Transcript Prevention and Response To Mass Trauma and Disaster

Prevention and Response To Mass Trauma
and Disaster: How Trauma-Informed
Organizations Mitigate Harm and Promote
Health
Francis R. Abueg, Ph.D.
TraumaResource
Clinical & Forensic Psychology
Sunnyvale, California
Objectives
●
●
●
Overview: Big Picture
Inner World of Trauma &
Community Experience
Management, Response & Advances
Personal Context
●
Family of Origin
●
Differential Coping
●
Research & Clinical Choice Making
Part I: Big Picture
Disaster Defined
●
Disaster is a “process that encompasses an event ,
or series of events, affecting multiple people,
groups, and communities
Disaster Defined
●
Disaster is a “process that encompasses an event ,
or series of events, affecting multiple people,
groups, and communities and causing damage,
destruction, and loss of life…socially constructed
(at least by some) as being outside of ordinary
experience
Disaster Defined
●
Disaster is a “process that encompasses an event ,
or series of events, affecting multiple people,
groups, and communities and causing damage,
destruction, and loss of life…socially constructed
(at least by some) as being outside of ordinary
experience and causing damage, destruction, and
loss of life…socially constructed (at least by
some) as being outside of ordinary experience
Disaster Defined
Disaster is a “process that encompasses an event , or
series of events, affecting multiple people, groups,
and communities and causing damage, destruction,
and loss of life…socially constructed (at least by
some) as being outside of ordinary experience and
causing damage, destruction, and loss of
life…socially constructed (at least by some) as being
outside of ordinary experience, overwhelming usual
individual and collective coping mechanisms,
disrupting social relations, and at least temporarily
disempowering individuals and communities.”
--Joshua Miller (2012) in Psychosocial Capacity Building in Response to Disaster.
NY: Columbia University Press.
Mass Shootings
●
●
Mass shootings defined in a recent Congressional
Report “as incidents occurring in relatively public
places, involving four or more deaths—not
including the shooter(s)—and gunmen who select
victims somewhat indiscriminately. The violence
in these cases is not a means to an end such as
robbery or terrorism.”
--Bjelopera, J.P., Bagalman, S., Caldwell, E.W., Finklea &
McCallion, G. (March 18, 2013). Public Mass Shootings in the
United States: Selected Implications for Federal Public Health and
Safety Policy. Congressional Research Service.
Defining Disasters
Mass
Killings
Terrorism
Man-Made
Natural
Newtown Connecticut
Problem in Defining the Problem
●
Narrowing of Perception
●
The Cult of Personality
●
Debunking Profiling
Why School Shootings?
●
Simple theorizing not sufficient
●
Common elements
–
–
–
–
–
Socially marginalized
Psychosocial stressors
Cultural “scripts” (gender bias)
Failure in surveillance
Gun availability
Bridge to Disaster Mental Health
Part II: Inner World of Surviving
Horrific Events
In the Eye of Mindstorm
●
Hot and Cold Emotions
●
Narrowing of Perception
●
Misattribution or Overattribution of Cause
Context of Silencing
Intrapersonal
Interpersonal
Biological
Psychophysiological
Sociocultural
Contexts
Familial (violence, incest, sibling abuse)
Institutional (government, military, religious)
Art Spiegelman
Graphic Comic Artist
●
Maus Comics (Vols. 1 & 2)
●
In the Shadow of No Towers (2004)
Mardi Horowitz Triumvirate of
Traumatic Emotionality
●
Overwhelming Anxiety
●
Shame
●
Rage
Defining posttraumatic silencing
(PT-Sil)
●
In an attempt to broaden our understanding of
