One important goal of psychotherapy that is basic to all trauma therapy is increasing the terror victim's or surviving family member's sense of controllability and predictability. In this regard, the construction of meaning from adversity is an active process that appears to affect the outcome of the traumatic experience and recovery. The meaning of any kind of catastrophe to a particular individual emerges from the interaction of his or her past history, present life circumstances, and the idiosyncratic interpretation of the traumatic event. The ascribed meaning will then direct individual behaviors of what to do, what to fix, and whom to blame. Remember that the "meaning" of any given traumatic event is dynamic, not static; it changes over time as the individual's psychosocial context changes.
Hanscom describes a treatment model that emerged from her work with survivors of torture, and may be applied to victims of terrorism, especially incidents involving abduction, hostage-taking, and abuse. In this model, an essential condition of healing of survivors of torture and trauma is the reestablishment of the experience of trust, safety, and the ability to have an effect upon one's world. This relearning relies less on particular therapeutic techniques and procedures than on the compassionate human interaction and therapeutic alliance between the survivor and a counselor who is willing and able to listen effectively.
Hanscom describes what she calls the HEARTS model, which is an acronym for the following:
H = Listening to the HISTORY. This includes providing a gentle environment, listening with body language, attending the flow of speech; hearing the voice and tone of the speaker, observing the speaker's movements and reactions, looking at facial expressions, remaining quietly patient, and listening compassionately. Clinicians will recognize this as a basic description of "active listening."
E = Focusing on EMOTIONS and Reactions. This involves using reflective listening, asking gentle questions, and naming the emotions.
A = ASKING about Symptoms involves using your own personal and therapeutic style to investigate current physical symptoms, current psychological symptoms, and suicidality.
R = Explaining the REASON for Symptoms. This includes showing how the symptoms fit together, describing how the body reacts to stress and trauma, explaining the interaction between the body and mind, and emphasizing that these are normal symptoms that normal people have to a very abnormal event.
T = TEACHING Relaxation and Coping Skills involves instructing the patient in relaxation skills, such as abdominal breathing, meditation, prayer, imagery, visualization, and others, and discussing coping strategies, e.g., recognizing how they have coped in the past, reinforcing old and healthy strategies, and teaching new coping skills.
S = Helping with SELF-CHANGE. This involves discussing the person's world view--the original view, any changes, adaptations, or similarities--and recognizing the positive changes in the self.
Whether it is a single family member who is hurt or killed in a terrorist attack, or a mass-terroristic casualty incident where hundreds of families are killed, injured, or displaced, family members can act as both exacerbating and mitigating factors to one another in their efforts to cope with trauma. Accordingly, a key therapeutic task often involves turning vicious cycles of recrimination and despair into positive cycles of support and hope.
Family therapists will recognize that the effects of successive traumas are often cumulative, and therapy for terroristic bereavement may have to deal with unresolved traumatic material from the past, which will almost certainly be re-evoked by the more recent trauma of the murder. Also, other aspects of life cannot automatically be put on hold when the death occurs, so therapy must address coexisting issues such as school and job problems, marital conflict, substance abuse, or other preexisting family stresses. This may require some prioritization by the therapist in terms of what are "front-burner" vs. "back-burner" issues.
Throughout the course of therapy, the supportive nature of the clinical intervention and the therapeutic relationship are essential elements in the traumatic resolution for families. The nature of the therapeutic relationship may serve to buffer the effects of the trauma, increase self-esteem, and alter the family's role functioning, thereby helping to mitigate the traumatic impact of the event.
Spungen cites Getzel & Masters' delineation of the basic tasks of family therapy after bereavement by homicide. These involve helping the family understand and put into perspective the rage and guilt they feel about their loved one's death. Therapy can also help survivors examine their grief reactions and other people's availability to them so that they can regain some confidence in the social order. Families must learn to accept the death of their relative as something irrevocable yet bearable. This will be facilitated by assisting members of the immediate and extended kinship system to establish a new family structure that permits individual members to grow in a more healthy and fulfilling manner.
