1. Ongoing Traumatic Stress (OTS) and Post-Traumatic Stress Disorder (PTSD): The impact of cartel related violence on the U.S./México border.
Understand what motivated this work..
Thom Taylor

2. Agenda A brief background to traumatic stress
Post-Traumatic Stress Disorder (PTSD)
Ongoing Traumatic Stress (OTS)
Preliminary study of OTS in population exposed to violence and insecurity in Ciudad Juárez
Considerations for U.S./México Border Public Health and Safety communities

4. No studies in Americas of impact at psycho-social level of cartel related violence on public-more on drug policy, political and economic issues, etc.

7. Traumatic Stress Background

8. “Violence and Insecurity”
Extreme increase in cartel and community related violence in northern México
Cartel related murders (2000+ in past year)
Kidnappings
Car-jackings
Robberies/Extortion (“Cuotas”)
Constant threat
U.S. not immune
Cartel and army related violence (CARV)
Psycho-social costs to a community
Increases stress
Understanding PTSD and other forms of traumatic stress through lens of current cartel related violence and insecurty
Caetano, 2009; U.S. Department of State, 2009; Thoumi, 2002; Chan, Air, & McFarlane, 2003

9. Extreme Stress Reactions
Post-Traumatic Stress Disorder (& Probable PTSD)
Exposure to traumatic experience (s)
Feelings of fear, helplessness, and/or horror peri-event
Intrusive thoughts/Re-experiencing (1+ symptoms)
Avoidance/numbing to situations (3+ symptoms)
Hyper-arousal (2+ symptoms)
Psycho-social impairment
Partial PTSD
Threshold for full PTSD may be too high
Impairment still seen (e.g., anger)
American Psychiatric Association (APA), 2000; Berstein et al., 2007; Mitka, 2008; Galea et al., 2003; Stein et al., 1997

10. Acute Event PTSD: Implicit Assumptions
Note change in VHA policies in July, 2010 regarding listing a specific event. What if multiply exposed over and over again?
Note that bringing perception in line with reality is not just psychological “changing emotions and cognitions about situations;
Entails helping the body become aware that it is in a safe situation-retraining the body; why they call it the bio-psycho-social model
(big book slam as example maybe-unpredicable and uncontrallable, albeit minor)

11. Identified Traumatic Stress Trends
Chronic PTSD (> 3 months)
Acute PTSD (> 1 Month)
Resistant
Resilient
APA, 2000; Bonnano, 2004; Norris et al., 2009

17. Re-experiencing / Intrusive Thoughts
Core Trauma Symptoms
Avoidance / Numbing
Re-experiencing / Intrusive Thoughts
Hyper-Arousal
Want to revisit the core symptoms of traumatic stress

18. PERI Trauma (Immediate) Considerations
Unpredictable and Un-controllable
Subjective exposure
Fear
Helplessness
Horror
Direct forms of Trauma (e.g., assault, terrorism)
Indirect forms of Trauma (e.g., witnessing, media, trauma by proxy-such as family member)
Subjective interpretation
Subjective component; Daniel Pearl
A lot of indirect forms of trauma happening in Cd. Juarez
Breslau et al., 2004; Gray et al., 2004; Gabriel et al., 2007; Suvak et al., 2008; Collimore et al., 2008; Foa & Riggs, 1995; Weathers & Keane, 2007

19. PRE-Trauma Risk Factors
Demographic risk factors (e.g., female gender)
Exposure to multiple traumata (re-exposure)
Anxiety disorders rarely present in pure form
Pre-existing anxiety disorders may worsen traumatic stress after exposure
Anxiety Sensitivity predisposes to traumatic stress after exposure
Depression
Unclear if PRE or POST factor
Depression highly comorbid with TS post-event (correlation)
May worsen traumatic stress
Demographic risk factors include female gender, ethnicity, though not acculturative stress/perhaps mixed depending on refugee status, low ses/incom; younger age (though restriction in range in present data)
A lot of talk about desensitization, but when it is traumatic, seems to do more sensitizing
Brewin et al., 2000; Ozer et al., 2003; Norris et al., 2003b; Dunner, 2001; Goldenberg et al., 1996; Elwood et al., 2009; Gabriel et al., 2007; Jaycox et al., 2003; Collimore et al., 2008; Breslau et al., 1997; Breslau et al., 1991; Breslau et al, 2000

