Prevention and Response To Mass Trauma and Disaster: How Trauma-Informed Organizations Mitigate Harm...

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 DefinedDisaster 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

BiologicalPsychophysiological 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 post-trauma: 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-5Re-experiencing or Intrusive Symptoms (1 of 5)*

Unexpected or expected reoccurring, involuntary, and intrusive upsetting memories of the traumatic eventRepeated 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 againStrong 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 eventStrong 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 behaviorImpulsive or self-destructive behaviorFeeling 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 enjoyFeeling detached from othersThe 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. derealization4. depersonalization5. 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 ExperiencesWhich Increase Threat Perception

● Exceptional emotionality of trauma (Te, Drd, Hr, Dg, Sh)

Social/Cultural ExperiencesWhich Increase Threat Perception● Exceptional emotionality of trauma (Te, Drd, Hr, Dg, Sh)● Explicit threats to disclosure (Lister, 1987)

Social/Cultural ExperiencesWhich 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, 2006KRT Wire | 03/29/2006 | `Hurricane tours' the latest rage

in adventure travelJust 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 post-disaster

● 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

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: drfrancis@traumaresource.com● Tel: 408.390.3520● Web: www.traumaresource.com