Kate Walker, Kendra Watson, Chi-Sing Li
Sam Houston State University
When a traumatic event happens, society is accustomed to turning to mental health professionals for directions on coping and recovering. Past research on the efficacy of psychological debriefings, however, is divided (Gist & Devilly, 2002; Harvard Mental Health Letter, 2003; McNally, 2002; Rose & Bisson, 1998; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002; Watson, Friedman, Gibson, Ruzek, Norris, & Ritchie, 2003). In an effort to determine the efficacy of therapeutic interventions in a single case study, the authors triangulated data from research documenting information as related by a person who was a victim of a traumatic crime and research documenting police reports and anecdotal data from the victim's advocate therapist. The compilation of the data from these two research endeavors has resulted in a snapshot of what one victim perceived to be helpful and unhelpful therapeutic interventions following a trauma.
A Case Study of Therapeutic Interventions as Related by a Person Who Was a Victim of Traumatic Crime
Critical or potentially traumatic events (PTE) often include a life-threatening episode in which the person involved feels overwhelmed or helpless (Antai-Otong, 2001). Reactions to the event can include fear, anger, anxiety, sleeplessness, shock, and depression (Antai-Otong). Psychological Debriefing (PD) for victims of a PTE is almost universally utilized (Gist & Devilly, 2002). When a crisis or PTE happens, our society is accustomed to turning to mental health professionals for direction on coping and recovering from the event.
Early literature on crisis intervention originated in 1964 in London (Rose & Bisson, 1998). One of the original forms of crisis intervention was PD for emergency service personnel and soldiers who had been involved in combat (Arendt & Elklit, 2001). Later, the more popular writings of Mitchell and Everly emerged, which advocated debriefings with individuals in emergency services professions (Rose & Bisson). Eventually, the PD became a type of trauma intervention model as well as a popular term for crisis intervention.
From Psychological Debriefings, Critical Incident Stress Management (CISM) and Critical Incident Stress Debriefing (CISD) emerged and deviated from the original PD structure (Arendt & Elklit, 2001). CISM, and its component CISD, were initially developed to help reduce the effects of trauma on the tightly knit populations of emergency workers, including police officers, fire fighters, nurses, and ambulance personnel (Antai-Otong, 2001; Everly, Flannery & Eyler, 2002; Everly, Flannery, Eyler & Mitchell, 2001; Jerry, 1998; Richards, 2001). For these populations, a debriefing following a traumatic event allowed discussion and healing to begin as individuals shared their common experience with their co-workers (Everly, 1995).
Though believed to be effective with certain populations, many researchers have found that CISM was not only being used without any empirical evidence of its effectiveness, but also that it was being applied to a population for which it was not intended and for whom it might actually do more harm than good (Gist & Devilly, 2002; Harvard Mental Health Letter, 2003; McNally, 2002; Rose & Bisson, 1998; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002; Watson, Friedman, Gibson, Ruzek, Norris, & Ritchie, 2003). In their meta-analysis, van Emmerik et al. (2002) found that CISM could actually result in re-victimization by causing the victim to re-live the event too soon, and by hindering the body's natural defense mechanisms.
Proponents of CISM and CISD, however, argue that when quantitative researchers find fault with the effectiveness of PD, it is primarily because the PD model they are studying is misapplied, it is administered to inappropriate populations, at ineffectual times or by inappropriate means (Everly, Flannery, & Eyler 2002; Litz, Gray, Bryant & Adler 2002). Many researchers have found that, when used in a standardized fashion with the population for which it was intended, psychological debriefings are more effective for treating post-traumatic stress disorder (PTSD) than no treatment at all (Antai-Otong, 2001; Everly, Flannery, Eyler & Mitchell, 2001; Everly, Flannery & Eyler, 2002; Jerry 1998; Richards, 2001).
The challenge of determining the efficacy of CISD and CISM has led some researchers to attempt to determine better outcome measures ( Fullerton , Ursano, Vance, & Wang, 2000). Researchers have also explored the difficulties in developing an accurate and ethical quantitative assessment instrument that will not traumatize the victim of a crime or trauma even further (van Emmerik, et al., 2002). Even if such an assessment is possible, individual education and assessment prior to a traumatic event are hard variables to take into account during a crisis intervention debriefing (van Emmerik, et al.).
