CRT Chapter 18

Chapter Eighteen:

Stress Reactions of Caregivers

Not a day passes over the earth but men and women of no note do great deeds, speak great words, and suffer noble sorrows. Of these obscure heroes, philosophers, and martyrs the greater part will never be known till that hour when many that were great shall be small, and the small great.

_ Charles Reade

Most crisis responders are among these "obscure heroes, philosophers, and martyrs." They are caregivers in everyday life. They are law enforcement officers, victim assistance providers, mental health professionals, nurses, doctors, clergy, fire fighters, emergency workers, school teachers, or others. Most are exposed to crises in the workplace on a daily basis. In addition to that stress, they must deal with general workplace stress such as too much work and too little time to do it, an inability to set priorities or schedules, lack of recognition, repetitive demands, paperwork, discontent with salaries, and problems with co-workers. They also deal with stress in their families and their social lives. This chapter does not address either general workplace stress or family and social stress. Its focus is on the stress reactions of crisis responders in hopes of helping them continue to strive to care for others as well as to thrive in their own lives.

I. Background to Dealing with Stress Reactions of Crisis Responders

Many crisis responders who are exposed to repeated events are vulnerable to long term stress reactions.

"Burn-out" is the most common complaint, and justifiably so. Burn-out usually results from a confluence of physical, emotional and mental exhaustion. Sometimes caregivers suffer physically but still are inspired to continue in their work. With rest and physical care, they may continue their involvement with crisis response.

Other caregivers may not feel physically exhausted but find themselves wondering why they are doing what they are doing. They continue to exert themselves but feel less and less connected to their efforts.

Cynicism may affect caregivers when they believe that they have been exposed to aberrant or evil behavior. They may not have understood that such behavior was possible and that such behavior might have an effect of their lives.

II. Crisis Responders Often Face Burn-out and Vicarious Victimization

A. Burnout

1. Burnout is characterized as a state of emotional, mental and physical exhaustion. It is usually accompanied by physical symptoms of fatigue, sleep disruptions, headaches or stomachaches, body aches, or susceptibility to colds or flus. It may show up in work performance through absenteeism, tardiness or declining productivity. There is often depersonalization in interactions with colleagues and those to whom service is provided. Emotional and behavioral symptoms include: feelings of helplessness, irritability, anxiety, depression, pessimism, cynicism, isolation or carelessness. Burnout occurs over time and may begin gradually but, unless interrupted, will grow worse until the individual feels completely unable to function.

2. Contributing factors to burnout include:

a. Professional isolation.

Caregivers may find that they have no one with whom they can talk about the nature of their work or its impact on their lives. Friends and family members may admire what they do, but may not want to hear stories of disaster, murder, or misery. Even if some are willing to listen, sometimes caregivers find it difficult to talk about their experiences when friends or family cannot understand the effects of exposure to trauma.

Despite the fact that crisis responders are trained in issues of trauma and caregiving, they often function in a work culture that values self-sufficiency, stoicism, and repression of personal emotional reactions. They may be reluctant to allow their colleagues to know how they are feeling and fear ridicule if they reveal anxiety, tension or turmoil over their confrontation with traumatic events.

b. Emotional and physical drain of providing continuing empathy.

Caregivers are faced with constantly giving of themselves to others. They must listen with care to the stories of victims or survivors and try to provide them solace and reassurance. They feel called upon to be available for the people they serve at all hours. They are compelled by an ethical imperative to sacrifice themselves for the needs of victims.

In addition, many "professional" caregivers also serve as caregivers to their family members and friends. They may be perceived, and function, as the source of strength when others falter. In part, this is because they are inclined to do so because of their personalities and, in part, it is because they have the experience and knowledge with which to deal with difficult issues.

It is not unusual for crisis intervenors to find complete strangers who learn of the intervenors' work to tell them of their own tragic stories. Unless caregivers have social support systems that can also provide them with empathy and understanding, their emotional resources are constantly flowing towards other people and their own emotional reservoir is slowly depleted.

c. Ambiguous successes.

More than one crisis intervenor has felt ambivalence in the aftermath of a crisis response. The coordination of the effort, the group work, and the response of the community may have all gone extremely well; victims and survivors may have responded with gratitude and appreciation; local caregivers may have indicated that the training presentations were effective. Nonetheless, it is normal for the intervenor's gratifications to be mixed with depression.