20. PRE-Trauma Sources of Coping
Social support strongly buffers against traumatic stress
Coping in uncontrollable situations
Problem focused (limited in uncontrollable situations)
Emotion-focused
Active
Self distraction (+ or -)
Venting (+ or -)
Cognitive acceptance of situation/experience ( + or -)
Avoidance based
Denial ( generally - )
Giving up/feeling hopeless ( - )
Self-blame ( - )
Substance use ( - )
Brewin et al., 2000; Lazarus & Folkman, 1984; Solomon, 1989; Carver et al., 1989

21. Unique Opportunity
Virtually no empirical study of psycho-social impact of cartel related violence in the Americas
Limited knowledge of real-time (daily) impact
Memory distortion after the fact (e.g., months, years, melding of traumas? Such as in VHA situation)
More refined understanding of impact of ongoing traumatic situations
Note on lack of information on cartel related violence (E.g., Colombia)-rare to be able to study when even journalists targeted
Needed understanding of ongoing conflict situations; rare to have ability to be immersed, but safe (though somewhat limited because of travel restrictions).
Nisbett & Wilson, 1977; Wolfer, 1999

22. Preliminary Study of Ongoing Traumatic Stress
Assess Ongoing Traumatic Stress (OTS)
Examine impact of factors commonly associated with PTSD in:
Ongoing (daily) Traumatic Stress
Ongoing (daily) Re-experiencing symptoms
Ongoing (daily) Avoidance symptoms
Ongoing (daily) Hyperarousal symptoms
What do you think you did (perceptual SM) and what did you actually do?

23. Methods

24. Participants
N = 121 (N days = 816)
Inclusion Criteria
Travel/live in Cd. Juárez at least 3 days/week
Internet access at least every 24 hour period
Bilingual
UTEP student
Comfort with online survey; anonymity/confidentiality
Post-hoc advantage; could still recruit after UTEP travel ban
Compensation: $40USD giftcard to Target OR 4 experimental credits

25. Measures: Main Outcome
All measures professionally translated and back-translated with subsequent native Spanish speakers’ input on items
Post-traumatic Stress Disorder Checklist (PCLS)
Specific event-adapted for CARV: “…violencia relacionado con el narcotrafico u hostilidad y maltrato militar.”
Past 30 day Acute PTSD (α = .89)
Adapted version for daily traumatic stress for past 24 hours (PCLSD): α range =
Brislin, 1970; Liu, 2002; Weathers et al., 1993 Ruggiero et al., 2003; Orlando & Marshall, 2002

26. Background Measures
Life Events Checklist (LEC) documents 17 traumatic events often associated with PTSD
Experienced Directly (direct)
Witnessed (indirect)
Learned of/Heard about (indirect)
Depression, Anxiety, and Stress Scale (DASS)
Depression (α = .86)
Anxiety (α = .78)
General Stress (α = .85)
Note: DASS mixes frequency of symptoms and degree of symptomology
Gray et al., 2004; Lovibond & Lovibond, 1995; Crawford & Henry, 2003; Daza et al., 2002

27. Background Measures Continued
Multi-dimensional Scale of Social Support (MSPSS)
Family (α = .89)
Friends (α = .96)
Significant Other (α = .92)
Brief COPE coping measure (BCOPE); Carver encourages malleability given nuances of coping
Problem Focused Coping (α = .78)
Emotion Focused Active Coping (α = .73)
Avoidance Coping (α = .76)
Zimet et al., 1988; Carver et al., 1997, Schneider et al., 2007; Perczek et al., 2000

