me to dissuade him from con- Offering myself to men for vember, they could pretty in her letters that she is tinuing his disgusting line a price gave me a feeling easily acquit him with the aware of what happened. of “conversation” with of worth and importance, “reasonable doubt” crite- But no one will hold my me, but it didn’t change and an exchange that was rion. It’s my word against dad responsible for what his mind, and now that business-like and for me, his, and my word will not he’s done. It’s me, not submission of mine gives unemotional. “Safe” sex. count for anything. him, who’s left the family strength to his side of the The power and worth, of I will get to speak, at circle. […] story by letting everyone course, are illusions. The least. I will be able to tell known something humili- defence attorney is going the truth about his attempt July 8, 1994 ating and demoralizing to ask how I could be so to seduce me and his sub- I wonder if I’ll ever enjoy about me that they need stupid or mixed-up not to sequent rape of me after sex again. It’s hard to im- not have found out about, realize that from the be- failing at the seduction. agine those feelings ever if I’d kept my mouth shut ginning. And how can I The truth. No one in the returning to my body, after that day in the hospital. expect to be believed that courtroom has to believe thinking about this upcom- My worst are not the male nurse raped me me, and many probably ing preliminary hearing. that my history will throw when the court knows I won’t. But being believed The defence lawyer is go- my credibility out the win- was a whore, and whores is a lot harder to achieve ing to try to make me look dow (although this would always want it, right? than I used to think. like a slut, a whore—and be painful and angering) I’m fed up with being My dad still strongly one with a mental disor- but that Bob and Jan (who female. And frigid. denies that he abused me. der. I dread the inevitable both plan to come to the Anyhow, aside from I got a letter from my half- questions regarding my hearing) will come into the above stresses, things brother saying he wanted (slim) experiences with the courtroom despite my are going quite well for me.

Visions Journal | Vol. 3 No. 3 | Winter 2007 21 experiences and perspectives

I love my job, I love feeling Testifying was diffi cult, There have been ups I wanted to have sex with like I’m doing something the cross-examination be- and downs—the Crown a strange man while com- worthwhile, and working ing much more grueling and my lawyer were suc- mitted to psychiatric unit in the same hospital that than at the preliminary cessful at the disclosure because of suicidal and gave me back life back hearing last July. But I was hearing in preventing any dissociative thoughts. last year. And I love these prepared. I’ve been watch- of my medical records It still hurts me to think hot summer nights. The ing all the proceedings and from being entered; the of this verdict, although realization is gradually I feel like I’m living in that defence lawyer is very the Crown has assured me sinking in that despite the courtroom. I don’t want to good at what she does, that the jury believed me; challenges and diffi culties miss a minute of it, because and has pointed out some they did not like him at all. ahead, I am ready to deal I want to know exactly why inconsistencies in my They sympathized with with them—with anything. the jury makes the decision statements to the police, me and wanted to be able I know how to fi ght, and it eventually makes. I sit as well as focusing relent- to convict him. The prob- with my mood solid as a there at the back, watching lessly on my prostitution lem was the law. rock. I can plough my way the witnesses answer the issue. (I dreaded this—the I did not resist the as- through whatever tough lawyers’ questions, watch- humiliation I feel while lis- sault (after declining, in times I run into. It’s hard ing the judge at His Lord- tening to her belittle me our conversation about to accept this because it ship’s desk, watching the publicly is overwhelming). ethics) because I implicitly gives me no excuse to give expressions on the faces of When the video of trusted he would not as- up, give in. If I am capable the jury, staring at the back the male nurse’s confes- sault me; he was in a po- of surviving, I simply must of the accused’s head in sion (that is, to “consen- sition of authority, and his survive…. the prisoner’s box. When sual” sex to the police breach of trust was shock- I can’t stand to look at was played for the court, ing and overwhelming to March 4, 1995 anyone, I stare at the royal I started feeling much bet- me so that I felt frozen. I I’m actually optimistic; I crest on the wall above the ter. He is one twisted man, managed to retreat into just can’t stop crying. This judge’s head, and pray to verging on psychopathic, the bathroom and eventu- has been the hardest week God and to the justice sys- and I think this is very ap- ally to say “Stop it, stop, I’ve had—well, maybe not tem in Canada. I’ve decid- parent to the jury. it hurts.” But in the eyes ever, but one of the top fi ve ed to believe in both this The problem remains of many people, includ- of my hardest weeks ever. week. that it is unclear (from a ing the judge, the defence legal point of view) wheth- lawyer, the accused and at Hear the heart-warming and thought provoking stories er I consented to sex, be- least some of the jurors, I of people who are living proof that cause I just “allowed it” allowed the rape to occur. and cried while he raped For the sex to have Mental illness is not what it used to be… me in my hospital room. If been nonconsensual, the the Crown can apply one law says he must have Recovery is possible! of the laws involving sex- “exercised his authority” ual relations with a person (not enough evidence he in the position of authority exercised it, whatever that or caregiver, this will help. means) or been “reckless But from the arguments or willfully blind” by fail- NOW AVAILABLE ON DVD I’ve been listening to be- ing to take the necessary tween the lawyers, the law steps to ensure I was con- A candid look at a cross-section of is very vague regarding a senting. (Defence argued people living with schizophrenia and depression – situation like mine. Per- that he did take these each with their own story of recovery haps this case will set a steps and I agreed to precedent. sex—in fact, said “Okay, “This DVD is NOT about suffering, where can we do it?”) disability and loss: it is about human March 12, 1995 The justice system resiliency and heroism in the face of Last Wednesday night at 9 does not work. The reso- profound challenges. Be prepared to pm after 16 hours of de- lution I expected to feel be inspired and energized as you liberation over two days, at the end of this trial is learn from the experts!” the jury announced their missing.[...] verdict: Not guilty. Dr. Michael Eleff MD FRCPC Hearing it was crush- ing. It felt like telling me For orders, please contact: I had not been raped; I MANITOBA SCHIZOPHRENIA SOCIETY, INC. Only made a fuss over nothing; 4 Fort Street, Winnipeg Manitoba R3C 1C4 $30.00 Phone: 1-204-786-1616 Fax: 1-204-783-4898 plus taxes 22 Visions Journalor | Order Vol. 3 on-line No. 3 at | www.mss.mb.caWinter 2007 alternatives and approaches