impediments to healing post-trauma, PT-Sil can
be defined as any experiences of the poorly
adapting trauma survivor that inhibit disclosure of
a traumatic event
Exceptional adaptations posttrauma: Good & Bad
●
Posttraumatic adaptations are diverse
–
–
–
–
–
●
Up to 18% ASD
PTSD lifetime prevalence 7.8%*
Posttraumatic major depression: most prevalent
Alcohol/Substance abuse: 2nd most prevalent
Partial PTSD: up to 70% by some estimates
Posttraumatic growth and “super-coper” outcomes
–
9/11 survivor families and Moussaoui trial
*Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995).
Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen
Psychiatry, 52, 1048-1060.
Clues to Silencing in PTSD
Diagnosis
●
Life threat
●
Fear, helplessness, horror (deleted from DSM-5)
DSM-IV-TR to DSM-5
●
●
●
A2 Criterion Removed (Fear, helplessness, horror)
3-Clusters (DSM-IV-TR)
Re-experiencing
Avoidance
Hyperarousal
4-Clusters (DSM-5)
Intrusion
Avoidance
Numbing
Hyperarousal/Hyperreactivity
PTSD per DSM-5
Re-experiencing or Intrusive Symptoms (1 of 5)*
Unexpected or expected reoccurring, involuntary, and intrusive
upsetting memories of the traumatic event
Repeated upsetting dreams where the content of the dreams are related
to the traumatic event.
The experience if some type of dissociation (for example, flashbacks),
where the person feels as though the traumatic event is happening
again
Strong and persistent distress upon exposure to cues that are either
inside or outside of the person’s body that are connected to the
person’s traumatic event
Strong bodily reactions (for example, increased heart rate) upon
exposure to a reminder of the traumatic event
*note how every symptom is tied to the traumatic event
Clues to Silencing in PTSD
Diagnosis (continued)
Avoidance (1 of 2)
Efforts to avoid thoughts, feelings, or conversations
associated with the trauma
Efforts to avoid activities, places, or people that arouse
recollections of the trauma
*symptoms both tied to the trauma
PTSD per DSM-5 (continued)
●
Hyperarousal/Hyperreactivity (3 of 4)*
Irritability or aggressive behavior
Impulsive or self-destructive behavior
Feeling constantly on guard or that danger is lurking around
the every corner (hypervigilance)
Heightened startle response
*None of these symptoms is tied directly to the trauma
PTSD per DSM-5 (continued)
Numbing/Detachment/Amnesia
The inability to remember an important aspect of the
traumatic event.
Persistent and elevated negative evaluation about one’s self,
others, or the world.
Elevated self-blame or blame of others about the cause or
consequence of the traumatic event.
A negative emotional state (shame, anger, fear) is present.
Loss of interest in activities one used to enjoy
Feeling detached from others
The inability to experience positive emotions (love,
happiness, joy)
Review of ASD versus PTSD
●
(the “fourth” cluster) Either while experiencing or
after experiencing the distressing event, the
individual has three (or more) of the following
dissociative symptoms within one month of event:
1. a subjective sense of numbing, detachment, or absence of
emotional responsiveness
2. a reduction in awareness of his or her surroundings (e.g.,
"being in a daze")
3. derealization
4. depersonalization
5. dissociative amnesia (i.e., inability to recall an important
aspect of the trauma)
Notes on the values/risks of
dissociation
●
Lifton construct and tree metaphor
●
Trance states of emotion
Why is disclosure important?
●
Centrality of trauma exposure in empirically
supported treatments of PTSD
–
–
–
ISTSS expert working group established best practices
based on 29 randomized clinical trials (RCTs)*