In cases of individual and family therapy for parents of murdered children--the daycare center at the Oklahoma City Murrah Building would be a stark example--Rynearson cautions against pushing the cathartic narrative too quickly, especially in the early stages of treatment. A common defense against overwhelming emotional turmoil is for many bereaved family members to adopt what appears to be either an unnatural flippancy or a hyperrational "just-the-facts" attitude, which others may mistake for unconcern or callousness. If, immediately following the terroristic homicide, some family members cope better by using the twin emotional crutches of avoidance and denial, this should be provisionally respected by the therapist. Remember, even in orthopedics, the legitimate function of a real crutch is to support a limb until sufficient healing occurs to begin more active rehabilitation.
When the therapeutic narrative does begin to flow, therapists should inquire about individual family members' private perceptions of death. Nihilism and despair are common early responses, and helping patients and families to recover or develop sustaining spiritual or philosophical beliefs or actions can buffer the destabilizing and disintegratory effects of the murder. Therapeutic measures may involve exploring the family members' concepts of life and death, as well as encouraging both private meditative and socially committed activities, such as support groups or political or religious antiterrorism activities. Many Oklahoma City and World Trade Center survivors have started or joined various charitable or social service foundations as a way of memorializing their slain loved ones.
Pictures and other mementos of the deceased can serve as comforting images. In reviewing family picture albums together, the therapist and survivors can try to summon nurturant, positive imagery that may counterbalance the haunting recollections of the terroristic homicide. Similar memorializing activities include writing about the deceased or creating a scrapbook. Again, this should not become an unhealthy, all-consuming preoccupation, although in the early stages, some leeway should be afforded to allow the memorializers to "get it out of their system." If possible, family members should collaborate in these personalized memorial rituals and projects as a way of forging a renewed sense of meaning and commitment within the family structure.
Children should be included in these memorialization activities, albeit at an age-appropriate level. They should be part of both the planning process and presentation of memorial services. Children may write poems or stories, draw pictures, create a scrapbook, plant a tree, or create some other memorial. This can be done either as an individual or family project, or both.
Once the psychological coping mechanisms of self-calming and distancing from the homicide event have been strengthened, therapy can begin to confront the traumatic imagery more directly. Less verbally expressive family members may be asked to draw their perception of the scene of death in order to provide a nonverbal expression of reenactment that can be directly viewed by, and shared with, the therapist. Family members can then be encouraged to place themselves within the drawn enactment to allow the process of abstract distancing to take the place of mute avoidance. In these exercises, family members often portray themselves as defending, holding, or rescuing the deceased.
Finally, the sad truth is that some members of a given family may be more willing and/or able than others to leave the grim past behind and move on; some members just "can't let go." In such cases, family separations may be inevitable for some members to escape the stifling emotional turmoil of unhealthy family enmeshment and misery in order to make a fresh start and find their own way back into the world of the living.
In this regard, clinicians need to remind themselves of the limited therapeutic goals in most cases of homicidal bereavement, including terrorism. Don't expect families to totally "work through" the trauma of the murder of a loved one, and don't tell them they'll "get over it"--they won't. The bereaved family will always maintain an attachment to the slain loved one, especially a child, and it would be a mistaken therapeutic objective to insist on complete decathexis. Instead, it is hoped that the bereaved family will learn to maintain involvement with others, while always retaining an internalized relationship with the slain child's, parent's, sibling's, or spouse's image.
The therapist's task, then, is first, to keep the family members from destroying themselves and one another, and second, to restore some semblance of meaning and purpose in their lives that will allow them to remain productive, functioning members of their community. Often, the crucial first step is to get the family members to believe in one simple fact: "You can live through this." In the best of cases, family members may "grow" from such a horrendous experience as the brutal murder of a loved one, but such cases are the blessed exceptions, not the rule, and most families do well just to survive.
- Miller, Laurence; Psychotherapeutic Interventions for Survivors of Terrorism; American Journal of Psychotherapy, 2004, Vol. 58 Issue 1, p1-16
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #5
The preceding section contained information
regarding the “HEARTS” model of individual psychotherapy for children affected by terrorism. Write
three case study examples regarding how you might use the content of this section
in your practice.
What are the components of the HEARTS model of individual psychotherapy for children affected by terrorism? Record the letter of the correct answer