Post-Traumatic Stress Disorder Choosing the treatment that is right for you

ost-traumatic stress disorder (PTSD) is a common Medications and CBT Steven Taylor, PhD, ABPP P condition that sometimes arises after a person has There are several different types of effective medica- experienced a traumatic event such as sexual assault, a tions for PTSD. These include a class of drugs known as Steven is a Clinical or combat. Some people with PTSD are “selective serotonin reuptake inhibitors,” such as Pro- Psychologist and Professor unable to hold a job or socialize with friends, because zac, Celexa and Paxil. The choice of medication often in Psychiatry at the they are so seriously affected by the disorder. depends on the specifi c nature of your problems. These University of British People suffering from PTSD are confronted with a medications are typically prescribed by a psychiatrist Columbia. He has published bewildering array of treatment options. To add to the or sometimes by a family doctor. over 180 scientifi c journal confusion, some practitioners make dramatic claims CBT and medications are equally effective for the articles and book chapters, about the effectiveness of their treatments, often with- average patient. However, for reasons that are cur- and 12 books, primarily on out any supporting evidence. The following are some rently unclear, some patients benefi t more from one the nature and treatment scientifi cally supported recommendations for choosing treatment than another. Your family doctor or mental of anxiety disorders among treatments. (Detailed reviews of treatment ap- health professional (i.e., psychologist or psychiatrist) proaches appear in the related resources and footnotes can help you decide which treatment option is likely sections at the end of this article.) to be best for you. People with particularly severe PTSD The fi rst step is to get an evaluation from your fam- may require a combination of treatments, such as CBT ily doctor. Your doctor might also decide to refer you to plus one or more medications. a clinical psychologist or psychiatrist for further evalua- CBT and medications are effective in treating chil- tion. An important part of the assessment process is to dren and youth with PTSD, although over the past few decide when it is appropriate to begin PTSD treatment. years there has been some concern that certain medica- Some people with PTSD also have other problems, such tions, such as the serotonin reuptake inhibitors, might as severe depression or a serious drug or alcohol prob- increase the risk of suicide. These harmful effects appear footnotes lem. These problems might need to be addressed be- to occur in only a minority of patients—possibly those fore treating the person’s PTSD. with a history of impulsive, self-destructive behaviour. 1. Taylor, S. (2006). If the time is right for you to be treated for PTSD, Not all clinicians are convinced that these medications Clinician’s guide to PTSD: A cognitive-behavioral approach. then there are several options. The two leading, scien- have these harmful effects, so the issue remains contro- New York: Guilford. tifi cally supported treatments are cognitive-behavioural versial. Health Canada advises that patients (or caregiv- therapy (CBT) and particular types of medication.1-2 ers) consult the treating physician to confi rm that the 2. National Collaborating Centre for Mental Health. drug’s likely benefi ts outweigh any risks. (2005). Clinical Guidelines 26: Cognitive-behavioural therapy Post-traumatic stress disorder: CBT is a form of psychotherapy, typically provided by Be aware The management of PTSD in a clinical psychologist. The goals of treatment partly There are many other treatments for PTSD, although adults and children in primary depend on your particular symptoms and problems, there is little evidence that some of these treatments are and secondary care. London, UK: Gaskell and the British and your specifi c goals. CBT typically involves teaching useful, and for other treatments the claims of their ef- Psychological Society. you ways of improving your coping skills (e.g., breath- fectiveness have been exaggerated. www.nice.org.uk/page.aspx ing exercises or particular types of relaxation training), • Eye Movement Desensitization and Reprocessing ?o=CG026fullguideline. 1-2 along with ways of helping you become less frightened (EMDR) – may be helpful in some cases 3. van Etten, M. & Taylor, 2-3 of harmless, but fear-evoking things in your life. CBT • Hypnosis – little evidence that this is effective S. (1998). Comparative effi cacy can also reduce other PTSD symptoms such as recur- • – little evidence that this is effective2-3 of treatments for post-traumatic rent nightmares. • Thought Field Therapy – no evidence that this is useful4 stress disorder: A meta-analysis. To illustrate, Alison was tormented each night • Neuro-Linguistic Programming – no evidence that this Clinical Psychology and Psychotherapy, 5, 126-145. by terrifying nightmares of a sexual assault that hap- is useful4 pened several years ago. During her CBT sessions, Ali- • Emotional Freedom Technique – no evidence that this 4. Devilly, G.J. (2005). son worked at desensitizing herself to the nightmares is useful4 Power therapies and possible threats to the science of by writing a vivid description of the sexual assault and • Critical Incident Stress Debriefi ng – no evidence that psychology. Australian and reading it over and over, until it became boring. This this is useful for preventing PTSD; indeed, some evi- New Zealand Journal of and other CBT methods gradually reduced the frequen- dence suggests that some forms of debriefi ng may Psychiatry, 39(6), 437-445. cy of Alison’s nightmares. be harmful1-2

Visions Journal | Vol. 3 No. 3 | Winter 2007 23 alternatives and approaches

related resources Inform yourself When choosing a treatment for PTSD, it is important that Matsakis, A. (1996). I can’t get over it: A handbook for trauma survivors (2nd ed.). Oakland, CA: New Harbinger. you take the opportunity to learn about the treatments being proposed. Check out the references and websites at Taylor, S. (2005). Post-traumatic stress disorder. the end of this article. Ask your doctor or therapist about www.anxietycanada.ca/PTSDEn.pdf the scientifi c evidence for whatever treatment is being proposed. Part of overcoming PTSD involves becoming Visit our www.heretohelp.bc.ca for our web-only article titled “Medication Treatment of Post-Traumatic Stress Disorder” by Joseph more empowered. This starts with you making informed Wang, MD, PhD, Wei Zhang, MD, PhD and Jonathan Davidson, MD. choices about the treatment you are willing to receive.

Post-Traumatic Stress Disorder— and Traffi c Crashes

John Vavrik at is running late. tions may include anxiety, within a few months; how- when the actions of other She can barely depression, anger, grief, ever, some continue to re- drivers are perceived to be John is a Consulting P wait for the light to guilt, travel phobias and port chronic symptoms of intentionally directed at Psychologist with ICBC, change. When it does, she post-traumatic stress disor- post-traumatic stress, which the victim (such as in road focusing on the application instantly accelerates across der (PTSD). hinder their psychological rage incidents), when the of research on psychological the intersection. In a split If Pat were to devel- and physical recovery. driver feels responsible issues arising from motor second she is engulfed in op PTSD, she may suffer Of those who do de- for the crash, when close vehicle accidents—in a wave of deafening noise, from insomnia. When velop some PTSD symp- friends or family are in the particular, assessments, ripped out of her seat and she does sleep, she may toms, most recover within vehicle, and when some- risky driving behaviours smashed against a wall “re-experience” the crash the fi rst year. About half of one is trapped in the vehi- and crash prevention. Also of shattering glass, with in nightmares. She may those meeting PTSD crite- cle after the crash. a Registered Psychologist metal and limbs spinning try to avoid driving, par- ria at one year following Pat’s history with other in private practice, John around violently. Her sens- ticularly through intersec- the crash recover by the traumatic events, including specializes in educational, es all seem in overdrive tions, fearing another sim- end of the third year. other crashes, as well as vocational and disability- yet her mind is blank. Pat ilar crash. When she does The relationship be- pre-existing conditions such related assessments and feels like she’s watching a drive, she is likely to con- tween crashes and PTSD as anxiety, emotional prob- therapeutic interventions fi lm in slow motion. She stantly check and recheck is not simple because it lems, depression and exces- watches passively as her all cars, buses and trucks depends on the type of sive health concerns also in- car rotates in the air, land- (especially the trucks)—to crash, the type of individ- fl uence her risk of develop- ing on its roof. Hanging the point of being worn ual involved, as well as on ing crash-related PTSD. upside down in the over- out by the intense, in- the social, economic and How she responded footnotes turned vehicle, she can see discriminating watchful- legal issues that emerge emotionally during and 1. Taylor, S., Thordarson, its underbelly as if watch- ness (i.e., hypervigilance), following a crash. While immediately following the D.S., Maxfi eld, L. et al. ing it from above. Later she which can actually cause the severity of Pat’s crash crash is also relevant. If (2003). Comparative ef- learns that she is actually her attention to drift. may put her at greater her reaction suggests some fi cacy, speed, and adverse looking at the chassis of risk of PTSD, how she per- type of dissociative experi- effects of three PTSD treat- ments: , the truck that smashed into Will Pat develop PTSD? ceives the crash will likely ence, such as feeling numb, EMDR, and relaxation her. Despite the high speed The good news is that sim- play an even larger role. dazed or watching the crash training. Journal of Consulting impact, Pat lives, suffering ply being in a crash, even a “Traumatic” crashes from the outside looking in, and Clinical Psychology, 71(2), only non-life-threatening serious crash, will not au- are often described as she may be at a greater risk 330-338. physical injuries. tomatically affl ict Pat with sudden, unexpected, un- of PTSD. 2. Rabe, S., Maercker, Motor vehicle crashes, PTSD. In fact, the odds are predictable, uncontrol- The way she “process- A., Zollner, T. et al. (2006). in addition to being one generally in her favour. lable and scary. Crashes es” the crash (i.e., how she Neural correlates of post- of the top causes of death Only about one in 10 seem to be more stressful appraises or interprets the traumatic growth after and injury in Canada and individuals who describe severe motor vehicle ac- cidents. Journal of Consulting around the world, can their collision as and Clinical Psychology, 74(5), sometimes trigger or wors- “traumatic” actually 880-886. en existing psychological develop PTSD. Most only about 1 in 10 individuals who described conditions. These condi- crash victims recover their collision as “traumatic” actually develop PTSD

