"Journal of "Therapy Today

Coping with trauma – healing with metaphoric cards

Dr. Ofra Ayalon

 

Crisis and disaster are part and parcel of life. We are exposed to dangerous environments through war and terrorism, ecological, natural or technological disasters and urban violence. Poverty, racial persecution and physical or sexual abuse also cause suffering and trauma, as do domestic and individual crises such as loss and death of dear ones, destruction and loss of home, abandonment and betrayal.

 

The “trauma vortex”

Survivors of such disasters are often left feeling helpless or depressed, plagued with guilt or anger, caught in the trauma vortex. The “trauma vortex”, a metaphor coined by Peter Levine (1997), describes the whirlpool of chaos in the  aftermath of trauma. Also called the “black hole” of trauma, it is a downward spiral that traps the traumatized. They may find it difficult to control their sensations, images, feelings, thoughts and behaviors. Their essential needs for safety are shaken, as is the right to exist without danger, the sense of competency and the ability to control one’s destiny. Anger and rage mount, coupled with a deep sense of powerlessness at their ability to right the situation. It is a rage that can be turned against themselves or against others. Trauma has a polarized effect on people. It can create a vortex that pulls people down and tempts them to adopt the"victim" identity, to the detriment of all previous personal achievements and future plans. When the "traumatic narrative" takes over, it becomes the center of our thoughts, feelings and relationships. The price for adopting victimhood is giving up control and mastery over one's life. One such example was reflected by H., a survivor of an  Israeli school disaster, where  adolescents were held as hostages and 22 of them killed by the terrorists. Twenty years later H. still signed all his letters as "victim of the Ma'alot massacre". He kept visiting the graves of his 22 schoolmates every day, apologizing to them for his survival (Desivilya, Gal & Ayalon, 1996).

 

From victim to victor

Another outcome of trauma may be a healing spiral that pulls people up. People are apt to find inner hidden resources, transform their priorities by attending to family, social and spiritual values. How do we make the choice to move from being a victim to becoming a victor?  Some do it by taking an active role in resolving the trauma, assuming responsibility for self healing, assuming responsibility for healing others. Others may choose compassion and forgiveness. One dramatic example is the forgiveness rituals engaged by the Amish community in Pennsylvania following the massacre of 6 girls by a local milk lorry driver who shot himself after the murders (ABC World News, October 2006). Some survivors may focus on altruistic work and lobby for important social causes. One amazing example is Mrs. G., the mother of a murdered girl, who wished to spare the life of her daughter's murderer  and made it her life mission to fight against the death penalty in California (Personal communication, 1999).nnThere are healing methods that will help traumatized individuals manage their hyper-arousal and contain their explosiveness and hyper-sensitivity.  This can be done by shedding light on the pull of the trauma vortex, and providing knowledge & practice of coping resources. It is imperative to understand the nature of traumatic reactions and how individuals and groups vacillate between the two vortices, from hope, optimism, energy, and altruism to fatigue, frustrations, disillusionment, polarized thinking, and back again (Ross, 2003).

 

The art of healing – when trauma is "beyond words"

When trauma is beyond words, we look for non-verbal and psychologically  safe methods of expression and sharing. People are relieved when offered the opportunity to approach their painful experiences step by step, starting by using symbols and metaphors. One of the most effective tools in eliciting healing metaphors are a set of illustrated cards called COPE Cards , that belong to a specially designed genre of associative cards (the OH- Cards series). These cards enable their users, whether playfully or therapeutically, to access deep feelings and narrate their experiences. By using COPE Cards participants can learn to identify their own particular ways of coping with crisis, stress and trauma. The experience of randomly selecting cards and dealing with the associations they evoke can elicit new ideas and possibilities, instead of repeating familiar patterns of thought and response. COPE Cards help us reach our inner pain and discover our inner strength. A sort of "virtual training" takes place in dealing with challenging situations, in surfing beyond time and space, in experimenting with possible solutions to conflict laden issues – all within the safe world of image and metaphor (Ayalon, 2003).

