Posttraumatic Stress Disorder Resulting from Workplace Violence

Introduction

Workplace violence and mass shootings in the office environment can significantly impact the mental health of those directly or indirectly affiliated with the organization: the injured, survivors and witnesses, colleagues, family members, and in some cases, clients and customers of the organization. It is not uncommon for survivors of a violent attack or mass shooting to experience a variety of responses including depression, anxiety, and post traumatic stress disorder (Shultz, 8). Posttraumatic stress disorder (PTSD) is when a person experiences or is exposed to a traumatic event or events which may result in a variety of debilitating symptoms. In the book Posttraumatic Stress Disorder, PTSD is described as when “posttraumatic stress reactions persist for at least 1 month and interfere significantly with personal adjustment and functioning” (Ford et al., 7). When a victim of trauma experiences these symptoms or posttraumatic stress reactions for a prolonged period and it causes significant and negative changes to their way of life, then it is likely that they are struggling with PTSD.

Though serious, PTSD can be treated to result in successful resolution for the patient. There are a variety of treatment options including cognitive psychotherapies, experiential and psychodynamic therapies, body and breath work, mindfulness practice, and more (Ford, et al., 300). The following case study provides an example of a traumatic event experienced by a young woman. This paper will address her personal trauma history, her physical and emotional reactions to the event, and the effects of these on her life. It will conclude with her diagnosis of posttraumatic stress disorder and the recommended therapeutic treatment plan for her recovery.

Case Study: Callie (This case study is fictionalized. Any resemblance to a real person(s) or situation is completely coincidental and unintended.)

Callie is a 31-year old Mexican-American female who witnessed workplace violence that ended in multiple deaths. She was not directly threatened by the perpetrator, but saw five coworkers shot, three of whom died from their wounds. Callie had been with the company for about two years and was friendly with her colleagues, though they didn’t socialize outside of the office except a time or two after work. While she knew the offender, a coworker, they did not frequently work together on projects nor socialize. Callie left the company shortly after the shooting stating she couldn’t face returning to the scene. Callie’s fiancé, Derek, expressed concern to her family and friends after she began waking in the middle of the night in a state of fear, withdrew from most of her friends and her sister with whom she is extremely close, and became more prone to outbursts of anger toward him than usual. He recounted that she’d even said one night, while drinking and angry, that they should maybe call off the wedding. She’s experienced headaches and frequently complains of fatigue. Derek and her family describe Callie as ordinarily being relaxed, optimistic, and patient, so this behavior is out of character. It was Derek and her family who encouraged Callie to seek help from a therapist who works with victims of trauma though she was reluctant to attend.

During an introductory session, Callie informed her therapist that she grew up in nice home in Kansas City and has close relationships with most of her family. However, as a child and adolescent she frequently witnessed violence against her mother and oldest brother at the hands of her father. She and her sister experienced aggression by their father, but never physical abuse such as hitting, slapping, or kicking. She revealed that it scared her and she knew it was wrong. She feared her father would eventually turn on her and often hid with her sister when he was angry. She added that Derek is “nothing like that” and she feels safe and loved with him. In this same session, she acknowledged that she feels angry a lot, doesn’t want to talk to anyone including a therapist, gets incredibly anxious when Derek tries to get her to go out in large, public places, and revealed that she started smoking again, after 5 years without a cigarette. Callie stated that she knows the shooting at work has affected her and she’s “not handling it well” and that’s why she finally agreed to try to get some help.

Diagnosing Posttraumatic Stress Disorder: Signs and Symptoms

The symptoms of posttraumatic stress are broad, but several of the symptoms Callie has described meet the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Callie has experienced “recurrent distressing dreams,” and “involuntary and intrusive distressing memories of the traumatic event.” Additionally, she quickly left the company following the event, which the DSM-5 describes as “avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings…associated with the event” (271). And finally, she exhibits indications of the DSM’s criteria for PTSD with her newly formed negative beliefs about the safety of the world and society, angry outbursts at those she cares about, withdrawal from family and friends, and increased negativity (272).

Based on the initial assessment of Callie, her symptoms, and the violent event she both witnessed and survived, as well as the knowledge that she has experienced these for more than a month and does not have a history of drug or alcohol abuse, her therapist determined her diagnosis as posttraumatic stress disorder.

The shooting at her company left Callie dually traumatized as both a survivor in the attack and a witness to multiple murders. Trauma can be both experienced or observed and either can lead to PTSD. Briere and Scott (2015) explain that in cases of murder or suicide “witnessing such events can produce significant psychological distress and symptomatology” especially when the victims are known to the witness (19). This alone would be enough to cause Callie extreme emotional instability, but combined with her own confrontation with the possibility of being a victim, this combination easily heightened her vulnerability to posttraumatic stress.

