1. Coping with Trauma and Psychological First Aid for Disaster Survivors: Suggestions for American Indians EMERGENCY PREPAREDNESS CONFERENCE August 9, 2007 Portland, Oregon

2. Research Professor Schools of Nursing and Public Health and Community Medicine Faculty Faculty Northwest Center for Public Health Practice University of Washington Randal Beaton, PhD, EMT

3. Funding Support CDC/ASPH Centers for Public Health Preparedness Cooperative Agreement U09/CCU024247-03. (J. Thompson, PI) HRSA Advanced Nurse Education Training grant #1 D09HP08334-01-00- Disaster & Environmental Health Nursing (R. Beaton, PI)

4. Special Thanks Linda Frizzell, E. Cherokee & Lakota June Strickland Ticey Casey, Siletz Joe Finkbonner Jay LaPlante, Blackfoot National Child Traumatic Stress Network

5. Learner Objectives 1. To identify various ways of coping with traumatic events including disasters 2. To examine some existing coping strategies in American Indians and other suggested potential coping strategies 3. To analyze Psychological First Aid as a potential intervention for American Indian individuals and tribes in the aftermath of trauma & disaster

6. Traumatic Events Traumatic stressors are events that challenge our existing ways of making sense out of our own reactions, our perceptions of others and challenge our “fair world assumptions”: the world is safe, the world is predictable and “bad things do not happen to good people” Traumata can evoke fear, uncertainty (can I cope?), helplessness & hopelessness

7. Types of Traumatic Events Time-limited single events- such as a motor vehicle accident or sexual assault Sequential stressors which can have a cumulative effect– such as the exposures that firefighters experience in line of duty Complex– long lasting exposures to danger such as war zone combat or intrafamilial child abuse

8. Disaster Magnitude Crisis- almost routine. Usually can be handled by family & support system; e.g., job loss Emergency- may require 911 response or visit to hospital; e.g. injury or acute illness Disaster- may require resources from outside community (FEMA definition) Catastrophe- Poster child: “Katrina”

9. Cataclysmic Events These are events or a series of events that are of such a magnitude, scope and severity that “disaster” is not really the appropriate term. For example: the “Historical Trauma” of American Indians which occurred over a span of 500 years resulting in collective emotional injury over life spans & across generations (Yellow Horse Brave Heart & DeBruyn, 1998)

10. Types of Disasters- (From Beaton & Bridges, “Disaster Nursing”,in press) Natural Man-made Technological Biological Unintentional Tsunamis, Floods, Hurricanes, Earthquakes, Wildfires, etc. e.g., Bhopal, Haz- Mat, Case study of uranium mining industry and the Navajos (Markstrom & Charley, 2003) Epidemic & pandemics e.g., 1918- 1919 global Influenza Pandemic Intentional “Act of God” Chemical, Nuclear, Radiological, Explosion, Acts of Terrorism Bioterrorism

11. Mental Health: Are we ready? Ready for what?

12. Coping with Traumatic Events Obviously depends on the nature, type & duration of the trauma, threat or disaster As examples, marriage, divorce & death of a spouse are all major live events that tax our ability to cope. Disaster Exemplar(s) Compare and contrast the Exxon Valdez Oil Spill/ Ecological Disaster with the Great Alaskan Earthquake/Tsunami of 1964

13. The Great Alaskan Earthquake On Mar. 27, 1964 (5:36 pm Alaska standard time) a 9.2 magnitude earthquake struck Alaska Epicenter was North Prince William Sound Earthquake lasted 4-5 minutes and spawned a deadly tsunami

14. The six-story Four Seasons apartment building in Anchorage was completely destroyed.

15. Tsunami – Mechanism

16. Close-up view of tsunami damage along the waterfront at Kodiak.

17. Disaster Impact(s) Resulted in 115 fatalities in Alaska– 106 due to the tsunami The tsunami caused damage and casualties along the Western Canadian, Washington and Oregon Coasts $84 million in property damage in Alaska alone

18. The Exxon Valdez Oil Spill On March 24, 1989 just after midnight the Exxon Valdez oil tanker struck a reef in Prince William Sound and eventually leaked 10.8 million gallons The oil covered large areas of the surface of Prince William Sound and drifted with the currents & winds onto the rocky shores of many of the beaches in the region

19. Map of the Exxon Valdez Oil Spill

20. Exxon Valdez tanker circled with containment boom.

21. Dead murrelet.

22. Oiled sea otter on shore.

23. Ecological Disaster Impact(s) No human casualties Animal deaths included an estimated 250,000-500,000 seabirds, 2,800-5,000 sea otters, 300 harbour seal, 250 bald eagles and 22 orca whales Impact on fishery, fishing, seafood, sorts fisheries & tourism industries- economic and lifestyle impacts Protracted litigation

24. Coping may be viewed from a variety of perspectives Individual Family Community Tribal In many cases trauma and disaster exceed the coping capability of individuals and families and require community and tribal intervention and structures

25. Coping Strategies: Defined Coping strategies refer to specific efforts– social, behavioral, cognitive and emotional– that people employ to master, tolerate or minimize threats associated with stressful events. (after Taylor, 1998)--