Nothing can eradicate the facts of the disaster _ the numbers of dead or injured, the property lost, and the amount of destruction. No matter how much is done in response, it may never seem to be enough. Crisis responders may particularly feel this void because they are rarely in contact with the community directly in the months or years that follow their intervention. They may never know if what was done was truly helpful or useful.

d. Erosion of idealism.

Many caregivers came to the field of victim assistance or crisis counseling with strong beliefs in such ideals as the goodness of people, the ability to create a better world, the conviction that justice will prevail, and their own power to make a difference. Many of these ideals are challenged in crisis response work.

While crisis responders meet many good people among victims and survivors, they are often confronted with human evil in the creation of community disasters, and, too often, appalling incivility in the aftermath of disasters. Efforts to improve the lives of others are often undercut by countervailing forces, including bureaucracy, divisiveness in a community, and barriers to service. It has become almost a cliche among victim service professionals that, at least in its worst moments, the criminal justice system can become a victim injustice system.

Some responders feel as though they become the embodiment of the Myth of Sisyphus. They are condemned to roll their rocks to the top of the mountain, only to see the rocks roll back down, and have to return to the bottom of the mountain to begin again.

e. Lack of expected rewards.

Most crisis intervenors do not look to financial gain as a reward. Crisis intervenors are notoriously underpaid, if paid at all, for their services. Some are not. They may be able to get compensation from their agency to cover the costs of being on-call at any time. Those who volunteer their services know that they will give up time with their families, time at their jobs, and time for themselves. They do not seek financial rewards.

However, sometimes they are frustrated by a lack of acknowledgment of their service. Sometimes they are frustrated by a lack of public recognition. Sometimes they are frustrated by comparing their work with the work of others and seeing the rewards others get.

B. Vicarious victimization or countertransference

1. Countertransference occurs when a caregiver's own scars and injuries are revisited due to the sights, sounds, stories, or issues raised by the victims or survivors. The caregiver emotionally takes on the reactions of the victims or survivors. Yael Danieli ("Countertransference and Trauma: Self-Healing and Training Issues," Handbook of Post-Traumatic Therapy) in focusing on issues relating to emotional responses and other problems experienced by psychotherapists in working with Nazi Holocaust survivors and their offspring, identifies the following countertransference themes.

a. Bystander's guilt

b. Rage

c. Dread and horror

d. Shame and related emotions

e. Grief and mourning

f. Victim/liberator

g. Viewing the survivor as hero

h. "Me too"

i. Sense of bond

j. Privileged voyeurism

k. Defense

2. Contributing factors to countertransference include the following.

a. A recent or similar trauma in the caregiver's life. Such trauma does not have to be directly related to the current disaster.

A caregiver is more likely to be subject to the possibility of countertransference when he or she works with someone who has suffered a similar trauma as he or she has. One reason for screening crisis responders is to avoid the pitfalls of assigning someone who has recently experienced a traumatic event to an event of a similar nature. At the same time, caregivers need to be aware of their own backgrounds. The line between understanding another's pain or grief and one's own pain or grief is marginal. The more isometric the particular tragedy to a previously experienced one by the caregiver, the more it should be examined.

b. Similarities between victim and caregiver; for example, age, gender, profession, educational level, family status and so forth.

It is often observed that the more a "victim" looks like "you" the more you become affected. This observation relates directly to the concept of community. Communities are based upon general consensus of values surrounding cultures, personalities, and spiritual connections. Any time victims or survivors make connections themselves and a community or culture, and the caregivers make similar connections, the caregivers may face a tension in providing service. Caregivers and victims always make an initial assessment of each other when they meet. The more the victim sees a similarity in the caregiver, the more trust may be extended. The more the caregiver sees a similarity in the victim, the more empathy may be extended. This social exchange of emotional connection is valuable but raises caution. Caregivers have the burden of that caution.

c. Physical and emotional fatigue.

It is not unusual for caregivers to be both emotionally and physically spent from their efforts at a community crisis. Physical fatigue causes the body to be more susceptible to sensory input. The cognitive functions begin to shut down and emotions surface more quickly in response to what is perceived. Organization of perceptions is more likely to become confused, and perceptions themselves become somewhat blurred and distorted. What may be described as "emotional" fatigue is perhaps more realistically seen as "cognitive" fatigue. The brain becomes less adept at controlling emotional responses. Thus, when caregivers hear stories about trauma, they are less able to keep their thoughts in order. They may respond to those stories as if the events, reactions, and feelings were happening to them. They take in the facts more viscerally than they would if their cognitive functions were working normally.