28. Daily Assessment Completed online >24 hours for 7 days
PCLSD (daily traumatic stress)
Time-varying explanatory covariates
Travel to CJ (# hours)
Reasons for being in CJ (family, friends, business, antro/club/bar)
Perceived degree of exposure to violence (fear, helplessness, horror)
Note that not carrying around something lessens reactions from those whom have strong opintions one way or the other regarding the violence (from reactions of avoidance and denial that it is a problem, to those who are overly interested and want to discuss the issue at length)

29. Lemonade out of Lemons
Drop out rarely positive outcome, but allows unique analysis in present study
20% did not return for follow-up
Unique opportunity in trauma study
Avoidance unpleasantness  drop-out?
Re-experiencing  unpleasantness  drop-out?
Hyper-arousal  unpleasantness  drop-out?

30. Informative Drop-Out Diggle-Kenward Selection Model (DKSM)
Single covariate entered due to estimation complexity: Past 30 day traumatic stress (PCLS)
Survival indicator from daily reports 3 to 4 constrained to be 0; no drop-out in interval
To allow estimation, only intercept allowed to co-vary with past 30 day acute PCLS scores
Drop-out unassociated with traumatic stress, all Zs < |.65|, all ps > .52
Take Home Point: Preliminary support that asking about trauma on a daily basis does not make it worse for those assessed.
Rubin, 1976; Molenberghs, Michiels, Kenward, & Diggle, 1998; Diggle & Kenward, 1994

31. Approach to Analysis: Multi-level modeling
Specified Expectation-Maximization in Maximum Likelihood; robust to MAR
Grand Mean centered variables
Standardized (N~0,1) covariates to give common scale to psychological factors
OPTS dependent variable (PCLSD)
Condition on demographics, LEC, DASS, MSPSS factors, BCOPE sub-scales
Time varying covariates
Presence in CJ (hours)
Perceived exposure to violence occurring (fear, helplessness, and horror)
Exchangeable correlation for random effects var/covar matrix-IT IS NOT GENERALIZED ESTIMATING EQUATIONS
Snijders & Bosker, 1999; Gardiner, Luo, & Roman, 2009

32. Preliminary Study Results

33. Demographic Highlights
Some have more exposure to lifetime traumatic events more than others; eg those in Cd. Juarez, etc. those in gangs, police officers, combat veterans, sex workers (both in Cd. Juarez and in El Paso, such as at truck stops, etc.), homeless population, drug using populations (some debate about whether substance users may be more likely to get themselves into situations where they are likely to experience traumatic event than the average citizen-revolving door situation)

34. Note that not a representative sample of UTEP students, or young adults in general.

35. Sample Continuous Characteristics
Variable
Possible Range
Mean SD
Med.
Min.
Max.
Days in Cd. Juárez, Chih per week
0 to 7
4.84
1.81 4 1 7
Days in El Paso, TX per week
4.73
1.56 5
Family who live in Cd. Juárez, Chih (%)
0 to 100
67.31
30.18 80
100
Friends who live in Cd. Juárez, Chih (%)
60.79
31.76 70
Age (years) --
21.62
3.40 21 18 44
PTSD Checklist Past 30 day Score (PTSD)
17 to 85
43.87
13.71 43 85

36. Sample Continuous Characteristics
Variable
Possible Range
Mean SD
Med.
Min.
Max.
Days in Cd. Juárez, Chih per week
0 to 7
4.84
1.81 4 1 7
Days in El Paso, TX per week
4.73
1.56 5
Family who live in Cd. Juárez, Chih (%)
0 to 100
67.31
30.18 80
100
Friends who live in Cd. Juárez, Chih (%)
60.79
31.76 70
Age (years) -
21.62
3.40 21 18 44
PTSD Checklist Past 30 day Score (PTSD)
17 to 85
43.87
13.71 43 85

37. Sample Continuous Characteristics
Variable
Possible Range
Mean SD
Med.
Min.
Max.
Days in Cd. Juárez, Chih per week
0 to 7
4.84
1.81 4 1 7
Days in El Paso, TX per week
4.73
1.56 5
Family who live in Cd. Juárez, Chih (%)
0 to 100
67.31
30.18 80
100
Friends who live in Cd. Juárez, Chih (%)
60.79
31.76 70
Age (years) -
21.62
3.40 21 18 44
PTSD Checklist Past 30 day Score (PTSD)
17 to 85
43.87
13.71 43 85