More than 40 outcome studies total; fewer than 18
RCTs specifically on exposure treatment (diverse adult
samples, very limited in children)
Laboratory/analogue studies of psychological and
physical symptom reduction with trauma disclosure
(e.g., Pennebaker, Stanton)
*Foa, Keane & Friedman, 2000
Why the emphasis on sociocultural
context
●
●
Evidence that social and moral factors lead to early
dropouts and inhibit good outcomes (Foa, Kubany,
Cloitre, Janof-Bulman)
Factors related to subject characteristics
(Digiralomo, 1999 WHO data)
–
–
–
●
●
●
Poverty
Gender
Race/ethnicity
Healing occurs in a social context
Retraumatization occurs in putative “recovery”
contexts (“conspiracy of silence”)
Betrayal literature, perpetrator trauma & feminist
perspectives(e.g., Freyd, Root, Brown)
Social/Cultural Experiences
Which Increase Threat Perception
●
Exceptional emotionality of trauma
(Te, Drd, Hr, Dg, Sh)
Social/Cultural Experiences
Which Increase Threat Perception
●
●
Exceptional emotionality of trauma
(Te, Drd, Hr, Dg, Sh)
Explicit threats to disclosure (Lister, 1987)
Social/Cultural Experiences
Which Increase Threat Perception
●
●
●
Exceptional emotionality of trauma
(Te, Drd, Hr, Dg, Sh)
Explicit threats to disclosure (Lister, 1987)
Implicit sociocultural impediments
–
–
●
Taboo (deep structure: “you just don't talk about
that”)
Unspeakability of child killing and
countertransferential communications which shut
down narrative (e.g., Danieli, 1987)
Context as threat: highly charged posttraumatic
“recovery” environments including therapy
Katrina/FEMA anecdote
March 29, 2006
KRT Wire | 03/29/2006 | `Hurricane tours' the latest rage in
adventure travel
Just when I thought I had heard and seen just about
everything...Here is an excerpt from an article by KRT
Newswire about Hurricane Adventure Travel:
"The willing pay $1,500 and more for three days of little sleep,
canned tuna and crackers and miserable weather. Customers are
on a 48-hour e-mail notice list. They fly out to the site of a
predicted landfall, jump in vans decked out with reclining seats
and The Weather Channel and drive miles to a parking structure
to wait for the storm. After it passes, the tours wander around to
see the damage. Storm chasing protocol dictates that it is in
poor taste to boast about one's experience in what one chaser
described as ''mixed company.'' In other words: Don't talk about
the great hurricane you just witnessed next to a native who just
lost his home".
Intrapersonal Factors
●
Symptom clusters of ASD PTSD
–
–
●
●
●
Note the 8 symptoms of PTSD directly tied to trauma
Dissociation, numbing & startle
Preexisting psychopathology (Axis I & II)
Complex PTSD (multiple trauma history)
Resourcefulness, intellectual strengths, creativity,
social network/support, spirituality/religiosity
Clinical anecdote: Filipino Red Cross Volunteer
Biological/Psychophysiological
●
●
●
●
Hyperarousal, reexperiencing, avoidance
(HPA axis; DSM-V & fear circuitry proposal)
Fight, flight, freezing (vagal research)
Startle
“Low road” brain function (impaired executive
functioning, overselection of threat cues)
Interpersonal Silencing
●
●
●
●
Explicit threats
Shock, startle and unconscious shaming
Silencing through indifference or avoidance
Iatrogenic treatments, institutional failures
Sociocultural Factors
●
●
●
●
Gender, class or ethnic identity and problem of
power differential, lack of “voice”
Taboo, stigma, shame with negative moral
judgments
Rigidity of “moral” institutions, mob and cult
psychology
Finding meaning in activism, forgiveness (e.g.,
Luskin work), helping other survivors
(generativity)
Mass Violence and Disasters

