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

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Presentation on theme: "Trauma Interventions For Survivors of Natural Disasters Kathryn Wetzler, Psy.D Adult Staff Psychologist Consortium Director Kaiser Permanente, Vallejo,"— Presentation transcript:

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

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  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

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

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 Strengths  Both individual and group  Belief systems addressed  Trauma-related guilt/atroccities  Strong empirical support Weaknesses  Labor Intensive  Cognitive/Educatio n requirements

43 Strengths and Weaknesses: Prolonged Exposure Strengths  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


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