38. Sample Continuous Characteristics
Variable
Possible Range
Mean SD
Med.
Min.
Max.
Days in Cd. Juárez, Chih per week
0 to 7
4.84
1.81 4 1 7
Days in El Paso, TX per week
4.73
1.56 5
Family who live in Cd. Juárez, Chih (%)
0 to 100
67.31
30.18 80
100
Friends who live in Cd. Juárez, Chih (%)
60.79
31.76 70
Age (years) -
21.62
3.40 21 18 44
PTSD Checklist Past 30 day Score (PTSD)
17 to 85
43.87
13.71 43 85

39. Sample Daily CharacteristicsSD
Continuous Variable
Range
Mean
Overall
Betw.
Within
Hours each day in Cd. Juárez
0 to 24
11.87
9.00
6.74
6.39
Daily traumatic stress level
17 to 85
32.30
13.50
11.74
6.11
Peri-traumatic experiences
Fear
0 to 6
1.91
1.85
1.44
1.16
Helplessness
1.93
1.89
1.49
1.20
Horror
1.58
1.83
1.47
1.11
Coping via substance use
0.49
1.15
1.10
0.54

40. Sample Daily CharacteristicsSD
Continuous Variable
Range
Mean
Overall
Betw.
Within
Hours each day in Cd. Juárez
0 to 24
11.87
9.00
6.74
6.39
Daily traumatic stress level
17 to 85
32.30
13.50
11.74
6.11
Peri-traumatic experiences
Fear
0 to 6
1.91
1.85
1.44
1.16
Helplessness
1.93
1.89
1.49
1.20
Horror
1.58
1.83
1.47
1.11
Coping via substance use
0.49
1.15
1.10
0.54

41. Sample Daily CharacteristicsSD
Continuous Variable
Range
Mean
Overall
Betw.
Within
Hours each day in Cd. Juárez
0 to 24
11.87
9.00
6.74
6.39
Daily traumatic stress level
17 to 85
32.30
13.50
11.74
6.11
Peri-traumatic experiences
Fear
0 to 6
1.91
1.85
1.44
1.16
Helplessness
1.93
1.89
1.49
1.20
Horror
1.58
1.83
1.47
1.11
Coping via substance use
0.49
1.15
1.10
0.54
Daily traumatic stress may have more to do with daily exposure than Past 30 day scores; resilience

42. Sample Daily Characteristics Cont.
Categorical Variable
Overall %
Between %
Within Avg. %
Daily Traumatic Stress Risk Category
Limited (PCL less than 34) 60 81 74
Moderate (PCL of 34 to 43) 21 52 41
Clinical (PCL greater than 44) 19 37
Reasons for being in Cd. Juárez: Family No 25 55 46
Yes 75 93
Reason for being in Cd. Juárez: Friends 67 92 72 33
Reason for being in Cd. Juárez: Business 99 8 26 30
Reason for being in Cd. Juárez: Antro/Bar 95
100 96 5 23
Either some more exposed more reactive or mixture of exposure and worse reaction.

43. Sample Daily Characteristics Cont.
Categorical Variable
Overall %
Between %
Within Avg. %
Daily Traumatic Stress Risk Category
Limited (PCL less than 34) 60 81 74
Moderate (PCL of 34 to 43) 21 52 41
Clinical (PCL greater than 44) 19 37
Reasons for being in Cd. Juárez: Family No 25 55 46
Yes 75 93
Reason for being in Cd. Juárez: Friends 67 92 72 33
Reason for being in Cd. Juárez: Business 99 8 26 30
Reason for being in Cd. Juárez: Antro/Bar 95
100 96 5 23

