Continuous Traumatic Stress:

Expanding the Lexicon of Traumatic Stress

Gillian Eagle
University of the Witwatersrand
Debra Kaminer
University of Cape Town
Despite substantial theoretical and empirical advances in the eld of traumatic stress
since the introduction of the diagnosis of posttraumatic stress disorder (PTSD) into the
mental health nomenclature, existing conceptualizations of traumatic stress retain the
assumption that traumatic experiences have occurred in the past. We propose contin-
uous traumatic stress (CTS) as a supplementary construct within the lexicon of
traumatic stress, to describe the experience and impact of living in contexts of realistic
current and ongoing danger, such as protracted political or civil conict or pervasive
community violence. We discuss four key characteristics of CTS and consider these in
relation to existing formulations of complicated traumatic stress: the context of the
stressor conditions, the temporal location of the stressor conditions, the complexity of
discriminating between real and perceived or imagined threat, and the absence of
external protective systems. We advance a tentative descriptive picture of how CTS
may present and discuss the potential adaptive and pathological dimensions of the
phenomenon.
Keywords: continuous traumatic stress, complicated traumatic stress, ongoing danger, commu-
nity violence, protracted conict
Daily exposure to violence and trauma is
common for many individuals and communities
globally, with an absence of safe spaces to
escape from danger or threat. Despite this, ex-
isting formulations of traumatic stress responses
continue to assume that trauma exposure is lo-
cated in the past, although it intrudes into the
present in distressing and maladaptive ways.
The idea of continuous traumatic stress
(CTS), in contradistinction to the post in post-
traumatic stress disorder (PTSD), was originally
generated among a group of anti-apartheid men-
tal health activists in the context of the political
violence and state oppression of 1980s South
Africa, and was rst formally introduced into
the literature by Straker and the Sanctuaries
Counselling Team (1987). Those working with
South African victims of state repression who
had been detained, tortured, tear-gassed, beaten,
shot at, and threatened with loss of life observed
that, in many instances, therapy was constrained
by the fact that clients faced the realistic pros-
pect of future victimization and were often liv-
ing under precarious circumstances, including
moving from one potential place of refuge to
another. In one instance, the church-run center
at which a number of activists were being
treated was raided by security forces in the early
hours of the morning, illustrating quite how
little protection there was for these young peo-
ple at this time in South Africa (Straker & the
Sanctuaries Counselling Team, 1987).
It was hypothesized that the impact of these
kinds of ongoing stressor conditions might be
somewhat different to that encompassed by
PTSD, which centers on physiological and psy-
This article was published Online First April 8, 2013.
GILLIAN EAGLE is Professor of Psychology in the School
of Human and Community Development at the University
of the Witwatersrand, and is also a practicing Clinical
Psychologist. She has worked in the traumatic stress eld in
South Africa for over 30 years as researcher, activist, ther-
apist, trainer, supervisor, and consultant.
DEBRA KAMINER is a Senior Lecturer in the Department
of Psychology and Director of the Child Guidance Clinic at
the University of Cape Town, South Africa. She teaches and
supervises clinical psychology trainees working with
trauma survivors and has conducted research on trauma
exposure and sequelae in the South African population.
CORRESPONDENCE CONCERNING THIS ARTICLE should be
addressed to Gillian Eagle, Department of Psychology, Uni-
versity of the Witwatersrand, Private Bag X3, WITS, 2050.
South Africa. E-mail: gillian.eagle@wits.ac.za
Peace and Conict: Journal of Peace Psychology 2013 American Psychological Association
2013, Vol. 19, No. 2, 8599 1078-1919/13/$12.00 DOI: 10.1037/a0032485
85
chological responses that are focused on past
traumatic events that continue to intrude into the
present. However, although Straker and the
Sanctuaries Counselling Team (1987) inferred
certain characteristics of CTS, the central focus
of their discussion was upon therapeutic or in-
tervention approaches designed to take account
of the experiences of individuals living under
conditions of continuous trauma exposure.
Since then, CTS has gained considerable pur-
chase among South African trauma theorists
and service providers, and, as evidenced in
emerging research on continuing and ongoing
trauma in other parts of the world (Cohen, Man-
narino, & Murray, 2011; Diamond, Lipsitz, Fa-
jerman, & Rozenblat, 2010; Lahad & Leykin,
2010), it appears to have resonance beyond the
South African context. However, the parame-
ters, usefulness, and validity of the CTS con-
struct have been underexplored since it was rst
introduced into the literature some 25 years ago.
This article aims to address this gap by exam-
ining the conceptual identity of CTS. The sa-
lient features of CTS, and their implications for
treatment approaches, will be elaborated and
considered in relation to other traumatic stress
conditions, in order to explore whether the con-
struct may be a valuable supplement to the
existing trauma lexicon.
At the outset, it should be emphasized that
this article seeks to esh out the dimensions of
CTS primarily from a phenomenological per-
spective rather than proposing a new diagnostic
category. Being all too aware of the manner in
which human suffering has, in some respects,
been colonized by psychiatric theorization and
the dominance of diagnostic framings such as
PTSD (Eagle, 2002; Reisner, 2003; Summer-
eld, 2001), we revisit the construct of CTS
with circumspection in this regard.
We recognize a tension in developing CTS as
a descriptor and seeking to secure an identity for
the construct in the mental health eld. On the
one hand, following in the footsteps of those
who rst articulated CTS from an experiential
base, we believe that foregrounding the notion
of CTS represents some push back against the
centralization of PTSD as the benchmark
against which all traumatic-stress-related re-
sponses and conditions are assessed. In this
sense, proposing the usefulness of CTS as a
further or complementary descriptor to existing
conceptualizations is a political intervention
aimed at highlighting the kind of traumatic
stress suffered primarily by systematically op-
pressed, deprived, and marginalized popula-
tions, as will be further highlighted in the ensu-
ing discussion.
On the other hand, elaborating a construct
that has its etymological base in the language of
posttraumatic stress, and attempting to describe
what such a condition might encompass, creates
the potential for overpathologizing response
patterns to particularly violent and dangerous
environments. For this reason, it should be
noted that while borrowing from the terminol-
ogy of PTSD, CTS is advanced as a construct
without the attached disorder label. At the
same time, it is important to note that we un-
derstand the kinds of contexts in which CTS
might arise to be unnatural or aberrant. Even if
they are more common than generally appreci-
ated, the kinds of stressors to which community
members are exposed in the context of CTS are
extreme and involve the kinds of threat to life
and bodily integrity that are generally under-
stood to constitute traumatic rather than chronic
stressors. For this reason, the article engages
with existing traumatic stress literature and con-
structs at the same time that it seeks to stretch
the boundaries of what is usually encompassed
within this framework. Questions about adapta-
tion and maladaptation are more fully debated
toward the end of the discussion, following the
eshing out of what is encompassed under the
rubric of CTS.
It is also worth noting that as critical clinical
psychologists, as opposed to critical social or
community psychologists, we are invested in
exploring the kind of impact that such contexts
may characteristically have on individuals and
groups and in thinking about treatment implica-
tions in a therapeutic sense. This is not to say
that we fail to recognize that, ultimately,
situations of continuing violence are most ef-
fectively addressed by large-scale political, eco-
nomic, and social interventions. However, such
interventions are very often difcult to achieve
for a whole range of reasons (as is evident in the
ongoing, apparently intractable, conict be-
tween Palestinians and Israelis), and while con-
ict and violence persist, individuals are forced
to endure ongoing conditions of potential
trauma exposure. We believe that there is merit
in thinking about such conditions of existence
in terms of CTS. In order to advance our elab-
86 EAGLE AND KAMINER
oration of the construct, we begin by engaging
with related constructs in the trauma literature
with a view to highlighting similarities and dif-
ferences between these constructs and CTS.