A victim's perceptions of therapeutic interventions administered following a trauma yielded a wealth of information that is often unreported in quantitative data. This qualitative study, encompassing a victim's advocate counselor (VAC) narrative, police document analysis, and a trauma victim interview, attempted to address interconnected theoretical, methodological and ethical concerns associated with the administration of therapeutic interventions immediately following a trauma. The purpose of this research was twofold:
1. To explore the interventions applied to a victim following a trauma, and
2. To describe what interventions are perceived by the victim to be helpful and not helpful.
The data collected provide valuable information about the interventions applied to a trauma victim in the weeks following a violent crime. Our research questions were:
1. What are the victim's recollections of therapeutic interventions applied by a VAC?
2. What were helpful interventions?
3. What were not helpful interventions?
In summary, this research explored qualitatively what a victim of trauma found to be helpful and unhelpful interventions as applied by a victim's advocate counselor.
The idea behind the debriefing model is the belief that early intervention can lessen long-term impact from trauma (Antai-Otong, 2001). Psychological debriefings attempt to help victims of trauma restructure cognitive thoughts about the traumatic event ( Fullerton , 2000). The role of the facilitator or counselor is to provide immediate emotional support, normalize the emotional feelings about the event, provide education about stress reactions, help with symptom reduction, offer help with coping skills, and provide information about where to find further support if necessary (Antai-Otong; Rose & Bisson, 1998).
The case study participant was an unmarried, white, female college student who had reported to the Central Texas Police Department (CTPD) that she was a victim of a sexual assault. She subsequently received services from the CTPD victim's advocate counselor. She was over 18 years of age, and she was able to understand and speak English. The participant was not employed and was considered a full time college student. She was receiving services from the victim's advocate counselor at the time of the interview.
The participant was provided information about the study from both the VAC and the interviewer. Permission to do research with human participants was obtained from the University's Internal Review Board before conducting this study. Written and verbal consent from the participant was obtained prior to the interview. The victim's identity was protected and in this research, she is referred to as “Jane,” or “participant.” The interview was conducted face-to-face in the VAC office in the Central Texas Police Department. The interview began with an explanation that she was not obligated to discuss anything that caused her pain or to feel re-victimized, and she could stop the process at any time. She was also assured of the availability of free, lifetime counseling services through the CTPD.
The intent of the authors was to explore this data and resist developing or presenting bias. Our goal was to ensure that the data and our analysis were plausible, credible, trustworthy, defensible and valid (Burke-Johnson, 1997). Grounded theory, or theory that is developed inductively from the data, (Borgatti, n.d.) was the basis for our data analysis. The authors utilized open coding, which is the process of allowing categories to emerge from the data, (Borgatti) rather than imposing preconceived categories. In order to address the accuracy of emerging themes, each researcher read the other's data analysis and offered feedback about the experience that was portrayed. Since all identifying information had been deleted, in addition to this investigator triangulation, we were able to allow a third party not involved in our research to review our findings. This peer review was conducted by an expert in the field who was able to challenge our conclusions and offer constructive feedback.
No notes were taken during the interview, and all other data were collected using a digital audio recorder. At the end of the interview, the researcher noted impressions and wrote a summary of any non-verbal cues the participant displayed during the interview. Audio recordings were transferred to a recordable compact disk (CD-R) and transcribed as soon as possible. Once data were collected, the transcription was checked against the original tape recording and edited for accuracy. Computer analysis was not used. Emerging themes were identified and named using the following procedure:
1. The transcribed interview was read completely to get a sense of emerging themes
2. The researcher noted some emerging themes and then re-read the transcript noting in the margins where those themes seemed to occur
3. The researcher refined the list of themes and then re-read the transcript noting the sections in which the themes occurred. Eventually, the researcher decided on four recurring themes
4. The transcript was read again and coded according to the recurring themes until all data were classified
5. The codes/data were then grouped to reflect the patterns/emerging themes
Document Analysis and VAC Narrative
Following the traumatic event, the VAC had several counseling sessions with the participant. After each meeting, the VAC took case notes. Dialogue with the first responding officer and the case detective during the investigation was also included in the case notes. The press release from the CTPD to the local media regarding the case was also included in the documents. After completion of the investigation and stabilization of the case in the criminal justice system, official police report documents were obtained for analysis. The nature of this case led to two police reports, one report regarding the original victim (our participant) of the assault, and one regarding a previous victim who later declined to testify. Data from both reports were included in this study.