24 Visions Journal | Vol. 3 No. 3 | Winter 2007 alternatives and approaches event in the context of her one reason care must be emotions and actions at the taken in designing preven- time) might affect how she tion programs that use forms an autobiographical mock accidents to raise Connecting Virtually memory of the event, which awareness of crash conse- might in turn enable more quences. Webcast on women, violence involuntary “fl ashbacks” of the crash as time goes on. If Treatment and outlooks and substance use her memory of the crash is If Pat does develop full disorganized or fragmented, PTSD, there are many ef- she is also more likely to ex- fective therapies available: perience PTSD. • Exposure therapy ap- n the last week of September 2006, 200 research- Pat might also be pears to be effective in ers, policy makers and service providers from across more at risk if she views reducing the re-experi- I Canada met “virtually” in a webcast to hear about: Nancy Poole any intrusive thoughts encing symptoms and • connections between women’s experience of vio- and memories of the travel phobias1 lence/trauma and substance use problems Nancy is a Provincial crash negatively (e.g., • Relaxation therapy may • developments in reducing the “mystifying separa- Research Consultant on “I’m going out of my be especially useful for tion”1 between anti-violence and addictions services Women’s Substance Use mind” vs. “These are just managing hypervigilance1 • models for discussing substance use with women Issues with BC Women’s uncomfortable but tempo- • Eye movement desensi- who have experienced violence Hospital and with the rary thoughts I am willing tization and reprocess- • models from BC, Canada, UK and US that provide in- British Columbia Centre of Excellence for Women’s to accept for now.” She ing (EMDR) therapy has depth, integrated support would also be at greater also been shown to re- • information helpful for women who are examining Health. She works on research and knowledge risk if she used common duce PTSD symptoms1 their own substance use following an experience of (and often natural) cop- violence exchange relating to policy ing strategies that actually Recent research also con- • other implications for research, policy and work with and services for women promote the maintenance fi rms what many crash women with substance use problems of PTSD symptoms—for victims have been say- example, if she tried hard ing for years: confronting The webcast format allows many people to participate si- to suppress all intrusive a life-threatening event multaneously. You view the presentation on your compu- thoughts, ruminated about like a motor vehicle crash ter screen and hear the presenters through your computer footnotes the crash, or dwelled on can lead to very positive speakers. And you can type in questions for the present- why the crash happened psychological changes. ers. Responses, questions and information on this topic visit www.heretohelp.bc.ca/ publications/visions to her specifi cally. (Try as Pat may experience such of violence and substance use connections rolled in from for Nancy’s complete hard as you can not to “post-traumatic growth” if interested participants from coast to coast. footnotes or contact us by think of a big black truck she begins to re-evaluate The content shared in the webcast (and summa- phone, fax or e-mail (see that is about to hit you). her priorities in life, build rized below) was the consensus of 20 women who page 3). If Pat receives very more meaningful relation- work in violence- and addictions related agencies, and little support from her ships with friends and in research and policy contexts. These women had par- friends and family, if she family, and gain strength ticipated in a virtual “com- has fi nancial diffi culties and confi dence from her munity of practice” over and if she becomes in- diffi culties.2 a four-month period from want to know more? The cross-country webcast media fi le is available on volved in a legal case, she April through July 2006. request. Five information sheets designed to extend will be more likely to de- Prevention This virtual community the discussion and action on this important issue velop and maintain PTSD. The simplest way to re- and the webcasts are part will be posted on these project sponsor websites: Legal action, with its em- duce the negative psycho- of a larger project entitled | BC Centre of Excellence for Women’s Health: phasis on psychological logical impacts of crashes Coalescing on Women www.bccewh.bc.ca injury rather than recov- is, of course, to prevent and Substance Use: Link- | Canadian Women’s Health Network: ery, has particularly been crashes in the fi rst place. ing Research, Practice and www.cwhn.ca shown to be a risk factor. Simply checking for cross Policy. | Canadian Centre on : Finally, although we traffi c before entering the www.ccsa.ca have focused on Pat, the intersection, even if the Compelling Connections driver, it is important to light was green, might Women’s substance use is Five more virtual learning communities on women remember that post-crash have been Pat’s most ef- strongly associated with and substance use issues are being planned as stress reactions can some- fective strategy for elimi- their experience of vio- part of this project. For information contact Nancy times develop in people nating the risk of crash-re- lence, abuse, assault and Poole or Katja Clark by e-mail at [email protected]. who simply witness a lated PTSD. trauma. For example, alco- ca, or phone 604-875-2424, Ext. 6488. traumatic crash. This is hol problems are up to 15

Visions Journal | Vol. 3 No. 3 | Winter 2007 25 alternatives and approaches

Somatic Experiencing Therapy ‘Unfreezing’ the trauma response

Amanda Sawatzky, omatic Experiencing Animal instinct: is being approached by a a surge of chemicals in the MEd, CCC, SEP (SE) is an approach fi ght, fl ee or freeze large dog will evaluate the animal’s body that slows S for working with and Levine researches animals area and decide if it has the respiratory system, Amanda holds a degree healing trauma. It was de- in the wild. Animals have an escape route. If it does, the heartbeat and all other in Psychology, a master’s veloped by Dr. Peter Lev- a reptilian brain and act it will fl ee—and burn off functions. The system is degree in Counselling, ine,1 who holds a doctorate purely out of instinct to all the adrenalin pumping basically ‘shut down,’ and a certifi cate in Confl ict in both medical biophysics survive. When animals through its body as a result the animal is immobilized. Resolution and is a certifi ed and psychology. Dr. Levine feel threatened, they have of fear. If there is no escape, The key with the freeze Somatic Experiencing took his observations from three choices of action the cat may fi ght. This will response is what happens practitioner. She works both both these fi elds and tried that help them survive: to also burn off the adrenalin. afterward. Let’s say the in private practice and for a new way of working with fi ght, fl ee or freeze. All will If the cat decides the dog is dog decides not to go af- Cowichan Lake Community people that has had amaz- help the animal stay alive. far too large to fi ght, it may ter the cat any more and Services ing results. For instance, a cat who freeze. In freezing, there is goes away. Since animals connecting virtually | continued from page 25 times higher among women who are survivors of inti- source Society in locations throughout the Lower Main- mate partner violence than in the general population.2 land, have found ways of making it safe to talk about Girls who experience physical and sexual abuse by dat- one’s substance use in the context of their services. ing partners are 2.5 times more likely to be smoking heavily within 30 days.3 Mothers who have children with Seeking safety fetal alcohol syndrome have serious histories of abuse Anti-violence services have also identifi ed the need to and partners who don’t want them to quit drinking.4 provide more in-depth support for women experienc- ing trauma and substance use problems. For example, Service silos service providers at the Victoria Women’s Sexual Assault In spite of the strong relationship between substance use Centre (VWSAC) observed that women with trauma-relat- and experience of violence/trauma, few service agencies ed and substance use problems are often in crisis. They have philosophies and visible services that integrate as- rotate through services, unable to get their complex is- sistance to women. Many anti-violence services restrict sues addressed.6 In response, VWSAC staff, in collabora- access to women who have substance use problems. In tion with other community providers, are offering inte- addition, women seeking help with violence concerns grated treatment groups that utilize the Seeking Safety have received confl icting information about the nature of model7-8 as a foundation. substance misuse and its connection to woman abuse/ For women, care systems have often failed to rec- trauma, and about treatment and support options. ognize the overlap between violence, substance use and mental health problems, so haven’t provided inte- Integrating support grated support and treatment. Anti-violence services, Service providers recognize that there are many roads though, are increasingly rising to the challenge of pro- to change or recovery.5 For women with substance use viding such integrated support. problems, a key step in their growth may be to explore Policy and research that articulate and support this in- how substance use is connected to experiences of tegration are much needed. Virtual learning communities woman abuse, early or other forms have a role in facilitating researchers, program providers of gender-based violence. We need to create contexts and policy makers to come together to engage with the for integrating this knowledge into both anti-violence issues and be inspired to act on promising strategies. and substance use services. The Coalescing on Women’s Substance Use: Link- Resources for supporting discussion of substance ing Research, Practice and Policy project is sponsored use problems by anti-violence service providers were by the British Columbia Centre of Excellence for Wom- related resource discussed. It was pointed out how safety planning can en’s Health, co-sponsored by the Canadian Women’s be useful as a common theme for providing support. Health Network and the Canadian Centre on Substance Seeking Safety: Many anti-violence services, such as the Phoenix Tran- Abuse, and funded by Health Canada under the Drug www.seekingsafety.org sition House in Prince George and Atira Women’s Re- Strategy Community Initiatives Fund.