Existing Formulations of Complicated
Traumatic Stress
Indicative of increasing renement and elab-
oration of the impact of traumatic stressors over
the past 20 or so years, there have been a range
of constructs introduced into the literature de-
signed to theorize what might be termed com-
plicated forms of traumatic stress, that is, psy-
chological responses to prolonged or multiple,
as opposed to single, potentially traumatic
events. Complex PTSD (C-PTSD; Ford &
Courtois, 2009; Herman, 1992) and develop-
mental trauma disorder (van der Kolk, 2005) are
proposed diagnostic categories that attempt to
capture the psychological impact of prolonged
abuse within the context of a relationship with a
perpetrator, whereas collective or historical
trauma (Gone, 2007, 2009) and identity trauma
(Kira, 2001) are constructs that have emerged to
reect the impact of traumas that target specic
groups of people, rather than individuals. As a
rst step in examining the identity of CTS, it
appears important to unpack these complemen-
tary formulations of complicated trauma. The
later discussion of CTS will examine its over-
laps with, and differences from, these existing
constructs.
Complex PTSD and Developmental
Trauma Disorder
Clinicians and researchers have observed that
exposure to traumatic stressors during child-
hood, particularly to multiple and chronic stres-
sors such as child maltreatment, abuse, and ne-
glect, may produce very particular effects.
Whereas the impact of extrafamilial traumatic
stressors may be minimized via the mediation
and intervention of caregivers, abuse by attach-
ment gures, or what are often referred to as
Type II traumas (Terr, 1991), may produce last-
ing effects in respect of biological, affective,
cognitive, and interpersonal functioning.
Hermans (1992) conceptualization of C-
PTSD is a formulation that has gained increas-
ing purchase in the trauma literature, despite the
likelihood that it will not become included as a
formal diagnostic category in the fth edition of
the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5; American Psychiatric Asso-
ciation, in press; see Resick et al., 2012). Her-
man (1992) introduced the idea of C-PTSD into
the literature specically to describe the clinical
presentation of persons who had been exposed
to prolonged and repeated traumatic stressors,
most often in situations that were inescapable.
She proposed that adults with histories of child-
hood abuse, survivors of intimate partner vio-
lence, prisoners of war, concentration camp sur-
vivors, and girls forced into sex slavery, among
others, were likely to present quite differently
from those who had experienced single-event
traumas. Drawing upon her own observations
and the work of a range of other theorists and
researchers, she proposed that there are specic
symptomatic, characterological, and relational
patterns that can be identied in these kinds of
populations (Herman, 1992).
For example, Herman (1992) argued that so-
matization, dissociation, and affective changes,
particularly proneness to depression, were com-
mon, and also that PTSD symptoms were likely
to be more diffuse and intractable. Very signif-
icantly, she suggested that the kinds of adapta-
tions that individuals are compelled to make in
situations of sustained subordination might be-
come incorporated into their characteristic ways
of being over time, such that individuals might
become passive, withdrawn, or intensely depen-
dent, and might experience their identities to be
precarious and unstable. In addition, she ob-
served that victims of prolonged victimization
might engage in repetitive behaviors or interac-
tions that were harmful to them, such as becom-
ing involved with violent partners or engaging
in self-injury or substance abuse.
Whereas Herman (1992) based her formula-
tion of C-PTSD largely upon clinical observa-
tions of adult survivors of abuse, developmental
trauma disorder has been proposed more re-
cently by van der Kolk (2005) as a diagnostic
category that applies to abused children. Van
der Kolk argues that the diagnosis of PTSD
does not adequately reect the developmental
impact of prolonged abuse on children, which
includes disturbances in attachment patterns,
the loss of strivings for autonomy, emotional
dysregulation, impaired judgments about risk,
negative self-attributions, and the loss of expec-
tancy of protection from others. There is sub-
87 CONTINUOUS TRAUMATIC STRESS
stantial overlap between the diagnostic pictures
proposed by C-PTSD and developmental
trauma disorder, with both emphasizing emo-
tional dysregulation, disturbances in identity,
instability in attachment relationships, and an
increased risk for traumatic reenactments. Fur-
ther, these diagnostic formulations bear many
similarities to the diagnosis of borderline per-
sonality disorder (Lewis & Grenyer, 2009), a
disorder that is strongly associated with a his-
tory of child abuse (Zanarini et al., 1997). Her-
man (1992) argues that the diagnosis of border-
line personality disorder does not explicitly link
symptoms with traumatic antecedents in the
way that the diagnosis of C-PTSD does, result-
ing in ineffective treatment of many abuse sur-
vivors. C-PTSD also represents a less pejorative
diagnosis because causation is understood to be
situational or external to the individual (Her-
man, 1992).
Reading Hermans original 1992 paper on
C-PTSD, it is evident that much of the theori-
zation pertains to conditions of pathological
bondage to a powerful, persecutory object stim-
ulated by prolonged, forced interaction with,
and dependence upon, such a personage. She
writes in the introductory section of the paper,
Captivity, which brings the victim into pro-
longed contact with the perpetrator, creates a
special type of relationship, one of coercive
control (Herman, 1992, p. 377), and further
argues that this control is based upon the sys-
tematic, repetitive iniction of psychological
trauma. These methods are designed to instill
terror and helplessness, to destroy the victims
sense of self in relation to others, and to foster
a pathologic attachment to the perpetrator (p.
384). Herman emphasizes the destruction of
autonomy and the isolation of the victim from
other supports, such that a primitive relationship
of dependence with the perpetrator/s is set up,
creating conditions for traumatic bonding. Al-
though Herman acknowledges that subordina-
tion may in some contexts be more abstract, as
in the exercise of repressive political power, it
appears that the conditions within which C-
PTSD can be most plausibly theorized to de-
velop require an intense interpersonal interac-
tion in which there is overt domination and
deliberate humiliation and terrorization. What
we wish to emphasize here is that the formula-
tion of C-PTSD is strongly embedded in an
attachment theory framework, which is perhaps
why there has been an increasingly powerful
linking between C-PTSD and developmental
trauma disorder.
Historical, Collective, and Identity Trauma
A second salient conceptualization of com-
plicated traumatic stress is encompassed under
what has been termed historical trauma (Gone,
2007, 2009) or collective trauma, and may also
be broadly related to what has been termed
identity trauma (Kira, 2001). It has been argued
that some traumatic events are directed at and
affect whole groups, rather than individuals,
and in this sense become collective traumas.
The collective usually comes under attack be-
cause of particular group identity characteris-
tics, the most widely acknowledged illustration
of this kind of trauma being the persecution of
people of Jewish ancestry (along with homosex-
uals and gypsies) in Nazi Germany. However,
there are numerous other examples of such
group traumatization, such as the mass rape and
murder of Tutsis during the Rwandan genocide,
the attacks experienced by both people of Cath-
olic and Protestant afliation during the 30-year
troubles in Northern Ireland, and the ongoing
persecution of Kurdish people in parts of Tur-
key. Although the 9/11 attacks in the United
States were of short-lived duration, they have
also been described as a collective trauma af-
fecting the nation as a whole rather than only
those individuals most directly victimized (Up-
degraff, Cohen Silver, & Holman, 2008).
