Presentation on theme: "Ongoing Traumatic Stress (OTS) and Post-Traumatic Stress Disorder (PTSD): The impact of cartel related violence on the U.S./México border. Understand."— Presentation transcript:
1Ongoing 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
2Agenda 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 JuárezConsiderations for U.S./México Border Public Health and Safety communities
8“Violence and Insecurity” Extreme increase in cartel and community related violence in northern MéxicoCartel related murders (2000+ in past year)KidnappingsCar-jackingsRobberies/Extortion (“Cuotas”)Constant threatU.S. not immuneCartel and army related violence (CARV)Psycho-social costs to a communityIncreases stressUnderstanding PTSD and other forms of traumatic stress through lens of current cartel related violence and insecurtyCaetano, 2009; U.S. Department of State, 2009; Thoumi, 2002; Chan, Air, & McFarlane, 2003
9Extreme Stress Reactions Post-Traumatic Stress Disorder (& Probable PTSD)Exposure to traumatic experience (s)Feelings of fear, helplessness, and/or horror peri-eventIntrusive thoughts/Re-experiencing (1+ symptoms)Avoidance/numbing to situations (3+ symptoms)Hyper-arousal (2+ symptoms)Psycho-social impairmentPartial PTSDThreshold for full PTSD may be too highImpairment still seen (e.g., anger)American Psychiatric Association (APA), 2000; Berstein et al., 2007; Mitka, 2008; Galea et al., 2003; Stein et al., 1997
10Acute 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)
17Re-experiencing / Intrusive Thoughts Core Trauma SymptomsAvoidance / NumbingRe-experiencing / Intrusive ThoughtsHyper-ArousalWant to revisit the core symptoms of traumatic stress
18PERI Trauma (Immediate) Considerations Unpredictable and Un-controllableSubjective exposureFearHelplessnessHorrorDirect forms of Trauma (e.g., assault, terrorism)Indirect forms of Trauma (e.g., witnessing, media, trauma by proxy-such as family member)Subjective interpretationSubjective component; Daniel PearlA lot of indirect forms of trauma happening in Cd. JuarezBreslau 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
19PRE-Trauma Risk Factors Demographic risk factors (e.g., female gender)Exposure to multiple traumata (re-exposure)Anxiety disorders rarely present in pure formPre-existing anxiety disorders may worsen traumatic stress after exposureAnxiety Sensitivity predisposes to traumatic stress after exposureDepressionUnclear if PRE or POST factorDepression highly comorbid with TS post-event (correlation)May worsen traumatic stressDemographic 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 sensitizingBrewin 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
20PRE-Trauma Sources of Coping Social support strongly buffers against traumatic stressCoping in uncontrollable situationsProblem focused (limited in uncontrollable situations)Emotion-focusedActiveSelf distraction (+ or -)Venting (+ or -)Cognitive acceptance of situation/experience ( + or -)Avoidance basedDenial ( generally - )Giving up/feeling hopeless ( - )Self-blame ( - )Substance use ( - )Brewin et al., 2000; Lazarus & Folkman, 1984; Solomon, 1989; Carver et al., 1989
21Unique OpportunityVirtually no empirical study of psycho-social impact of cartel related violence in the AmericasLimited knowledge of real-time (daily) impactMemory distortion after the fact (e.g., months, years, melding of traumas? Such as in VHA situation)More refined understanding of impact of ongoing traumatic situationsNote on lack of information on cartel related violence (E.g., Colombia)-rare to be able to study when even journalists targetedNeeded 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
22Preliminary Study of Ongoing Traumatic Stress Assess Ongoing Traumatic Stress (OTS)Examine impact of factors commonly associated with PTSD in:Ongoing (daily) Traumatic StressOngoing (daily) Re-experiencing symptomsOngoing (daily) Avoidance symptomsOngoing (daily) Hyperarousal symptomsWhat do you think you did (perceptual SM) and what did you actually do?
24ParticipantsN = 121 (N days = 816)Inclusion CriteriaTravel/live in Cd. Juárez at least 3 days/weekInternet access at least every 24 hour periodBilingualUTEP studentComfort with online survey; anonymity/confidentialityPost-hoc advantage; could still recruit after UTEP travel banCompensation: $40USD giftcard to Target OR 4 experimental credits
25Measures: Main Outcome All measures professionally translated and back-translated with subsequent native Spanish speakers’ input on itemsPost-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
26Background MeasuresLife Events Checklist (LEC) documents 17 traumatic events often associated with PTSDExperienced 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 symptomologyGray et al., 2004; Lovibond & Lovibond, 1995; Crawford & Henry, 2003; Daza et al., 2002
27Background 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 copingProblem 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
28Daily Assessment Completed online >24 hours for 7 days PCLSD (daily traumatic stress)Time-varying explanatory covariatesTravel 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)
29Lemonade out of LemonsDrop out rarely positive outcome, but allows unique analysis in present study20% did not return for follow-upUnique opportunity in trauma studyAvoidance unpleasantness drop-out?Re-experiencing unpleasantness drop-out?Hyper-arousal unpleasantness drop-out?