Triangulation of Data
The researchers' goal was to transform the data from the participant interview, document analysis and VAC narrative into a comprehensive story that captured the participant's voice, emotion, and experience. Notes and transcriptions were analyzed by the two researchers using the following method:
1. The transcribed interview, police report one, police report two, and the VAC case notes were read completely to obtain a sense of the whole
2. The participant interview, police reports, and case notes were reread, and categories were established from the emerging themes
3. Information was coded according to the categories
4. Codes were grouped into categories to reflect the emerging themes
The therapeutic interventions applied by the VAC in this case included providing social support, cognitive reframing, psycho-education about the criminal justice system, rapport building, and providing referrals. In this section, we present the themes that emerged from the VAC narrative data, triangulated with the themes that emerged from the interview with the participant, and police report data. During the interview analysis and reflection, codes were named and renamed, clustered, and grouped into four broad categories. These broad categories were matched with themes that emerged from the narrative data and document analysis. The following is a list of themes that emerged from the research data:
a. Helpful interventions allowed the participant to feel a sense of control.
b. Helpful interventions did not challenge the participant's defense mechanisms.
c. Helpful individuals encouraged the participant to define herself as a person, not just as a victim.
d. Gender, and the roles played by each gender in the participant's past, played a part in the participant's perception of a helpful intervention.
Some of these categories easily emerged because they were stated overtly by the participant. Others were inferred by the researchers because of recurring themes throughout the document analysis, the interview, the participant's body language, her non-verbal utterances, and voice tone.
Theme 1: Females and Males – Past Roles May Affect the Helpfulness of the Intervention
The interventions applied by the VAC in this case included providing social support, cognitive reframing, psycho-education about the criminal justice system, rapport building, and providing referrals. One of the first steps in successful rapport building with Jane was identifying her apprehension about the opposite gender. She had been molested by two different males at age six and again at age eight. The officer wrote in the report that, “Jane told me she could not talk to a man because she was molested years ago, and when she was counseled by a man, she could not talk to him.” The male law enforcement officers who worked with Jane reported that she could not look them in the eye and was “terrified” to speak to other male officers.
Two males in Jane's past that had played a major role in her life were her father and her brother. Melsky (2004) described how victims of a trauma involving an aggressive individual, may begin to identify with that individual as a tactic for dealing with the trauma. During the interview, Jane recalled past behaviors by her father:
or like in school in general I was like [if I] try really hard in school like I'd be like ‘Dad look at my report card' and he'd be like ‘Oh. Cool.' And he'd never say like I'm proud of you or good job or anything, he'd be like, ‘neat, get out of my face, I wanna watch TV' or something.
Her older brother, on the other hand, was, by the participant's account, someone she idolized. Both her choice of school and her choice of major were decisions she made based on conversations with him. The researchers correlated her statements with her appearance: a baseball cap low on her forehead, baggy pants and a hooded sweatshirt. Whereas she might not have been making a conscious decision to identify with the male gender through her choice of clothing, perhaps she was striving to look less like the stereotypical college-age female.
Theme 2: Feeling a Sense of Control, Even if it Results in Detachment
Detaching or avoidance often characterize the natural processing of a traumatic event (van Emmerik, et al. 2002). It became apparent from the number of comments relating to maintaining control that Jane was often practicing the detachment that protected her from facing trauma. The protection provided by this control and detachment was evidenced in her description of a conversation she had with a friend about two incidents of molestation she experienced as a child:
and so I was talking to (inaudible) who was a friend at the time, and I was just talking to him about this whole thing, and then the guy had remembered, like, one of my brother's friends, had done it to me also and I never actually said it, and if I didn't say it I didn't have to deal with it, and then once I told my friend about it, I was like, ‘Oh crap,' [at this point she laughed and then continued in a small high-pitched voice] I guess I'm gonna have to deal with this too now.
The VAC enhanced rapport with Jane when she allowed her to have control over necessary steps, such as who she wanted in the hospital examining room (for the rape kit exam) and who she wanted to have notified. Additionally, Jane was helped by the VAC to address outside concerns such as school tests and papers that would be overdue the following day.
Theme 3: Techniques/Interventions Can be an Added Assault
Many interventions following her crisis were perceived negatively by Jane. Usually, as she related these negative interventions, her voice would get louder or her laugh would change from a nervous short giggle to an extended deep exhortation. This strong emotion, or change of emotion, as well as the use of words like ‘shocked' or ‘drained' was interpreted by the interviewer as an indication that the interventions affected the participant negatively. The intensity of the emotion or emotional change and use of strong adjectives to describe them seemed to indicate that the intervention was so negative as to leave the participant injured in some way. One of the more striking characteristics of an unhelpful intervention, according to our participant, was the loud voice used by the rape crisis support representative. Our participant stated:
like there was this one lady from the rape crisis center who, when she came in and she was like, ‘whoa' (laugh) and I was like ‘oh my gosh' (laugh) and I just couldn't handle it. I was like, I was almost, like, I was just drained.