44. Predicting Ongoing (Daily) Traumatic Stress Response Symptoms

45. Multi-Level Model Predicting Ongoing Traumatic Stress
Time Invariant Covariates B
95% CI p
Female
0.02
-0.20 -
0.24
U.S. Resident vs. citizen
0.04
-0.16
0.25
Income (ref. is Less than 15,000USD)
15,001 to 30,000USD
0.01
-0.23
0.26
30,001 to 45,000USD
-0.26
0.34
45,001USD to 60,000USD
0.11
-0.24
0.45
More than 60,000USD
-0.01
-0.53
0.52
Prior Trauma Exposure (Life Events Checklist)
Heard about (Indirect)
-0.04
-0.14
0.06
Witnessed (Indirect)
-0.08
0.12
Directly experienced
-0.12
0.10
Psychological Symptoms (DASS-21)
Depression
-0.06
-0.22
Anxiety
-0.18
General Stress
0.18
0.37
0.07
Social Support (MSPSS)
Family
-0.03
-0.15
Friends
-0.10
0.03
Significant Other
0.14
0.27
<.05
Coping
Problem focused
-0.21
0.09
Active emotion focused
-0.05
Avoidance based
0.08
Acute Post-Traumatic Stress Disorder
0.42
0.29
0.54
<.01
Time Varying Covariates
Hours in Cd. Juárez
Reason for being in Cd. Juárez
0.00
0.22
Business
0.15
0.28
Club/Bar/Antro
Peri-event exposure reactions
Fear
0.19
Helplessness
0.21
Horror
Full day indicator also tested; insensitive indicator; fixed effect of drop-out indicator not significant in any model

46. What the data say:
-what is not there may be as important as what is there

47. Multi-Level Model Predicting Ongoing Re-Experiencing Symptoms
Time Invariant Covariates B
95% CI p
Female
-0.17
-0.38 -
0.04
U.S. Resident vs. citizen
-0.10
-0.29
0.09
Income (ref. is Less than 15,000USD)
15,001 to 30,000USD
0.07
-0.16
0.30
30,001 to 45,000USD
0.12
0.40
45,001USD to 60,000USD
0.24
-0.08
0.56
More than 60,000USD
-0.41
0.59
Prior Trauma Exposure (Life Events Checklist)
Heard about (Indirect)
-0.02
-0.12
Witnessed (Indirect)
-0.09
-0.18
0.01
Directly experienced
0.00
-0.11
0.10
Psychological Symptoms (DASS-21)
Depression
-0.25
0.05
Anxiety
-0.14
0.13
General Stress
0.16
0.33
0.08
Social Support (MSPSS)
Family
Friends
-0.20
Significant Other
-0.04
0.20
Coping
Problem focused
Active emotion focused
-0.05
-0.19
Avoidance based
-0.03
0.21
Acute Post-Traumatic Stress Disorder
0.35
0.23
0.47
<.01
Time Varying Covariates
Hours in Cd. Juárez
0.06
Reason for being in Cd. Juárez
0.14
0.18
Business
Club/Bar/Antro
-0.21
0.22
Peri-event exposure reactions
Fear
0.19
Helplessness
0.17
0.25
Horror
Stepping out on more of a limb analyzing traumatic stress sub constructs

49. Multi-Level Model Predicting Ongoing Avoidance Symptoms
Time Invariant Covariates B
95% CI p
Female
-0.03
-0.30 -
0.24
U.S. Resident vs. citizen
0.09
-0.16
0.34
Income (ref. is Less than 15,000USD)
15,001 to 30,000USD
-0.08
-0.38
0.21
30,001 to 45,000USD
-0.21
-0.57
0.15
45,001USD to 60,000USD
0.10
-0.32
0.52
More than 60,000USD
-0.93
Prior Trauma Exposure (Life Events Checklist)
Heard about (Indirect)
-0.04
-0.17
0.08
Witnessed (Indirect)
0.01
-0.11
0.13
Directly experienced
-0.02
0.11
Psychological Symptoms (DASS-21)
Depression
-0.01
0.18
Anxiety
-0.07
-0.24
General Stress
0.38
Social Support (MSPSS)
Family
0.14
Friends
-0.12
-0.27
0.04
Significant Other
0.16
0.32
<.05
Coping
Problem focused
-0.05
-0.23
Active emotion focused
-0.26
Avoidance based
-0.06
Acute Post-Traumatic Stress Disorder
0.37
0.22
<.01
Time Varying Covariates
Hours in Cd. Juárez
Reason for being in Cd. Juárez
0.07
0.00
-0.09
Business
0.29
0.44
Club/Bar/Antro
-0.10
Peri-event exposure reactions
Fear
Helplessness
0.05
Horror
0.06

