What drew you to this book? Perhaps your interest in trauma emerges from personal experience, and either you or people you care about deeply have suffered as a result of exposure to traumatic events. Or it may stem from genuine compassionate concern for those who suffer, even without such intimate knowledge of the topic. For others, the exploration of this aspect of human existence may be more academic, in the sense that trauma has become a major area of study in the disciplines of psychology, sociology, and related fields.
Whichever of the above categories best fits you, studying trauma is likely to have some degree of personal impact. The horror of entering into the worlds of those who are trauma survivors, even if only on paper, can often produce a resistance to thinking and learning about trauma, perhaps to the extent of denying its prevalence or severity. Alternately, it can lead to a desire to understand the complexities of why trauma happens, how people survive, and what is involved in recovery. Either way, you may find this book a difficult read as page after page and chapter after chapter describe the ways in which trauma survivors have been affected by the horrendous things they have experienced. So we recommend that you pace yourself as you read so that you can sit with the material and monitor your emotional reactions to it as you go along. Practicing good self-care (see chap. 4 for suggestions) is also a wise idea.
It is big—unfortunately, too big. In some significant ways trauma provides the context of human experience. Following are a few research-based statistics on the ubiquity of traumatic experiences. Other authors in this volume have added prevalence rates with respect to their specific areas of focus.
The US Department of Justice (n.d.) reports the following:
9.3% of cases of maltreatment of children in 2012 were classified as sexual abuse (62,939 cases of child sexual abuse); however, approximately only 30% of sexual assault cases are reported to authorities.
Approximately one in seven (13%) youth Internet users received unwanted sexual solicitations.
About 20 million out of 112 million women (18%) in the United States have been raped during their lifetime.
Research conducted by the Centers for Disease Control (CDC) estimates that approximately one in six boys and one in four girls are sexually abused before the age of 18.
Approximately one in five female high school students report being physically and/or sexually abused by a dating partner.
Estimated Risk for Developing PTSD
• Rape: 49%
• Severe beating or physical assault: 31.9%
• Other sexual assault: 23.7%
• Serious accident or injury (for example, car or train accident): 16.8%
• Shooting or stabbing: 15.4%
• Sudden, unexpected death of family member or friend: 14.3%
• Child’s life-threatening illness: 10.4%
• Witness to killing or serious injury: 7.3%
• Natural disaster: 3.8%
(Sidran Institute, n.d.)
The National Center for PTSD (2016) reports that “going through trauma is not rare. About 6 of every 10 men (or 60%) and 5 of every 10 women (or 50%) experience at least one trauma in their lives. Women are more likely to experience sexual assault and child sexual abuse. Men are more likely to experience accidents, physical assault, combat, disaster, or to witness death or injury.” Furthermore, about 7%–8% of the population (about 10% of women and 4% of men) will develop posttraumatic stress disorder (PTSD) at some point in their lives. The rate of sexual assault within the military has been a national concern, with 23% of women reporting sexual assault while serving in the military.
The National Trauma Institute (2014) reports similar trauma statistics in a different way:
Trauma is the number-one cause of death in the United States for people 1–46 years old.
Trauma is the number-three cause of death in the United States overall.
Each year, trauma accounts for 41 million emergency room visits and 2.3 million hospital admissions.
Trauma injury accounts for 30% of all life years lost in the United States.
The economic burden of trauma is more than $671 billion annually.
Each year, more than 192,000 people lose their lives to trauma.
The United Nations Office for Disaster Risk Reduction (n.d.) reports the following economic and human impact of disasters worldwide (2004–2014):
$1.4 trillion damage
1.7 billion people affected
0.7 million people killed
Most of these statistics focus on the US context. If the United States is one of the safer countries in the world in which to live, then rates are likely higher in most other countries (see Rhoades & Sar, 2005, for examples). In addition, the associations between trauma prevalence rates and challenging social conditions are high: lack of education, poverty, war, community violence, intrafamilial violence, natural and human-caused disasters, human rights violations, torture, and so on all contribute to the risk of trauma. A Christian mental health response is necessary.
The field of traumatology has exploded in the past decade. The concept and language of trauma have entered the mainstream of not only the mental health fields but also the broader culture. As Christians, we believe in the power and relevance of the Bible to our current cultural context and our personal lives. Scripture and the resources of our faith, therefore, are directly relevant to the human experience of traumatic events. While this book is not primarily a theological or biblical treatise, we believe that Christian faith has direct application to understanding and responding to trauma through the overarching redemptive story of the Bible (creation, fall, redemption) and the long-affirmed power of the Jesus story (birth, life, death, and resurrection).