C. Burnout and vicarious victimization change perspectives on life.

1. Both burnout and vicarious victimization cause caregivers to experience a lasting alteration in their belief systems that have a significant impact on their feelings, relationships and life. Such alterations are similar to those that may take place among victims and survivors. The difference for crisis responders is that with repeated interventions, these alterations can become solidified because the interventions confirm the validity of the changes in their beliefs. This is particularly true if they have also been directly victimized in their lives. The belief systems which are changed are inherent in the hierarchy of human needs. [See Maslow's "Basic Hierarchy of Human Needs" below.]

a. Survival: most people live their lives believing they will survive, indeed, that they will live long lives. Crisis responders may find themselves thinking of the possibility of death each day. They have seen the consequences of random disaster and live with the knowledge that their future is precarious and their fate arbitrary.

b. Safety and security: crisis responders may become concerned with safety issues. The world has been proven to them to be unsafe. It is not unusual for them to react in one of two ways: to begin to take more safety precautions than they would have before their experiences with disasters, or to deny their disaster realities and become more risk-taking in the recognition that no matter what is done, disaster can happen anyway.

c. Cognitive functioning for care of daily living: Cognitive functioning is dependent upon having control over life. Crisis responders may grow to feel out of control and powerless with their sense of the enormity of the world. Some may seek to impose order and control in their everyday life in order to overcome that feeling. Others may simply become overwhelmed with everyday tasks.

d. Love and belongingness: These needs are normally met through the development of trust and intimacy. The ability to trust other people may be circumscribed and beliefs in healthy relationships altered. It is not unusual for victim assistance providers who have worked with numerous domestic or child abuse cases to find themselves speculating about abuses in ordinary situations.

A father bouncing his daughter on his knee in a park may cause a provider to wonder if he is truly the father _ if he is really innocently playing _ or if he is a molester.

Intimacy with others may be disrupted because caregivers feel estranged and isolated due to their unique experiences. Communication may be inhibited and feelings of love or joy diminished.

e. Self-esteem and meaning: The belief in one's own self-value may be corrupted by a sense of shame or stigma because of one's powerlessness in the face of tragedy. The belief that others deserve respect or esteem can change as caregivers are constantly exposed to cruel or evil people.

f Self-actualization: Self-actualization depends on assumptions of independence and freedom. The ability to feel strong or independent is in turn dependent upon feelings of safety, trust, and purposefulness. As these feelings are corroded, the realization of potential or the possibility of that realization becomes less and less likely.

2. Contributing factors to these changes include:

a. Constant re-exposure to sudden, random, arbitrary disaster.

Re-exposure to disaster and its consequences is inherent in the role of crisis responders. Re-exposure to trauma triggers the imprinting of traumatic responses in the brain and repeatedly confirms the perception of alarm, danger and its impact. Crisis responders may become hyperalert and vigilant in everyday life.

b. Exposure and re-exposure to the impossible.

Many crisis responders find one of the most disturbing aspects of their work to be the exposure to "impossible" events. What most ordinary people never see in a lifetime the crisis counselor has not only experienced but experienced over and over again.

c. Lack of positive countervailing exposure to human good and world order.

This is a critical factor. Crisis responders who are able to maintain their abilities to function in a positive and healthy way are those who have strong social support; anchor themselves in the knowledge of people who are good; and are able to sustain themselves with their sense of spiritual connections.

d. Lack of nurturing resources.

Crisis responders need to have others who will take care of them. They need to know there are times and places when they can be cared for. Someone once said that each of us carries a little child within us. That little child needs nurturing throughout life. Sometimes caregivers try to take care of the little child all by themselves. When that happens, the child and the caregiver become lonely and frightened. The need for external care is as crucial as is the need for internal care.

III. Compassion Fatigue

A. Compassion fatigue has been a term that has sought to consolidate issues of burnout and vicarious victimization. It was defined initially by Charles Figley in describing secondary traumatic stress reactions in caregivers. While many elements of burnout, vicarious victimization, countertransference, and constructivist self-development contribute to compassion fatigue, there are three salient features that distinguish it. First, compassion fatigue is trauma-specific. Other stress reactions are usually the result of an ongoing process. Second, the symptoms of compassion fatigue are parallel to the symptoms of posttraumatic stress syndrome, prompting Dr. Figley to suggest that posttraumatic stress syndrome might better be named primary traumatic stress syndrome, with compassion fatigue being secondary traumatic stress syndrome. Third, symptoms of compassion fatigue may be eased by immediate intervention, while other forms of stress reactions may call for more radical changes in life styles or work exposure.