The term historical trauma tends to have
specic reference to the near genocide of indig-
enous peoples in North America with the arrival
of colonizing forces. Gone (2007) cites Stan-
nard, who estimates that 95% of the indige-
nous population died (p. 292) within a rela-
tively short period of American colonial history.
Genocidal practices were targeted at both as-
pects of psychological and physical survival:
Native people in the United States are heirs to
a shattering legacy of Euro American colonial-
ism in which both material and ideological war
was waged on the cultural practices of indige-
nous societies (Gone, 2007, p. 291). It is ap-
parent that, in many instances, collective trauma
is about the eradication of peoples cultural
beliefs and practices alongside actual annihila-
tion of persons, especially those who might
reproduce the targeted population.
88 EAGLE AND KAMINER
Although it is possible that some of those
within the targeted population may present with
conditions in line with PTSD, especially those
most directly targeted, it is further contended
that people may suffer from collective trauma-
tization by virtue of their group afliation and
identication with those who have suffered and
have lost their lives. The woundedness is car-
ried by the group and may produce powerful,
shared trauma narratives, affects, and practices.
For example, feelings of rage and/or pain and
retributive impulses may be collectively expe-
rienced, contributing to ongoing cycles of inter-
group conict. Collective trauma is often trans-
mitted across generations and may be carried by
descendants who have had no direct experience
of traumatic events themselves (Danieli, 1998;
Gone, 2007). Thus, it assumes indirect or vicar-
ious trauma transmission mechanisms.
The notion of identity trauma, closely tied to
collective trauma by virtue of emphasizing that
it is group identity characteristics that lead to
fears of persecution, harm, or even annihilation,
suggests both past and present trauma impacts.
In his conceptualization of identity trauma, Kira
(2001) suggests that experiences of discrimina-
tion, invalidation, and ideological attack may be
experienced as traumatic, and that the denition
of what constitutes a traumatic stressor should
be expanded to take account of these kinds of
attacks on identity: Complex, and other trau-
mas, for example, racism which is ongoing trau-
matic stress, cross-generation transmission of
severe poverty or relative deprivation, torture,
and genocide that threaten more the collective
identity of the individual are a completely dif-
ferent class of traumas (Kira et al., 2008, p.
63).
Having highlighted and described some of
the formulations of complicated trauma that are
most closely connected to notions of ongoing or
continuous traumatization, the discussion now
turns to elaborating the phenomenon of CTS
and its various dimensions, with the aim, in
part, of illustrating how CTS captures a domain
of traumatic stress that is distinct from these
existing constructs.
Characteristics of CTS
The idea of continuous traumatic stress is
tied to the recognition that, for many citizens of
the world today, trauma exposure is both cur-
rent and to be realistically anticipated in the
future, rather than being past or post. The dis-
tinguishing characteristics of CTS relate to its
context, the temporal location of the stressor
conditions, the complexity of discriminating be-
tween real and perceived or imagined threat,
and the absence of external protective systems.
Each of these characteristics will be discussed,
in turn, and considered in relation to the existing
formulations of complicated traumatic stress.
Finally, we will consider the potential adaptive
and pathological dimensions of CTS.
The Context of CTS
As opposed to C-PTSD or developmental
trauma disorder, which occur in the context of
more intimate or established relationships (such
as between prison guard and prisoner, or be-
tween abusive parent and child), CTS is under-
stood to occur in contexts in which danger and
threat are largely faceless and unpredictable, yet
pervasive and substantive. The rst kind of con-
text in which CTS is likely to be observed is in
conict-affected zones, such as those in which
there is low intensity warfare, in which there are
frequent terrorist attacks, including upon civil-
ian targets, or in which repressive state forces
operate with impunity. In relation to war and
political conict, Summereld (1999) observes,
it becomes a permanent emergency, something
constant and internal that colors the whole web
of relations across the society and the daily
calculations of its citizens (p. 1459).
Examples of this might be the experience of
living in the occupied territories in Israel or in
the Israeli towns bordering the occupied terri-
tories, or in the towns and villages of Syria that
are targeted by the state. The second common
context for CTS is that of chronic community
violence, especially where gangs are dominant
and state security forces are unable to intervene
to protect community members. Such circum-
stances have been observed in Mexico City
(Etter, 2011), in the favelas of Brazil (Arias &
Davis Rodrigues, 2006), and in the Cape Flats
communities of South Africa (Shields, Nada-
sen, & Pierce, 2008). A third context in which
we have observed that CTS may be prominent is
in respect of people who have been displaced by
virtue of persecution or warfare who nd them-
selves living in xenophobic contexts in which
they are preyed upon by others in society. For
89 CONTINUOUS TRAUMATIC STRESS
example, in South Africa, refugees, asylum
seekers, and immigrants who have ed vio-
lence-torn countries on the African continent
are disproportionately subject to harassment,
muggings, and criminal attack (Landau, 2006).
Although this list is not exhaustive, it is ap-
parent that these kinds of contexts are very
different from the relational contexts described
by Herman (1992) and van der Kolk (2005) as
producing C-PTSD or developmental trauma
disorder. Such contexts have closer overlap
with notions of collective, historical, or identity
trauma, but yet there are important distinctions.
The term historical trauma emphasizes previ-
ous events and processes rather than current and
ongoing ones, a temporal aspect that we elabo-
rate further in the next section. The term identity
trauma encompasses stressors (such as discrim-
ination) that are not necessarily classically un-
derstood to be traumatic in the sense of being
life threatening or threatening to physical integ-
rity (American Psychiatric Association, 2000).
The term collective trauma may not be a
useful descriptor of contexts of community
violence, because community violence does
not necessarily target people who share spe-
cic group-identity characteristics; and al-
though this term clearly has more resonance
for contexts of ongoing war, political vio-
lence, or xenophobia (which frequently entail
oppression or conict driven by group-based
identities), it tends to emphasize collective
responses to such conditions, rather than more
individualized responses.
The context of CTS may best be illustrated
with some case material. A woman who pre-
sented for treatment at a Johannesburg trauma
clinic reported that her husband and his business
partner had been murdered a fortnight previ-
ously by members of a rival taxi association.
Although she was evidently traumatized as a
consequence of this violent loss, her main con-
cern in the sessions was about her own and her
brothers safety. She believed that upon her
husbands demise, she and her brother, who
were involved in the same business, had be-
come the target of their rivals aggression. She
reported that she thought she had been followed
on a number of occasions and that there were
people watching her house. Her brother had
gone into hiding after being shot at, and her
contact with him was clandestine and infre-
quent. Although the murders had been reported
to the police, they had taken little action and
appeared afraid and reluctant to intervene. She
felt isolated from her existing supports and was
struggling to maintain her daily routine. There
was no possibility of her moving out of her
home and neighborhood, and the income for the
family was tied to her sustaining her involve-
ment in the business. Thus, she felt she had little
choice but to attempt to continue to exist within
these circumstances, and at times appeared fa-
talistic about her survival. She indicated that she
was unable to sleep because of constant fear of
attack, that she was on the alert at all times, that
she found it difcult to know who to trust
around her, that she was suffering from severe
headaches, and that her concentration was im-
paired.
Although these symptoms are largely consis-
tent with PTSD, they occur in a context of
realistic ongoing threat and therefore cannot be
characterized as a maladaptive false alarm
response to a past event. It is further evident that
this clients experience of stress differs from the
kinds of contexts that might give rise to C-
PTSD or developmental trauma and to collec-
tive or identity trauma. This would be the kind
of case that we would see as presenting with
what could be called CTS.
