1. Trauma Interventions For Survivors of Natural Disasters
Kathryn Wetzler, Psy.D
Adult Staff Psychologist
Consortium Director
Kaiser Permanente, Vallejo, California

2. Agenda Three Phases of Intervention Barriers to Treatment
Provider Issues
Brain Based Biology of Trauma
Evidence Based Treatment
Vallejo Study

3. Topography Typhoons Earthquakes Volcanic Ring of Fire
Need for evidence based or evidence supported responses
Heterogeneity of traumatic events defies specific guidelines (Hobfall, et al.)
1990 MHTFDM

4. Initial Phase - Stabilization
Psychological First Aid (early to mid- phases)
Developed after Hurricane Katrina (National Center for PTSD and the NCTSN)
Focus on non intrusive compassionate attitude of the part of clinicians
Core focus of PFA on the practical needs of trauma survivors

5. Initial Phase – Stabilization (cont’d.)
Consistent with research evidence on risk and resilience following trauma
Applicable and practical in field settings
Appropriate for developmental levels across the lifespan
Culturally informed and delivered in a flexible manner

6. Early to Middle Phase Five Intervention Principles (Hobfoll, et al.)
Empirical support
Aimed at early to mid- phases
Promotion of a sense of safety
Corrective information to help get a realistic view of the future
Information about friends and relatives

7. Early to Middle Phase (cont’d.)
Safety from rumors and sensationalized media
Leadership must take a role in ensuring accurate information is disseminated and fear is not used for political purposes
Psychological organizations may use their voice to guide media and political strategy

8. Early to Middle Phase (cont’d.)
Exposure to televised images may heighten psychological distress
Children may think the disaster is still occurring

9. Promotion of Calming
High levels of emotionality and arousal may be common especially in the post-trauma period
High levels of arousal may lead to panic symptoms and other non-adaptive responses
Most will return to pre-morbid functioning
Toolbox of skills:
Inoculation training
Bullet these and talk in some detail about the interventions

10. Promotion of Calming (cont’d.)
Grounding
Cognitive re-appraisal
Deep breathing
Diaphragmatic breathing
Deep muscle relaxation
Mindfulness
Normalization of symptoms (i.e. not going crazy)
Sleep hygiene

11. Promotion of Calming (cont’d.)
Delivery of these interventions can be individual, group or community based. Public Health interventions can be directed at large- scale community outreach programs and media used to disseminate information
Technology can also be used to disseminate information
At this point CISD (Critical Incident Stress Debriefing) may actually heighten arousal at a time when you want to dampen it

12. Promotion of Calming (cont’d.)
Studies have shown CISD is not effective in preventing PTSD and may exacerbate some people’s stress after the trauma
Role of positive emotions in coping with stress and trauma including
Joy
Humor
Contentment
love

13. Promotion of Calming (cont’d.)
Problem-focused coping
People may perceive the disaster as one big unmanageable problem
Break it down into manageable chunks, which will help in feeling some sense of control

14. Self and Collective Efficacy
Following a disaster people may be at risk of losing their sense of competency at problem solving which may generalize from the initial trauma to everyday life
Teaching children emotional regulation skills
Community self-efficacy through activities such as
Religious activities
Mourning rituals

15. Self and Collective Efficacy (cont’d.)
Praying
Singing
Bayanihan
Appointment of natural leaders

16. Promotion of Connectedness
Extensive research of the importance of social support and sustained attachments to loved ones - Oxytocin
Salutogenic factors (Antonovsky 1979), such as social support, extend beyond the initial trauma

17. Promotion of Connectedness (cont’d.)
Fundamental importance to children and adolescents
Church
Identify those with minimal social support
Provide formalized support
Organize places for teens to organize under supervised support, etc.

