Traumatic stress in a violent world

People with post-traumatic stress disorder, or PTSD, cope with the effects of past trauma that manifest themselves in such debilitating symptoms as flashbacks, hypervigilance and insomnia. But what happens to people who face trauma on an ongoing basis — the millions who live with the daily reality of genocide, war, displacement or community violence?

Psychologists and other researchers tackle that question from theoretical, empirical and applied perspectives in the May issue of Peace and Conflict: Journal of Peace Psychology, the journal of APA's Div. 48 (Peace). In 11 articles examining a construct called "continuous traumatic stress," 35 authors from Israel, Germany, South Africa, the United States and Zimbabwe argue that the current traumatic stress framework must be supplemented with one that considers the reality and effects of the many ongoing traumas people face, particularly in the world's poorer, politically unstable regions, as well as in urban areas marked by poverty and violence in the United States and elsewhere.

"We wanted to adopt a less individual, less pathologizing understanding of trauma, and also to address its social and political implications," says Debra Kaminer, a University of Cape Town psychologist who was the special issue's lead editor. "In our view, it's quite problematic to pathologize individuals in contexts that are normatively toxic and dangerous."

The term continuous traumatic stress was coined in the 1980s by South African mental health professionals working in the Apartheid era. Their goal was to give psychological support to victims who were repressed by the government. The original construct of continuous traumatic stress focused on the intervention implications of working with traumatized clients in politically unstable contexts, specifically by developing a single, powerful intervention session. In re-visiting the continuous traumatic stress concept, the special issue authors sought to expand that framework by describing the characteristics of contexts in which continuous traumatic stress occurs; exploring the psychological impacts of continuous traumatic stress; and considering a variety of intervention types and levels, Kaminer explains.

The contributors view continuous traumatic stress as more of a conceptual than a diagnostic construct, says Kaminer, who co-edited the issue with Garth Stevens and Gillian Eagle, PhD, of the University of the Witwatersrand in Johannesburg, South Africa, and Craig Higson-Smith, of the Center for Victims of Torture.

The authors distinguish continuous traumatic stress from PTSD in several ways. For one, the framework recognizes that people who experience such stress often lack safe places to heal or recover. Therefore, clinicians should help clients develop coping strategies to help them function within realistic conditions of ongoing danger as well as advocate for changes to the conditions causing the traumatic stress. Examples include normalizing and validating realistic safety concerns; exploring current safety strategies and reinforcing effective ones; and exploring and enhancing social supports and addressing barriers to accessing those supports.  

In addition, people under chronic traumatic stress are much more preoccupied with the present and future than with the past, so, again, clinicians should focus on helping them find realistic coping strategies and on working toward systemic solutions, says Kaminer, who has worked with victims of Apartheid since the 1980s.

For researchers and clinicians, the construct opens the door to a broader and deeper sociocultural and political understanding of trauma, notes Usha Tummala-Narra, PhD, a Boston College assistant professor in counseling psychology who studies trauma, immigration and cultural competence in psychotherapy. For example, human trafficking is often rooted in poverty, economic and political instability, war and gender-based power differences, and it's important to understand the influence of such factors when addressing affected individuals and communities. For instance, survivors of international trafficking remain vulnerable to victimization because of limited financial resources, stigma, or alienation, and may face ongoing threats to their physical and psychological safety both in their country of origin and in the host or adoptive country, she says.

Meanwhile, scholars debate whether PTSD is even a valid diagnosis in some cultures, Tummala-Narra adds. In societies where war and conflict have persisted across prolonged periods of time and over many generations, for instance, continuous traumatic stress may better describe and be less stigmatizing than PTSD, she says.

Peace and Conflict's editor, Susan Opotow, PhD, of the John Jay College of Criminal Justice in New York, adds that the journal issue should provide important new insights to mental health providers who are used to viewing traumatic stress through individual, clinical and medical lenses.

"This issue will resonate with clinicians who wonder about the best way to treat individuals who live in contexts where they are not safe," she says.

Tori DeAngelis is a writer in Syracuse.