How exactly this plays out in the therapy room is the focus of this book. Chapter authors have examined the secular literature as it pertains to their topics, while also looking at what could be helpful adaptations or additions to treatment protocols for use by Christian counselors.
This book is a combined effort to introduce Christian reflections, trauma information, and counseling approaches to contribute to this literature and need. It is specifically geared to students and clinicians desiring to be involved in some way with responding to the intense suffering of people. We hope this book challenges Christians to continue to enter the dark world of human depravity and to bring the light and healing of Christ. As you read and explore the various chapters, it will become clear that we still have much to understand, learn, and do.
Beginning in chapter one and throughout the book, aspects of Christian spirituality are specifically addressed. Because we recognize that Christian spirituality encompasses a wide range of biblical and theological positions, we decided to provide a broad approach to how various Christian theologies and resources are related to the topic of trauma. We encourage you to keep this broader definition of spirituality in mind as you read. The appendix at the end of the book, described more fully in the first chapter, will be a valuable resource to any of you who are interested in the academic literature that addresses spirituality and trauma.
Having edited all of the chapters in this book, we are struck with a number of core ideas and themes that emerge. Despite the diversity of authors and topics, it is possible to identify a set of threads that are woven through the tapestry of the book. Here we briefly identify a number of them:
Pain. This word tends to be used to describe physical discomfort but has broader applications as well.
Suffering. Perhaps a more holistic concept than pain, suffering encompasses both physical pain, emotional distress, relational stress, life disruption, existential disorientation, and spiritual anguish.
“All the cruel and brutal things, even genocide, start with the humiliation of one individual.”
Kofi Annan of Ghana, Nobel Peace Prize laureate and former secretary general of the United Nations
Humiliation. This is a unique aspect of suffering that recently emerged in the trauma literature and speaks to a central feature of almost all trauma experience. Embarrassment is included, but so often a profoundly deeper experience of shame and humiliation accompanies trauma. We need to pay attention to this aspect of treating trauma. Spirituality becomes a critical resource in this regard (see Hartling & Lindner, 2016).
Resilience. Why is it that the same potentially traumatic event has varying impacts on different individuals? How is it that some people bounce back fairly quickly while others are scarred for life? The relatively new literature on resilience to trauma offers some answers.
Posttraumatic growth. It is not all bad news! A corrective emphasis in recent years rightly affirms that while trauma is devastating and can end life and livelihood, humans have a remarkable ability not only to survive and recover from trauma but also to continue to grow in the aftermath of trauma. It is easy enough to acknowledge that individuals, communities, and countries can be unalterably changed through the negative impact of trauma. While it may be very difficult in the midst of traumatic experiences to recognize the growth that can occur, traumatic experience can be likened to a forest fire that eradicates everything in its path, and yet, given a few years, the green begins to return and decades later has grown into a new forest. Growth cannot be divorced from trauma.
Hope. Related to resiliency and posttraumatic growth is the human capacity to continue to hope in the face, the midst, and the aftereffects of trauma. Movies and novels are often predicated on this capacity for hope. The power of hope cannot be underestimated.
Meaning. A final, related theme is that resilience, growth, and hope are not founded on wishful thinking and unbridled optimism; trauma can create meaning and purpose for life. Meaning is not always or even often apparent in the midst of trauma, but it is there to discover.
"To remain alive after such a traumatic event and to give meaning to life takes a lot of work. Surviving may not be that difficult, but to go back to fully living, after something like that, takes a lot of energy and commitment."
Laura Dolci-Kanaan, in “Aid Worker Deaths: The Families Left Behind”
In addition to the above themes, we recognize the wide variety of language used in the trauma literature in reference to unique, yet sometimes overlapping, aspects of trauma. Some of these are child abuse, sexual abuse, domestic violence, intimate partner abuse, community violence, school violence, medical trauma, ethnic trauma, societal trauma, human trafficking, commercial sexual exploitation, extreme and torturous experiences, persecution, torture, acute events, cumulative microtraumas, nonverbalized trauma, intergenerational transmission, and dislocation trauma.
Other terms within the field may be less familiar to readers. Following are some examples:
Traumatology is the academic field that studies the various interdisciplinary aspects of trauma, a growing and immensely helpful perspective. Expertise in traumatology is a critical need in the mental health professions.