30Informative 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 intervalTo allow estimation, only intercept allowed to co-vary with past 30 day acute PCLS scoresDrop-out unassociated with traumatic stress, all Zs < |.65|, all ps > .52Take 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
31Approach to Analysis: Multi-level modeling Specified Expectation-Maximization in Maximum Likelihood; robust to MARGrand Mean centered variablesStandardized (N~0,1) covariates to give common scale to psychological factorsOPTS dependent variable (PCLSD)Condition on demographics, LEC, DASS, MSPSS factors, BCOPE sub-scalesTime varying covariatesPresence 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 EQUATIONSSnijders & Bosker, 1999; Gardiner, Luo, & Roman, 2009
33Demographic 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)
34Note that not a representative sample of UTEP students, or young adults in general.
35Sample Continuous Characteristics VariablePossible RangeMeanSDMed.Min.Max.Days in Cd. Juárez, Chih per week0 to 74.841.81417Days in El Paso, TX per week4.731.565Family who live in Cd. Juárez, Chih (%)0 to 10067.3130.1880100Friends who live in Cd. Juárez, Chih (%)60.7931.7670Age (years)--21.623.40211844PTSD Checklist Past 30 day Score (PTSD)17 to 8543.8713.714385
36Sample Continuous Characteristics VariablePossible RangeMeanSDMed.Min.Max.Days in Cd. Juárez, Chih per week0 to 74.841.81417Days in El Paso, TX per week4.731.565Family who live in Cd. Juárez, Chih (%)0 to 10067.3130.1880100Friends who live in Cd. Juárez, Chih (%)60.7931.7670Age (years)-21.623.40211844PTSD Checklist Past 30 day Score (PTSD)17 to 8543.8713.714385
37Sample Continuous Characteristics VariablePossible RangeMeanSDMed.Min.Max.Days in Cd. Juárez, Chih per week0 to 74.841.81417Days in El Paso, TX per week4.731.565Family who live in Cd. Juárez, Chih (%)0 to 10067.3130.1880100Friends who live in Cd. Juárez, Chih (%)60.7931.7670Age (years)-21.623.40211844PTSD Checklist Past 30 day Score (PTSD)17 to 8543.8713.714385
38Sample Continuous Characteristics VariablePossible RangeMeanSDMed.Min.Max.Days in Cd. Juárez, Chih per week0 to 74.841.81417Days in El Paso, TX per week4.731.565Family who live in Cd. Juárez, Chih (%)0 to 10067.3130.1880100Friends who live in Cd. Juárez, Chih (%)60.7931.7670Age (years)-21.623.40211844PTSD Checklist Past 30 day Score (PTSD)17 to 8543.8713.714385
39Sample Daily Characteristics SDContinuous VariableRangeMeanOverallBetw.WithinHours each day in Cd. Juárez0 to 2411.879.006.746.39Daily traumatic stress level17 to 8532.3013.5011.746.11Peri-traumatic experiencesFear0 to 61.911.851.441.16Helplessness1.931.891.491.20Horror1.581.831.471.11Coping via substance use0.4188.8.131.52
40Sample Daily Characteristics SDContinuous VariableRangeMeanOverallBetw.WithinHours each day in Cd. Juárez0 to 2411.879.006.746.39Daily traumatic stress level17 to 8532.3013.5011.746.11Peri-traumatic experiencesFear0 to 61.911.851.441.16Helplessness1.931.891.491.20Horror1.581.831.471.11Coping via substance use0.4184.108.40.206
41Sample Daily Characteristics SDContinuous VariableRangeMeanOverallBetw.WithinHours each day in Cd. Juárez0 to 2411.879.006.746.39Daily traumatic stress level17 to 8532.3013.5011.746.11Peri-traumatic experiencesFear0 to 61.911.851.441.16Helplessness1.931.891.491.20Horror1.581.831.471.11Coping via substance use0.4220.127.116.11Daily traumatic stress may have more to do with daily exposure than Past 30 day scores; resilience
42Sample Daily Characteristics Cont. Categorical VariableOverall %Between %Within Avg. %Daily Traumatic Stress Risk CategoryLimited (PCL less than 34)608174Moderate (PCL of 34 to 43)215241Clinical (PCL greater than 44)1937Reasons for being in Cd. Juárez: FamilyNo255546Yes7593Reason for being in Cd. Juárez: Friends67927233Reason for being in Cd. Juárez: Business9982630Reason for being in Cd. Juárez: Antro/Bar9510096523Either some more exposed more reactive or mixture of exposure and worse reaction.