B. Compassion fatigue results when caregivers experience a trauma event through listening to the story of the event, experience the reactions to the trauma through empathetic contact with victim or survivor, and are unable to distance themselves from the event. Without the ability to cognitively provide that distance, they begin to live with the trauma, reexperiencing the event as though it happened to them. Dr. Figley illustrates the difference between compassion stress and compassion fatigue through the following diagrams:

IV. Preparation for Being a Crisis Responder

Most of the guidelines for preparing to be a crisis responder focus on how one can best sustain their basic needs and create opportunities for peak performances in their daily lives as well as at the scene of a catastrophe. Exposure to traumatic events often places helpers directly in danger from physical, psychological and emotional harm. Prior preparation is essential for being able to withstand threats to physical survival and to cognitively process what is being experienced. The goal of preparation is to build one's adaptive capacities as much of possible and to reduce daily stressors.

A. Physical Health and Abilities

Maintaining a good diet and nutrition help to fuel the body for times when adequate and healthy food is not available. Vitamins and minerals are important to keep the body and mind functioning well. Fluids help to reduce stress and drinking water helps to maintain functioning.

Regular rest and sleep are important for mental functioning and staying alert and response to stimuli in the environment. Try to maintain consistent and uninterrupted sleep patterns. It is estimated that most adult Americans get less sleep than they need. Crisis often brings times when sleep is impossible for days at a time. Being rested prior to responding to a crisis allows helpers to function efficiently and effectively for longer periods of times.

Regular exercise should be a part of everyday life. It relieves stress at the same time has building physical strength and stamina. A fit body helps create a fit mind for dealing with crisis.

B. Emotional Capacity

Developing insight into one's emotions and reactions helps to develop emotional resilience. Practicing good communication skills and developing the ability to gauge the temperament of others improves emotional strength. Crisis responders should spend time examining their own personal concerns with pain, grief, carnage, anger, fear or death. To some extent such an examination should focus on what issues cause immediate emotional reactions and the development of an awareness of self defusing strategies.

C. Cognitive Abilities

Cognitive capacity can be enhanced and improved through a number of means. Learning new skills in any area helps to expand one's ability to associate experiences and identify options. Problem-solving techniques can help people set concrete goals and plan better for the future. Such planning can often minimize adversity itself. Clarification of values, biases and prejudices help create a conscious understanding of potential difficult situations and issues. Memory can be improved through practice and the use of mnemonic devices. Crisis responders should also do a self-appraisal of their own responses to life and crisis. How do they deal with stress? Understanding reactions to situations assists people in building upon their own strengths. Examination of one's response to tragedy in the past can help responders to develop and refine their coping skills.

Some studies suggest that negative stressors are reduced when individuals know that they had a choice in whether they were exposed to such stressors and that they have control over how such stress will be experienced. Crisis responders should be aware that by becoming part of a crisis team they are choosing to expose themselves to stress. If they are reluctant to endure such exposure, they should make a conscious decision to not participate.

Managing time and information effectively also contributes to cognitive capacity. Time management in daily life helps responders cope better with the chaos imposed by crisis. If the laundry is done, the bills paid, the car serviced and groceries purchased, then leaving that everyday life for seventy-two hours will be less stressful. Establishing routines can help with time management and they also help people return more smoothly to daily life after a crisis. They are an anchor for thinking and responding to regular life demands.

Information management can also be useful. Some caregivers make the decision not to listen to daily news to avoid being overwhelmed with constant reports of crime and crisis. Others may decide to avoid violent television shows or movies.

D. Education/Experience

Education and experience has been identified as one of the most critical factors in resiliency and one of the easiest to improve. A broad education and a wide scope of experience tends to improve cognitive capacity. But, the act of learning itself also tends to increase self-esteem. For most people, the type of education or the kinds of new experience does not matter in the expansion of adaptive capacity. However, for the crisis responder, it is evident that basic and continuing training and education on the nature of crisis and crisis reaction is vital. Not only is new research and knowledge being developed rapidly, but the constant repetition of basic theories and skills makes it more likely that intervenors will be able to rapidly access and use what they know when they, themselves, are under the pressures of catastrophe.