26 Visions Journal | Vol. 3 No. 3 | Winter 2007 alternatives and approaches naturally know how to feres with our natural ability these symptoms to be signs trauma, with both children footnote discharge the chemicals to heal by somehow block- of unresolved trauma. and adults. In a typical SE 1. Levine, P.A. & Freder- and energy that has built ing or changing normal re- session, I may ask you to ick, A. (1997). Waking the tiger: up, the cat will shake and actions to the event. Trauma Somatic Experiencing track and describe sensa- Healing trauma. Berkeley, CA: tremble to effectively burn symptoms are not caused —releasing the body tions you are experiencing North Atlantic Books. them off. And then the cat by the event itself, but by As a counsellor, my job is or images that appear as will go on its way, basi- our reaction to the event. to help people get out of you talk about the subject. cally no worse from the For example, if the the freeze response and These may be indicators of experience. trauma was a result of a discharge the adrenalin blocked responses or of re- Humans, too, have non-life-threatening car and chemicals that are sources that could help you this reptilian brain and the accident, a normal reac- keeping them stuck. SE move forward. You may fi ght, fl ee and freeze re- tion after the accident helps people become spend part of the session sponses. But we also have may be to cry, shake and resourced (i.e., strong with your eyes closed, try- a rational brain that moder- have our muscles turn to enough) to handle the en- ing to focus inward as we ates whether we follow our ‘jello.’ But what if, instead, ergy from the unresolved chat and explore how the instinct or ‘thwart’ it. It is you pretend everything trauma and to allow the body has stored the trau- the ‘thwarting’ that leads to is okay and ‘be strong’? energy to be discharged. matic event. I may ask you trauma symptoms. What if you jump out of Without resourcing, there to do some ‘exercises’ to the car, tell everyone you may be retraumatization. help stimulate various parts Trauma as a frozen are fi ne, hold back the Since trauma is locked of your nervous system, freeze response tears and carry on to work and blocked at a body level, which may be shut down. Trauma can result from al- as normal? we need to free it at a body I am very excited to most any experience—a After several weeks or level. Body? What’s that? have this tool and knowl- fall off a bike at six years months, you may notice Most people live in their edge—Somatic Experi- old, sexual abuse as a teen, that you have a great deal heads, and are unaware encing—to share with the surgery, a car accident or of anxiety when driving. that a body is attached. So- people in my community. having a death in the fam- You may also notice that matic Experiencing helps Often, the result of this ily. Trauma is created when you are extremely irritable people access informa- way of working is the dis- a devastating moment is around your family, and tion not only at a cognitive appearance of physical frozen in time. That surge of you have no desire to work. level, but also at sensation, or mental symptoms that adrenalin and chemical that You feel depressed most of behavioural, imaginal and had no apparent cause was not discharged or let the time, and your neck and emotional levels. previously. Increased joy out, stays within us creating back are tense and ache My training has taught and liveliness is a frequent havoc. It acts as an ‘internal constantly. Somatic Expe- me numerous ways to result, as people open straightjacket,’ and inter- riencing would consider work on various types of themselves up again.

The Aftermath of Rape Cognitive-behavioural treatment for post-traumatic stress disorder

omen and men, young and old, rich and poor— reactions can include feeling like they are reliving the Debra Kaysen, PhD W sexual assault is common and cuts across gen- rape, having nightmares about it, trying not to think der, age, race and socioeconomic status. It is normal about it or remember it, avoiding things that may Debra is an Assistant and usual to feel a wide variety of emotions after a make them think about it, feeling cut off from their Professor in Psychiatry and rape. Survivors may feel very isolated and alone after- feelings or relationships, feeling jumpy or on guard, Behavioral Sciences at the wards. They may feel like they can never tell anyone, having problems sleeping or concentrating, and feeling University of Washington in like they will never heal. But in fact, reactions to rape depressed or down. Seattle. Her research has vary widely from person to person. And many people Some survivors may have been experiencing psy- focused on PTSD in female actually recover on their own, or with the help of fam- chological troubles before the rape, which may make victims of interpersonal ily, friends or their faith. recovery more diffi cult. Survivors may try to manage violence and, specifi cally, on Some people, however, may develop chronic reac- their reactions by using alcohol or drugs. Alcohol or the relationship between tions that signal a need for professional help. These drugs might work momentarily to improve symptoms, PTSD and alcohol problems

Visions Journal | Vol. 3 No. 3 | Winter 2007 27 alternatives and approaches

footnotes but do not work well over time, leading to possible sub- Both exposure-based and cognitive therapies have visit www.heretohelp.bc.ca/ stance dependence on top of the other reactions. been found to be generally safe and effective and ap- 6-8 publications/visions for pear to have lasting benefi ts. These therapies can be Debra’s complete footnotes The cognitive-behavioural treatment option conducted individually with a therapist or in a group set- or contact us by phone, fax Post-traumatic stress disorder (PTSD) is the most com- ting. To benefi t from these therapies, survivors need to or e-mail (see page 3). mon diagnosis associated with rape. The good news is be able to step forward and ask for help. And, they have that there are a number of treatments that have been to be willing to talk about the rape with the therapist. developed for PTSD. There are both medications and Even now, rape is a vastly under-reported crime. several (talk therapies) that research- ers have found treat PTSD well.1 The focus of this article Impact of alcohol and drugs on PTSD treatments is on cognitive-behavioural therapy (CBT). PTSD together with substance use can be a particularly CBT has been found across a variety of research diffi cult combination for survivors and treatment provid- studies to effectively treat PTSD symptoms.2-3 This ther- ers to address. PTSD symptoms may make it more dif- apy is generally focused and short term, and includes fi cult for survivors to fi nish substance abuse treatment learning new skills. It may involve practicing new skills and to remain clean and sober. At the same time, sub- between sessions. It will often include teaching clients stance abuse may make it harder for survivors to fi n- and their families about how people get PTSD and how ish PTSD treatment. Also, many therapists will not offer treatment is likely to help them get better. cognitive-behavioural therapy for PTSD to someone who Treatment may involve exposure.4 This can include is currently substance dependent, because of concerns exposure to memories of the event and exposure to safe about treatment drop-out or making someone’s sub- reminders of the event. Both of these parts of treatment stance use worse. allow the survivor to re-experience reminders of the A number of researchers and clinicians believe that event in a safe place. They also allow survivors to look treating both the PTSD and substance dependence at at their reactions and beliefs about the rape. This allows the same time is the best option.9-11 Several combined survivors to resolve strong feelings, like shame, fear, an- CBT treatments have been created that teach people ger, guilt or disgust that are common for rape victims. ways of coping without using alcohol or drugs and also The other goal for exposure treatments is to teach survi- help treat PTSD symptoms. Another option that some vors how to cope with their reactions to the rape without people choose is to have separate PTSD and substance getting overwhelmed or avoiding. abuse/dependence treatment providers. Both PTSD and Therapy may also work directly on thoughts or be- substance use are then treated at the same time, but by liefs about the rape. This has also been found to be help- experts in each treatment area. ful.5 Beliefs may have been shaped by the rape in a way that is either inaccurate or unhelpful. Survivors are taught In summary skills to fi nd these unhelpful beliefs, test them and change It is not uncommon for rape survivors to give up hope that them if they are not working. The idea is that by changing their post-rape reactions can improve. They can get better, beliefs you can change emotions and behaviours too. however. Some people may need to seek additional help Therapy might also include learning: breathing skills or resources. Treatments exist for PTSD and for substance or to reduce anxiety, new ways to manage dependence that work. CBT treatments are the ones we or reduce anger, coping skills for future trauma reactions, know the most about how well they work. The fi rst step and ways to communicate more effectively with people. toward recovery may be picking up the phone.