The Temporal Location of Traumatic
Stressors
To date, almost all conceptualizations of trau-
matic stress, and perhaps most iconically post-
traumatic stress disorder, assume a response
picture that develops as a result of prior expo-
sure to a traumatic stressor. The literature is
replete with descriptions of how traumatic stress
conditions reect problematic processing of an
experience that has already occurred. One of the
three main symptom clusters of PTSD (Ameri-
can Psychiatric Association, 2000) falls under
the umbrella label of intrusion. Intrusion ap-
pears to be a highly salient element of the trau-
matic stress response, and in fact, Brewin, La-
nius, Novac, and Galea (2009) have gone so far
as to propose that the only two symptoms that
distinguish PTSD from other psychiatric condi-
tions are the intrusive symptoms of ashbacks
and nightmares. It is evident that intrusion and
prior experience of trauma go hand in hand; the
content or subject matter of intrusive images
and associated stimuli is derived from the past
90 EAGLE AND KAMINER
traumatizing experience. For example, in the
language of classical conditioning theory (Foa
& Kozak, 1986), a stimulus, such as the color of
someones clothing, previously related to in a
neutral way, becomes imbued with anxiety and
produces physiological arousal states as a con-
sequence of the mapping of the traumatic (con-
ditioning) experience onto a current stimulus.
Anxiety in the present stems from a past anxi-
ety-laden experience.
In addition, many of the features encom-
passed under the second major PTSD symptom
cluster of avoidance also assume that what is
avoided is the product of a historical occur-
rence, that is, a trauma that has already taken
place. For example, the second symptom de-
scription under Section C of the diagnosis is
worded as follows: efforts to avoid activities,
places, or people that arouse recollections of the
trauma (American Psychiatric Association,
2000, p. 468), the word recollections clearly
connoting something about an event that has
already taken place. In this respect, it is appar-
ent that PTSD symptomology is powerfully de-
termined by prior trauma exposure. Finally, the
third symptom cluster of PTSD, which encom-
passes aspects of increased physical arousal,
assumes that the need for physical preparedness
for danger is no longer realistically required, as
the traumatic event is in the past. For example,
this cluster includes symptoms such as hyper-
vigilance and an exaggerated startle response
(emphasis added), responses that are inappro-
priate or excessive if danger and threat are no
longer realistically present. Further highlighting
the centrality of the assumption that traumatic
stress is primarily related to the (maladaptive)
processing of past events are references in the
trauma literature to PTSD as fundamentally a
disorder of memory, involving a kind of tem-
poral dislocation in which the present becomes
overlaid by the past (Brewin, 2001; van der
Kolk, 1996).
Similarly, in the case of C-PTSD, the infer-
ence is that the individual is being observed and
treated, having now escaped their conditions of
captivity. The diagnostician or therapists pri-
mary task is to address the aftereffects of the
prolonged and multiple victimization, rather
than to assist the client to cope or function
within ongoing conditions of traumatization.
When therapy for clients with C-PTSD includes
attention to addressing abusive dynamics in cur-
rent relationships, these are worked with as rep-
resenting a repetition of the core trauma that
remains the primary focus of therapeutic work,
as this is where the pathology originated. Re-
peated references in the PTSD and C-PTSD
literature to notions of reliving, replaying, and
reenactment of past traumatic experiences cap-
ture this assumption that in posttraumatic stress,
the past becomes imposed on the present in
problematic ways.
However, the notion of CTS assumes a dif-
ferent temporal focus, one that appears to re-
quire alternative or supplementary theorization
of mechanisms of traumatization. Whereas
those living in contexts of ongoing threat have
often experienced prior exposure to traumatic
events, and often multiple prior exposures, the
primary preoccupation in CTS is with their cur-
rent and future safety, rather than with past
events. When the primary focus of traumatic
awareness is upon anticipated danger, it is likely
that thinking is dominated by fantasies of what
might occur and ways of avoiding this. Thus,
rather than intrusions being dominant in cogni-
tion, preoccupation with safety is likely to be
most prominent (Diamond et al., 2010). Instead
of attempting to process and detoxify imagery
and arousal linked to previous experience, the
task in this instance is to prepare for future
traumatization and to develop the ability to dis-
criminate between stimuli that might pose a
real, immediate, or substantial threat from other
everyday stimuli. In this respect, there is some
resonance with the literature on Type II trau-
mas, such as experiences of recurrent physical
or sexual abuse, in which it is suggested that
anticipatory anxiety and related vigilance
comes to play an increasingly prominent role.
Marx, Heidt, and Gold (2005) have proposed
that adult survivors of childhood sexual abuse
who perceived the abuse to be unpredictable
and uncontrollable focus their resources on
emotional regulation of fear and arousal re-
sponses. We would suggest that individuals in
contexts of CTS experience similar concerns
about loss of control in respect of the realistic
likelihood of facing future violation and simi-
larly may devote their energies predominantly
to managing the anxiety associated with this
possibility or prospect.
Thus, the mental life of the person experienc-
ing CTS is characterized by preoccupation with
thoughts about potential, future traumatic
91 CONTINUOUS TRAUMATIC STRESS
events (possibly informed by imagery derived
from prior and immediate exposure of either an
indirect or direct nature), rather than with the
details of a previous unprocessed event. Al-
though this distinction may seem somewhat in-
substantial, we would argue that this difference
in where psychic energy is focused, in terms of
temporal emphasis, has a range of important
implications for how traumatic states present
and for how they might optimally be understood
and addressed. For example, it is apparent that
the exposure elements so central to many
traumatic stress treatment approaches (Marotta,
2000), such as repeated retellings of the trau-
matic memory in the safe presence of the ther-
apist, are designed to reduce the anxiety asso-
ciated with the processing of a past experience.
Such interventions tend to assume that treat-
ment takes place in a context of safety in which
it is appropriate to reinforce the idea that the
danger is now past. This is clearly not the case
in CTS, as is further discussed in the subsequent
section.
Discriminating Between Real and Perceived
or Imagined Threats
We would suggest that one of the dening
features of CTS is the realistic (as opposed to
exaggerated) appraisal of future threat. Citing
Liras (1988) observations about state conict
in Chile, Martn-Bar (1989) writes,
a situation of state terrorism such as that undergone by
Chile under Pinochet provokes a state of fear in people
and, though fear is a subjective and, to a degree, a
private experience, upon being produced simultane-
ously in thousands of people in a society, it acquires an
unsuspected relevance in social and political behav-
ior. (p. 15)
What is proposed is that it might in fact be
abnormal not to share concerns about safety in
a context such as this, given that the majority of
the population appreciates that there are perva-
sive malevolent forces.
It is apparent, however, that even if, in terms
of consensual reality, there is agreement that an
environment is dangerous (such as in a neigh-
borhood that is under frequent missile attack or
experiencing regular gang wars), there will in-
evitably be a degree of subjectivity in how risk
is appraised, as previously acknowledged. Part
of the task in thinking through CTS as a clini-
cian is to weigh the interpretation of threat
perceived by the individual with the apparent
facts about their environment. Questions as to
when one may be dealing with more paranoid-
type responses and when one is dealing with a
legitimate preoccupation with safety become
salient. For example, counselors working with
refugees at a trauma clinic in Johannesburg
encountered cases in which it was alleged that
clients or their family members had been ab-
ducted by members of rival political groupings,
even while living within South Africa. Al-
though initially skeptical of the idea that polit-
ical spies or forces from as far away as So-
malia, for example, might be operating in this
clandestine way in South Africa, it became ap-
parent that there was veracity to these accounts.