Callie was initially hesitant to pursue treatment but finally did so at the urging of her family and fiancé. Corrigan and Hull (2015) described some of the reasons why patients choose not to seek out treatment despite acknowledging they need help which included “a perceived lack of effectiveness (it would not help or did not help in the past), dissatisfaction with services, stigma or fear of forced hospitalisation” (80). When pressed as to why she was reluctant to meet with a therapist, she explained that she felt “broken” and that she would not be able to get over what she witnessed. In her case, the negativity, avoidance of any recollection of the event, and ongoing distress caused by this trauma appeared to have initially disrupted her ability to recognize the potential benefit of therapy. Additionally, it is also likely that her past traumas from childhood and lack of a successful resolution at that time, may have also contributed to her reluctance.

How Previous Traumas Can Affect New Traumas: The Physical, Neurological Effects of Trauma

After developing a rapport with her counselor, Callie divulged details of her childhood and adolescence, some filled with immense joy, peace, and love and others with terror, embarrassment, and anger. A history of trauma can have a significant impact on how a person reacts to a new trauma situation, particularly neurologically and physically. When the early traumas occur in childhood, this can have a long-term impact well into adulthood. In a 1992 study by Cole and Putman, it was reported that intrafamilial abuse is progressively more acknowledged as a precedent for symptoms of complex traumatic stress (van der Kolk, 228). Despite her happy life and sunny disposition before the shooting, it’s highly probably that Callie’s history of family violence was a significant factor in her short and long-term reaction to that event.

Trauma specialist Bessel van der Kolk explains how trauma is able to influence multiple levels of the brain from the brainstem which controls homeostasis to the limbic system which balances between internal and external environments, to the neocortex which analyzes and responds to the external world (214). The human brain’s hardwired stress reactions like flight, fight, freeze, attach, and submit have innate and biological adjuncts which may be triggered years following the early trauma (Corrigan & Hull, 80). What this means is that when trauma is sustained at a young age or multiple or chronic traumas are endured, these are stored within both the brain and the body. They have the detrimental power to reemerge suddenly when triggered. This may result in a somatic response to a new trauma also known as body memory, a psychological response such as dissociation, or a multitude of both physical and psychological reactions. It is when these responses culminate and remain in a heightened state for a prolonged period of time that a diagnosis of PTSD may be confirmed. While experiencing a single trauma or multiples does not always lead to PTSD, it is more common than not. For example, in 2007 and 2008 studies on mass shootings by Virginia Tech University and Northern Illinois University, their results showed that survivors of past sexual assault were more prone to PTSD and depression one year post-shooting (Shultz et al., 9). The impact of their past trauma had a direct correlation to their psychological outcome following their experience with a mass shooting.

In the 2014 article, Multiple Vantage Points on the Mental Health Effects of Workplace Violence, the authors reported that “study findings consistently show that symptom levels of posttraumatic stress disorder (PTSD), anxiety, and depression increase following mass shootings, at least within a short-term time horizon, for individuals with a certain level of exposure” (8). In Callie’s case, she bore witness to multiple people being wounded and fatally injured and she also experienced the terror of becoming a potential victim herself.

Recommended Treatment Plan for Callie’s PTSD Diagnosis

Several treatment options exist to help resolve symptoms of PTSD. Psychotherapy, eye movement desensitization and reprocessing therapy (EMDR), and pharmacotherapy are most often cited as effective treatment options (van der Kolk, 417). Exposure therapy, self-inoculation training (SIT), and affect regulation training are also shown to be effective. Some of these methods can serve as highly effective supplemental aides to more traditional or common methods. For example, breathing techniques and grounding exercises to get the client to focus on their body. Another is known as intrinsic processing and works with the natural tendency and ability of human beings to process traumatic events and adapt their functioning (Briere & Scott, 97). With Callie, a combination of these methods and others were recommended. These included: EMDR, cognitive behavior therapy (CBT), meditation and mindfulness practice, and physical activity and body work.