Post-Traumatic Stress in the Workplace

Hans Beihl, PhD n 2005 there were over verse effects of an injury becomes overwhelmed by when the scaffold col- 164,000 workplace in- can be stressful, but most anxiety and stress and has lapsed and he fell to the Hans provides Ijuries reported in our workers manage to adjust great diffi culty coping with ground 15 feet below. Joe psychological consultation province. Most workplace without serious diffi culties. even ordinary daily tasks. suffered a neck injury and for WorkSafeBC. The views accidents involve physical Sometimes, however, when fractures to both his legs. expressed in this article are injuries ranging from mi- a worker’s life is threat- Joe At the time of the accident those of the author and nor back strains to more ened or placed in serious Consider, for example, he thought he would die. do not refl ect the offi cial serious injuries such as danger, the person can be- Joe, a healthy 47-year-old He slowly recovered from policies of WorkSafeBC loss of limbs or paralysis. come emotionally trauma- worker, who was install- his physical injuries, but Coping with the ad- tized. That is, the person ing windows in a high-rise remained highly fearful of

28 Visions Journal | Vol. 3 No. 3 | Winter 2007 alternatives and approaches working at heights. He had her home on her own. She trauma. Individuals who is one of the greatest chal- footnotes frequent dreams of falling feared that someone would have a pre-injury history lenges for the client, since 1. Follette, V.M., Ruzek, and would wake up in a come up behind her and of sexual assault, problems the instinctive reaction is J.I. & Abueg, F.R. (Eds.). sweat. Even weeks later attack her. Even when her with depression or anxiety to keep distant from what (2006). Cognitive-Behavioral he often replayed the ac- friends accompanied her to or with alcohol and drug is feared. Therapies for Trauma (2nd ed.). cident over in his mind as public places, she felt nerv- abuse, or prior exposure Antidepressant medi- New York: Guilford Press. if it had happened yester- ous and was constantly on to emotional or physical cations are also often used day. When he saw others the lookout for danger. At abuse, are more at risk in combination with CBT, 2. Colotla, V.A. et al. (2000, climbing ladders, his anxi- night, Mary often woke up of becoming emotionally or as an alternative treat- November). Post-traumatic stress disorder (PTSD) in the ety would shoot up and his in panic, thinking she had traumatized. ment approach. workplace. Poster presented knees buckle. Joe worried heard someone breaking at the 16th annual meeting that he would never be into her home. She lost Cognitive- Recovery of the International Society able to return to his job. interest in everything and behavioural therapy Individuals differ in their of Traumatic Stress Studies, began to drink more heav- Sometimes the anxiety ability to tolerate anxiety San Antonio, TX. Mary ily to numb her feelings. symptoms that develop and face their fears. Most While most work acci- following a workplace ac- people recover from PTSD dents involve physical in- Traumatic events cident resolve over time. within three to six months. juries, some do not. Mary, and risk factors In more severe cases, how- In some cases, despite a single mother with two Both Joe’s and Mary’s anx- ever, treatment is required treatment, symptoms children, was working as a iety symptoms were diag- to help the person regain may last for years. In one teller in a bank, when two nosed as post-traumatic control of his or her life. study of 44 people who masked men armed with stress disorder (PTSD). Cognitive-behavioural were emotionally trauma- guns stormed in. Every- Their anxiety symptoms therapy (CBT)1 is the most tized in the workplace in one was ordered to were controlling their commonly used non-med- BC, two thirds were able down on the fl oor. One of lives, and they felt help- ical approach to treatment to return to work by 10 the robbers kicked Mary less to change their situa- of PTSD. This approach fo- months, many returned and told her he would kill tion on their own. cuses on helping the client to the same or a modifi ed her if she moved. Mary In BC last year, there come to terms with the job, some workers were was so frightened she lost were over 100 work inju- traumatic event and regain placed in a different job, control of her bladder. For ries resulting in PTSD. As- a more realistic perspective and one third wasn’t able hours after the robbery, saults in the workplace, of the risks and dangers in to return to work.2 she shook uncontrollably. loss of fi ngers or limbs, the world. A key aspect of Both Mary and Joe, Before the robbery, falls and serious motor ve- this treatment approach however, with treatment, Mary’s world had looked hicle accidents are some of involves helping the per- managed to regain control safe and predictable, but the types of accidents that son face the situations they of their lives and return to now she was afraid to leave can result in emotional avoid due to anxiety. This work.

iolence and trauma have serious health impacts Shanti Hadioetomo Violence and Vfor women. In 2002 the BC Centre of Excellence for Women’s Shanti is an undergraduate Health (BCCEWH) published a report, Violence and Trau- student in communication Trauma in the ma in the Lives of Women with Serious Mental Illness: studies at Simon Fraser Current Practices in Service Provisions in British Colum- University. She is currently Lives of Women bia.1 The report looked at how services are delivered on a co-op term at to women with chronic and persistent mental health Canadian Mental Health problems who are survivors of violence. The research Association, BC Division with Serious team focused on fi ve different mental health care set- tings in two BC health regions, using focus groups and Mental Illness interviews. They also surveyed programs across BC. The report found that mental health programming A report synopsis and planning still doesn’t thoroughly attend to the broad psychological and social aspects of mental health, despite a commitment in the 1998 BC Mental Health Plan.2 Marina Morrow, the lead investigator on the report, continued on page 31

Visions Journal | Vol. 3 No. 3 | Winter 2007 29 regional programs

Sex for Stuff It’s Not a Fair Trade

Heather Miko-Kelly “I didn’t and still don’t WAYS campaign ed with young people from diffi cult times. Mindyour- know who to blame, if any- “I was 12 years old, try- elementary and second- mind.ca acknowledges Heather is the Youth one. I don’t know who I’m ing to get someone to buy ary schools, group homes that those being sexually Projects Coordinator with more disappointed with: me cigarettes at a vari- and community youth exploited often turn to mindyourmind.ca, an the people that took advan- ety store in a fairly good groups. The results were self-harming behaviours award-winning international tage of me, my parents for neighbourhood of our city. astonishing as youth after and substance use to re- website for youth, based in not being there, other peo- I was approached by a youth disclosed personal duce the pain and trauma. London, ON. Mindyourmind. ple for not stopping it, or middle-aged man with a stories of exploitation and And they often have sui- ca promotes personal myself for doing it.” * car seat in the back of his abuse. Approximately 300 cidal thoughts. The web- coping, positive mental minivan. He had exposed anonymous youth were site provides information, health and reaching out to t’s not something himself to me and propo- asked if they had ever resources and tools to help get help and give help when we like to talk about sitioned me to watch him been sexually exploited manage stress, crisis and times are tough or even think about, masturbate—and in return and 20% answered yes. mental health problems. I but the reality is that he would buy me smokes. When asked if they knew Mindyourmind.ca, young people in our He was insistent and con- someone who had been also based in London, saw urban and rural communi- niving with his words and sexually exploited, 55% the positive impact the * passages in italics are ties are trading sexual acts behaviour. I didn’t feel like answered yes. It’s impor- WAY S awareness campaign excerpts from one young for ‘things’—like a place I had a choice. I felt sick tant to realize that many was having on the local person’s story to stay, a ride somewhere to my stomach and anx- youth don’t ever disclose community and wanted or even a pack of smokes. ious. I wanted someone to abuse and that having to promote it on a farther- Most adults have no idea help me, but really wanted enough trust to confi de in reaching scale. Given their this is happening. smokes too.” someone can take years. parallel missions, it made This is called sexual These numbers, therefore, good sense for the two or- exploitation. Engaging or This personal story, sub- could be a major under- ganizations to join efforts luring a person under 18 mitted by an anonymous representation. in increasing awareness into the sex trade or por- youth, and many others about sexual victimization nography, with or without similar to it were the rea- Mindyourmind.ca of youth. their consent, is a crimi- son Western Area Youth builds on WAYS In collaboration with nal act. The exploiter is Services (WAY S), a youth “I left the group home when WAY S, mindyourmind.ca often in a position of trust agency in London, On- I was 16 to pursue my inde- created an electronic ver- or authority and takes ad- tario, initiated a campaign pendent ‘career’ of prostitu- sion of the booklet about vantage of this trust. Too against sexual exploita- tion and crazy drug addic- sexual exploitation, and many children and youth tion. tion. I lived in shelters off developed a short online are being victimized every In January 2006, WAY S and on. I walked the streets quiz. Having these resourc- day. It is not okay. received seven months of and had sex for money and es on the website and the funding from the Ministry drugs. I dated drug dealers posters available as free of the Attorney General, and they ‘helped’ me with downloads targets a much factors increasing a youth’s Ontario Victim Services ‘leads.’ It was out of control. broader audience. Mindy- Secretariat, to increase My body was not mine, and ourmind.ca reaches over risk for sexual exploitation awareness and educate I completely disassociated 60 countries worldwide, | Seeking a sense of identity or belonging people in their communi- and separated my head including China, where | Using drugs or alcohol ty. The agency developed from my body.” a signifi cant number of | Having low self-esteem/self-worth posters, youth booklets women and children are | Surviving past abuse and parent brochures, Mindyourmind.ca is an traffi cked for the purposes | Mental health issues and gave presentations to international website for of sexual exploitation. | Homeless or at risk for becoming homeless social service providers, youth, by youth. It strives | Disconnected relationships with friends/family schools and parents. to reach out to youth who “For me, it is too late to | Being gay or lesbian Groups were conduct- are struggling through prevent what happened or