It was then possible for counselors to engage
with their clients very real fears of potential
future abduction, assault, and even assassina-
tion, without the kind of caution and concerns
about reality testing that accompanied initial
encounters with these clients.
Interestingly, counselors uncertainties as to
what constitutes a realistic appraisal of danger
are very often replicated in the minds of people
who are living in contexts of CTS. Clients at-
tending the Johannesburg Trauma Clinic often
self-report that they nd it difcult to determine
what the likelihood of their own victimization
may be, and to distinguish how immediate and
how serious environmental threats are at any
specic moment. Although there may be slip-
page into more paranoid ways of thinking, in
which threat becomes exaggerated and overgen-
eralized, in the main, the fact that individuals
themselves are consciously engaged in such
self-questioning tends to distinguish CTS re-
sponses from clinically diagnosable paranoia.
This is not to say that people living in such
contexts over extended periods of time might
not develop some sort of paranoid condition as
a consequence of this, but such outcomes would
be viewed as the exception rather than the norm.
What is apparent is that, in the case of CTS,
the anxiety associated with the idea of being or
going crazy is not so much linked to the
experiencing of traumatic stress symptoms, as
in PTSD, but is rather linked to concerns as to
whether the perception of threat is accurate or
distorted. This again raises some important
questions about intervention. Interventions for
PTSD include some attention to the develop-
ment of more adaptive cognitive appraisals re-
92 EAGLE AND KAMINER
garding risk or threat, but in contexts of perva-
sive ongoing danger, threat discrimination may
become an especially important focus of psy-
chological intervention. This may not only en-
tail attempting to narrow the focus of that which
is perceived to be threatening so as to reduce
anxiety, when feasible (as in the treatment of
PTSD), but, in some instances, might require
encouraging a greater alertness to risk, however
counterintuitive this may feel to the counselor.
In contexts of CTS, denial or minimization of
danger may be more problematic than exagger-
ation, even if such defenses allow for reduction
of anxiety. The counselor needs to determine,
together with the client, what an optimal level
of alertness might entail. Given the well-
established association between childhood
abuse and revictimization in adulthood (Wyatt,
Guthrie, & Notgrass, 1992), interventions for
C-PTSD also emphasize the need to increase the
adult survivors capacity to identify potential
sources of threat or harm. However, here, threat
discrimination is more specically focused on
the relational domain, rather than on identifying
and managing threats in the broader environ-
ment and from often unpredictable sources.
In developing clients optimal threat discrim-
ination capacities, it becomes apparent that the
counselors own appraisal of the external envi-
ronment is signicant, and that they can only be
of help to the client if they are able to think
reasonably clearly and to entertain the possibil-
ity of likely future threat, rather than denying
this element of the individuals current circum-
stance. When counselors themselves are living
in the same dangerous contexts as their clients,
the likelihood of overidentication and contam-
ination of thinking needs to be very carefully
managed, as also observed by Straker and
Moosa (1994). Further, in contexts of CTS,
assessment of the reality basis for clients anx-
ieties about current and future threat or harm
also requires awareness by counselors of the
realistic absence of protective systems in the
clients environment, as elaborated in the next
section.
Absence of Protections in Conjunction
With Exposure to Danger
We would propose that a further signicant
dimension of CTS is the premise that the ab-
sence of protections from threat and danger is
perhaps of equal signicance as actual risk of
exposure. One of the features that characterizes
contexts of CTS is that there is a failure of the
usual systems of law and order. In the case of
war and civil conict, it is evident that the
normal functioning of society, such as the ap-
prehension, trial, sentencing, and punishment of
offenders, is compromised by the fact that the
state apparatus is being employed in the service
of other kinds of emergencies. In addition, in
the case of repressive regimes as highlighted in
the work of Martn-Bar (1989), and in the
South African context in which the construct of
CTS originated, it is apparent that the perpetra-
tors of violence and atrocity were precisely
those who would usually be charged with the
regulation of violence and the protection of
communities. In such contexts, the law is part
of the problem rather than potentially part of the
solution (Straker & Moosa, 1994, p. 458).
Even in situations of endemic community vio-
lence, it is very often the case that systems
designed to create a sense of accountability and
to minimize harm to citizens are ineffectual or
overstretched, at best, or corrupt and collusive
with informal systems of power, at worst. For
example, it is not uncommon for gangster orga-
nizations to pay off police personnel in order to
secure territory, meaning that those negatively
affected by gang activity have little trust in
ofcial authorities and minimal protection or
redress. As with the apprehension of danger, it
is both the real and perceived lack of benign,
just, and effective regulatory systems that af-
fects peoples sense of condence that they are
safe from harm. In contexts in which state con-
trols fail or are abused, fear, apprehension, and
a sense that existence is precarious is not inap-
propriate and may even be predictable.
Psychologically, it may be useful to think
about the absence of protections, as this might
be understood both at the level of alterations to
cognitive schemas and more psychoanalyti-
cally. In writing about the shattering of core
beliefs, which she terms basic assumptions,
Janoff-Bulman (1992) suggests that trauma
shakes the foundational premises upon which
most people base their lives. She argues that the
majority of any society holds to three basic
assumptions, two of these concerned with per-
ceptions of the world in general. First, she main-
tains that there is a common assumption that the
World is benign, and, second, that the World
93 CONTINUOUS TRAUMATIC STRESS
is meaningful, the latter predicated upon pre-
dictability and comprehensibility. Violation by
an aggressor shatters such assumptions, with
ensuing alterations to personal schema systems,
but if such violation is further accompanied by
resignation, collusion, nonretribution, and li-
cense for further violation at a systemic level,
schema rupture is compounded. Both expecta-
tions of safety and attempts to render daily life
comprehensible are damaged or destroyed.
Complementary to Janoff-Bulmans (1992)
social cognitive framework is Kirshners
(1994) psychoanalytically informed theory
about rupturing of what he refers to as the third
layer, anchored, to a large extent, in the Laca-
nian notion of the symbolic order. With ref-
erence to large-scale social traumas, Kirshner
(1994) argues in Lacanian terms, such extreme
traumas might be dened as experiences pro-
ducing a tearing of the network of signication
which supports symbolic relationships, result-
ing in the negative affects of psychic numbing,
profound withdrawal and addictive oblivion
(p. 238). He goes on to observe that this kind of
tearing results from specic kinds of conditions
that entail perversion of expected social rela-
tionships, including on a social level, severe
disruption of the lives of signicant individuals
who represent the symbolic order for a given
community (p. 239). Although, in this latter
statement, Kirshner appears to be referring to
the damage inicted on social groups when
community leaders or icons are attacked or vi-
olated, one could also read this statement as
pertaining to the rupture associated with the
collapse of those charged with upholding the
social order. Kirshner views this kind of dam-
age to the social order as producing numbing,
withdrawal, alienation, and disillusionment. It is
also important to appreciate the kind of desper-
ation and rage that individuals may feel when
there is no recourse to protection and justice.
It is likely, then, that in addition to dealing
with the ever present anxiety that infuses CTS
contexts, there is the difculty of dealing with a
world that appears fundamentally unjust and
devoid of legitimate regulation. The bad is
not only predominant in experience but also
experienced as eradicating or destroying the
good. This may manifest in passivity and hope-
lessness, and a sense of impotence or learned
helplessness. If there is no point in attempting
to activate protective forces, then one may as
well resign oneself to the situation and manage
this through minimization, avoidance, and dis-
investment in living. Thus, CTS may instill a
degree of nihilism in community members.