Mass violence and disasters are associated with risk for a range of
psychosocial problems






posttraumatic stress disorder (re-experiencing, avoidance, hyperarousal)
generalized anxiety (excessive worry)
major depression (loss of interest/pleasure in activities, depressed mood)
alcohol- and drug-use problems (binge drinking, substance use and abuse)
increased cigarette use
Note: most disaster victims are resilient or recover quickly
Mass Violence and Disasters

Characteristics of disasters associated with risk:
widespread damage to property
 serious and ongoing financial problems
 human error or human intent that caused the disaster
 high prevalence of injury, threat to life, loss of life

Mitigating Organizational Barriers
to Recovery Post-Disaster
1. Pre-Disaster Networking
1. Explicit Leadership in Preparedness
Resource Allocation
Identification of Committee/Departmental Roles
Release time for disaster networking, response,
volunteering
3. Policymaking in Support of Preparedness Initiatives
Local, State, Federal
Mitigating Organizational Barriers
to Recovery Post-Disaster (cont’d)
Themes in DMH: Respecting the
Trauma Membrane
●
●
●
●
●
Minimize harm
Maximize bond while avoiding splitting
Acknowledge context
Keep eye on goal of safe disclosures
Manage personal reactivity with increased
attention to self-care
Part III: Organizational
Preparedness and Resilience
Mass Violence and Disasters

Mass violence and disasters are associated with risk for a range of
psychosocial problems






posttraumatic stress disorder (re-experiencing, avoidance,
hyperarousal)
generalized anxiety (excessive worry)
major depression (loss of interest/pleasure in activities, depressed
mood)
alcohol- and drug-use problems (binge drinking, substance use and
abuse)
increased cigarette use
Note: most disaster victims are resilient or recover quickly
Mass Violence and Disasters
(cont’d)

Characteristics of disasters associated with risk:
widespread damage to property
 serious and ongoing financial problems
 human error or human intent that caused the disaster
 high prevalence of injury, threat to life, loss of life

Organizations
& Communities At Risk
●
Disadvantaged Populations
–
Racial/Cultural
–
Economic
–
Psychiatric
–
Medical
–
Active Duty Military & Veterans
Organizational resilience postdisaster
●
●
●
●
●
Prepared and Practiced
Trauma Informed
High Cohesion and Sense of Mission
Resourceful: Meaningful and Purposeful
Connection to Community
Open Lines of Communication
Mitigating Organizational Barriers
to Recovery Post-Disaster
1. Pre-Disaster Networking
1. Explicit Leadership in Preparedness
Resource Allocation
Identification of Committee/Departmental Roles
Release time for disaster networking, response,
volunteering
3. Policymaking in Support of Preparedness Initiatives
Local, State, Federal
Mitigating Organizational Barriers
to Recovery Post-Disaster (cont’d)
Technology as a Game Changer in
Disaster
●
Web delivered mental health interventions
●
Proliferation of Mobile & Cloud based technology
–
Psychological First Aid (PFA)
–
Skills for Psychological Recovery (SPR)
Technology Overview
POTS
Web
Interventions
Clinical VTel
Home Video
(Movi)
Mobile Apps
PTSD Coach Overview
PTSD Coach is a mobile phone
application for people with PTSD
and those interested in learning
more about PTSD
This application provides:

Education about PTSD

A self-assessment tool

Portable skills to address acute
symptoms

Direct connection to crisis support
and

Information about treatment
aimed at guiding those who could
benefit into care
Used to augment face-to-face care or
as a stand-alone education and
symptom management tool
Home Screen
•
•
•
From the home screen (seen
here), users can choose from
the four main actions of the
application
Users may also use “Setup” to
personalize the app with media
from their own phone. Users are
guided through this process
automatically on their first time
through the app
The “About” button provides
users with information about the
application and access to the team
that built it.
Final Notes on Resilience
●
Eva Schloss, Step-Sister of Anne Frank
http://www.bbc.co.uk/news/world-22126164
“Connecticut Governor Dan
Malloy signs far reaching gun
control legislation”
“Mother of Sandy Hook
victim Jackie Barden looks
on as Governor Malloy
hugs her husband, Mark
Barden, after signing the
historic legislation”
Contact Information
●
●
●
●
Francis Abueg, Ph.D. (pronounced UH-BWEG)
Email: [email protected]
Tel: 408.390.3520
Web: www.traumaresource.com