Ongoing 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

Agenda 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 Juárez Considerations for U.S./México Border Public Health and Safety communities

No studies in Americas of impact at psycho-social level of cartel related violence on public-more on drug policy, political and economic issues, etc.

Traumatic Stress Background

“Violence and Insecurity” Extreme increase in cartel and community related violence in northern México Cartel related murders (2000+ in past year) Kidnappings Car-jackings Robberies/Extortion (“Cuotas”) Constant threat U.S. not immune Cartel and army related violence (CARV) Psycho-social costs to a community Increases stress Understanding PTSD and other forms of traumatic stress through lens of current cartel related violence and insecurty Caetano, 2009; U.S. Department of State, 2009; Thoumi, 2002; Chan, Air, & McFarlane, 2003

Extreme Stress Reactions Post-Traumatic Stress Disorder (& Probable PTSD) Exposure to traumatic experience (s) Feelings of fear, helplessness, and/or horror peri-event Intrusive thoughts/Re-experiencing (1+ symptoms) Avoidance/numbing to situations (3+ symptoms) Hyper-arousal (2+ symptoms) Psycho-social impairment Partial PTSD Threshold for full PTSD may be too high Impairment still seen (e.g., anger) American Psychiatric Association (APA), 2000; Berstein et al., 2007; Mitka, 2008; Galea et al., 2003; Stein et al., 1997

Acute 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)

Identified Traumatic Stress Trends Chronic PTSD (> 3 months) Acute PTSD (> 1 Month) Resistant Resilient APA, 2000; Bonnano, 2004; Norris et al., 2009

Re-experiencing / Intrusive Thoughts Core Trauma Symptoms Avoidance / Numbing Re-experiencing / Intrusive Thoughts Hyper-Arousal Want to revisit the core symptoms of traumatic stress

PERI Trauma (Immediate) Considerations Unpredictable and Un-controllable Subjective exposure Fear Helplessness Horror Direct forms of Trauma (e.g., assault, terrorism) Indirect forms of Trauma (e.g., witnessing, media, trauma by proxy-such as family member) Subjective interpretation Subjective component; Daniel Pearl A lot of indirect forms of trauma happening in Cd. Juarez Breslau 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

PRE-Trauma Risk Factors Demographic risk factors (e.g., female gender) Exposure to multiple traumata (re-exposure) Anxiety disorders rarely present in pure form Pre-existing anxiety disorders may worsen traumatic stress after exposure Anxiety Sensitivity predisposes to traumatic stress after exposure Depression Unclear if PRE or POST factor Depression highly comorbid with TS post-event (correlation) May worsen traumatic stress Demographic 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 sensitizing Brewin 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

PRE-Trauma Sources of Coping Social support strongly buffers against traumatic stress Coping in uncontrollable situations Problem focused (limited in uncontrollable situations) Emotion-focused Active Self distraction (+ or -) Venting (+ or -) Cognitive acceptance of situation/experience ( + or -) Avoidance based Denial ( generally - ) Giving up/feeling hopeless ( - ) Self-blame ( - ) Substance use ( - ) Brewin et al., 2000; Lazarus & Folkman, 1984; Solomon, 1989; Carver et al., 1989

Unique Opportunity Virtually no empirical study of psycho-social impact of cartel related violence in the Americas Limited knowledge of real-time (daily) impact Memory distortion after the fact (e.g., months, years, melding of traumas? Such as in VHA situation) More refined understanding of impact of ongoing traumatic situations Note on lack of information on cartel related violence (E.g., Colombia)-rare to be able to study when even journalists targeted Needed 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

Preliminary Study of Ongoing Traumatic Stress Assess Ongoing Traumatic Stress (OTS) Examine impact of factors commonly associated with PTSD in: Ongoing (daily) Traumatic Stress Ongoing (daily) Re-experiencing symptoms Ongoing (daily) Avoidance symptoms Ongoing (daily) Hyperarousal symptoms What do you think you did (perceptual SM) and what did you actually do?