This said, it may also be the case that some
community members engage with the perver-
sion of the good, and the breakdown of systems
of regulation and control, by assuming control
themselves in violent and threatening ways.
Agency in CTS contexts may become synony-
mous with the expression of aggression and
enactment of violence. It is recognized that such
responses are gender related, with men being
much more likely to respond in this way than
women. A third, more constructive, option, may
of course be to attempt to engage in the envi-
ronment in such a way as to rebuild the social
fabric despite the breakdown of external sys-
tems and controls. However, what we seek to
emphasize here is that the precariousness of life
in contexts of CTS is as much the product of
failures of systems of protection as it is of the
active perpetration of violence, and that optimal
adjustment or resilience in such contexts is ex-
tremely difcult to achieve because the social
contract between the state and individuals is
fundamentally broken.
Although perhaps something of an aside, it is
noteworthy that the absence of protections may
be one of the features that distinguishes CTS
from occupationally related (traumatic) stress. It
could be argued that those involved in emer-
gency services and other highly stressful occu-
pations, such as peace-keeping, are also re-
quired to manage vulnerability to likely current
and future traumatic stimuli exposure and in this
sense have much in common with those living
in CTS producing contexts. Although such pop-
ulations have been found to be vulnerable to
occupational stress impacts, including traumatic
stress conditions (McFarlane & Bryant, 2007),
they generally operate in predominantly stable,
functional, and well-regulated societies, and, in
many instances, may in fact be invested in their
role in sustaining such regulation. They are able
to entertain some sense of the environment as
coherent and supportive, and nonwork contexts
can be assumed to offer some respite from oc-
cupationally related threat. Although there may
be other dimensions of their experience that
enable emergency workers to manage their oc-
cupational stress, such as camaraderie, group
cohesion, preparatory training, and action pro-
94 EAGLE AND KAMINER
tocols, it is vital to their mental health that their
work takes place within a meaningful context.
Once such assumptions are challenged, as in
the highly publicized case of two female para-
medics who were violently raped when called to
attend to a child burn victim in a South African
township (News24, 2012), stress levels among
such workers become markedly elevated and
one might well see the development of CTS. It
is evident that the rape of these two paramedics
symbolized precisely the kind of breakdown of
the social order that we maintain characterizes
contexts of CTS, although, in this instance,
some sense of order was restored via the arrest
and prosecution of the perpetrators. Without
recourse to containment and redress, it is evi-
dent that persecutory and annihilatory anxiety
becomes part of everyday lived experience.
CTS may well be experienced as unbearable
and unmanageable as a consequence of the rup-
ture of the social fabric.
What this discussion of the dangers of both
over- and underattention to threat cues, and of
the psychological implications of the break-
down of social protections suggests, is that it
may be important to interrogate the construct of
CTS somewhat further in terms of examining
whether it is more accurately thought about in
terms of adaptation or maladaptation to a prob-
lematic context, as the next section elaborates.
Are Responses to Continuous Trauma
Adaptive or Pathological?
One of the difculties in trauma theorization
lies in disentangling references to the stressor
conditions and references to their impact, as the
term trauma is often employed to refer to both
(Kaminer & Eagle, 2010). The terms develop-
mental trauma and collective trauma refer si-
multaneously to the type of trauma exposure
and to the manner in which responses might
manifest. This is also true of CTS and may
explain some of problems in attempting to ar-
ticulate and rene the construct. Is one referring
to a set of environmental conditions, or is one
referring to a particular kind of clinical response
set or symptom presentation, or is one referring
to both? In the case of CTS, the possible dis-
tinction between these two different applica-
tions of one term is of considerable importance.
On the one hand, we might wish to explore
whether some individuals are particularly vul-
nerable to the effects of living in such contexts
and develop some sort of syndrome-like condi-
tion, in the same way that it is understood that a
minority of individuals exposed to traumatically
stressful events actually develop PTSD (Kes-
sler, Sonnega, Bromet, Hughes, & Nelson,
1995). This would clearly require dedicated re-
search of a comparative kind, and is even more
constrained than current research into C-PTSD,
as there are currently no acceptable or estab-
lished instruments to measure CTS. The kind of
conceptual work elaborated in this article seems
necessary as a precursor to operationalization of
the construct in measurable form, if this is in-
deed even desirable or warranted.
If, on the other hand, one perceives of the
context as that which is abnormally stressful, or,
in a sense, as that which carries the pathology,
then we are bound to conclude that adaptation
to this context requires some kind of necessary
psychic (and social) adjustment. Similar to con-
structions of developmental trauma disorder
and C-PTSD, it is understood that in order to
function optimally in an enduringly dangerous
environment, individuals are challenged to de-
velop adaptive strategies. However, outside of
the context in which they develop, such adap-
tations may be understood as pathological and
may take on a different meaning; adaptation and
maladaptation are intricately intertwined and, in
large measure, contextually dened. CTS in-
volves exposure to a highly unpredictable envi-
ronment in which it becomes useful to map out
areas, sites, or even likely time periods of safety
and danger. Flexible employment of defensive
adaptation is required, allowing for continued
engagement with the world at the same time as
being able to draw upon whatever limited pro-
tections may be available at short notice, where
and when required. This may translate into a
high level of vigilance that becomes subliminal
and habitual.
It is evident that even if one chooses not to
ascribe pathology to CTS-related responses in
the more pejorative sense of disability or mal-
function, these responses may nonetheless be
understood as running counter to well-being
and optimal mental and psychosocial health.
Drawing upon observations from South Amer-
ica, Martn-Bar (1989) summarizes the re-
sponses of people living under conditions of
extreme fear as evident in four processes: (1) a
sensation of vulnerability, (2) exacerbated alert-
95 CONTINUOUS TRAUMATIC STRESS
ness, (3) a sense of impotence or loss of control
over ones own life, and (4) an altered sense of
reality, making it impossible to objectively val-
idate ones own experiences and knowledge
(p. 15). In addition, he cites the work of Sa-
mayoa (1987) on the cognitive and behavioral
changes caused by the necessity of adapting to
war that bring about dehumanization (p. 14),
elaborating ve such effects: (1) selective
inattention and a clinging to prejudices, (2)
absolutism, idealization, and ideological ri-
gidity, (3) evasive skepticism, (4) paranoid
defensiveness, and (5) hatred and desire for
revenge (p. 14), Thus, mirroring some of the
earlier discussion, Martn-Bar suggests that
such contexts may have both symptomatic
and meaning-related effects.
In one of the very few empirical studies com-
paring the impact of ongoing exposure with
traumatic stressors versus intense periodic ex-
posure, Lahad and Leykin (2010) found that the
population facing ongoing exposure presented
with more severe levels of PTSD symptoms and
that symptoms mainly consist of arousal and
avoidance rather than intrusion (p. 695). This
is consistent with the earlier discussion of the
temporal focus in CTS, in which we observe
that intrusion symptoms are likely to be less
prominent. Lahad and Leykin (2010) suggest
that the constant sense of threat keeps people
permanently on alert and aroused (p. 695),
and, further, that such populations do not have
time for respite and are thus constantly gov-
erned by their physiological reactions of fright
or ight, or employ avoidance in the attempt to
control these sensations (p. 695). Their re-
search ndings are in keeping with those of
Besser and Neria (2009) and Diamond et al.
(2010), the former also noting alterations to
belief systems in response to living in contexts
of enduring conict.