E. Access to Community and Family Support

Strong supportive relationships with others provides people with role models for coping as well as a safety net when life gets too difficult to handle by oneself. Support alone is helpful, but more important is the ability of individuals to reach out and ask for help when they need and to build extended supportive networks. Within such networks, different people may fulfill different roles. Some people may be particularly helpful in providing comfort and care in the aftermath of trauma. Other people may provide support by reinforcing self-esteem. Others may be a source of fun and release. The support system may be family members, friends, or colleagues but at times it may be useful to have the support of a trained counselor or clergy member.

To help people give help in appropriate ways, it is beneficial to educate members of a support network on the issues relating to trauma. Crisis responders should plan with family, friends or employers what will happen if a crisis situation arises. They should clarify job assignments, travel expectations, and family responsibilities. They should ensure that everyone is aware of what they will be asked to do when a disaster strikes.

F. Self-esteem

Many adaptive capacities contribute to the sense of self-esteem. But, crisis responders can take direct steps to strengthen their own sense of worth. Hobbies and activities in which crisis responders excel should be nurtured and pursue. Association with others who recognize and acknowledge the skills and abilities of the intervenor are recommended, particularly after experiences in which the intervenor felt inadequate or incompetent.

G. Spiritual connections

Faith in the future or a higher power helps most crisis responders survive what they experience. Just as faith seems to be essential for victims and survivors of catastrophe, so it is that faith seems to guide lives of those that intervene. It is important to establish and continue to refine the sense of a meaning in life and a purpose for existence. Helpful aids in that exploration include reading theology, philosophy, poetry and literature. Examination of what life purposes are and how current goals relate to that purpose is also of assistance. Crisis responders should take time to think about how your involvement in crisis or disasters contributes to their sense of a meaning in life. They may also take advice from Victor Frankl's view that it is not necessarily the nature of disaster that will most affect their ability to cope with its consequences but rather their own attitude towards disasters.

H. Personality

Everyone has a different personality and handles stress and crisis differently. There are some hints for working in crisis despite these differences.

1. Design a crisis intervention strategy before involvement with a catastrophe.

2. Establish a safe place for trauma reactions.

3. Allow opportunities to express reactions.

4. Predict when traumatic feelings may be most potent and make a plan for dealing with them.

5. Acknowledge the trauma confronted.

• It is normal to be sad and depressed after tragedy.

• It is normal to feel isolated and removed from others who have not been a part of the tragedy.

• Caregivers often feel good about their interventions because of positive feedback from disaster survivors; but many caregivers focus on the problems in their interventions, not the successes.

• Tragedy hurts but you can "live through the time when everything hurts" and learn from your experience.

V. Responding to Trauma at the Site

A. Physical Health and Abilities

Team members are encouraged to eat healthy food, sleep as much as they can and exercise when possible. However, it is recognized that many regular routines to maintain physical health will be abandoned at the site of the disaster. Team members are reminded that they are responsible for bringing necessary medication and informing the team leader and manager of any special health needs.

B. "Cognitive IQ"

Team members are encouraged to make notes of what they experience and to talk about their observations at group crisis intervention sessions with team members. Such activities help to reinforce memory and promote cognitive processing of experiences.

C. "Emotional IQ"

Team members are encouraged to report to the team leader and to discuss with other team members any problems that they are have in responding to the crisis situations. Of particular note is the need to process the emotions of others when they are in crisis intervention sessions.

D. Education/Experience

Team members are required to attend all of the training sessions that are given for local caregivers, if they are not otherwise engaged. The consistent reinforcement of the education and training that they have received will help them with issues that arise during their site visit.

E. Community and Family Support

Team activities do much to promote the sense of personal support for each team member. The team leader and manager is responsible for emphasizing team building, mutual respect and trust. Every team member is selected for their expertise, experience and skills. The team leader should emphasize this with other team members. In most cases, the team leader will be provided with short biographies of other team members to distribute to the team as a whole. Leaders should insure the team has a chance for laughter and fun. They should also organize daily crisis intervention sessions for the team.

F. Spiritual Connection

The team leader should encourage the team members to remember how they chose to participate and what their participation means in their personal lives. Team members should be encouraged to participate in worship when it is meaningful to them. Memorials and funerals may raise the issue of spirituality for team members. These issues should be explored in team crisis intervention sessions.

G. Personality

On most occasions team members get along with each other and develop special and long-lasting relationships. At times, personalities disrupt these possibilities and the crisis situation may make it difficult to resolve such personality differences at the scene of a crisis. The team leader is responsible for defusing team member conflicts and reporting to the NOVA staff if there is an unresovlable conflict.

