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Managing Community Trauma Theory and Intervention in support after tragic community events. Rob Gordon PhD

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1 Managing Community Trauma Theory and Intervention in support after tragic community events. Rob Gordon PhD

2 Before the threat: Rational, reasoning used to solve problems Time sequences, cause effect Social role within a system Social world, stable, constant, secure Cultural values resonate with personal priorities Expressed and perpetuated in social routines Emotions related to reality Reality taken for granted Function within a “comfort zone”

3 How is ‘Comfort Zone’ Maintained? Feedback detects variation outside comfort states Feedback measures current state against baseline Baseline is defined by stable reference points that do not change “Constancies” Constancies provide basis for feedback to detect change Discrepancy from Comfort State initiates corrective adjustments This is up- or down-regulation

4 CONSTANCIES Formed from the regular, repeated states of experience Key to any recognition of change or regulation Without constancies there is disorder, chaos, death Any living system must establish constancies to ensure regulation is possible. Constancies can be repaired if experience provides the same states as formed them

5 Rob Gordon CISM Training 9/04 Sub-Systems and their Constancies Physiological: neurotransmitters, blood levels, arousal, etc Cognitive: constancies of space, time, causality, sequence, memory, behaviour of mass and energy, rate of processing, attention and short term memory span, perceptual constancies, expectations Emotional: stability of affect, connection between affect and experience, moods, range of emotions, emotional meaning, predictability.., trust, character. Action: self efficacy, competence, control safety, intentions, self regulation, habit, routine. Social: trust, understanding of motives, self-image, reference others, familiar relationships, Existential: beliefs, assumptions, values, ideals, philosophy of life, human nature, self concept, meaning of life, memories, sense of future, purpose and goals

6 Rob Gordon CISM Training 9/04 WHEN CONSTANCIES CAN’T BE REPAIRED: Living systems actively interact with experiences, Disrupted constancies require new constancies to be created & new feedback systems formed. Constancies may be formed from the experiences that damaged them, if the baseline state is lost The system re-creates itself by making the new state the constancy The world is reorganised around the tragedy and enshrines it in the baseline This is PTSD or “scar tissue”.

7 Homeostatic Comfort Zone Higher psychological functions designed to operation when in “comfort zone” (thinking, “reality” orientation, self management, social life etc. Input balances output, healthy maintenance When comfort zone is exceeded by threat: Psycho-social function is compromised But may be maintained by training, routines and actions where processing has been done before Maintains functions but rigid and less adapted

8 Rob Gordon CISMFA 7/06

9 Arousal outside comfort zone Threat detected by primitive systems – subjective, biased for danger Adrenalin via Sympathetic NS – energy Prepares for physical action to survive material threat Holistic energising of mind & body to meet threat Comfort zone replaced by “Emergency Mode”

10 Calcutta Fire Rescue

11 11/05/10 Rob Gordon 11 Trauma (Greek): a wound, hurt; of things, a hurt, damage; in war, a blow, defeat (Liddell & Scott) Therefore a psychological trauma is: “An experience of sufficient quality or intensity as to wound or damage the psychic apparatus.”

12 Rob Gordon CISMFA 7/06 Fleeing from S11

13 Losing Social Role in Emergency Mode - Trauma Threat exceeds existing skills, knowledge, behaviour Arousal overwhelms existing capacities Requirements can’t be met – helplessness Links to social environment & role lost Constancies damaged or disrupted Redistributed energy not absorbed – can’t discharge through action - disorganises Capacity to reduce arousal & return to comfort zone is damaged or destroyed

14 Witnessing Others’ Trauma 9/11

15 11/05/10 Rob Gordon 15 Social Debonding Profoundly disrupts pre-existing physical, emotional and social continuity; It is unfamiliar - neither recognised nor understood; It affects all that is constant, taken for granted, not consciously experienced; Self-focus excludes awareness of what is lost. Its reversal is not automatic, immediate or complete Bonds may be damaged by: Either: a single traumatic “rupture”; Or: progressive degradation in chronic stress.

16 Israel Bombing

17 London Bombing

18 Effect of high arousal on Perception & Memory Biased to detect threat, neglect non-threat cues Threat details intensified & torn out of context Perceptual dimensions distorted (time, distance) Holistic, multi-modal, affect-laden, non-verbal Highly aroused information in Explicit Memory (spontaneously available) Reassuring information in Implicit Memory (neglected and needs to be prompted) Keeps arousal up, perpetuates threat state.

19 Effect of High Arousal on Thinking Linear, concrete, rigid, problem solving thinking More visual, less verbal thought Simplified associations, instead of reasoning Judgemental, jump to conclusions Not distinguishing thought from imaginings, emotions, associations, possibilities, High arousal elements linked in false combinations Help survival, prevents planning, problem solving Keeps arousal up, perpetuates threat state.