26. Problem- vs. Emotion Focusing Coping Problem-focused coping- trying to figure out what the problem is, addressing the root cause of the problem and trying to resolve it Emotion-focused coping- engaging in emotional discharge; for example crying, yelling, venting; e.g., “rants” From Tiet et al (2006) Journal of Traumatic Stress, 19, 799-811

27. Approach & Avoidance Coping Approach coping– making plans, confronting difficult situations, trying hard to work things out & focusing on the positive Avoidance coping— Social withdrawal, trying to avoid and/or not think about the problem, avoid confrontations and conflict & even emotional numbing (avoiding one’s feelings)

28. Adaptive vs. Maladaptive Coping Adaptive coping: effective coping which protects or buffers us against stress and helps reduce tension. Maladaptive coping: ineffective coping which neither reduces stress nor resolves the situation. (See Beaton & Murphy, 2002)

29. The Importance of Stressor Appraisal & “Self-talk” How we label our perceptions can influence our response. Little difference in stress physiology between “excitement” and “anxiety” Paramedics who label a task or event as a “challenge” as opposed to a “stressor” have lower blood pressure readings Most people, most of the time are resilient- and say to themselves: “I know I can handle this challenge”=self-efficacy

30. Coping & Self-talk in Apollo Astronauts

31. Biological reaction to stress Under extreme stress frontal lobe turns off, limbic system turns on. H. Simpson Coping in Puget Area Firefighters (Beaton et al, 1999)

32. Little empirical data are available to guide suggestions for coping with trauma in American Indians Importance of tribal cultural traditions in building community resilience Importance of ceremony and ritual in coping- the drums, the colors Importance of tribal connectedness and cohesion through song, dance Importance of native art as therapy

33. Skokomish Tribe

34. Importance of nature and resources: Siletz hatchery

35. Sacred Places: Siletz Medicine Rock

36. The Journey Puget Sound canoe journeys promote tribal cohesion & sense of community

37. Skokomish Tribe

38. Tribal healers & elders Wisdom and compassion Sacred beliefs and customs Contrast with non-Indian culture & youth worship

39. Additive Coping Strategies In addition to American Indian customs, traditions and tribal ways of coping These coping strategies may or may not be culturally appropriate for some or most American Indian tribes-- Suggestions Think of these additional coping strategies as a MENU– pick and choose ones that may work for you, your family & your tribe

40. Preventive Approaches to Coping with Disaster Disaster planning- everybody and every family needs a family disaster plan. Washington State Disaster Preparedness Handbook is available @ http://www.metrokc.gov/prepare/docs/PR_ WaDisPrepHandbk2005.pdf http://www.metrokc.gov/prepare/docs/PR_ WaDisPrepHandbk2005.pdf This includes concrete suggestions for helping children adjust after a disaster

41. Helping Children After a Disaster (From Disaster Preparedness Handbook, 2005) Talk with the children about how they are feeling. Assure them that it’s OK to have those feelings. Children should not be expected to be brave or tough. Tell them it’s OK to cry. Don’t give children more information than they can handle about this disaster.

42. Other Preventive Approaches to Foster Individual & Community Resilience Survival and Red Cross Training– learn CRP and basic survival skills Join a community emergency response team such as CERT. UW CERT webpage site http://www.washington.edu/admin/busines s/oem/cert/ http://www.washington.edu/admin/busines s/oem/cert/

43. UW CERT Training Program Training will touch on 8 subject areas and will provide basic skills needed to assist disaster victims. The courses are free and will take place over a period of only two and half days. The training will finish up with a 4 hour practical exercise designed to put all of the new CERT skills to the test. An example of a CERT module: Individual and Family Preparedness Learn the types of hazards that are most likely to affect your homes and community Learn the functions of CERTs and their role in immediate response Identify steps to prepare yourself and your family for a disaster

44. CERT for Tribal Nations In Nov. of 2002 members of five Midwest tribes– the Kickapoo Tribe in Kanasa, the Omaha Tribe of Nebraska, the Praire Band of the Potawatomi Nation, the Sac and Fox Nation of Missouri and the Winnebago Tribe of Nebraska– participated in a CERT course supported by a FEMA grant

45. Preventative Approaches An ounce of prevention is worth a ton of cure. Strategies that can prevent a crisis or emergency or mitigation strategies that minimize the impact of a disaster are the most important in terms of avoiding the harmful mental health effects of trauma

46. Personal Strategies to Foster Resilience in the Aftermath of Trauma and Disaster (Adapted From APA, 2002 Resilience Fact Sheets) Avoid viewing event as insurmountable– “I will recover, my family will recover, my tribe will survive and thrive” Rely on connections with family, friends, elders and tribal leaders Accept that change and loss are part of living

47. Fostering resilience (continued) Avoid withdrawal coping strategies- engage in problem solving and take action Potential for posttraumatic growth- trauma can actually lead to opportunities for growth and self-discovery (Tedschi et al, 1998) Meditation & spiritual practices Maintain a hopeful outlook. There is very, very little downside to optimism

48. “Positive Illusions” and Creative Self-Deception

49. Some “Unrealistic” Optimism may actually be adaptive 50% of marriages fail within five years, yet marriage remains very popular 95% of cancer survivors think they are doing better than most Key is to avoid “catastrophizing”– that is, assuming the worst (and even worse) However, “minimization” (or an extremely positive skew) can be problematic when real hazards are downplayed or ignored.