 

BASIC Ph coping modes and corresponding therapeutic methods

In the process of researching for ways of promoting  resilience and healthy ways of coping we have developed a new model of "coping resources" acronymed  "B.A.S.I.C. Ph". This is a holistic multi-modal framework,  that contains six modes of coping resources: Belief  systems, Affective expression, Social support, Imagination/creativity, Cognitive processing, Physical behaviour. (Ayalon 1992; Lahad 2000). These six modalities merge into one fabric in our world-wide trauma-coping  training programs.

These modes are represented by six COPE  "hand-cards":

Belief systems refer to faith in God or a supernatural power, trust in other human beings or trust in oneself. Faith and hope are well documented mental coping resources with trauma (Frankl, 1988).nn

Pic – hand

 

Affect  is the feeling aspect of consciousness.

The heart symbolizes love & hate, fear & courage, grief & joy, jealousy & compassion, and so on. This coping mode  involves first and foremost the ability to recognize feelings and to name them. Then comes the  expressing of feelings, by verbalizingn (telling, writing, dramatizing) or by non-verbal activities ,such as free play, dance, painting, sculpting or music.

Pic – heart Social coping skills focus on interaction with others. Such interactions include giving and receiving support, by family members, friends and also by professional helpers. In the aftermath of trauma there is a strong need to bear witness -the traumatic experiences need to be acknowledged, expressed listened to, witnessed by caring others, tolerated, contained treated and healed.

Pic hands

The Imaginative/metaphoric mode is the key to coping when traumatic experiences are "beyond words". It offers many creative ways of expressing painful memories.

 Images presented in the "COPE cards elicit personal hidden memories or fantasies related to the traumatic experience. Any COPE card (or combination of several cards) can function as an opportunity to surpass dire realityAnd find solace in imagination.

pic rock

Cognitive reprocessing. This mode uses cognitive skills to make sense of the traumatic narrative as it unfolds in reaction to the visual images of the cards. This is yet another mode of gaining control over post-traumatic issues and painful memories. The purpose of re-telling the trauma story is to re-visit the scene in a safe mode and, in so doing, release its grip of terror and horror, analyze and understand the demand of the situation, and plan strategies of rescue & coping.

Pic chses

The Physical (body/mind) coping modes.  The trauma is stored in the body. Levine (1997) suggests the use of body awareness and Somatic Experience (SE) for unfreezing the somatic trauma and regaining body-mind control. These methods are used to build a flexible balancing of tension and relaxation, establish body-boundaries and re-examine the relationship between personal space and trust.

Pic rope

The projective-metaphoric cards, that support verbal and non-verbal expressive methods, help to access repressed experiences. We have found this multi-modal approach most effective in helping people cope with trauma and negotiate ways of resolving conflicts in situations of violent  armed conflicts, suicide prevention  and domestic violence. In actual traumatic situations people usually employ a combination of coping styles to survive.

 

Getting started with metaphoric cards

The first step toward recovery and healing is to reach physical and psychological safety and security. In this safe space it is possible to vent feelings by verbal and nonverbal means, to share dreams, nightmares and other traumatic reactions. When appropriate, mourning and memorial rituals can promote positive affirmations of resilience.

 

Telling the trauma story and finding coping resources

Any COPE card (or combination of several cards) can function as a trigger for the narration of the event and responses to it. Using the COPE Cards provides an opportunity for recounting personal recollections of traumatization in a safe environment, as metaphoric stories triggered by the visual images of the cards are one step removed from anguished reality. This "creative distance" facilitates recall and the working though of trauma experience. The use of image and imagination serves as a protective screen against being overwhelmed by intense emotions. When the memories become too much to bear, one can always return to the imagined story, or look for other cards that may serve as anchors for a sense of thriving, surviving and healing.

 

Guidelines for identifying your coping skills with the "BASIC Ph” model

 Rational:

This activity aims to discover what our own coping that we use to deal with daily hassles and stress and also in  crisis situations. In this process participants will also identify those coping modes that are blocked in times of crisis. What resources would be required to open them up and make them, too, available in times of need?

Process: 1. Spread the six COPE "hand cards" face up on the table, and identify each of them according to the BASIC Ph model (Belief, Affect, Social, Imaginative, Cognitive, Physical modes).2. Pick 6 cards at random from the COPE Cards deck and place them face down on top of the “hand cards”, so that each "hand card" is covered by one card.