Complex trauma and dissociation. The complex trauma literature has exploded in the past decade. The important distinction has been made between posttraumatic stress disorder (PTSD) without the dissociative subtype, which can be the result of even a single traumatic incident, and chronic relational trauma, which often begins in childhood and extends into and complicates adulthood. The latter is often referred to as complex traumatic stress disorder, or complex PTSD. This distinction does not appear in the Diagnostic and Statistics Manual of Mental Disorders (DSM-5) but has become generally accepted in the trauma field. Survivors of complex trauma could potentially fit criteria for numerous DSM-5 diagnoses, with PTSD (dissociative subtype) and dissociative disorders being relatively common. For dissociative identity disorder (DID) alone, a recent review of the international research literature has found that 1.1%–1.5 % of the general population meet criteria (Brand et al., 2016).
Integration refers to the collaboration, coalescing, or coming together of what might be considered disparate parts or aspects of an issue. In this book integration can refer to the intersection of psychological and biblical/theological concepts and approaches—a significant goal of the book. However, it might also refer to the linking together of aspects of human experience. For instance, counseling can be seen as a process of facilitating the integration of fragmented aspects of self (e.g., emotions, cognitions, behavior, body, spirituality)—something commonly experienced by traumatized people. At the risk of confusing readers, integration can also refer to the mutual interaction between theories and concepts within various approaches to treatment. For instance, the theoretical integration between cognitive approaches and behavioral approaches to helping has resulted in what is commonly referred to as cognitive behavior therapy (CBT).
Theodicy and theology of suffering. Theodicy refers to the centuries of philosophical and theological discussions regarding the origins and nature of evil. The phrase “theology of suffering” has recently become a focus among theologians and mental health professionals since the reality of trauma has not appeared to diminish in our postmodern world. Despite technology and economic prosperity, evil and suffering have not abated, and we need the biblical and theological resources of our faith to help us understand and respond.
It is important to recognize the range of opinion in society regarding the relatively new language of trauma. Over the past 20 or so years, the concept of trauma has moved to center stage of the mental health field and has in many respects entered our everyday, household vocabulary. You will notice in the various chapters that authors use different language regarding trauma. They are each addressing different types and contexts of trauma, and they have different theoretical orientations. Some take a more academic approach focused on research and evidence-based practice. Others take a more descriptive or narrative approach, writing for a pastoral or ministry context. In addition, the various authors use different biblical stories and teaching passages from Scripture as they describe the theological dimensions and spiritual consequences of trauma as well as the faith-based resources that are at the disposal of Christian therapists doing trauma work. This is one of the advantages of an edited book: it represents perspectives from multiple authors.
The authors also have different examples of trauma in mind as they write, which reflects the reality that not all trauma is alike. In considering the book as a whole, there are both explicit and implicit variations in how authors interpret the concept of trauma and what constitutes a traumatic experience. While this may at times be unsettling to the reader in terms of the need for precision and accuracy, we have allowed authors to speak from their own understanding and contexts. This also reflects the differences within the broader trauma field.
English is a relatively rich language with regard to emotionally laden descriptions of human experience. The word trauma has many synonyms, and each cognate has nuances in denotative and connotative meaning. Take, for instance, words like atrocity, cataclysm, ordeal, or tragedy or less intense, more common words such as disaster, distress, or unfortunate circumstances. English has a plethora of words with overlapping meanings that range from mild to strong in intensity as well as having more positive or more negative emotional valence.
Language evolves over time as a society notices and then highlights different aspects of human experience. I (Fred) recently read a newspaper article by an essayist (Carter, 2016) about the use of the word tragedy to describe recent world events such as natural disasters or terrorism or any event with terrible, life-threatening consequences. The author wondered whether the word tragedy has lost its powerful meaning and has been “dulled by overuse.” While the impact of a tsunami is indeed tragic, my favorite restaurant going bankrupt and closing hardly qualifies. Tragedies raise questions about life and death, about how the world functions, and ultimately about faith, God, suffering, and redemption.
Examples of Trauma Experiences that Risk the Development of PTSD
Anyone who has been victimized or has witnessed a violent act or who has been repeatedly exposed to life-threatening situations is at risk of developing PTSD. This includes survivors of the following:
• Domestic or intimate partner violence
• Rape or sexual assault or abuse
• Physical assault such as mugging or carjacking
• Other random acts of violence such as those that take place in public, in schools, or in the workplace
• Unexpected events in everyday life such as car accidents or fires
• Natural disasters such as tornadoes or earthquakes
• Major catastrophic events such as a plane crash or terrorist act
• Disasters caused by human error, such as industrial accidents
Also included are the following types of survivors:
• Children who are neglected or sexually, physically, or verbally abused, or adults who were abused as children
• Combat veterans or civilian victims of war
• Those diagnosed with a life-threatening illness or who have undergone invasive medical procedures
• Professionals who respond to victims in trauma situations, such as emergency medical service workers, police, firefighters, military, and search and rescue workers
• People who learn of the sudden unexpected death of a close friend or relative
(Sidran Institute, n.d.)
