Objectives

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

2. Objectives • Overview: Big Picture • Inner World of Trauma & Community Experience • Management, Response & Advances

3. Personal Context • Family of Origin • Differential Coping • Research & Clinical Choice Making

4. Part I: Big Picture

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

6. 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

7. 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

8. 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.

9. 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.

10. Defining Disasters Mass Killings Terrorism Natural Man-Made

11. Newtown Connecticut

13. Problem in Defining the Problem • Narrowing of Perception • The Cult of Personality • Debunking Profiling

14. Why School Shootings? • Simple theorizing not sufficient • Common elements • Socially marginalized • Psychosocial stressors • Cultural “scripts” (gender bias) • Failure in surveillance • Gun availability

15. Bridge to Disaster Mental Health

16. Part II: Inner World of Surviving Horrific Events

18. In the Eye of Mindstorm • Hot and Cold Emotions • Narrowing of Perception • Misattribution or Overattribution of Cause

19. Context of Silencing Intrapersonal Interpersonal BiologicalPsychophysiological SocioculturalContexts

20. Familial (violence, incest, sibling abuse) Institutional (government, military, religious)

21. Art SpiegelmanGraphic Comic Artist • Maus Comics (Vols. 1 & 2) • In the Shadow of No Towers (2004)

23. Mardi Horowitz Triumvirate of Traumatic Emotionality • Overwhelming Anxiety • Shame • Rage

24. 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

25. 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.

26. Clues to Silencing in PTSD Diagnosis • Life threat • Fear, helplessness, horror (deleted from DSM-5)

27. 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

28. 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

29. 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

30. 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

31. 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)

32. 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)

33. Notes on the values/risks of dissociation • Lifton construct and tree metaphor • Trance states of emotion

34. 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

35. 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)

36. Social/Cultural ExperiencesWhich Increase Threat Perception • Exceptional emotionality of trauma (Te, Drd, Hr, Dg, Sh)

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

38. 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

39. 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".

40. 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

41. 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)

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

43. 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)

44. 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

45. 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

46. 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

47. Mitigating Organizational Barriers to Recovery Post-Disaster (cont’d)

48. 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

49. Part III: Organizational Preparedness and Resilience

50. 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