50. Fostering Resilience in the Aftermath Staying flexible– sometimes it is fine to experience strong emotions; other times you may need to control your emotions to continue to function Flexibility and balance in recovery– sometimes you will need to deal with demands and other times you may need to step back and re-energize yourself

51. Psychological First Aid (PFA) National Child Traumatic Stress Network www.NCTSN.org National Center for PTSD www.ncptsd.va.gov

52. Basics of Psychological First Aid What is Psychological First Aid? An evidence-informed approach to assist children, adolescents, adults, and families in the immediate aftermath of disaster and terrorism This approach to disaster survivors ’ mental health has been adopted by: American Red Cross Medical Reserve Corps Community Emergency Response Teams (CERT) Among others

53. How Do We Know How to Respond Following Disasters?

54. “You’ve lost your home, your job and your pet– how do you feel about that?” Sigmund Freud

55. Five Empirically-Supported Early Intervention Principles

56. Promotion of Psychological Sense of Safety Reduces biological aspects of traumatic stress reactions Positively affects thoughts that inhibit recovery

57. Promotion of Calming Reduces anxiety, high arousal, numbing, or strong emotions Supports better: –Sleep –Eating –Decision-making –Performance of life tasks May reduce the probability of long-term psychological difficulties

58. Promotion of Self-Efficacy Encourage disaster survivors to play an active role in their own recovery Increases people ’ s beliefs about their capabilities Increases self-control of thought, emotions, and behavior

59. Promotion of Connectedness Related to better emotional well-being and recovery Provides opportunities for: –Information about resources –Practical problem-solving –Emotional understanding –Sharing of experiences –Normalization of reactions and experiences –Sharing of ways of coping

60. Instilling Hope Favorable outcomes are associated with: Optimism Positive expectancy A feeling of confidence in life and/or self Strong faith-based beliefs

61. Basics of Psychological First Aid Who is it for? Individuals experiencing acute stress reactions or who appear to be at risk for significant impairment Who is it delivered by? Disaster response workers or others who are trained to provide early assistance When is it intended to be delivered? Immediate aftermath Where can it be delivered? A broad range of emergency settings, in either single or multiple sessions (shelters, community out-reach)

62. Some Basics  Expect normal recovery  Assume survivors are competent  Recognize survivor strengths  Promote resilience

63. Contact and Engagement 1: Establish a connection with survivors in a non-intrusive, compassionate manner. Introduce self and describe role Ask for permission to talk Explain objective Ask about immediate needs

64. Safety and Comfort 2: Enhance immediate and ongoing safety, and provide physical and emotional comfort. “ Are you cold – do you need a blanket? ”

65. Stabilization 3: Calm and orient emotionally- overwhelmed/distraught survivors.

66. Information Gathering: Current Needs and Concerns 4: Identify immediate needs and concerns, and gather additional information, and tailor PFA interventions. Nature and severity of experiences Death of a loved one (or family pet) Concerns about the post-disaster circumstances and threat Separation from or concerns about the safety of loved ones Physical illness, mental health conditions, and need for medications Losses incurred as a result of the disaster Extreme feelings of guilt or shame Thoughts about causing harm to self or others Immediate developmental impact Availability of social support Prior alcohol or drug use Prior exposure to trauma and death of loved ones

67. Practical Assistance 5: Offer practical help to survivors in addressing immediate needs and concerns. Identify the most immediate need(s) Clarify the need Discuss an action plan Act to address the need

68. Connection with Social Support 6: Help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources.

69. Information on Coping 7: Provide information about stress reactions and coping to reduce distress and promote adaptive functioning. What is currently known about the unfolding event What is being done to assist them Available services Post-disaster reactions and how to manage them Self-care and family care Coping Alcohol & substance abuse

70. Linkage with Collaborative Services 8: Links survivors with available services needed at the time or in the future. Provide direct link to additional needed services What counseling services are available to your tribal members?

71. Possible Indications of a Need for a Referral An acute medical or mental health problem Threat of harm to self or others Concerns related to the use of alcohol or drugs Cases involving domestic, child, or elder abuse (be mindful of reporting laws as well) Ongoing difficulties with coping (4 weeks or more after the disaster) Significant developmental concerns about children or adolescents When the survivor asks for a referral Medication evaluation?

72. Summary and Next Steps American Indian tribes and peoples have 500 years of experience of coping with trauma Historical trauma has been considered a “risk factor” for PTSD but it may also serve as a source of strength Effective ways of coping depend on the cultural context, the nature, intensity & duration of the trauma or disaster

73. Summary and Conclusions– Coping with Trauma and Disaster American Indian tribes and individuals have a number of protective traditions, rituals and ceremonies as well as other cultural sources of resilience The principles and actions of Psychological First Aid might also assist American Indian tribes, families and individuals to cope in the aftermath of traumatic events including disasters