18. Hope
Instilling hope critical because of shattered worldview (Janoff Bullman, 1992)
Goes beyond the bounds of psychotherapy
Sense of Coherence (Antonovsky 1979)
Meaning
Manageability
Comprehensibility
Clean-up rebuilding

19. Hope (cont’d.) Housing Employment Relocation
Building on strengths, etc.

20. Barriers to Treatment Somatization Ongoing access to services
Validate symptoms
Provide education on etiology
Stigma
Ongoing access to services
Fear of letting guard down

21. Provider Issues Vicarious Trauma Burnout/Compassion fatigue
Assessing resiliency in providers
Self care
Gaining perspective
Feelings of incompetency/fear of failure
Realistic expectations of what constitutes help

22. Symptoms What can I expect? Nightmares Flashbacks
Avoidance of thought feelings or places
Mild, moderate or extreme detachment
Sleep disturbance
Anger or irritability

23. Symptoms (cont’d.) Hyper-vigilance Exaggerated startle response
Feelings of hopelessness
Loss of connection with faith or spirituality
Disruption in the ability to hope trust or care about others

24. Comorbidities Depression (psychotic) Panic disorder
GAD General Anxiety Disorder)
Separation anxiety
Somatization
Complicated or Traumatic Grief
Drug and Alcohol Abuse
Specific Phobias

25. Medications Possible use of medications:
SSRIs (e.g., Celexa, Paxil, Prozac, Zoloft)
Prazosin
Alpha-adrenergic blocker (blocks adrenaline)
Reduces nightmares in PTSD

26. The Brain and PTSD Amygdala Hyperactivity
Role of the Pre-Frontal Cortex (PFC)
Davidson work on Emotional Styles and PFC
Resilience – PFC and Amygdala
Hippocampal Abnormalities
HPA Axis (Hypothalamic Pituitary, Adrenal)
PTSD and Memory

27. Assessment Measures Clinical Interview
PCL-CIV (Post-Traumatic Checklist-Civilian)
BDI (Beck Depression Inventory)
Orienting to Life Questionnaire (Resilience)

28. Evidence Based Treatments for PTSD
Cognitive Processing Therapy
Prolonged Exposure (PE)
EMDR
ACT

29. Cognitive Processing Therapy
The gold standard in Veterans Administration clinics
Look at how beliefs in these domains have been impacted by trauma
Common Trauma-Related Cognitive Distortions:
“The world is dangerous”
“Events are unpredictable and uncontrollable”

30. Cognitive Processing Therapy (cont’d.)
“What happened was my fault”
“I am incompetent”
“Other people cannot be trusted”
“Life is meaningless”
Emphasis on Socratic questioning, thought records, confronting avoidance and homework
Highly structured-detailed agenda for each session

31. Cognitive Processing Therapy (cont’d.)
12 weekly sessions; mins.; individual and group modality options; PCL every session
Cognitive Restructuring and Exposure
Cognitive restructuring using thought records centered around domains of safety, trust, power/control, intimacy and esteem
Exposure done through writing about the experience, reading it in session and reading it in between sessions

32. Prolonged Exposure Overall aim is to emotionally process the trauma
Includes the following procedures
Education about most common reactions
Breathe retraining
In vivo exposure to avoided situations or places
Repeated prolonged imaginal exposure to trauma memories

33. EMDR Eye movement desensitization reprocessing
Assumption of maladaptive information processing
Bi-lateral stimulation aimed at unblocking traumatic memories
Tapping
Some controversy regarding mechanisms of change

34. Acceptance and Commitment Therapy
Origins in functional contextualism and Relational Frame Theory
FC – focuses on the function that a behavior serves as opposed to the actual behavior and how effective that behavior is in moving toward an identified goal
RFT – the building of associations; thoughts and feelings can assume meaning and qualities by being associated with one another
ACT works on the assumption that a certain amount of pain is part of being human and is unavoidable
“Pain is inevitable but suffering is optional”
Why do we suffer?
Experiential avoidance + cognitive fusion
RFT – This association is helpful in understanding why thoughts and feelings can trigger pain and then avoidance;
-Simple example with trauma- a victim of assault may now associate a knife with danger and pain, even having a mental image of a knife can elicit an intense sense of danger and pain. This individual now may do everything in his power to avoid any thoughts related to knives to avoid the discomfort associated with this image.
Pain vs Suffering: Pain is fear, anger, sadness, grief (natural emotions); Suffering is depression, chronic anxiety, loss of relationships, loss of meaning, substance use