VI. The Aftermath of Tragedy

A. Physical Health and Abilities

1. Team members should reestablish good nutritional and health plans.

2. If individuals are suffering from poor health or do not the same energy level prior to the crisis, it is recommended that they contact their doctor as soon as possible.

3. It is often helpful to engage in activities or hobbies that relieve tension.

4. Crisis responders should avoid substance abuse and excessive sleep as coping strategies.

B. Cognitive IQ

1. Research suggests that engaging in activities that give one a sense of freedom and independence after a crisis situation helps to focus the mind and alleviate mental tension.

2. Resuming routines immediately after a crisis response is a stabilizing force. It can be difficult because many people feel isolated and disengaged from everyday activities. The value of such routines is that they force concentration on known tasks and provide a natural way to reestablish connections with support systems. While some people think that taking time off from work or taking a vacation will help them process the trauma and adjust to routine life, in most cases, returning to routine for at least a few days before taking a rest break is more beneficial.

3. Activities in which intervenors have a sense of control are also important in reentering their "normal" life.

4. Thinking through what happened and how it happened is useful. Crisis responders should try to develop a storyline or narrative of their activities during the disaster situation. Writing a report for NOVA is helpful in formulating those thoughts. Telling others what happened is also of assistance.

5. Intervenors should avoid making important decisions that will affect the rest of their lives. The time immediately after a crisis is not a time to decide to divorce, marry, move to another city, or, even buy a new car. Decisions should be postponed until emotional and cognitive equilibrium is restored.

C. Emotional I.Q.

1. Crisis intervenors should realize that they need to provide crisis intervention to themselves if they have serious reactions to the traumatic event.

2. Many crisis responders are caregivers in their professional life and their private lives. They need to be reminded that when they undergo severe stress, it is time to nurture themselves and to accept nurturing.

D. Education/Experience

1. It is helpful to attend training courses and review what is known about crisis and trauma. Such training courses will be useful in reviewing one's own reactions as well as allowing individuals to explore what alternative approaches or methods might have been used in responding to the most recent crisis.

2. Teaching others about what a crisis experience was like helps intervenors learn from the experience as well as to expand what they know

3. Learning some new skills that apply to trauma situations can also help refocus crisis intervenors.

For instance, training courses on the techniques mentioned in post-trauma counseling such as EMDR or VKD may help crisis intervenors obtain a new perspective on the impact of trauma and appropriate responses.

E. Community and Family Support

1. It is useful to consciously reconstruct trusting relationships with support system members, if the trauma situation has raised issues concerning the ability to trust others.

2. For some crisis responders it may be helpful to talk with a trusted colleague or another crisis intervenor in order to overcome the sense of isolation and distress. Many local crisis response teams and victim service programs have established plans for providing group crisis intervention to caregivers after a traumatic event.

3. Family, friends and colleagues should be told what has happened and what crisis responders have done. Intervenors may want to "edit" their stories with some members of their support system, but explain the general nature of the crisis and the response is important to enhance the ability of friends and family to provide reassurance to the intervenors. It is also useful to talk with others about how things might have been different or how one might have done things differently.

F. Self-esteem

1. Intervenors need to take time to think about the event by themselves. It is useful to remember that in most cases the intervention has been helpful and to think about those positive aspects of the crisis response.

2. NOVA tries to ensure that its volunteer crisis teams receive certificates of appreciation and copies of letters from communities thanking the teams for service.

G. Reestablish your spiritual connections.

1. Many crisis responders find that the process of resuming religious routines or contact with their spiritual or religious communities is essential in the aftermath of going to a crisis event.

2. Positive coping strategies for renewing spiritual connections include:

a. Thinking about the meaning of the event and integrating it with an understanding of the meaning of life.

b. Using prayer, meditation and, ritual to process the event.

c. Reading literature on spiritual issues and issues of trauma and death.

d. Spending time contemplating beauty and good in the world in contrast with the devastation or destruction that may have been experienced.

IV. Conclusion

Defeat may serve as well as victory to shake the soul and let the glory out. When the great oak is straining in the wind, the boughs drink in new beauty, and the trunk sends down a deeper root on the windward side. Only the soul that knows the mighty grief can know the mighty rapture. Sorrows come to stretch out spaces in the heart for joy.

_ Edwin Markham

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