30 Visions Journal | Vol. 3 No. 3 | Winter 2007 regional programs

report synopsis | continued from page 29 told Visions in a recent interview: “The most consistent Victimization in the mental health system message I heard was that violence and trauma are seen as Trauma associated with the mental health care system separate from mental illness and substance use, and more in British Columbia—that is, the way services and treat- holistic forms of mental health care are needed.” ment are provided in the province—has been recog- nized as a serious concern. THE REPORT Retraumatization may arise from standard treat- Relationship between mental health and trauma ment practices. For instance, physical and chemical The report discusses several views on the interrelation- restraints can trigger feelings of powerlessness. Stigma ship of violence, trauma and mental illness. and powerlessness are central to the experiences of trauma and psychiatric hospitalization. Betrayal is an- Mental illness as precipitated by abuse other dynamic of abuse. Even when treatment provid- Many practitioners fail to identify violence and trauma ers act in the ‘best interest of individuals, the treatment symptoms as separate from symptoms of major men- process may re-create previous patterns of abuse. tal illness; consequently, many victims of trauma enter the mental health system misdiagnosed with mental Findings illness. It is suggested that when practitioners do view The need for gender analysis trauma symptoms discretely, some diagnoses may be That women are more often targets of intimate violence revised to acknowledge PTSD, rather than, or in dual is a fact resulting from gender analysis (i.e., analysis that diagnosis with, major mental illness. examines differences in men’s and women’s lives). There are some practitioners who recognize that Many mental health professionals, however, down- abuse in childhood can be an important cause in a play the signifi cant role violence and trauma play in number of psychiatric disorders. women’s lives. Or, professionals choose to see it as an issue separate from mental health; consequently, current Mental illness as a risk factor for abuse assessment tools and treatment plans don’t regularly take Practitioners are more inclined to accept that mental violence and trauma into account. This severely limits the illness is a risk factor for abuse. The risk can be a direct ability of the mental health system to respond effectively outcome of the woman’s illness and/or medication that to people who have experienced violence and trauma. she takes for her illness. Medication, as well as co-oc- curring substance use problems, may impair her judg- Mandates and diagnoses ment, making it diffi cult for her to protect herself from Service providers working in hospital settings, as well violent attackers and/or coercive sex. as those working on community mental health teams, Studies have demonstrated strong links between stated that their treatment is driven by policy man- footnotes trauma and later substance abuse, suggesting that dates. Policy directs most of system’s resources to peo- 1. Morrow, M. (2002). 3 women may use substances to self-medicate the psy- ple who primarily have Axis I diagnoses, such as mood Violence and Trauma in the Lives chological symptoms arising from trauma. Not surpris- disorders, anxiety disorders and psychotic disorders. of Women with Serious Mental ingly, women with histories of repeated abuse are more Many symptoms associated with histories of severe Illness: Current Practices in Service likely to face homelessness, addiction and mental illness trauma and abuse, however, are consistent with symp- Provisions in British Columbia. 3 Vancouver, BC: BC Centre diagnoses, placing them at further risk for sexual and toms that result in Axis II diagnoses, such as border- of Excellence for Women’s physical abuse. As a result, homelessness, substance line , dissociative identity disorder, Health. www.bccewh. abuse and being diagnosed with mental illness are both eating disorders and post-traumatic stress disorder. An bc.ca/PDFs/violencetrau- outcomes of, and risk factors for, future abuse. Axis II diagnosis can mean being refused hospital or ma.pdf. community mental health services. This means that the 2. BC Ministry of Health practitioners were not able to adequately treat women and Ministry Responsible with Axis II diagnoses. As a result, a screening process for Seniors. (1998). Revital- may unintentionally affect the ability for violence and izing and rebalancing British stuff for sex | continued from previous page Columbia’s mental health system: trauma survivors to access services, resulting in over- The 1998 Mental Health Plan. to lessen the burn, and my so much taken away from use of emergency services. Victoria, BC: Queen’s experiences will not reap them because of other peo- Printer. www.healthservices. the immediate benefi ts of ple. This to me is the only Is addressing violence “counter-therapeutic”? gov.bc.ca/mhd/pdf/mhpd. this program. However, I bit of empowerment I, per- Trauma specialists suggest that women need suffi cient pdf feel solace in the fact that sonally, can get back.” ego strength and support to begin exploring traumatic 3. American Psychiat- for others it may not be as life events. Thus, bringing up the past is damaging if ric Association. (2000). isolating if initiatives like she is unable to access long-term support. Pragmati- Multiaxial assessment. In for more info Diagnostic and statistical manual this continue. I will contin- cally, many workers recognize that without specifi c of mental disorders (4th ed., text contact www.mindyourmind.ca ue to promote and advocate programs and supports in place for women, it is not revision). Washington, DC: or www.ways.on.ca. for people who have had possible to begin addressing trauma histories. author.

Visions Journal | Vol. 3 No. 3 | Winter 2007 31 regional programs

The need for training and specialized programs Innovative Practice and Programming Participating mental health providers identifi ed the More women-only services, programs, vi- need for training that addresses the interconnections olence-specifi c mental health programs, and gendered between violence, trauma, mental health and substance policy initiatives in mental health are recommended. use. They indicated that they had very little training and education on the topic of . A few fi nal words from the researcher Programs and opportunities exist, but they are not sys- What, to Morrow, was the most surprising discovery tematically required for mental health training. in this research? “Despite the evidence base of the im- Specialized programs are needed to serve distinct pact of violence and abuse on mental health, as well populations of women, such as Aboriginal, immigrant, as in the lives of people with mental illness, the mental refugee and incarcerated/imprisoned women. health fi eld has resisted developing programs and sup- ports for this population,” says Morrow. Role of women-serving community organizations There is, however, some evidence of emerging sen- Service demands and lack of training in working with sitivity in mental health to the needs of women sur- women diagnosed with mental illness means that some vivors of violence and trauma. The report describes a providers are unable to meet the needs of women with number of innovative programs and practices. Several chronic and persistent mental health problems. Some initiatives address mental health practitioner training, only serve these women if certain conditions are met; and there is some recognition that violence against e.g., if they are drug and alcohol free. Some workers women is a serious concern on a policy level. feel they are being used by an under-resourced mental What is lacking, however, is a clear commitment health system as a solution for women needing more to thoroughly addressing the impact of violence and intensive, long-term care. trauma on the mental health of women with chronic and persistent mental health problems. Morrow urges: “Get informed about the issue. Learn about the work being done in the anti-violence/wom- en’s service sector to develop programs that address violence, mental health and addictions.” VictimLINK

Shanti Hadioetomo A VictimLINK staffer was Ministry of Public Safety What do people against or treated unfairly. and Hazel Smith interviewed for this article. and Solicitor General, call about? So, victimization is seen She is a Certifi ed Informa- VictimLINK can provide The majority of inquiries much more broadly.” This Shanti is an undergraduate tion and Referral Specialist service in 130 languages, involve specifi c criminal is believed to be largely due student in communication and a Registered Clinical courtesy of multilingual offences. Spousal assaults, to effective promotion. studies at Simon Fraser Counsellor, who has volun- staff and a professional in- sexual and non-sexual as- University. She is currently teered as a victim services terpretation service. saults, , elder Who calls? on a co-op term at worker with the Vancouver Serving British Colum- abuse and criminal har- People of all ages, ethnici- Canadian Mental Health Police Department bians since 2003—and assment are most com- ties and walks of life con- Association BC Division Yukoners since 2004— mon. Less frequently tact VictimLINK. ictimLINK is a 24- VictimLINK replaced the mentioned offences in- Usually, the person Hazel is Coordinator of V hour, seven-day-a- former weekday Victims clude abduction, arson, who has been victimized Communications and week free telephone Information Line, which fraud and homicide. makes the call, but there Marketing at Information helpline for victims of fam- ISV had operated since Since VictimLINK start- is a small percentage of Services Vancouver ily and sexual violence, 1987. “This revamped ed, however, staff have calls—16% in 2005– and all other crimes. Certi- service also serves victims seen an increase in the 2006—from ‘third party’ fi ed information and refer- of all types of crimes, but number of calls relating to callers, frequently a family ral (I&R) specialists refer places more emphasis on non-Criminal Code issues. member or friend. This is VictimLINK callers—more the help we can give to vic- “Prior to VictimLINK, most common in spousal assault than 11,000 in 2005– tims of family and sexual of the calls were related to cases. In this type of situa- 2006—to a network of violence. It’s also available crimes like assault, abuse, tion, staff might encourage social, health, justice and around the clock now,” ex- theft and so on. Now we the concerned individual government resources. plains the ISV staffer. Since also get more calls about to maintain contact with Operated by Informa- the enhanced service was human rights violations, the woman who is be- tion Services Vancouver launched, call volume has and from people who feel ing abused. “This is very (ISV) and funded by the increased by 30%. they’ve been discriminated important and useful to the