Methods

Participants N = 121 (N days = 816) Inclusion Criteria Travel/live in Cd. Juárez at least 3 days/week Internet access at least every 24 hour period Bilingual UTEP student Comfort with online survey; anonymity/confidentiality Post-hoc advantage; could still recruit after UTEP travel ban Compensation: $40USD giftcard to Target OR 4 experimental credits

Measures: Main Outcome All measures professionally translated and back-translated with subsequent native Spanish speakers’ input on items Post-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 = .91 - .94 Brislin, 1970; Liu, 2002; Weathers et al., 1993 Ruggiero et al., 2003; Orlando & Marshall, 2002

Background Measures Life Events Checklist (LEC) documents 17 traumatic events often associated with PTSD Experienced 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 symptomology Gray et al., 2004; Lovibond & Lovibond, 1995; Crawford & Henry, 2003; Daza et al., 2002

Background 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 coping Problem 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

Daily Assessment Completed online >24 hours for 7 days PCLSD (daily traumatic stress) Time-varying explanatory covariates Travel 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)

Lemonade out of Lemons Drop out rarely positive outcome, but allows unique analysis in present study 20% did not return for follow-up Unique opportunity in trauma study Avoidance unpleasantness  drop-out? Re-experiencing  unpleasantness  drop-out? Hyper-arousal  unpleasantness  drop-out?

Informative 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 interval To allow estimation, only intercept allowed to co-vary with past 30 day acute PCLS scores Drop-out unassociated with traumatic stress, all Zs < |.65|, all ps > .52 Take 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

Approach to Analysis: Multi-level modeling Specified Expectation-Maximization in Maximum Likelihood; robust to MAR Grand Mean centered variables Standardized (N~0,1) covariates to give common scale to psychological factors OPTS dependent variable (PCLSD) Condition on demographics, LEC, DASS, MSPSS factors, BCOPE sub-scales Time varying covariates Presence 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 EQUATIONS Snijders & Bosker, 1999; Gardiner, Luo, & Roman, 2009

Preliminary Study Results

Demographic 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)

Note that not a representative sample of UTEP students, or young adults in general.

Sample Continuous Characteristics Variable Possible Range Mean SD Med. Min. Max. Days in Cd. Juárez, Chih per week 0 to 7 4.84 1.81 4 1 7 Days in El Paso, TX per week 4.73 1.56 5 Family who live in Cd. Juárez, Chih (%) 0 to 100 67.31 30.18 80 100 Friends who live in Cd. Juárez, Chih (%) 60.79 31.76 70 Age (years) -- 21.62 3.40 21 18 44 PTSD Checklist Past 30 day Score (PTSD) 17 to 85 43.87 13.71 43 85

Sample Continuous Characteristics Variable Possible Range Mean SD Med. Min. Max. Days in Cd. Juárez, Chih per week 0 to 7 4.84 1.81 4 1 7 Days in El Paso, TX per week 4.73 1.56 5 Family who live in Cd. Juárez, Chih (%) 0 to 100 67.31 30.18 80 100 Friends who live in Cd. Juárez, Chih (%) 60.79 31.76 70 Age (years) - 21.62 3.40 21 18 44 PTSD Checklist Past 30 day Score (PTSD) 17 to 85 43.87 13.71 43 85

Sample Continuous Characteristics Variable Possible Range Mean SD Med. Min. Max. Days in Cd. Juárez, Chih per week 0 to 7 4.84 1.81 4 1 7 Days in El Paso, TX per week 4.73 1.56 5 Family who live in Cd. Juárez, Chih (%) 0 to 100 67.31 30.18 80 100 Friends who live in Cd. Juárez, Chih (%) 60.79 31.76 70 Age (years) - 21.62 3.40 21 18 44 PTSD Checklist Past 30 day Score (PTSD) 17 to 85 43.87 13.71 43 85

