Title: Prevention and Response To Mass Trauma and Disaster: How Trauma-Informed Organizations Mitigate Harm and Promote Health
1- 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
2Objectives
- Overview Big Picture
- Inner World of Trauma
- Community Experience
- Management, Response Advances
3Personal Context
- Family of Origin
- Differential Coping
- Research Clinical Choice Making
4Part I Big Picture
5Disaster Defined
- Disaster is a process that encompasses an event
, or series of events, affecting multiple people,
groups, and communities
6Disaster 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 lifesocially
constructed (at least by some) as being outside
of ordinary experience
7Disaster 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 lifesocially
constructed (at least by some) as being outside
of ordinary experience and causing damage,
destruction, and loss of lifesocially
constructed (at least by some) as being outside
of ordinary experience
8Disaster 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 lifesocially
constructed (at least by some) as being outside
of ordinary experience and causing damage,
destruction, and loss of lifesocially
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.
9Mass Shootings
- Mass shootings defined in a recent Congressional
Report as incidents occurring in relatively
public places, involving four or more deathsnot
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.
10Defining Disasters
Mass Killings
Terrorism
Natural
Man-Made
11Newtown Connecticut
12(No Transcript)
13Problem in Defining the Problem
- Narrowing of Perception
- The Cult of Personality
- Debunking Profiling
14Why School Shootings?
- Simple theorizing not sufficient
- Common elements
- Socially marginalized
- Psychosocial stressors
- Cultural scripts (gender bias)
- Failure in surveillance
- Gun availability
15Bridge to Disaster Mental Health
16Part II Inner World of Surviving Horrific Events
17(No Transcript)
18In the Eye of Mindstorm
- Hot and Cold Emotions
- Narrowing of Perception
- Misattribution or Overattribution of Cause
19Context of Silencing
Intrapersonal
Interpersonal
BiologicalPsychophysiological
SocioculturalContexts
20Familial (violence, incest, sibling abuse)
Institutional (government, military, religious)
21Art Spiegelman Graphic Comic Artist
- Maus Comics (Vols. 1 2)
- In the Shadow of No Towers (2004)
22(No Transcript)
23Mardi Horowitz Triumvirate of Traumatic
Emotionality
- Overwhelming Anxiety
- Shame
- Rage
24Defining 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
25Exceptional 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. -
26Clues to Silencing in PTSD Diagnosis
- Life threat
- Fear, helplessness, horror (deleted from DSM-5)
27DSM-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
-
28PTSD 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
persons body that are connected to the persons
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
29Clues 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
30PTSD 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
31PTSD per DSM-5 (continued)
- Numbing/Detachment/Amnesia
- The inability to remember an important aspect of
the traumatic event. - Persistent and elevated negative evaluation about
ones 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)
32Review 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)
33Notes on the values/risks of dissociation
- Lifton construct and tree metaphor
- Trance states of emotion
34Why 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
35Why 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)
36Social/Cultural ExperiencesWhich Increase Threat
Perception
- Exceptional emotionality of trauma
- (Te, Drd, Hr, Dg, Sh)
37Social/Cultural ExperiencesWhich Increase Threat
Perception
- Exceptional emotionality of trauma
- (Te, Drd, Hr, Dg, Sh)
- Explicit threats to disclosure (Lister, 1987)
38Social/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
39March 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".
40Intrapersonal 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
41Biological/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)
42Interpersonal Silencing
- Explicit threats
- Shock, startle and unconscious shaming
- Silencing through indifference or avoidance
- Iatrogenic treatments, institutional failures
43Sociocultural 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)
44Mass 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
45Mass 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
46Mitigating Organizational Barriers to Recovery
Post-Disaster
- Pre-Disaster Networking
- 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
-
47Mitigating Organizational Barriers to Recovery
Post-Disaster (contd)
48Themes 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
49Part III Organizational Preparedness and
Resilience
50Mass 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
51Mass Violence and Disasters (contd)
- 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
52Organizations Communities At Risk
- Disadvantaged Populations
- Racial/Cultural
- Economic
- Psychiatric
- Medical
- Active Duty Military Veterans
53Organizational 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
54Mitigating Organizational Barriers to Recovery
Post-Disaster
- Pre-Disaster Networking
- 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
-
55Mitigating Organizational Barriers to Recovery
Post-Disaster (contd)
56Technology 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)
57Technology Overview
58PTSD 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
59Home 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.
60Final Notes on Resilience
- Eva Schloss, Step-Sister of Anne Frank
- http//www.bbc.co.uk/news/world-22126164
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62(No Transcript)
63Connecticut 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
64Contact Information
- Francis Abueg, Ph.D. (pronounced UH-BWEG)
- Email drfrancis_at_traumaresource.com
- Tel 408.390.3520
- Web www.traumaresource.com