32 Visions Journal | Vol. 3 No. 3 | Winter 2007 regional programs woman, because her situ- health disorders, who are offenders, youth gangs, and And, the I&R special- ation becomes more dan- suffering symptoms like gay, bisexual, lesbian and ists detail the resources gerous the more isolated paranoia, or transgender (GBLT) issues. that are available to a call- she becomes.” dissociation. Often, these Because staff are er. “We have a very com- Some people seek help individuals already have a trained to respond to calls prehensive database of immediately following mental health worker as- on all ISV helplines, which resources to draw on, so an incident, while others sisting them. Although Vic- includes the Alcohol and wherever the caller lives, wait. “We might get a call timLINK staff don’t deal di- Drug Information and Re- and whatever their con- from a parent who’s con- rectly with the caller’s men- ferral Line, they are very cerns, we can refer them VictimLINK cerned about an incident tal health and/or addiction comfortable dealing with to a variety of resources.” Available 24 hours, that happened to their issues, they do identify the cross-over issues that Some of the most seven days a week child some time back; it’s services best able to meet arise. For example, a Vic- frequent referrals are to BC toll-free: taken six months for the the individual’s particu- timLINK caller who has community-based victim 1-800-563-0808 parent to start putting the lar needs and encourage been assaulted might also services, police-based vic- pieces together. On the them to seek help. People have a drug addiction. tim services, counselling Deaf or hard-of- other hand, with sexual who feel victimized by the Every call is different, agencies, the Crime Victim hearing callers: abuse, we’re talking both system because of their but generally the staff’s Assistance Program and TTY 604-875-0885 historical and current. A disorder are referred to objectives when respond- transition houses. Other (collect calls recent incident can trigger advocacy groups and legal ing are to listen, to dif- referrals include mental accepted) or Text the caller to request coun- resources. fuse any crisis feelings, health teams or units, ad- 604-836-6381 selling as a result of past Crisis calls represent to have the caller identify diction counselling, special- or ongoing sexual abuse.” only a very small percent- resources (perhaps a fam- ized counselling, support People with mental age (2%) of VictimLINK’s ily member or friend) they groups, advocacy groups, illness or addiction issues annual total inquiries. can call upon for support, the Ombudsman and wom- are more often victims and to have the caller pri- en’s centres. I&R specialists of crime. And, victimiza- Who answers the calls? oritize their concerns so also provide information on tion can result in mental VictimLINK staff come they can focus on one is- the justice system, relevant health problems due to the mostly from social work sue at a time. Staff may laws and programs, crime trauma of the injury, viola- and psychology back- discuss the option, and prevention, safety plan- tion or abuse. As a result, grounds, and have worked possible outcomes, of re- ning, protection orders and VictimLINK staff often re- in a variety of social service porting a crime incident other resources as needed. spond to people who are settings. They are trained to the police. If necessary, “Most important, psychologically and emo- in-house through a com- callers who are in a crisis though,” says the ISV staff- tionally fragile. They also prehensive program that situation can be directly er, “is to listen and to let the receive calls from people includes specialized train- transferred to immediate person know that one-on- with diagnosed mental ing in such areas as sexual outside help. one help is available.”

Police Victim Services Overseeing Frontline Response Police Victim Services of British Columbia is a non- volunteers who have completed or are undergoing in- Carolyn Sinclair profi t association that enhances services to vic- tense basic and advanced training. Academic certifi ca- tims of crime and trauma by assisting and supporting tion has been newly launched by the Ministry of Public Carolyn is Executive frontline, police-based victim services programs. Our Safety and Solicitor General, Victim Services Division, Director of Police Victim members include victim services program managers, in partnership with the Justice Institute of BC. Some Services of British Columbia staff and volunteers who work within police agencies training is conducted in-house by individual programs. or detachments throughout BC. Coordinators and managers receive advanced training, Victim services units are made up of staff and sponsored by the Victim Services division of the Minis-

Visions Journal | Vol. 3 No. 3 | Winter 2007 33 regional programs

try of Public Safety and Solicitor General, and delivered Once the service has been offered and the victim by industry experts and specialists. Police Victims Serv- has accepted, a victim services staff member or trained ices of BC also hosts an annual training symposium, volunteer is assigned. Victims’ immediate needs are as- which provides two days of training and networking sessed as soon possible following a crime. Victim serv- opportunities for staff and volunteers. ices engage with the client once the victim’s health and Police victim service programs respond to police in- well-being are addressed and statements secured by the cidents where there is a victim of crime or trauma. A few police. Discussion between the victim, police member, examples of services provided include: responding to mo- health care professionals and/ or a case worker from a tor vehicle accidents to provide support or transportation; specialized agency will establish the priorities, resources assisting police offi cers in a sudden death situation, by de- and services to best meet the client’s needs. This can livering next of kin notifi cations; or offering support and take place minutes, hours or days following a crime. follow-up to victims of home invasions, robberies or as- Based on the needs assessment, the victim support saults. The frequency and severity of the calls responded worker connects with the appropriate professionals, to to vary from minor to extreme. ensure the victim’s needs are met. For instance, in cir- Police victim services are primarily “crisis response.” cumstances where a victim has needs related to mental Victim service workers are not trained in formal counsel- health, a professional in that fi eld would be contacted, ling; rather, they provide prompt, short-term intervention. a referral made and a case worker assigned. This can They assess victims’ needs, refer them to services and be done during regular hours by calling direct, or by uti- community resources that may benefi t or assist the vic- lizing “after-hour” contacts, who respond to incidents tim or their family, and provide follow-up. Emotional sup- occurring outside regular business hours. port is provided—in person, and/or over the phone. Service providers work together to develop a re- Victim services workers may assist the general sponse plan—this may include emotional support, public by managing fi les involving multiple victims of personal safety planning, court information, transpor- homicide or domestic violence. They help victims pre- tation, assistance and treatment. A collective approach pare victim impact statements, apply for compensa- and an effective referral system enable short- and long- tion if eligible and keep current on the court process. term planning for clients. Resource contact information Advising victims when offenders are released and the in the form of lists, directories and personal notebooks conditions of their release is critical information for ef- is usually kept near at hand. fective safety planning for some victims. Knowing what specialized community and health care programs are available, and fostering relationships Victim services support with other service providers, is one of the best ways to Victims and witnesses of a crime are entitled to vic- meet the needs of victims of crime and trauma. Victim tims services support. Following a criminal incident, a services and service agencies work together to promote police offi cer or case worker is responsible for ensur- one another’s strengths, bridge gaps where services ing that victim support service has been offered. When may be lacking, and strategize customized plans for ac- dealing with youth, the offi cer or case worker must get cess and delivery of services. Ongoing communication parental or guardian consent in order to provide the ensures current knowledge of the resources available in services to a youth. the community.

Complex Interactions Women, Trauma, Addictions and Mental Health

Susan Armstrong, ounsellors who work highly vulnerable to violence. drugs as ways of managing MEd, RCC with survivors of vio- One study revealed that peo- trauma related symptoms.3 C lence are aware that ple with a mental illness are As a Stopping the Violence Susan works in Vancouver many of their clients have is- 2.5 times more likely to be a counsellor and as a therapist as a Program Manager sues of addiction and mental victim of crime,1 and another specializing in trauma, I found for the BC Association of health. The relationship of trau- study documented that 81% that many of my female cli- Specialized Victim Assistance ma to addiction and mental of psychiatric inpatients had ents with addictions or men- and Counselling Programs. health is complex and, to date, experienced serious physical tal health diagnoses had sig- Previously she provided inadequately researched. and/or sexual assault.2 Other nifi cant histories of childhood trauma counselling in Research has document- studies reveal that women, abuse and and experi- Toronto and Vernon, BC ed that mentally ill people are in particular, use alcohol and ences of assault in adulthood.