51. Multi-Level Model Predicting Ongoing Hyperarousal Symptoms
Time Invariant Covariates B
95% CI p
Female
0.08
-0.14 -
0.31
U.S. Resident vs. citizen
0.02
-0.19
0.23
Income (ref. is Less than 15,000USD)
15,001 to 30,000USD
0.05
0.30
30,001 to 45,000USD
0.24
-0.06
0.54
45,001USD to 60,000USD
-0.07
-0.41
0.28
More than 60,000USD
0.21
-0.32
0.74
Prior Trauma Exposure (Life Events Checklist)
Heard about (Indirect)
-0.03
0.07
Witnessed (Indirect)
0.10
0.00
0.20
<.05
Directly experienced
Psychological Symptoms (DASS-21)
Depression
-0.08
-0.24
Anxiety
-0.21
General Stress
0.40
Social Support (MSPSS)
Family
-0.05
-0.17
Friends
-0.20
0.06
Significant Other
0.13
0.25
Coping
Problem focused
-0.22
Active emotion focused
-0.04
0.11
Avoidance based
0.15
0.27
Acute Post-Traumatic Stress Disorder
0.52
<.01
Time Varying Covariates
Hours in Cd. Juárez
-0.01
Reason for being in Cd. Juárez
0.12
-0.02
0.19
Business
-0.11
0.22
Club/Bar/Antro
Peri-event exposure reactions
Fear
0.16
Helplessness
Horror
0.03

52. Deals of nature of cartel conflict (violence and insecurity in Cd
Deals of nature of cartel conflict (violence and insecurity in Cd. Juarez)

53. Discussion

54. Ongoing Traumatic Stress
Border significantly affected by OTS and PTSD
Present sample might objectively be considered of less risk (many protective factors/buffers)
Still, sample evidenced both PTSD and OTS scores warranting concern
Assessing for PTSD can potentially help to reduce OTS
Yet, common prior factors associated with long term traumatic stress (PTSD) less impactful at daily levelmore nuanced?
Psycho-accumulation potentially related to prior exposure, though more ongoing than acute re-exposure over time
(psycho-accumulation of very frequent potentially traumatic events vs. fewer extreme)
Non-significant time spent in Cd Juarez/i.e, more in El Paso, as well as lack of association in citizenship status suggests family unit versus individual as unit of analysis
Diamond et al., 2010; Mineka & Zinbarg, 2006; Ozer et al., 2008; Ursano et al., 2009

55. Evidence for Ongoing Traumatic Stress
Objective exposure (i.e., less time in Cd. Juárez) does not reduce OTS
Very strong subjective component
Strong peri-event subjective reactions to exposure observed
Assessment of “real time” reactions important
Valid Anticipatory fears: the future as important as past
Unpredictability
Uncontrollability
Fear, helplessness, and horror on a daily basis
Reinforced avoidance and generalizing of fearful situations/psycho-social states
Residency status not associated with traumatic stress level in any model
Diamond et al., 2010; Hobfoll et al., 2009

56. What is not there that “should be?”
Gender (female) unassociated with Ongoing Traumatic Stress in the present sample
Variability (model ICCs) HUGE
Other important factors to assess nested within gender
Not “only a Mexican problem”
Socio-economic status not explanatory either
U.S. and Mexican citizens integrated in to both sides of border are significantly affected
Kessler et al., 1995, Ozer et al., 2008