Sir Walter Scott profoundly argued that the world needs tragedy since it evokes “that strong instinctive and sympathetic curiosity, which tempts men [and women] to look into the bosoms of their fellow-creatures, and to seek, in the distresses or emotions of others, the parallel of their own passions” (as cited in Carter, 2016, p. D1). A “strong and sympathetic curiosity”—what a great way to describe our efforts to produce this book.
This book includes 18 chapters with a total of 37 authors, all of whom are drawn by such a curiosity—a deep, compelling desire to know and understand more about human experience and how God is intimately involved in human tragedy. This curiosity is strong, and for many of us it is closely connected to our life callings as mental health professionals. It is sympathetic since each of us, either through our own life journeys or through the stories of the many people we have journeyed with, has felt the pain and suffering of tragedies at the individual, family, community, national, and global levels.
But whereas the word tragedy is often used to refer to external events, the word trauma, the core concept of this book, in addition to describing the tragic external events of life, designates the internal, personal responses and shared responses to such experiences. It is this intrapsychic, subjective level that is the primary focus of this book. External events may be the precipitating cause of trauma, but as mental health professionals we are primarily interested in the intrapsychic and relational consequences of trauma.
Human history is the history of trauma. From war, natural and human disasters, family violence, and brutal atrocities to sexual exploitation, child abuse, and terrorism, throughout human history it is likely that more people have experienced trauma than those who have not. But thankfully, human history is also the history of resilience, posttraumatic growth, and human flourishing. Stories of people’s lives recount both sides of tragic experiences.
But what is trauma? What constitutes a difficult set of circumstances versus a traumatic experience? To be blunt, trauma is not just a bad day. We remember reading to our young sons the story of the Muppets character Grover’s “bad, awful day” (Dickson, 1986). It is a legitimate attempt to introduce children to the fact that bad things happen in life. Our days can involve experiences of rain, losing one’s boot, and stepping in puddles, actually and figuratively. But to define trauma, as some authors have, as “anything that is less than nurturing” (Mellody, Miller, & Miller, 2003; Rosenthal, 2014), even if the complete definition adds “that changes your vision of yourself and your place in the world,” is potentially to minimize the seriousness of trauma. This tendency to generalize the meaning of the concept beyond its usefulness can also be seen in book titles such as The Trauma of Everyday Life (Epstein, 2014). To be fair, Epstein’s book has many helpful things to say about trauma, including its emphasis on the transformational potential of trauma to support human growth and development. Yes, traumas touch all of us—death, chronic illness, accidents, natural disasters—but these events in and of themselves do not constitute trauma; trauma must include the subjective experience of physical, emotional, or relational harm.
There probably is not much point in entering a detailed debate regarding which definitions are scientifically or theologically more correct, but suffice it to say that people who have experienced trauma generally know, at least at some level, that they have experienced a life event or series of life events that have hurt them—that have disrupted their ability to live life abundantly (Jn 10:10). The authors in this volume provide explicit or implied definitions in their chapters, but the focus of the book is not on definitions but on helping people overcome the impact of traumatic experiences. We know at some level that trauma is common in human experience and that it is often a shared human experience. Trauma is a painful disruption in personal, familial, or cultural/ethnic/national identity and involves a loss of assurance that the world is a safe place. At the same time, it is the experience of resilience, a vision of the indomitable human spirit that exists within the experience and survives trauma. Theologically, it is the affirmation of our creation in the image of a loving God and also the pervasive reality of sin. The trauma lens requires a new appreciation for the biblical themes of suffering, sin, redemption, resurrection, liberation, and hope. If Christianity is going to be relevant, it must address the issue of trauma and provide understanding and resources for living in the midst of a trauma-torn world.
As you read this book, it will be helpful to step back from concerns about what is and what is not trauma and acknowledge that, to a large degree, trauma is defined by the one experiencing it. While this could quickly dissolve into subjective meaninglessness, it keeps the focus on what might be helpful. It is clear from personal and therapeutic observation that people can experience horrific events and apparently have no negative longer-term consequences that would fit diagnostic criteria for acute stress disorder or PTSD. On the other hand, what to one person might be perceived as a negligible, unfortunate incident can be life altering to another individual.