43Sample Daily Characteristics Cont. Categorical VariableOverall %Between %Within Avg. %Daily Traumatic Stress Risk CategoryLimited (PCL less than 34)608174Moderate (PCL of 34 to 43)215241Clinical (PCL greater than 44)1937Reasons for being in Cd. Juárez: FamilyNo255546Yes7593Reason for being in Cd. Juárez: Friends67927233Reason for being in Cd. Juárez: Business9982630Reason for being in Cd. Juárez: Antro/Bar9510096523
45Multi-Level Model Predicting Ongoing Traumatic Stress Time Invariant CovariatesB95% CIpFemale0.02-0.20-0.24U.S. Resident vs. citizen0.04-0.160.25Income (ref. is Less than 15,000USD)15,001 to 30,000USD0.01-0.230.2630,001 to 45,000USD-0.260.3445,001USD to 60,000USD0.11-0.240.45More than 60,000USD-0.01-0.530.52Prior Trauma Exposure (Life Events Checklist)Heard about (Indirect)-0.04-0.140.06Witnessed (Indirect)-0.080.12Directly experienced-0.120.10Psychological Symptoms (DASS-21)Depression-0.06-0.22Anxiety-0.18General Stress0.180.370.07Social Support (MSPSS)Family-0.03-0.15Friends-0.100.03Significant Other0.140.27<.05CopingProblem focused-0.210.09Active emotion focused-0.05Avoidance based0.08Acute Post-Traumatic Stress Disorder0.420.290.54<.01Time Varying CovariatesHours in Cd. JuárezReason for being in Cd. Juárez0.000.22Business0.150.28Club/Bar/AntroPeri-event exposure reactionsFear0.19Helplessness0.21HorrorFull day indicator also tested; insensitive indicator; fixed effect of drop-out indicator not significant in any model
46What the data say:-what is not there may be as important as what is there
47Multi-Level Model Predicting Ongoing Re-Experiencing Symptoms Time Invariant CovariatesB95% CIpFemale-0.17-0.38-0.04U.S. Resident vs. citizen-0.10-0.290.09Income (ref. is Less than 15,000USD)15,001 to 30,000USD0.07-0.160.3030,001 to 45,000USD0.120.4045,001USD to 60,000USD0.24-0.080.56More than 60,000USD-0.410.59Prior Trauma Exposure (Life Events Checklist)Heard about (Indirect)-0.02-0.12Witnessed (Indirect)-0.09-0.180.01Directly experienced0.00-0.110.10Psychological Symptoms (DASS-21)Depression-0.250.05Anxiety-0.140.13General Stress0.160.330.08Social Support (MSPSS)FamilyFriends-0.20Significant Other-0.040.20CopingProblem focusedActive emotion focused-0.05-0.19Avoidance based-0.030.21Acute Post-Traumatic Stress Disorder0.350.230.47<.01Time Varying CovariatesHours in Cd. Juárez0.06Reason for being in Cd. Juárez0.140.18BusinessClub/Bar/Antro-0.210.22Peri-event exposure reactionsFear0.19Helplessness0.170.25HorrorStepping out on more of a limb analyzing traumatic stress sub constructs
49Multi-Level Model Predicting Ongoing Avoidance Symptoms Time Invariant CovariatesB95% CIpFemale-0.03-0.30-0.24U.S. Resident vs. citizen0.09-0.160.34Income (ref. is Less than 15,000USD)15,001 to 30,000USD-0.08-0.380.2130,001 to 45,000USD-0.21-0.570.1545,001USD to 60,000USD0.10-0.320.52More than 60,000USD-0.93Prior Trauma Exposure (Life Events Checklist)Heard about (Indirect)-0.04-0.170.08Witnessed (Indirect)0.01-0.110.13Directly experienced-0.020.11Psychological Symptoms (DASS-21)Depression-0.010.18Anxiety-0.07-0.24General Stress0.38Social Support (MSPSS)Family0.14Friends-0.12-0.270.04Significant Other0.160.32<.05CopingProblem focused-0.05-0.23Active emotion focused-0.26Avoidance based-0.06Acute Post-Traumatic Stress Disorder0.370.22<.01Time Varying CovariatesHours in Cd. JuárezReason for being in Cd. Juárez0.070.00-0.09Business0.290.44Club/Bar/Antro-0.10Peri-event exposure reactionsFearHelplessness0.05Horror0.06
51Multi-Level Model Predicting Ongoing Hyperarousal Symptoms Time Invariant CovariatesB95% CIpFemale0.08-0.14-0.31U.S. Resident vs. citizen0.02-0.190.23Income (ref. is Less than 15,000USD)15,001 to 30,000USD0.050.3030,001 to 45,000USD0.24-0.060.5445,001USD to 60,000USD-0.07-0.410.28More than 60,000USD0.21-0.320.74Prior Trauma Exposure (Life Events Checklist)Heard about (Indirect)-0.030.07Witnessed (Indirect)0.100.000.20<.05Directly experiencedPsychological Symptoms (DASS-21)Depression-0.08-0.24Anxiety-0.21General Stress0.40Social Support (MSPSS)Family-0.05-0.17Friends-0.200.06Significant Other0.130.25CopingProblem focused-0.22Active emotion focused-0.040.11Avoidance based0.150.27Acute Post-Traumatic Stress Disorder0.52<.01Time Varying CovariatesHours in Cd. Juárez-0.01Reason for being in Cd. Juárez0.12-0.020.19Business-0.110.22Club/Bar/AntroPeri-event exposure reactionsFear0.16HelplessnessHorror0.03