Following this intervention, the VAC referred Jane her to university resources, the rape crisis center, and the services available at the police department. Providing her with referrals reinforced the fact that there would be people available to help her through this process and that people in the Central Texas community cared about her needs beyond the criminal justice system.
Theme 4: Feeling the Need to be Known as a Person, Not Just a Victim
Jane found that the most helpful interventions were those that allowed her to feel like a person, not just a victim. She described her experience with the nurse administering the rape kit at the hospital, as “awesome,” the strongest positive adjective she had used in the entire interview. She stated:
she (nurse) just talked to me about other things, like it wasn't like about, like I was a person, and not just like, a victim, not someone that's been molested or, sexually assaulted or whatever… like we talked about school, kind of get my mind off it a little bit while… like we did talk about other things, like she told me about her husband and her kids. It was interesting to get to know her as a person, not just a nurse, I guess.
This need to feel like someone other than a victim seemed to permeate the platonic relationships in her life. She had acquaintances and close friends who helped her on “bad days”, but she did not discuss things with them related to her past traumas. She reported that her time with the VAC was important and valuable to her because, “I talk to her (VAC) about everything…she's the trained one, and I don't want to make my friendships, revolve around what happened as a kid or whatever.”
Her reluctance to disclose victim-related information appeared to negatively affect her support system. During the immediate post-crisis intervention, she did not contact a relative, even though she had a Mother, Father, two brothers, and a sister-in-law residing in the local area. The only people that were contacted by the victim during her hospital rape examination included her roommate and another friend. She also used her cell phone to text message a male friend that she had known for about a month.
Whereas researchers may disagree on the efficacy of psychological debriefings, both sides agree that the need for more data is great (van Emmerik, et al., 2002). The authors of this case study added to the literature by giving voice to a victim of trauma and illuminating her feelings about the interventions applied to her. As professional counselors who have experience working with victims of violent crime, domestic violence and acute trauma, the researchers in this study realized that more qualitative data are needed in order to get a clearer picture of what interventions are helpful in preventing the effects of PTSD with victims of trauma and violent crime. A quantitative, reductionist view of psychological interventions applied following a traumatic event cannot provide the rich information about the emotional impact of the trauma and the subsequent interventions. This study attempted to describe the efficacy of therapeutic interventions by illustrating the lived experience of the participant who experienced the trauma and the subsequent interventions.
A limitation to our study was the inability of interviewing victims until their cases had been resolved in court. As a result, a single case study design was our best option. Another limitation was our inability to perform extended fieldwork. Since this research was part of a class assignment, we were limited in the amount of time we were able to wait for cases to resolve and then attempt to gain interviews with the crime victims. Ideally, more time acquiring interviews and conducting data analysis would have been optimal.
While a single case study is considered a limitation when trying to conduct generalizable, quantitative research (Burke-Johnson, 1997) generalizability was not the intent of our study. Rather, we were attempting to portray the experience of one individual victim of trauma as accurately as possible. Although we may not have documented universal findings, we feel confident that we were able to document an experience that may be generalizable to other individuals in similar situations and settings.
Through qualitative studies, we can enrich the debate surrounding psychological debriefing. It was our intent to allow the participant to speak in her own voice so that we could hear from her perspective which interventions were helpful and which were perhaps detrimental to her recovery. From Jane, we heard that interventions applied following a traumatic event were not helpful if they assaulted the defenses she had already put in place to deal with other traumas in her life. We learned that for her, intervention effectiveness depended on the gender of the person applying it. We also learned that communication and insight were possible, but only if she was allowed to go at her own pace, keep a sense of control, and be seen as a person rather than a victim.
It is our belief that this study will stimulate more research into PD and encourage investigators to strive to understand the individual experiences of victims of trauma and violent crime. While it is unrealistic to expect that research can be done at the instant or even in the first few hours following a trauma, we must recognize the need for intervention. Future research must continue to try to inform the professional of not only the victim's emotions resulting from the current trauma, but also how those emotions are affected by the victim's past. The implications for the counseling profession are significant in that the more we learn about what interventions are helpful following a trauma, the better we can help those who depend on us.
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