Sample Continuous Characteristics Variable Possible Range Mean SD Med. Min. Max. Days in Cd. Juárez, Chih per week 0 to 7 4.84 1.81 4 1 7 Days in El Paso, TX per week 4.73 1.56 5 Family who live in Cd. Juárez, Chih (%) 0 to 100 67.31 30.18 80 100 Friends who live in Cd. Juárez, Chih (%) 60.79 31.76 70 Age (years) - 21.62 3.40 21 18 44 PTSD Checklist Past 30 day Score (PTSD) 17 to 85 43.87 13.71 43 85

Sample Daily Characteristics SD Continuous Variable Range Mean Overall Betw. Within Hours each day in Cd. Juárez 0 to 24 11.87 9.00 6.74 6.39 Daily traumatic stress level 17 to 85 32.30 13.50 11.74 6.11 Peri-traumatic experiences Fear 0 to 6 1.91 1.85 1.44 1.16 Helplessness 1.93 1.89 1.49 1.20 Horror 1.58 1.83 1.47 1.11 Coping via substance use 0.49 1.15 1.10 0.54

Sample Daily Characteristics SD Continuous Variable Range Mean Overall Betw. Within Hours each day in Cd. Juárez 0 to 24 11.87 9.00 6.74 6.39 Daily traumatic stress level 17 to 85 32.30 13.50 11.74 6.11 Peri-traumatic experiences Fear 0 to 6 1.91 1.85 1.44 1.16 Helplessness 1.93 1.89 1.49 1.20 Horror 1.58 1.83 1.47 1.11 Coping via substance use 0.49 1.15 1.10 0.54

Sample Daily Characteristics SD Continuous Variable Range Mean Overall Betw. Within Hours each day in Cd. Juárez 0 to 24 11.87 9.00 6.74 6.39 Daily traumatic stress level 17 to 85 32.30 13.50 11.74 6.11 Peri-traumatic experiences Fear 0 to 6 1.91 1.85 1.44 1.16 Helplessness 1.93 1.89 1.49 1.20 Horror 1.58 1.83 1.47 1.11 Coping via substance use 0.49 1.15 1.10 0.54 Daily traumatic stress may have more to do with daily exposure than Past 30 day scores; resilience

Sample Daily Characteristics Cont. Categorical Variable Overall % Between % Within Avg. % Daily Traumatic Stress Risk Category Limited (PCL less than 34) 60 81 74 Moderate (PCL of 34 to 43) 21 52 41 Clinical (PCL greater than 44) 19 37 Reasons for being in Cd. Juárez: Family No 25 55 46 Yes 75 93 Reason for being in Cd. Juárez: Friends 67 92 72 33 Reason for being in Cd. Juárez: Business 99 8 26 30 Reason for being in Cd. Juárez: Antro/Bar 95 100 96 5 23 Either some more exposed more reactive or mixture of exposure and worse reaction.

Sample Daily Characteristics Cont. Categorical Variable Overall % Between % Within Avg. % Daily Traumatic Stress Risk Category Limited (PCL less than 34) 60 81 74 Moderate (PCL of 34 to 43) 21 52 41 Clinical (PCL greater than 44) 19 37 Reasons for being in Cd. Juárez: Family No 25 55 46 Yes 75 93 Reason for being in Cd. Juárez: Friends 67 92 72 33 Reason for being in Cd. Juárez: Business 99 8 26 30 Reason for being in Cd. Juárez: Antro/Bar 95 100 96 5 23