52Deals of nature of cartel conflict (violence and insecurity in Cd Deals of nature of cartel conflict (violence and insecurity in Cd. Juarez)
54Ongoing Traumatic Stress Border significantly affected by OTS and PTSDPresent sample might objectively be considered of less risk (many protective factors/buffers)Still, sample evidenced both PTSD and OTS scores warranting concernAssessing for PTSD can potentially help to reduce OTSYet, common prior factors associated with long term traumatic stress (PTSD) less impactful at daily levelmore 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 analysisDiamond et al., 2010; Mineka & Zinbarg, 2006; Ozer et al., 2008; Ursano et al., 2009
55Evidence for Ongoing Traumatic Stress Objective exposure (i.e., less time in Cd. Juárez) does not reduce OTSVery strong subjective componentStrong peri-event subjective reactions to exposure observedAssessment of “real time” reactions importantValid Anticipatory fears: the future as important as pastUnpredictabilityUncontrollabilityFear, helplessness, and horror on a daily basisReinforced avoidance and generalizing of fearful situations/psycho-social statesResidency status not associated with traumatic stress level in any modelDiamond et al., 2010; Hobfoll et al., 2009
56What is not there that “should be?” Gender (female) unassociated with Ongoing Traumatic Stress in the present sampleVariability (model ICCs) HUGEOther important factors to assess nested within genderNot “only a Mexican problem”Socio-economic status not explanatory eitherU.S. and Mexican citizens integrated in to both sides of border are significantly affectedKessler et al., 1995, Ozer et al., 2008
57Past/Future Exposure Considerations Evidence for resilience from past traumataMuch exposure already in these young adultsLittle impact on traumatic stress when accounting for other factors identified in traumatic stress literatureStill, fear regulation strongly disrupted in traumatic stress; differentially to other anxiety disordersLong-term impact from short term OTS?Virtually nothing at the individual or family unit level related to cartel violence, not even from ColombiaBonanno, 2004; deRoon-Cassini et al., 2010; Norris et al., 2009; Dutton & Greene, 2010; Etkin & Wager, 2007; Wilson & Freer, 2010; Ginzburg et al., 2010
58Sample is clearly resistant to trauma given life events checklist effects, but…
60Other Factors to Consider: Psycho-Accumulation of Trauma? Re-exposure assumes a somewhat linear processPsycho-accumulation, potentially quadratic?Bio-psycho-social accumulation of stressorsNote that PTSD higher than OTS in sample, evidence both for separate constructs, but also that psycho-accumulation may already be occurring
61Depression, Anxiety, General Stress, and Traumatic Stress In ongoing traumatic stress, depression may or may not be presentFew depression symptoms overall (floor effect)Still, depression assessment likely always warranted when assessing traumatic stress in generalSample applies for other anxiety disordersMay 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
62Coping with Ongoing Traumatic Stress Problem-focused coping difficult in uncontrollable/unpredictable situationsAdaptive routes/variation of routes to go somewhere in the cityOthers examples from your perspective?Active/emotion-focused coping may not fully compensate for OTSCoping may be very diverse in OTSAre some strategies helpful in one context of ongoing violence, while harmful in others?Many of you see coping first-handRiolli & Savicki, 2010; Bonanno, 2004; Lazarus, 2000; Bal et al., 2003; Ullman, Filipas, et al., 2007
63Family, Familiarity, Stability Decision to move/stay in Cd. Juárez?Separation from loved ones and familiarityFamily may still be exposed even if one individual family member is safe.“For better or worse…” (the family unit)Resource loss worsens traumatic stressPsycho-social resources (e.g., friends)Kids can do a little better here—from research perspectiveOlder adults can be vulnerable to effects of displacementPhysical resources/accessExtortion (“Cuotas”)Example: IMSSNote 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 connectionAlim et al., 2008; Rivera et al., 2008; Hobfall et al., 2009; Wyshak, 1994; Fozdar, 2009