57. Past/Future Exposure Considerations
Evidence for resilience from past traumata
Much exposure already in these young adults
Little impact on traumatic stress when accounting for other factors identified in traumatic stress literature
Still, fear regulation strongly disrupted in traumatic stress; differentially to other anxiety disorders
Long-term impact from short term OTS?
Virtually nothing at the individual or family unit level related to cartel violence, not even from Colombia
Bonanno, 2004; deRoon-Cassini et al., 2010; Norris et al., 2009; Dutton & Greene, 2010; Etkin & Wager, 2007; Wilson & Freer, 2010; Ginzburg et al., 2010

58. Sample is clearly resistant to trauma given life events checklist effects, but…

60. Other Factors to Consider: Psycho-Accumulation of Trauma?
Re-exposure assumes a somewhat linear process
Psycho-accumulation, potentially quadratic?
Bio-psycho-social accumulation of stressors
Note that PTSD higher than OTS in sample, evidence both for separate constructs, but also that psycho-accumulation may already be occurring

61. Depression, Anxiety, General Stress, and Traumatic Stress
In ongoing traumatic stress, depression may or may not be present
Few depression symptoms overall (floor effect)
Still, depression assessment likely always warranted when assessing traumatic stress in general
Sample applies for other anxiety disorders
May meet criteria for multiple anxiety disorders (e.g., GAD)
General stress may be one area where we can intervene for those exposed to OTS (more later)
Breslau et al., 1991; Breslau et al, 2000; Collimore et al., 2008; Breslau et al., 1997

62. Coping with Ongoing Traumatic Stress
Problem-focused coping difficult in uncontrollable/unpredictable situations
Adaptive routes/variation of routes to go somewhere in the city
Others examples from your perspective?
Active/emotion-focused coping may not fully compensate for OTS
Coping may be very diverse in OTS
Are some strategies helpful in one context of ongoing violence, while harmful in others?
Many of you see coping first-hand
Riolli & Savicki, 2010; Bonanno, 2004; Lazarus, 2000; Bal et al., 2003; Ullman, Filipas, et al., 2007

63. Family, Familiarity, Stability
Decision to move/stay in Cd. Juárez?
Separation from loved ones and familiarity
Family may still be exposed even if one individual family member is safe.
“For better or worse…” (the family unit)
Resource loss worsens traumatic stress
Psycho-social resources (e.g., friends)
Kids can do a little better here—from research perspective
Older adults can be vulnerable to effects of displacement
Physical resources/access
Extortion (“Cuotas”)
Example: IMSS
Note that applies to many trauma victims, not just the violence and insecurity in Cd. Juárez.
Recall that time in Cd. Juarez did not affect traumatic stress; family connection
Alim et al., 2008; Rivera et al., 2008; Hobfall et al., 2009; Wyshak, 1994; Fozdar, 2009

64. Social Support Strongest buffer to Post-Traumatic Stress
Applies to retrospective reports
Potentially more accessible when exposure is acute vs. ongoing
May be more nuanced in Ongoing violence
Supporting others in uncontrollable and unpredictable ongoing stressors may be difficult
Larger families may have resources spread across many individuals
Provider vs. receiver?
Brewin et al, 2000b; Bradley et al., 2005; Kwak, 2003; Szapocznik & Kurtines, 1993; Monson et al., 2009

66. “For better or worse…”

67. “For better or worse…”

69. Community Support Opportunity
Regional attention to traumatic stress
A need (Cartel violence, Veterans of OEF/OIF)
An opportunity to be a “Star” community for helping those affected by traumatic stress
Psychological/Psychiatry is important, but not the only answer:
Limit mental health stigma and shame
Promote autonomy: “feeling in control”
Potential nuances of exposure therapy
In a way, this is community wide problem focused coping
Particularly noteworthy as men did not differ from women in being affected
Social resources not necessarily mental health-e.g., parental support groups (Dr. Brown)
Maybe the solution is not just to throw everyone in to one-on-one or group therapy with a trained profession—although that is A VERY IMPORTANT component of community public health support for many who are affected---also worth considering that these resources are limited along the USMB.
Joseph, 2010; McCart et al., 2010; Jones, 2007; Diamond et al., 2010; Litz et al., 2002; Rose et al., 2002; Shalev et al., 2004; Milliken et al., 2007; Bradley et al., 2005