Predicting Ongoing (Daily) Traumatic Stress Response Symptoms

Multi-Level Model Predicting Ongoing Traumatic Stress Time Invariant Covariates B 95% CI p Female 0.02 -0.20 - 0.24 U.S. Resident vs. citizen 0.04 -0.16 0.25 Income (ref. is Less than 15,000USD) 15,001 to 30,000USD 0.01 -0.23 0.26 30,001 to 45,000USD -0.26 0.34 45,001USD to 60,000USD 0.11 -0.24 0.45 More than 60,000USD -0.01 -0.53 0.52 Prior Trauma Exposure (Life Events Checklist) Heard about (Indirect) -0.04 -0.14 0.06 Witnessed (Indirect) -0.08 0.12 Directly experienced -0.12 0.10 Psychological Symptoms (DASS-21) Depression -0.06 -0.22 Anxiety -0.18 General Stress 0.18 0.37 0.07 Social Support (MSPSS) Family -0.03 -0.15 Friends -0.10 0.03 Significant Other 0.14 0.27 <.05 Coping Problem focused -0.21 0.09 Active emotion focused -0.05 Avoidance based 0.08 Acute Post-Traumatic Stress Disorder 0.42 0.29 0.54 <.01 Time Varying Covariates Hours in Cd. Juárez Reason for being in Cd. Juárez 0.00 0.22 Business 0.15 0.28 Club/Bar/Antro Peri-event exposure reactions Fear 0.19 Helplessness 0.21   Horror Full day indicator also tested; insensitive indicator; fixed effect of drop-out indicator not significant in any model

What the data say: -what is not there may be as important as what is there

Multi-Level Model Predicting Ongoing Re-Experiencing Symptoms Time Invariant Covariates B 95% CI p Female -0.17 -0.38 - 0.04 U.S. Resident vs. citizen -0.10 -0.29 0.09 Income (ref. is Less than 15,000USD) 15,001 to 30,000USD 0.07 -0.16 0.30 30,001 to 45,000USD 0.12 0.40 45,001USD to 60,000USD 0.24 -0.08 0.56 More than 60,000USD -0.41 0.59 Prior Trauma Exposure (Life Events Checklist) Heard about (Indirect) -0.02 -0.12 Witnessed (Indirect) -0.09 -0.18 0.01 Directly experienced 0.00 -0.11 0.10 Psychological Symptoms (DASS-21) Depression -0.25 0.05 Anxiety -0.14 0.13 General Stress 0.16 0.33 0.08 Social Support (MSPSS) Family Friends -0.20 Significant Other -0.04 0.20 Coping Problem focused Active emotion focused -0.05 -0.19 Avoidance based -0.03 0.21 Acute Post-Traumatic Stress Disorder 0.35 0.23 0.47 <.01 Time Varying Covariates Hours in Cd. Juárez 0.06 Reason for being in Cd. Juárez 0.14 0.18 Business Club/Bar/Antro -0.21 0.22 Peri-event exposure reactions Fear 0.19 Helplessness 0.17 0.25   Horror Stepping out on more of a limb analyzing traumatic stress sub constructs

Multi-Level Model Predicting Ongoing Avoidance Symptoms Time Invariant Covariates B 95% CI p Female -0.03 -0.30 - 0.24 U.S. Resident vs. citizen 0.09 -0.16 0.34 Income (ref. is Less than 15,000USD) 15,001 to 30,000USD -0.08 -0.38 0.21 30,001 to 45,000USD -0.21 -0.57 0.15 45,001USD to 60,000USD 0.10 -0.32 0.52 More than 60,000USD -0.93 Prior Trauma Exposure (Life Events Checklist) Heard about (Indirect) -0.04 -0.17 0.08 Witnessed (Indirect) 0.01 -0.11 0.13 Directly experienced -0.02 0.11 Psychological Symptoms (DASS-21) Depression -0.01 0.18 Anxiety -0.07 -0.24 General Stress 0.38 Social Support (MSPSS) Family 0.14 Friends -0.12 -0.27 0.04 Significant Other 0.16 0.32 <.05 Coping Problem focused -0.05 -0.23 Active emotion focused -0.26 Avoidance based -0.06 Acute Post-Traumatic Stress Disorder 0.37 0.22 <.01 Time Varying Covariates Hours in Cd. Juárez Reason for being in Cd. Juárez 0.07 0.00 -0.09 Business 0.29 0.44 Club/Bar/Antro -0.10 Peri-event exposure reactions Fear Helplessness 0.05   Horror 0.06