64Social Support Strongest buffer to Post-Traumatic Stress Applies to retrospective reportsPotentially more accessible when exposure is acute vs. ongoingMay be more nuanced in Ongoing violenceSupporting others in uncontrollable and unpredictable ongoing stressors may be difficultLarger families may have resources spread across many individualsProvider vs. receiver?Brewin et al, 2000b; Bradley et al., 2005; Kwak, 2003; Szapocznik & Kurtines, 1993; Monson et al., 2009
69Community Support Opportunity Regional attention to traumatic stressA need (Cartel violence, Veterans of OEF/OIF)An opportunity to be a “Star” community for helping those affected by traumatic stressPsychological/Psychiatry is important, but not the only answer:Limit mental health stigma and shamePromote autonomy: “feeling in control”Potential nuances of exposure therapyIn a way, this is community wide problem focused copingParticularly noteworthy as men did not differ from women in being affectedSocial 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
70http://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
73Creative Community Support Promote predictabilityMay be limited in Cd. Juárez (ideas?)El Paso/U.S. side of the borderEducate on traumatic stress and the range of people affected-builds empathyStreamline policies/systems to accommodate range of victims’ needsLimit daily stressors: “the daily grind”Wears down mental resourcesUnprepared when crisis occursBehavioral economists, I/O psychologists, and combat deployed cliniciansSutton, 2010; Hobfoll et al., 2007; Wei et al., 2010; Bryan, 2010
74In a crisis, which battery do you want? 1.2.Psycho-neuro-immunological example (e.g., flu); Remember-Traumatic stress is a bio-psycho-social problem3.4.
75Preventing “low power” Address daily stressors of patients/clients/staffIs a action/policy a barrier, a benefit, or both for thePatient/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 staffSupport the supportersRemember, 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.”
76Focus on “Small Wins”Big changes are rare and when they do occur, there is sometimes a backlashFind ways to make “small wins”Recognize small wins as wins none-the-lessReinforces future action that can promote future “small wins”Promotes self-efficacyMay promote community efficacySmall wins add up.Bryan, 2010
77Limitations and Strengths of Present Study Threshold for impairment in PCLS may be different for this groupSensitivity and specificityNeed for focus on psycho-social impairment criterionConvenience/snowball sampling may limit generalizability of findingsLow statistical power due to large inter-individual variabilityStrengthsDaily level longitudinal assessment; not feasible in many casesProfessionally back-translated measures
78ConclusionsModerate to high levels of ongoing traumatic stress a likely reality for many with close ties to Cd. JuárezRisk factors and buffers commonly associated with PTSD nuanced in Ongoing (Daily) Traumatic StressCommunity can do a lot to indirectly help those affected by trauma“Small Wins”Creative opportunities for community support?
81The Future of CartelsWhen substance use revenues change, cartels may not disappear or even become weaker (VERY ADAPTIVE)Example: 1920s-1930s ChicagoU.S. GangsMay move in to other activities that traumatize the populationHuman/body trafficking (sex, labor, organs)Consideration of (illegal) supply chainsPartnerships with other dangerous entitiesWe need to consider the future of cartels to prevent future traumatization of our loved ones and friends.
82Spanish Trauma Questionnaires National PTSD CenterPost-Traumatic Stress Disorder ChecklistLife Events ChecklistContact me if you have questions on other scales:
83Acknowledgements Dr. Cooper Dr. Byrd Dr. Cohn Dr. Eno Louden Dr. MoreraHispanic Health Disparities Research Center, Grant No. 1P20MDA Smoke Free Paso del Norte, Grant NoAreli Guajardo and Ivan TorresCisco Salgado and José CabrialesPrevention and Treatment in Clinical Health LabVictoria A. Garcia and Richard Ford, Ph.D..
85Time permitting, I would like QuestionsA 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?