We would like to make a few suggestions regarding how readers might benefit from this book.
For students. This book is a pretty thorough overview of the kinds of experiences and treatment methods that incorporate spirituality into our understanding and treatment of trauma. The chapters do not need to be read sequentially, but we have been intentional in trying to offer a flow to the topics. Of course, you will not remember the specifics of each chapter, but we do hope that you will become convinced of the value of including spirituality in your future trauma work. In all mental health contexts, you will encounter trauma, and having some familiarity with the spiritual dynamics of trauma will aid you in your future work.
For instructors/professors. We hope that the range of perspectives represented in the various chapters will provide rich fodder for critical analysis and emotional engagement with the topic. We believe this book may serve as a primary or secondary text in counseling, psychology, and social work courses specifically focused on trauma and abuse. However, since trauma is a significant contemporary lens in psychopathology, its use in a diagnosis course will offer a broader perspective on the etiology and treatment of mental disorders. The inclusion of a new trauma section and reorganization of trauma-related categories in DSM-5 (American Psychiatric Association, 2013) suggests that there is recognition of a growing awareness of the benefits of a metatheoretical trauma perspective in our understanding of diagnostic classification.
Of course, foundational courses on counseling and psychosocial interventions, as well as supervision for practicum or internship experiences, must address trauma since a significant number of clients will enter treatment with trauma either as a presenting problem or at least in the background of whatever brings the client to treatment. While not all topics in the book are equally represented in the clinical populations, this book may provide a valuable brief introduction to the kinds of trauma that present in practice.
For clinicians. In addition to providing a theoretical basis for trauma treatment and introducing specific interventions, this book offers a brief overview of the role of spirituality in treating a variety of trauma situations. We hope that individual chapters will serve as a starting point for information on treating a specific type of trauma, which can be pursued in more depth using the reference lists.
For researchers. As mentioned earlier, we were pleasantly surprised by the number of references we found that incorporate spirituality into some type of trauma treatment. The appendix, while not exhaustive, points to the fact that there is a fledgling research base in this area. However, a quick glance over the column identifying the type of research indicates that most of the publishing in this area is conceptual in nature and that little quantitative or qualitative research has been conducted. The appendix gives evidence of a strong need for empirical research on the integration of spirituality into our understanding and treatment of trauma.
We will end this introduction by sharing a few of our reflections on the advantages and disadvantages of an edited book:
The book provides an introduction to the various types of trauma with a substantial overview of each of the topics. However, there are gaps because it is impossible in the space of a chapter to be exhaustive. Despite our editing, there is inconsistency in writing styles. We sought to maintain the uniqueness of the authors’ perspectives and voices.
The book is heavily referenced. Although this can be distracting at times, our goal is help readers in further research. We hope this volume encourages readers to delve further into the topic.
Because every author wants to share his or her passion and knowledge regarding the topic, the chapters tend not to be light reading. After all, trauma is not a light topic, and these pages represent thousands of hours of clinical work, teaching, and consulting with hurting and wounded people.
In academic projects it is sometimes easy to lose sight of the pain of the millions of people on this planet who are suffering; however, academic and narrative reflections together move us forward in the field.
On the basis these reflections, we think that the advantages of this being an edited book outweigh the disadvantages. We hope that others will extend and refine this work in the future. We also hope that, in reading, studying, and reflecting on the issues this book addresses, we will never lose our sensitivity to the suffering of the people in our own lives as well as the plight of billions of people throughout human history whom God loves and for whom Christ died and rose again.
An edited book with many authors could have multiple dedications, but we hope our coauthors will value the personal nature of this dedication in the midst of a large academic task. We (Heather and Fred) have been working on this project over a period of time that parallels the life of our three-year-old grandson, Rico. In our late fifties we are raising Rico, our beloved son’s son. Rico is an absolute joy—a gift and a blessing. But we would not have survived the past few years if it were not for two other people who came alongside us. Lynette, Rico’s Colorado “aunt,” has been for him and for us the doting extended family we do not have close by. Janet, nanny extraordinaire, has tirelessly cared for Rico with stability and flexibility. What could have been a traumatic life event for Rico and us has been a wonderful experience of family in community—God’s gift to us and the world. Thus we dedicate this book to Rico, Lynette, and Janet.
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