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

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• 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

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Objectives

• Overview Big Picture
• Inner World of Trauma
• Community Experience
• Management, Response Advances

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Personal Context

• Family of Origin
• Differential Coping
• Research Clinical Choice Making

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Part I Big Picture
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Disaster Defined

• Disaster is a process that encompasses an event
  , or series of events, affecting multiple people,
  groups, and communities

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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 lifesocially
  constructed (at least by some) as being outside
  of ordinary experience

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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 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

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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 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.

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Mass 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.

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Defining Disasters
Mass Killings
Terrorism
Natural
Man-Made
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Newtown Connecticut
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Problem in Defining the Problem

• Narrowing of Perception
• The Cult of Personality
• Debunking Profiling

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Why School Shootings?

• Simple theorizing not sufficient
• Common elements
• Socially marginalized
• Psychosocial stressors
• Cultural scripts (gender bias)
• Failure in surveillance
• Gun availability

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Bridge to Disaster Mental Health
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Part II Inner World of Surviving Horrific Events
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In the Eye of Mindstorm

• Hot and Cold Emotions
• Narrowing of Perception
• Misattribution or Overattribution of Cause

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Context of Silencing
Intrapersonal
Interpersonal
BiologicalPsychophysiological
SocioculturalContexts
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Familial (violence, incest, sibling abuse)
Institutional (government, military, religious)
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Art Spiegelman Graphic Comic Artist

• Maus Comics (Vols. 1 2)
• In the Shadow of No Towers (2004)

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Mardi Horowitz Triumvirate of Traumatic
Emotionality

• Overwhelming Anxiety
• Shame
• Rage

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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

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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.
•  

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Clues to Silencing in PTSD Diagnosis

• Life threat
• Fear, helplessness, horror (deleted from DSM-5)

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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

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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
  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

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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

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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

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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
  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)

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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)

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Notes on the values/risks of dissociation

• Lifton construct and tree metaphor
• Trance states of emotion

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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
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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)

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Social/Cultural ExperiencesWhich Increase Threat
Perception

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

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Social/Cultural ExperiencesWhich Increase Threat
Perception

• Exceptional emotionality of trauma
  
• (Te, Drd, Hr, Dg, Sh)
• Explicit threats to disclosure (Lister, 1987)

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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
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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".
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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

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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)

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Interpersonal Silencing

• Explicit threats
• Shock, startle and unconscious shaming
• Silencing through indifference or avoidance
• Iatrogenic treatments, institutional failures

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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)

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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

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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

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Mitigating 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

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Mitigating Organizational Barriers to Recovery
Post-Disaster (contd)
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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

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Part III Organizational Preparedness and
Resilience
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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

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Mass 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

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Organizations Communities At Risk

• Disadvantaged Populations
• Racial/Cultural
• Economic
• Psychiatric
• Medical
• Active Duty Military Veterans

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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

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Mitigating 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

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Mitigating Organizational Barriers to Recovery
Post-Disaster (contd)
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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)

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Technology Overview
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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

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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.

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Final Notes on Resilience

• Eva Schloss, Step-Sister of Anne Frank
• http//www.bbc.co.uk/news/world-22126164

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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
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Contact Information

• Francis Abueg, Ph.D. (pronounced UH-BWEG)
• Email drfrancis_at_traumaresource.com
• Tel [phone]
• Web www.traumaresource.com