E. Normalization For Asymptomatic Survivors And Responders

OBJECTIVE

Help trauma survivors and responders who are NOT themselves experiencing signs or symptoms recognize that these reactions in others are common in the aftermath of trauma and do not signify personal inadequacy, health problems, mental illness, or other enduring negative consequences.

BACKGROUND

Contemporary approaches to early intervention following trauma exposure emphasize the importance of “normalization” of acute stress reactions. This means that survivors or responders who show distressing symptoms or disturbed behavior are helped to understand that their reactions are “normal responses to the abnormal events.” Such an approach follows from the common clinical observation that individuals experiencing acute stress reactions often interpret their reactions as “personal weakness” or “going crazy,” which increases their demoralization and distress. Normalization is undermined if survivors or responders who are not feeling disruptive distress (yet) show a derogatory or punitive attitude to others who are. Also, the persons who most strongly deny or dissociate from their distress may be at increased risk for developing acute stress disorder (ASD) and subsequent PTSD. The education that should go with normalization may therefore help them recognize how to protect themselves better, and to seek care early if symptoms do start getting the better of their “self-control.” Even those who go on to develop PTSD may benefit from an understanding that their symptoms do not represent “personal weakness” and that although their symptoms may be severe and painful, they are not losing control of their minds.

RECOMMENDATIONS

1. Pre- and post-trauma education should include helping asymptomatic trauma survivor or responder understand that the acute stress reactions of other people are common and do not indicate personal failure or weakness, mental illness, or health problems. The responders should be taught the simple words and measures that will support the other peoples’ quick recovery, rather than push them towards a persisting disorder.
2. Education should include sufficient review of the many ways that post-traumatic problems can present, including symptoms in the ASD/PTSD spectrum, behavioral problems with family and friends, occupational problems, and alcohol or other substance misuse/abuse.
3. Provide education and access information to include the following:
   • Begin with clear statement about ASR being normal, common and expected responses to trauma, the reliance on self and buddy management, and other available resources if stress symptoms persist or worsen
   • Maximize positive expectation of mastery
   • Demystify PTSD (before listing symptoms) and emphasize the human brain and mind’s natural resiliency; e.g., our forefathers/mothers, generations ago survived very bad situations or we wouldn’t be here, and we can survive also
   • Painful memories sometimes get stuck, through no fault of the sufferer. Such memories cause real biological changes that can cause physical change and illness elsewhere in the body. Many of these changes can be reversed. All can be compensated for by developing new brain skills, aided by medication when appropriate
   • Professionals with special skills and capabilities (including some religious pastors and mental health professionals, other medical people and others with special training and supervision) can intervene to reverse this process
   • Resolving developing symptoms and problems.

DISCUSSION

Normalization is a concept that can incorporate helping asymptomatic survivors to:

• View other people’s (and their own possible future) stress reactions as normal, common, and expectable responses to trauma
• Recognize that peoples’ sometimes inadequate attempts to cope with their reactions are also within the range of “normal” for the strange situation.

Asymptomatic survivors can help symptomatic ones to see that it is natural for them to wonder how they’re doing and to be surprised or upset by the intensity, duration, or uncontrollability of their reactions.

The evidence base for the utility of normalization is weak. Few studies have attempted to assess the degree of normalization of survivor attitudes and establish a relationship with PTSD and other outcomes. Also unstudied is whether reassurance of normality and likely recovery provided by co-survivor peers or helpers actually serve to promote normalization. Nonetheless, the concept of normalization is consistent with theories of the development and maintenance of PTSD and with research showing a relationship between negative reactions to symptoms and PTSD (Steil & Ehlers, 2000).