34 Visions Journal | Vol. 3 No. 3 | Winter 2007 regional programs

The following client sto- and his association with a Alita * All names and some details have been changed to ries show the complex inter- gang. Alita was referred for coun- protect client confi dentiality. actions of trauma, mental Sylvia’s story illustrates selling by a public health health diagnoses and alco- how drug use can be a sur- nurse after having an epi- hol and drug use. vival strategy within abusive sode of rage during a home relationships. The drug use visit. Alita had overcome a bc association of specialized Sylvia helps distance a survivor from victim assistance and severe addiction to alcohol counselling programs Sylvia* was a participant in a feelings of terror. and had maintained sobriety re-employment program for for years. She was, however, | BCASVAP coordinates initiatives for women. She was referred for Karen a regular consumer of mari- and supports programs across BC counselling because she fre- Karen is a 20-year consumer juana and felt great shame including community-based victim quently zoned out in classes of mental health services. about her use. assistance, Stopping the Violence and was unable to remember She was referred to counsel- Alita’s trauma history counselling programs and sexual much of what had occurred ling at age 37 by her psy- was profound. Her child- assault centres in the day. Sylvia had a long chiatrist. Her psychiatrist hood was fi lled with severe | the organization provides a voice history of heroin addiction was aware that Karen had a neglect, assault and rape, for community based service and was on methadone. The history of childhood sexual and her adult life with seri- providers and for those who have program facilitator wanted abuse, but this had been left ous physical and sexual as- been victimized by violence. to know whether her atten- unexplored. She had been sault and ongoing | to fi nd anti-violence support near tion diffi culties were due to treated solely with medica- and racism. As she worked you, call 604-633-2506 or visit the methadone. tions and/or electric shock through her trauma his- the online services directory at After establishing rap- therapy. tory—both historical and wwww.endingviolence.orgww.endingviolence.org port with Sylvia, I conducted Karen remained in coun- current—Alita’s isolation de- a dissociation assessment. selling for her childhood sex- creased, and her self-esteem This revealed that she experi- ual abuse for years. She did and parenting improved. enced various forms of disso- recover her sense of safety Although Alita was able ciation on a consistent basis. and ultimately triumphed to reduce her marijuana us- When asked about her over her suicidal and self- age, she was unsuccessful life, Sylvia related how she harming behaviours. in abstaining completely. At- had become hooked on drugs Several years into her tempts to do so resulted in footnotes during a relationship with counselling process, I asked immobilizing depression and a man involved in the drug Karen what her psychiatric rage—symptoms that were 1. Hiday, V.A., Swartz, M., Swanson, J. et al. (1999). trade. She had engaged in diagnosis was. Laughing, she not successfully managed by Criminal victimization of persons with severe mental illness. Psychiatric Services, 50(1), 62-68. drug use and trade to keep asked me which one. She antidepressants. It became herself safer with her abusive had had nine diagnoses over clear that marijuana was med- 2. Jacobson, A. & Richardson, B. (1987). Assault experi- boyfriend: if Sylvia got high the years. Her psychiatrist icating Alita against some of ences of 100 psychiatric inpatients: Evidence of the need for routine inquiry. American Journal of Psychiatry, 144(7), 908-913. with him and complied with was now considering post- her strongest trauma-related his demands that she traffi c traumatic stress disorder as feelings. 3. Davis, R.E., Mill, J.E. & Roper, J.M. (1997). Trauma drugs, she was beaten less of- a primary diagnosis. and addiction experiences of African American women. Western Journal of Nursing Research, 19(4), 442-460. ten. Sylvia eventually ended Although Karen is men- These three case examples up on the streets. She went tally ill and remains on med- of courageous, resilient through drug treatment a ication, her self-esteem and survivors of trauma illus- number of times before man- self-love are restored, she’s trate the complex intersec- aging to leave the streets and engaged in her community tion of trauma, addiction the city permanently and be and she’s able to have trust- and mental health. It is im- placed on methadone. ing relationships. But I of- portant to assess whether In the years that Sylvia ten wondered what Karen’s an addicted or mentally ill was in and out of drug treat- life could have been if her woman has a trauma his- ment, no one had ever asked trauma history had been tory. Assisting women to her about childhood experi- assessed and a referral to safely containing their trau- ences of assault and neglect. counselling made when she ma-based symptoms while Nor had anyone adequately had her fi rst psychiatric ad- slowly working through understood her level of terror mission at 17. their experiences can truly regarding her ex-boyfriend transform lives. Other studies reveal that women, in particular, use alcohol and drugs as ways of managing trauma related symptoms.3

Visions Journal | Vol. 3 No. 3 | Winter 2007 35 resources

Support organizations • Traumatic exposure and PTSD in older adults. (2002). • VictimLINK: 1-800-563-0808 (available 24/7) or e-mail [Special issue] Journal of Clinical Geropsychology, 8(3). them via the form at www.vcn.bc.ca/isv/victims.htm • BC Association of Specialized Victims Assistance and Publications and tools Counselling Programs: www.endingviolence.org • BC Partners for Mental Health and Addictions In- • Police Victim Services of BC: formation. (2006). Child sexual abuse: A mental www.policevictimservices.bc.ca health issue. The Primer Fact Sheets on Mental Health • Griefworks BC: www.griefworksbc.com and Substance Use Issues. www.heretohelp.bc.ca/ • Anxiety Disorders Association of BC: anxietybc.com publications/factsheets. Also see our fact sheets on or 604-681-3400 Post-Traumatic Stress Disorder and on Violence • Anxiety Disorders Association of Canada: • Morrow, M. (2002). Violence and trauma in the lives of www.anxietycanada.ca women with serious mental illness: Current practices • Mental Health Information Line: 1-800-661-2121 or visit in service provision in British Columbia. BC Centre for this list is not our online message board at www.heretohelp.bc.ca Excellence in Women's Health. www.bccewh.bc.ca/ comprehensive • BC Institute Against Family Violence: www.bcifv.org PDFs/violencetrauma.pdf and does not imply or 1-877-755-7055 • Canadian Resource Centre for Victims of Crime: crcvc.ca endorsement of • National Center for PTSD, US Department of Veter- resources Research and networks ans Affairs: www.ncptsd.org. Check out the PTSD • Canadian Traumatic Stress Network: www.ctsn-rcst.ca Information Center and the Psychological First Aid don’t forget all the • International Society for Traumatic Stress Studies: Manual for Mental Health Care Providers resources listed at www.istss.org • Everett, B. & Gallop, R. (2000). The link between child- the end of Visions • National Center for Trauma-informed Care (US): hood trauma and mental illness: Effective intervention articles as well mentalhealth.samhsa.gov/nctic for mental health practitioners. Sage. • Australian Centre for Posttraumatic Mental Health: • Offi ce for Victims of Crime (US). Victim empow- www.acpmh.unimelb.edu.au erment: Bridging the systems—Mental health and • The Adverse Childhood Experiences (ACE) Study: The victim service providers (2000) and First response Effects of Adverse Childhood Experiences on Adult to victims of crime who have a disability (2002). Health and Well Being, Kaiser Permanente & US Cent- www.ojp.usdoj.gov/ovc/publications ers for Control and Prevention: acestudy.org • Disaster Mental Health Institute, University of South • Statistics Canada. (2007). Impacts and consequences Dakota: www.usd.edu/dmhi. Publications look at the of victimization, General Social Survey 2004. Includes aftermath of a disaster, witnessing a disaster and mental health impacts. www.statcan.ca/english/ how to help children cope. freepub/85-002-XIE/85-002-XIE2007001.htm • Coping with Traumatic Events website, US Substance • Serving the needs of women with co-occurring disor- Abuse and Mental Health Services Administration: ders and a history of trauma. (2005). [Special issue]. mentalhealth.samhsa.gov/cmhs/traumaticevents Journal of Community Psychology, 33(4). • Health Canada. (2004). Preparing for and respond- • The psychological impact of trauma: Theory, research, ing to workplace trauma: A manager’s handbook. assessment, and intervention. (2004). [Special issue]. www.hc-sc.gc.ca/ewh-semt/pubs/occup-travail/empl/ Psychotherapy: Theory, Research, Practice, Training, 41(4). trauma/man_hand-livret_gest/index_e.html

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