35. Acceptance and Commitment Therapy (cont’d.)
Experiential Avoidance:
Misapplied control of internal events
Paradoxical effect of control for internal events: the intensity of thoughts and feelings tend to increase (e.g., don’t think of a yellow jeep)
Cognitive Fusion:
Thoughts and feelings becomes truths
“I am worthless” is only problematic if you believe it to be true and you allow it to stop you from living a valued life (Walser & Westrup 2007)

36. Acceptance and Commitment Therapy (cont’d.)
Emphasis on living a valued life even with a trauma history
Counters belief that life cannot move forward until unwanted thoughts and feelings are gone
Immediate use of value-based actions in goal setting
The goal is not to change the thoughts and feelings but to change your relationship to those thoughts and feelings
Core Components of Acceptance and Commitment Therapy (ACT)

37. Acceptance and Commitment Therapy (cont’d.)
Values
The blueprint for what we want our life to stand for
Process is not a destination, i.e. like the North star
Mindfulness/Present Moment
Being in the present moment without judgment
Humans tend to spend most of their time in the past or the future

38. Acceptance and Commitment Therapy (cont’d.)
Cognitive Defusion
Incorporates mindfulness
“I notice that I’m having the thought that…”
Programming: Two Computers Metaphor
Techniques: Taking your mind for a walk
Acceptance/Willingness
Letting go of the struggle (Tug-Of-War exercise)
Willingness to have unwanted thoughts or feelings (Eyes On exercise)
What Willingness is not
Studies on the utility of Mindfulness

39. Acceptance and Commitment Therapy (cont’d.)
Self as Context
If I am not my thoughts and feelings then who am I?
Self as content versus self as context
I am my thoughts and feelings versus
I am a context upon which thoughts and feelings occur
Chess Board metaphor

40. Acceptance and Commitment Therapy (cont’d.)
Committed Action
Larger and larger patterns of effective action
Motivated by values
Barriers to Committed Action

41. Acceptance and Commitment Therapy (cont’d.)
ACT, the trauma program at Vallejo, is an eight-week closed group
Each week a new process is introduced
Patients commit to attend all 8 sessions
Facilitated by 2 therapists
Group guidelines include an agreement to not discuss the details of their trauma (different to CPT, et al.)
Exposure not directly addressed but inherent part of the process

42. Strengths and Weaknesses: Cognitive Processing Therapy
Both individual and group
Belief systems addressed
Trauma-related guilt/atroccities
Strong empirical support
Weaknesses
Labor Intensive
Cognitive/Education requirements

43. Strengths and Weaknesses: Prolonged Exposure
Strong empirical support
Significant reductions in PTSD symptoms
Re-experiencing and hyperarousal symptoms-fear based
Acute PTSD
Weaknesses
Treatment attrition
Only individual modality
Cardiovascular risks
Therapist reactions
Numerous Traumas
Not for atrocities
Not feasible with Kaiser (weekly, 90 min., intensive training/supervision)

44. Strength and Weaknesses: Acceptance and Commitment Therapy
Strengths
Both individual and group
Patients don’t have to talk (less attrition)
Complex Trauma
Lifestyle Changes
Present and future oriented
More accessibility to training
Addresses all painful emotions-comorbid conditions
Weaknesses
Less empirical support
Flashbacks, nightmares and startle-response not addressed
Cognitive/Education requirements
Initially confusing to patients

45. Acceptance and Commitment Therapy (cont’d.)
Vallejo study of the Effectiveness of ACT