Intrinsic processing builds upon the brain’s innate desire to heal from trauma. As explained in Principles of Trauma Therapy, Briere and Scott write that reexperiencing the event through flashbacks or nightmares is the brain’s way of desensitizing and integrating. What they suggest is that when faced with recurring memories of the traumatic event, the person is attempting to self-resolve their distress and painful feelings affiliated with the trauma. They imply that “this perspective reframes many posttraumatic symptoms as, to some extent, adaptive and recovery-focused rather than as inherently pathological” (98). They posit that exposure therapy methods, such as EMDR and sensorimotor psychotherapy, may be so effective because they enhance the brain’s innate attempts to heal. This more holistic approach to engaging both mind and body in the healing process works on both the limbic part of the brain and brain stem as well as the neocortex, each of which classify memory differently. The latter keeps explicit memory such as time and place, while the former knows no chronology but instead remembers sensory stimuli, muscle memory, reflex. It is in the body and the limbic and brain stem where traumatic memory is held because it is not cognitive. It is gut reaction, a flooding of the body with stress hormones, and physical shock from the horror of the event (Barnum). Corroborating this, Corrigan and Hull explain that it is through individual “motor tension patterns that trauma memories are accessed in body-based psychotherapy: these are the route to healing in somatic experiencing and sensorimotor psychotherapy” (80)

In their journal article Integrating EMDR in psychotherapy (2019), Balbo, Cavallo, and Fernandez fortify the notion that humans possess an inherent ability or at least drive to heal. When describing the basic concept of EMDR, they write consists of considering the existence of an innate system, which is physiologically oriented to process information to promote mental health (24). Just as when humans sleep and fall into rapid eye movement (REM), the mind and body is trying to cleanse and repair. EMDR combines information processing with a bilateral stimulation of the brain by guiding the patient’s eye movement quickly side to side while they visualize a traumatic image and concentrate on a negative cognition that accompanies it. Throughout the session, the counselor will stop the eye movement tracking to ask the client what they’re feeling or experiencing and will then encourage the client to stay with that emotion or memory, even if painful. It is during the eye movement process that the brain is actively healing and eventually, the goal is for a positive cognition to present stronger than the negative (Schupp, 140-141). The goal is for the counselor to be present with the client as they recall the trauma while “keeping one foot in the present” (Barnum). EMDR helps connect the traumatic memory with new information and blend the painful thoughts and emotions with positive ones.

For Callie, the image that came to mind was being on the ground in her office area hearing the screams of coworkers, the angry voice of the shooter, and gunshots as she stared in horror at the sight of one of her fallen colleagues only 15 feet away. She felt that her negative cognition was that she would never be safe and that she is now “a broken person.” During her first session, Callie finally felt the full weight of her despair, fear, sadness, and guilt. She released cathartic tears and screams, at times asking to end the session. She later expressed her surprise when memories of the violence of her childhood came up for her during the session. Following that revelation is when something began to shift in her cognitive belief and a new feeling began to take hold; a belief she described as no longer feeling guilty for the violence she witnessed in her youth or in the shooting and viewing herself not as a victim but a survivor with courage and grace.

Though the EMDR was highly effective, Callie’s treatment plan also included cognitive behavior therapy, an equally important therapy tool. CBT is an evidence-based approach that can have especially positive results for clients with trauma and the method “applies quite naturally to PTSD where clients cognitively recognize and emotionally respond to a life-threatening situation (Schupp, 132). Cognitive interventions utilize the client’s ability to change their way of thinking through insight, contradiction of negative thoughts or beliefs, and interpreting their problem through a new lens (Briere & Scott, 162). Trauma-focused CBT (TF-CBT) helps the patient recognize that “there really wasn’t much that he or she could do in the face of one or more uncontrollable traumatic events” (162). Thus, their guilt and shame that they survived, that they didn’t stop or prevent the trauma, or perhaps that they deserved it is contradicted.

Because Callie had both past and recent traumas to contend with, CBT worked well for her. Over several sessions, Callie’s narrative of her memories as a child watching her father hurt her mother and brothers, paralyzed in fear that one day he would turn on her and her sister began to shift away from feeling guilt because she should have intervened to acknowledging her young age and inability to stop the abuse, her ability to endure and survive, and her inner strength. And rather than stay with the belief that she should have stopped the shooter or gone to the aid of her wounded coworkers, with CBT she reoriented her thinking to focus on her courage, survival skills, and her desire to live the happy life she deserves. By the end of her sessions, she was able to confidently feel like she was no longer “broken.”

In addition to her CBT, some more holistic methods were recommended as well. More clinicians are recognizing the benefits to mindfulness-based practices such as meditation and yoga. In fact, within the last 15-20 years, more clinicians are acknowledging new thoughts on “cognitive-behavioral theories and therapies, involving the explicit compatibility of mindfulness with CBT” (Briere & Scott, 220). Her counselor introduced Callie to guided meditations using visual imagery, focus on the breath, and body scans. Daily meditation practice was incorporated into Callie’s treatment plan moving forward.