20 Effects of High Arousal on Emotions Lose complex emotions (regret, disappointment, sadness, compassion, resignation) Revert to primary instinctive emotions (fear, anger, distress, horror, disgust, shame, pain) Emotions unstable, fluctuate, shut down,numbed Emotions welded to & reactivated by memories Unjustified emotions stimulated by false conclusions & consolidate misjudgments as reality Keeps arousal up, perpetuates threat state.

21 BUT: It’s not so simple! During the event, arousal may be absorbed in survival action Afterwards the defined threat of the emergency ends It is replaced by less defined threats (police, legal, loss, uncertainty, confusion, guilt, conflict, fear, anger, distrust, self-criticism, disgust etc.) Arousal is not reduced but changed, spreads to other systems, is maintained. New Emotional/Social constancies form to stabilise an alien world.

22 2 sources of arousal 2 sources of injury: 1. The event itself 2. The aftermath (recovery)

23 Damaging Dimensions of Arousal 1. Height of arousal: if too high – irreversible 2. Trajectory of increase: if too sudden –irreversible 3. Period of arousal: if too long – irreversible Arousal activated by appraisal based on experience; Threat and damage are based on meaning – which is individual & unpredictable.

24 Rob Gordon 0906 24 Healthy Survival Requires alternation between stress and recovery Reconnect with ‘normal’ states and activities Confidence and hope Evaluation of own situation (by comparing with others’) Recreation. Doing something creative, but different (sport, culture, craft, etc). Not keeping going till its all done Not neglecting self, relationships and other aspects of life that can be put aside. Everything deteriorates if neglected.

25 The longer arousal is high, the more adjustments stabilise constancies beyond comfort zone to preserve emergency mode Like scar tissue forming when the body template is lost and healing improvises a new order. In trauma the template is:  Physical: body states;  Mental: knowledge;  Social: new role.

26 Hurricane Katrina

27 11/05/10 Rob Gordon 27 Social Disruption Loss of networks – through mobility, isolation, different issues, loss of common ground, impact/recovery differentials etc But Social networks buffer against distress Social support creates well-being. Well-being and “Ill-being” are independent dimensions of life. Loss of access to well-being degrades quality of life, reduces resilience

28 11/05/10 Rob Gordon 28 For social support to aid recovery: 1. Active communication 2. Organizing 3. Cognitive work, increasing understanding and meaning 4. Revealing more, adding new details 5. Accepting emotions as part of work 6. Represent emotions in language 7. Empathy – offering them something different 8. Generate positive emotions 9. Selective focus on some aspects, rather than the whole thing 10. Aiding control 1. Passive communication 2. Saying the same things 3. Reiterating or ruminating on losses 4. Express emotions without adding meaning 5. Avoiding discussing the emotions 6. Emotional expression (catharsis, “getting it out”) 7. Sympathy – offering them more of the same 8. Exhibit negative emotions 9. Reassurance, platitudes 10. Indiscriminate, unregulated meandering HelpfulHindering

29 11/05/10 Rob Gordon 29 Types of Support that reduce Distress Tangible support – money, transport, comfort, material aid Identity support – similar issues, community recognition, availability of friends Appraisal support – advice and information about the issues Psychological support – help to think, decide, problem solve, recognise own states etc

30 Recovery does not start till arousal is brought down by: Environment: secure, comfort, needs Meaning: information about event, reactions, next steps, supports and assistance Social: attachments to recovery system and that recognise the trauma Role: Induct into the role of being a “Recoveree”


32 Personal Support and Recovery What happens after the emergency may be as damaging as what happens in it Shock and trauma may prevent a person returning to normal People may make bad decisions and establish habits that prevent recovery The social world may not help recovery if not informed and organised. Personal support is to help recovery to start

33 Inadequately Managed Aftermath - 1. 1. De-personalisation: Insensitive contact with combatant services; causes distrust, avoidance or conflict with helpers. 2. Isolation and dislocation: People to shut down and do not connect with recovery system or peers. 3. Continuing dazed and distracted: People do not integrate the experience, remain aroused and develop Posttraumatic Problems. 4. Individual experiences: False assumptions and loss of common ground mean people judge each other

34 Inadequately Managed Aftermath - 2 1. Misguided supporters: Become a liability. Loss of control and impairment of self determination means they are unable to be autonomous or in control of themselves 2. Fractured support relationships through poor communication and misunderstandings leads to 3. Self questioning, guilt, inadequacy, poor self esteem and depression follow from lack of support and understanding what is normal. 4. Natural History of Trauma - shut down, develop a routine façade, feel threatened by contact with peers or the recovery community, keep going till exhausted.