Although writing primarily about PTSD,
Kesebir, Luszcynska, Pyszczynski, and Benight
(2011) observe that a crucial anxiety-buffering
mechanism is a strong retention of a meaningful
worldview: Faith in ones cultural worldview
is a major epistemic and existential security-
provider (p. 834). They also observe that
what is good for the individuals control of
anxiety (e.g., rigid worldview defense) may
sometimes have harmful consequences for so-
ciety (e.g., enhanced ingroup bias) (p. 835),
reinforcing suggestions that attempts to man-
age ever-present anxiety may translate into
mistrust, splitting, and prejudice. Thus, mean-
ing-related aspects of CTS responses seem
important to consider as part of the overall
presentation picture.
It is important to note that the suggestion that
some kind of characteristic response set or pat-
tern might be identiable and observable among
people living in CTS contexts does not exclude
the possibility that people in such contexts
might present with PTSD. Rather, what is being
proposed is that CTS may involve a set of
common responses that extend beyond PTSD,
and, in addition, that some PTSD symptom
clusters (or even parts of clusters) are more
likely to be evident than others.
A further observation is of signicance in
exploring the issue of adaptation and maladap-
tation in contexts of CTS. Diamond et al. (2010)
put forward what Lahad and Leykin (2010)
refer to as a new paradigm for the ongoing
exposure situation. . . They propose a new cat-
egory to dene a subsample living in ongoing
exposure areas, expressing PTSD symptoms
only in the affected area but not outside it
(Lahad & Leykin, 2010, p. 696). This represents
a fairly radical departure from conventional un-
derstandings of PTSD, and also C-PTSD, in
which enduring posttrauma exposure symptoms
are characteristic of the conditions. The idea
that trauma-related responses and symptoms
may remit, consequent upon removal from a
threatening environment, offers a radically con-
text-driven understanding of trauma impact. We
would suggest that such a conceptualization
may well be applicable in thinking about CTS
and that this is another element of the construct
that might become better dened with further
interrogation and research.
Conclusions
Based on the observations and arguments put
forward in this article, we would maintain that
the construct of CTS offers an important and
distinct vantage point from which to understand
particular kinds of trauma-inducing contexts
and their impact. Unlike C-PTSD and develop-
mental trauma disorder, CTS attempts to char-
acterize prolonged and ongoing threat that oc-
curs outside the exclusive context of attachment
relationships or other dyads (such as prisoner
and captor). Unlike PTSD, C-PTSD, develop-
96 EAGLE AND KAMINER
mental trauma, or historical trauma, CTS is
focused primarily on present and future trauma
exposure, rather than on that which has already
taken place. In keeping with developmental
trauma and C-PTSD, CTS places considerable
signicance upon anticipatory anxiety and its
impact; however, this anticipatory anxiety is
understood to emerge from a realistically threat-
ening situation that requires ongoing regulation
and management. Finally, although CTS has
some similarities to collective or identity
trauma, in that it may well entail large scale
traumatization across groups or populations and
also frequently involves indirect and vicarious
traumatization, CTS can be prevalent across
communities who share little in common with
regard to their group identity other than their
geographical location or economic status. Thus,
it may be more difcult to make sense of vic-
timization for those living in contexts of CTS,
and there is also likely to be less group identi-
cation, support, and resilience to threat. CTS
also assumes more immediate and severe exis-
tential risk than that encompassed under iden-
tity trauma, other than when the latter translates
into genocidal actions.
It has also been observed that C-PTSD has
greater permanency and is likely to persist de-
spite release from bondage, whereas CTS is
much more likely to remit if the individual is
able to escape the dangerous environment, sug-
gesting a more exible kind of adaptation. This
is, in part, why it appears to make more sense to
think of CTS as a construct designed to capture
the nature of lived experience within particular
kinds of sociopolitical contexts as opposed to
making the case for CTS as an alternative psy-
chiatric diagnosis, as is currently the project of
those championing the diagnostic category of
C-PTSD.
Based on these comparative observations it
should be apparent that although CTS has areas
of commonality with a number of other concep-
tualizations of complicated traumatic stress, it
also has unique dimensions. CTS captures a
domain of traumatic stress experience not ade-
quately formulated in the existing repertoire of
traumatic stress responses but which character-
izes the lived experience of many individuals
and communities around the globe. Further re-
search is required to explore whether there is a
constellation of symptoms that might arise
among individuals living in these kinds of con-
texts, whether some individuals may be more
vulnerable to presenting with such effects than
others, and whether responses to continuous
trauma exposure have adaptive or maladaptive
dimensions. In addition, it is evident that inter-
vention to ameliorate the impact of CTS re-
quires societal- and community-level change, as
well as modication of existing therapeutic ap-
proaches for working with trauma-related con-
ditions, and further theoretical and empirical
engagement with these different levels of inter-
vention is needed. The construct of CTS
provides an epistemological base, for both the-
oreticians and practitioners, from which to con-
tinue to think about, understand, research, and
document the experiences of individuals living
in currently precarious and violence-ridden
contexts.
References
American Psychiatric Association. (2000). Diagnos-
tic and statistical manual of mental disorders (4th
ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (in press). Diag-
nostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Arias, E. D., & Davis Rodrigues, C. (2006). The
myth of personal security: Criminal gangs, dispute
resolution, and identity in Rio de Janeiros favelas.
Latin American Politics and Society, 48, 5381.
doi:10.1353/lap.2006.0041
Besser, A., & Neria, Y. (2009). PTSD symptoms,
satisfaction with life and prejudicial attitudes to-
wards the adversary among Israelis exposed to
ongoing terrorist attacks. Journal of Traumatic
Stress, 22, 268275. doi:10.1002/jts.20420
Brewin, C. R. (2001). A cognitive neuroscience ac-
count of posttraumatic stress disorder and its treat-
ment. Behaviour Research and Therapy, 39, 373
393. doi:10.1016/S0005-7967(00)00087-5
Brewin, C. R., Lanius, R. A., Novac, A., & Galea, S.
(2009). Reformulating PTSD for DSM-V: Life
after criteria A. Journal of Traumatic Stress, 22,
366373. doi:10.1002/jts.20443
Cohen, J. A., Mannarino, A. P., & Murray, L. K.
(2011). Trauma-focused CBT for youth who ex-
perience ongoing traumas. Child Abuse & Neglect,
35, 637646. doi:10.1016/j.chiabu.2011.05.002
Danieli, Y. (Ed.). (1998). International handbook of
multigenerational legacies of trauma. New York,
NY: Plenum Press. doi:10.1007/978-1-4757-
5567-1
Diamond, G. M., Lipsitz, J. D., Fajerman, Z., &
Rozenblat, O. (2010). Ongoing traumatic stress
response (OTSR) in Sderot Israel. Professional
97 CONTINUOUS TRAUMATIC STRESS
Psychology: Research and Practice, 41, 1925.
doi:10.1037/a0017098
Eagle, G. T. (2002). Posttraumatic stress disorder
(PTSD): The malleable diagnosis? South African
Journal of Psychology, 32, 3742.
Etter, G. W. (2011). Drug wars: It is not all quiet on
the Mexican front. Journal of Gang Research, 18,
1945.
Foa, E. B., & Kozak, M. J. (1986). Emotional pro-
cessing of fear: Exposure to corrective informa-
tion. Psychological Bulletin, 99, 2035. doi:
10.1037/0033-2909.99.1.20
Ford, J. D., & Courtois, C. A. (2009). Dening and
understanding complex trauma and complex trau-
matic stress disorders. In C. A. Courtois & J. D.
Ford (Eds.), Treating complex traumatic stress dis-
orders: An evidence-based guide (pp. 1330). New
York, NY: Guilford Press.