She told her counselor that another tool that helped her feel empowered was her enrollment in yoga classes. Her counselor explained the benefits of mindfulness practice, breath work, and physical movement to aid in recovery for mind, body, and spirit. Explaining the science behind this methodology, Corrigan & Hull referenced Drs. Brown and Gerbarg writing that “body oriented breathing exercises…and yoga breathing cycles (e.g. Brown & Gebarg, 44), based in the respiratory central pattern generators of the brainstem, can be used clinically to augment affect regulation (83). Van der Kolk explained that breathing changes the body’s automatic nerve system and the brain processes trauma within both the body and the mind. PTSD cannot be processed solely by words and understanding. The whole body is disturbed in a traumatic situation which is why movement is such a powerful tool in helping clients with trauma.

Conclusion

Callie’s history of family violence, both as a witness and the chronic stress of the threat of violence upon her and her loved ones undoubtedly had a profound and lasting impression on her neurologically, physically, psychologically, and perhaps developmentally. While those experiences did not appear to have caused her to experience posttraumatic stress symptoms prior to the shooting, it seems evident that her past trauma had a sizable impact on her during and following her experience in the shooting deaths and injuries of her colleagues and perceived threat to her own life.

An event as rare as a mass shooting in the workplace would cause most anyone substantial fear, doubt, and pronounced grief. In fact, trauma of any kind has the ability to cause depression, anxiety, physiological impairments, problems focusing and sleeping, and other mental health issues. Posttraumatic stress disorder is also often diagnosed after traumatic events. Though it was initially considered a rarity when introduced in the DSM-3, posttraumatic stress disorder is more commonly diagnosed today, better understood and researched, and has several empirically supported treatments.

In the case of Callie, both her past and her recent traumas compounded leading to her PTSD diagnoses and subsequent therapeutic treatment utilizing CBT, EMDR, and a combination of breath work, body movement, and meditation. The combination of treatment methods helped Callie work through her painful and intrusive memories using both mind and body to redirect a narrative which was stuck in fear, resentment, and self-doubt. These methods were effective in treating her emotions, her body memory, her sensitivity to the memory of the shooting, and in helping her find healthy ways of self-regulating. Through her hard work, the efforts of her counselor, and the support of her loved ones these therapies provided Callie with the tools to progress with her life confidently and courageously and to be better prepared to withstand any potential future traumas.

Disclosure: I wrote this paper written for a class at the University of Oklahoma - Tulsa in the Clinical Mental Health Counseling graduate program in the fall of 2020. The knowledge, research, and references provided in this paper are from class lecture and the cited sources (reference list below). I'm a first-year graduate student, thus not yet licensed or degreed.

References

Ford, J.D, Grasso, D. J., Elhai, J.D., & Courtois, C.A. (2015). Posttraumatic Stress Disorder. San Diego: Elsevier Science & Technology.

Schupp, L. J. (2015). Assessing and Treating Trauma and PTSD. Ashland: PESI Publishing & Media.

Shultz, J.M., Thoresen, S., Flynn, B.W., Muschert, G.W., Shaw, J.A., Espinel, Z., Cohen, A.M. (2014). Multiple Vantage Points on the Mental Health Effects of Mass Shootings. Current Psychiatry Reports, 16(9), 1-17.

United States. Office of Justice Programs. Office for Victims of Crime, issuing body. (2017). Workplace violence. https://permanent.fdlp.gov/gpo81876/2017NCVRW_WorkplaceViolence_508.pdf

Balbo, Marina, Cavallo, Francesca, & Fernandez, Isabel. (2019). Integrating EMDR in Psychotherapy. Journal of Psychotherapy Integration, 29(1), 23-31.

Corrigan, F.M., Hull, A.M. (2015). Recognition of the neurobiological insults imposed by complex trauma and the implications for psychotherapeutic interventions. Cambridge: BJPsych Bulletin.

Van der Kolk, B. A., & McFarlane, A. C. (Eds.). (1996). Traumatic stress: The effects of overwhelming experience on mind, body, and society. Guilford Press.

Briere, J. N., & Scott, C. (2014). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment (DSM-5 update). Sage Publications.

Barnum, L. (2020, December). HR5623-980: EMDR, Somatic Approaches to Trauma. Traumatic Memory – “The Body Keeps the Score”. Lecture conducted from University of Oklahoma, Tulsa, OK.

Van der Kolk, B.A. (2006, February) National Child Traumatic Stress Network. Master Clinicians Series: Developmental Impact of Childhood Trauma. Lecture conducted from National Child Traumatic Stress Network, Rockville, MD.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Publisher.