35 Priorities for Early Intervention - 1 1. Terminate the threat, restore security – provide physical needs, information about the event, emotional support 2. Counteract debonding, re-form a recovery community. Form a collective identity complementary to victims’ normal identity as “clients of the recovery system”. 1. Stabilise the person, restore homeostasis: Reduce traumatic arousal, restore feedback and self-regulation of physical, emotional and mental states 4. Provide comfort and care: physical, emotional social support 5. Reconnect with loved ones, integrate the emergency experience into relationships, advise and inform loved ones, they too may be traumatised (informational trauma).

36 Calm, attentive communi- cation is the essence or Personal Support.

37 Priorities for Early Intervention - 2 6. Set realistic recovery assumptions: information and understanding of the time frame and nature of recovery. 1. Normalise reactions by providing information packages. 8. Make the system acceptable and meaningful to victims so they orient towards it when they need help and information. Develop a useful, relevant and trusting relationship. 9. Triage for needs (1) Those likely to leave the scene first; (2) Those who are most obviously distressed - see criteria; (3) Those less distressed who can wait. 10. Practical assistance (transportation, communication etc).


39 Psychological First Aid Intervention 1. Introduction: tell them who you are, why you are here and what your role is. 2. Engagement: Find out their most pressing concern 3. Assessment: As they talk, consider level of arousal and what specific elements are aroused. 4. Expression: Help them to give expression to whatever is on their mind. 5. Assistance: Consider their needs as arousal comes down. 6. Re-engagement with Self: When arousal is down, or they have said what they want, re-direct their attention to themselves, their state and their needs. 7. Implementation: Set about doing what has been shown to be needed and helpful.

40 PFA General Strategies: Do nothing to increase arousal. Avoid exploring emotions, uncovering, adding to or complicating them. Focus on what experiences are causing the emotions. Follow their lead in what they want to talk about. Keep practical, focus on the event, the facts, what they saw and heard, what will happen, and where to from here. If they are in high emotional distress just comfort and support without exploring, until they calm down.

41 Problem solving In high arousal people cannot:  reason, think with concepts,  put things in context,  think beyond their own experience  take in new information Don’t try to explain and reason before you have brought arousal down, Ask about the experiences and memories that are aroused - Use their information and memories Encourage them to draw conclusions by asking questions about what they are saying, not telling. Encourage them to listen to what others are saying event.

42 Talking About What Happened. Encourage talk (don’t insist or focus if distressed, but don’t avoid if they are willing). Encourage putting images & experiences into words, especially the most disturbing, but don’t insist. Talk about what they have seen. Try to understand & explain why it was as it was – introduce your own thinking & information – think out loud with them. Don’t shy away from gruesome or sad talk – let them share it, but don’t stay on it longer than they want. Try to keep them company in the awful place they are in; don’t try to move them to a better place before they can.

43 Helping Work Things Out. Help them think about what happened (why they did not get hurt, could not do more, reacted the way they did, etc). Help them answer questions by going back to what they remember of the event and add common sense conclusions. Don’t tell them, help them work it out. Draw conclusions from their experience by getting them to tell bits in the right sequence then asking them to draw conclusions. When they can’t accept something that happened focus on helping them see just why it did happen as it did. Check their interpretations, see if the facts are consistent with them. If not, ask questions to bring relevant facts into relationship.

44 When someone is focussed on one thing. 1. Start with what they are talking about (what happened, images, loved ones, shock, their worry) 2. Use the issue to make a contact with the person; Ask questions about the issue and explore it, help them put it into words 3. Find out why they are focussed on that 4. Lead it to some constructive end, (they must wait, understanding trauma, there will be support) 5. Change focus onto its impact on them now (how do you feel about it now?) 6. Provide information about how it will be helped and make a plan to help them (even if just to get information)

45 Engaging the reluctant person 1. Start with whatever they are saying 2. Ask further questions or detail about what they are concerned about 3. If they are not talking, quietly explain your role and talk about the event to normalise the process 4. Ask about where they were, how involved, what they have seen in others and what they think will be helpful 5. Direct their attention to what they can do to get over this. 6. Follow up with advice about themselves or facts about the event 7. Aim to establish contact through their issue of interest.

46 Engaging the distressed person 1. Don’t ask about feelings. Say who you are & why you’re there 2. Is there anything they need or you can do? 3. Where were they/how they were involved in the event 4. Discover the reason for distress (threat to self, threat or loss of others, shock, worry about loved ones, etc) 5. Spend time with them. Encourage discussion of the experience, not feelings 6. Reassure them about recovery support – not about the effects of the experience, arrange follow up contact 7. Problem solving: Find out what they need now, Offer assistance to go home

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