Gone, J. P. (2007). We never was happy living like
a Whiteman: Mental health disparities and the
postcolonial predicament in American Indian com-
munities. American Journal of Community Psy-
chology, 40, 290300. doi:10.1007/s10464-007-
9136-x
Gone, J. P. (2009). A community-based treatment for
Native American historical trauma: Prospects
for evidence based practice. Journal of Consulting
and Clinical Psychology, 77, 751762. doi:
10.1037/a0015390
Herman, J. L. (1992). Complex PTSD: A syndrome
in survivors of prolonged and repeated trauma.
Journal of Traumatic Stress, 5, 377391. doi:
10.1002/jts.2490050305
Janoff-Bulman, J. (1992). Shattered assumptions:
Towards a new psychology of trauma. Toronto,
ON: Free Press.
Kaminer, D., & Eagle, G. (2010). Traumatic stress in
South Africa. Johannesburg, South Africa: Wits
University Press.
Kesebir, P., Luszcynska, A., Pyszczynski, T., & Be-
night, C. (2011). Posttraumatic stress disorder
involves disrupted anxiety buffer mechanisms.
Journal of Social and Clinical Psychology, 30,
819841. doi:10.1521/jscp.2011.30.8.819
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M.,
& Nelson, C. B. (1995). Posttraumatic stress dis-
order in the National Comorbidity Survey. Ar-
chives of General Psychiatry, 52, 10481060. doi:
10.1001/archpsyc.1995.03950240066012
Kira, I. (2001). Taxonomy of trauma and trauma
assessment. Traumatology, 7, 7386. doi:10.1177/
153476560100700202
Kira, I. A., Lewandowski, L., Templin, T., Ramas-
wamy, V., Ozkan, B., & Mohanesh, J. (2008).
Measuring cumulative trauma dose, types and pro-
les using a development-based taxonomy of
trauma, Traumatology, 14, 6287. doi:10.1177/
1534765608319324
Kirshner, L. A. (1994). Trauma, the good object, and
the symbolic: A theoretical integration. The Inter-
national Journal of Psychoanalysis, 75, 235242.
Lahad, M., & Leykin, D. (2010). Ongoing exposure
versus intense periodic exposure to military con-
ict and terror attacks in Israel. Journal of Trau-
matic Stress, 23, 691698. doi:10.1002/jts.20583
Landau, L. B. (2006). Protection and dignity in Jo-
hannesburg: Shortcomings of South Africas urban
refugee policy. Journal of Refugee Studies, 19,
308327. doi:10.1093/jrs/fel012
Lewis, K. L., & Grenyer, B. F. (2009). Borderline
personality or complex posttraumatic stress disor-
der? An update on the controversy. Harvard Re-
view of Psychiatry, 17, 322328. doi:10.3109/
10673220903271848
Lira, E. (1988). Consecuencias psicosociales de la
represion en Chile [Psychosocial consequences of
repression in Chile]. Revista de Psicologia de El
Salavador, 28, 142150.
Marotta, S. (2000). Best practices for counselors who
treat posttraumatic stress disorder. Journal of
Counselling and Development, 78, 492495. doi:
10.1002/j.1556-6676.2000.tb01933.x
Martn-Bar, I. (1989). Political violence and war as
causes of psychosocial trauma in El Salvador. In-
ternational Journal of Mental Health, 18, 320.
Marx, B. O., Heidt, J. M., & Gold, S. D. (2005).
Perceived uncontrollability and unpredictability,
self-regulation, and sexual revictimization. Review
of General Psychology, 9, 6790. doi:10.1037/
1089-2680.9.1.67
McFarlane, A. C., & Bryant, R. (2007). Post-
traumatic stress disorder in occupational settings:
Anticipating and managing the risk. Occupational
Medicine, 57, 404410. doi:10.1093/occmed/
kqm070
News24. (2012). Accused in paramedic rape trial
evasive. Retrieved from http://www.news24
.com/SouthAfrica/News/Accused-in-paramedic-
rape-trial-evasive-20120718
Reisner, S. (2003). Trauma: The seductive hypoth-
esis. Journal of the American Psychoanalytic As-
sociation, 51, 381 414. doi:10.1177/
00030651030510021701
Resick, P. A., Bovin, M. J., Calloway, A. L., Dick,
A. M., King, M. W., Mitchell, K. S., . . . Wolf, E. J.
(2012). A critical evaluation of the complex PTSD
literature: Implications for DSM-5. Journal of
Traumatic Stress, 25, 241251. doi:10.1002/jts
.21699
Samayoa, J. (1987). Guerra y deshumanizacion: Una
perspectiva psicosocial [War and dehumanization:
A psychosocial perspective]. Estudios Cen-
troamericanos, 461, 213225.
Shields, N., Nadasen, K., & Pierce, L. (2008). The
effects of community violence on children in Cape
98 EAGLE AND KAMINER
Town, South Africa. Child Abuse & Neglect, 32,
589601. doi:10.1016/j.chiabu.2007.07.010
Straker, G., & Moosa, F. (1994). Interacting with
trauma survivors in contexts of continuing trauma.
Journal of Traumatic Stress, 7, 457465. doi:
10.1002/jts.2490070311
Straker, G., & the Sanctuaries Counselling Team.
(1987). The continuous traumatic stress syndrome:
The single therapeutic interview. Psychology in
Society, 8, 4878.
Summereld, D. (1999). A critique of seven assump-
tions behind psychological trauma programmes in
war-affected areas. Social Science & Medicine, 48,
14491462. doi:10.1016/S0277-9536(98)00450-X
Summereld, D. (2001). The invention of posttrau-
matic stress disorder and the usefulness of a psy-
chiatric category. BMJ: British Medical Journal,
322, 9598. doi:10.1136/bmj.322.7278.95
Terr, L. C. (1991). Childhood traumas: An outline
and overview. The American Journal of Psychia-
try, 148, 1020.
Updegraff, J. A., Cohen Silver, R., & Holman, E. A.
(2008). Searching for and nding meaning in col-
lective trauma: Results from a national longitudi-
nal study of the 9/11 terrorist attacks. Journal of
Personality and Social Psychology, 95, 709722.
doi:10.1037/0022-3514.95.3.709
van der Kolk, B. (1996). Trauma and memory. In B.
van der Kolk, A. C. McFarlane, & L. Weisaeth
(Eds.), Traumatic stress: The effects of overwhelm-
ing experience on mind, body and society (pp.
279302). New York, NY: Guilford Press.
van der Kolk, B. A. (2005). Developmental trauma
disorder: Toward a rational diagnosis for children
with complex trauma histories. Psychiatric Annals,
35, 401408.
Wyatt, G. E., Guthrie, D., & Notgrass, C. M. (1992).
Differential effects of womens child sexual abuse
and subsequent sexual revictimisation. Journal of
Consulting and Clinical Psychology, 60, 167173.
doi:10.1037/0022-006X.60.2.167
Zanarini, M. C., Williams, A. A., Lewis, R. E., Reich,
R. B., Vera, S. C., Marino, M. F., . . . Frankenburg,
F. R. (1997). Reported pathological childhood ex-
periences associated with the development of bor-
derline personality disorder. The American Jour-
nal of Psychiatry, 154, 11011106.
E-Mail Notication of Your Latest Issue Online!
Would you like to know when the next issue of your favorite APA journal will be
available online? This service is now available to you. Sign up at http://notify.apa.org/ and
you will be notied by e-mail when issues of interest to you become available!
99 CONTINUOUS TRAUMATIC STRESS