70. http://www. arabellaadvisors. com/pages/HIGO2009_conflictresolution
Texas can be pretty provincial, but opportunity exists to be a strong model for helping those who are suffering and in need in terms of traumatic stress as a result of conflict

73. Creative Community Support
Promote predictability
May be limited in Cd. Juárez (ideas?)
El Paso/U.S. side of the border
Educate on traumatic stress and the range of people affected-builds empathy
Streamline policies/systems to accommodate range of victims’ needs
Limit daily stressors: “the daily grind”
Wears down mental resources
Unprepared when crisis occurs
Behavioral economists, I/O psychologists, and combat deployed clinicians
Sutton, 2010; Hobfoll et al., 2007; Wei et al., 2010; Bryan, 2010

74. In a crisis, which battery do you want?1. 2.
Psycho-neuro-immunological example (e.g., flu); Remember-Traumatic stress is a bio-psycho-social problem 3. 4.

75. Preventing “low power”
Address daily stressors of patients/clients/staff
Is a action/policy a barrier, a benefit, or both for the
Patient/client?
Staff?
Can the action/policy be adapted to reduce “the daily grind?”
Can benefit not just the individual patient/client, but also the system and staff
Support the supporters
Remember, there is a hierarchy many systems
“____________ flows downhill.”
You fill in the blank (can be positive or negative word)
After presentation, I am interested in hearing your perspectives on how to prevent “low power.”
Potentially map out system/hierarchy, and identify actions and policies within each level of the hierarchy where something may be adapted to reduce the “daily grind.”

76. Focus on “Small Wins”
Big changes are rare and when they do occur, there is sometimes a backlash
Find ways to make “small wins”
Recognize small wins as wins none-the-less
Reinforces future action that can promote future “small wins”
Promotes self-efficacy
May promote community efficacy
Small wins add up.
Bryan, 2010

77. Limitations and Strengths of Present Study
Threshold for impairment in PCLS may be different for this group
Sensitivity and specificity
Need for focus on psycho-social impairment criterion
Convenience/snowball sampling may limit generalizability of findings
Low statistical power due to large inter-individual variability
Strengths
Daily level longitudinal assessment; not feasible in many cases
Professionally back-translated measures

78. Conclusions
Moderate to high levels of ongoing traumatic stress a likely reality for many with close ties to Cd. Juárez
Risk factors and buffers commonly associated with PTSD nuanced in Ongoing (Daily) Traumatic Stress
Community can do a lot to indirectly help those affected by trauma
“Small Wins”
Creative opportunities for community support?

79. One Final Note

81. The Future of Cartels
When substance use revenues change, cartels may not disappear or even become weaker (VERY ADAPTIVE)
Example: 1920s-1930s Chicago
U.S. Gangs
May move in to other activities that traumatize the population
Human/body trafficking (sex, labor, organs)
Consideration of (illegal) supply chains
Partnerships with other dangerous entities
We need to consider the future of cartels to prevent future traumatization of our loved ones and friends.

82. Spanish Trauma Questionnaires
National PTSD Center
Post-Traumatic Stress Disorder Checklist
Life Events Checklist
Contact me if you have questions on other scales:

83. Acknowledgements Dr. Cooper Dr. Byrd Dr. Cohn Dr. Eno Louden
Dr. Morera
Hispanic Health Disparities Research Center, Grant No. 1P20MD
A Smoke Free Paso del Norte, Grant No
Areli Guajardo and Ivan Torres
Cisco Salgado and José Cabriales
Prevention and Treatment in Clinical Health Lab
Victoria A. Garcia and Richard Ford, Ph.D. .

84. Thank you!

85. Time permitting, I would like
Questions
A discussion of problem focused coping from your eyes?
To hear about possible “Small wins” in change/adaptation of activities and policies you think could help your organization to help those affected by trauma?