  1. Turn the top card up, one at a time,  and reflect how they connect to the “hand card” that represent coping modes. Let the top card help you describe how you use the relevant coping mode in your life, in a positive or a negative way.

For example: My "imagination" helps me detach myself from my worries (positive), and my "social” coping mode makes me needy and over-dependant on others (negative).

  1. Now think of a time in your life when you experienced severe stress or crisis. Turn the remaining COPE Cards face up and choose 3 cards that describe this experience.
  2. Try to identify which of the coping modes you have employed to deal with that crisis. Use the cards to tell the story of your coping.
  3. Try also to identify those modes that you have not used – and turn their representative cards face down. These cards represent those coping modes that were blocked  by the traumatic event.
  4. Find cards that will help you re-activate those blocked modes.8. Reflect on the whole process of how you identified your existing resources for coping with crisis and how you activated additional resources. Share your reflections. Re-tell the story of your traumatic experience, and how it was transformed by the use of all six coping modes. The Tsunami storm – some examples The  following are examples of the variety of coping modes emerging from COPE cards work with survivors of the Tsunami disaster in Thailand (Ayalon, 2006). The stories were triggered by the COPE cards as a responses to the question: "what helped you most during and after the disaster? "Belief in God or in supernatural powers: "At the time of the Tsunami I was praying in the mosque. The wave arrived abruptly, flooded the street, circulated the mosque and did not touch it. A miracle happened and I was saved with the grace of God." Affect and expression of their feelings:" There was a time when I experienced an immense feeling of pain inside me. It’s hard to explain. I could not find words to share my feelings with my friends. I did not dare burden them with my agony. That’s why these cards were so important for me: They allowed me to deal with my own feelings, same as everybody else in our group. I am not ashamed any longer. It is a relief…".

Social skills: "I volunteered to help people who were hurt. Their suffering was much greater than mine. By helping others I helped myself".

Imagination: "Do you want to know how I was saved  from death? As I was drowning I imagined a strong rope in the water. I seized it and pulled myself up. I was saved, in spite the fact that there was no real rope in the water". Cognitive solutions, search for information and understanding: "Two weeks after the Tsunami I still could not fall asleep. So night after night I searched for information about Tsunami on the web. Then I started visiting schools and sharing my newly acquired knowledge. That is why they sent me to this training.

Physical activity: " I had to immerse myself in the hard work of cleaning the debris of the storm.  This was the only way I could manage my anxiety and sadness". Another teacher said: "working with children I succeeded in calming them down by engaging them in vigorous movements until they tired, sat quietly, breathed deeply and relaxed" .In conclusion There is no one single appropriate method of coping for all situations, all people or all ages. Each person, family, and community have their specific combination of coping modes, that constitute their basic coping language. The effective way for the therapist to help is to join the victims' basic language, and then guide them in developing additional coping resources.

Referencias

  1. Ayalon O (1992) Rescue – community stress prevention education. Ellicott City, MD: Chevron Publishing Corporation.
  2. : Ayalon, O. Rescue!   Community Oriented Preventive Education.  Ellicott city: Chevron Publishing Corporation; 1992.
  3. Ayalon, O. The HANDS project: Helpers Assisting Natural DisasterSurvivors. Community Stress Prevention 5 pp.127-135; 2003.
  4. Ayalon, O. Children's response to terrorist attacks. In: D. Knafo (ed.) Living with terror, working with trauma. New York: Jason Aronson. pp. 171-200; 2006.
  5. Desivilya, S., Gal, R. & Ayalon, O. Long-term effects of trauma in adolescence. Anxiety, Stress & Coping, 9 (3), 13-150;
  6. Frankl, V. The Will To Meaning.  New York: New American Library; 1988.
  7. Lahad, M. Darkness over the abyss: Supervising crisis intervention teams following disaster, Traumatology, 6 (1-4), 273-294; 2000.
  8. Levine, P. Waking the Tiger: Healing Trauma. Los Angeles: North Atlantic Books; 1997.
  9. Ross, G. Beyond the Trauma Vortex: The Media’s Role in Healing Fear, Terror & Violence. Los Angeles: North Atlantic Books. 2003.Pic