Multi-Level Model Predicting Ongoing Hyperarousal Symptoms Time Invariant Covariates B 95% CI p Female 0.08 -0.14 - 0.31 U.S. Resident vs. citizen 0.02 -0.19 0.23 Income (ref. is Less than 15,000USD) 15,001 to 30,000USD 0.05 0.30 30,001 to 45,000USD 0.24 -0.06 0.54 45,001USD to 60,000USD -0.07 -0.41 0.28 More than 60,000USD 0.21 -0.32 0.74 Prior Trauma Exposure (Life Events Checklist) Heard about (Indirect) -0.03 0.07 Witnessed (Indirect) 0.10 0.00 0.20 <.05 Directly experienced Psychological Symptoms (DASS-21) Depression -0.08 -0.24 Anxiety -0.21 General Stress 0.40 Social Support (MSPSS) Family -0.05 -0.17 Friends -0.20 0.06 Significant Other 0.13 0.25 Coping Problem focused -0.22 Active emotion focused -0.04 0.11 Avoidance based 0.15 0.27 Acute Post-Traumatic Stress Disorder 0.52 <.01 Time Varying Covariates Hours in Cd. Juárez -0.01 Reason for being in Cd. Juárez 0.12 -0.02 0.19 Business -0.11 0.22 Club/Bar/Antro Peri-event exposure reactions Fear 0.16 Helplessness   Horror 0.03

Deals of nature of cartel conflict (violence and insecurity in Cd Deals of nature of cartel conflict (violence and insecurity in Cd. Juarez)

Discussion

Ongoing Traumatic Stress Border significantly affected by OTS and PTSD Present sample might objectively be considered of less risk (many protective factors/buffers) Still, sample evidenced both PTSD and OTS scores warranting concern Assessing for PTSD can potentially help to reduce OTS Yet, common prior factors associated with long term traumatic stress (PTSD) less impactful at daily levelmore 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 analysis Diamond et al., 2010; Mineka & Zinbarg, 2006; Ozer et al., 2008; Ursano et al., 2009

Evidence for Ongoing Traumatic Stress Objective exposure (i.e., less time in Cd. Juárez) does not reduce OTS Very strong subjective component Strong peri-event subjective reactions to exposure observed Assessment of “real time” reactions important Valid Anticipatory fears: the future as important as past Unpredictability Uncontrollability Fear, helplessness, and horror on a daily basis Reinforced avoidance and generalizing of fearful situations/psycho-social states Residency status not associated with traumatic stress level in any model Diamond et al., 2010; Hobfoll et al., 2009

What is not there that “should be?” Gender (female) unassociated with Ongoing Traumatic Stress in the present sample Variability (model ICCs) HUGE Other important factors to assess nested within gender Not “only a Mexican problem” Socio-economic status not explanatory either U.S. and Mexican citizens integrated in to both sides of border are significantly affected Kessler et al., 1995, Ozer et al., 2008

Past/Future Exposure Considerations Evidence for resilience from past traumata Much exposure already in these young adults Little impact on traumatic stress when accounting for other factors identified in traumatic stress literature Still, fear regulation strongly disrupted in traumatic stress; differentially to other anxiety disorders Long-term impact from short term OTS? Virtually nothing at the individual or family unit level related to cartel violence, not even from Colombia Bonanno, 2004; deRoon-Cassini et al., 2010; Norris et al., 2009; Dutton & Greene, 2010; Etkin & Wager, 2007; Wilson & Freer, 2010; Ginzburg et al., 2010

Sample is clearly resistant to trauma given life events checklist effects, but…

Other Factors to Consider: Psycho-Accumulation of Trauma? Re-exposure assumes a somewhat linear process Psycho-accumulation, potentially quadratic? Bio-psycho-social accumulation of stressors Note that PTSD higher than OTS in sample, evidence both for separate constructs, but also that psycho-accumulation may already be occurring

Depression, Anxiety, General Stress, and Traumatic Stress In ongoing traumatic stress, depression may or may not be present Few depression symptoms overall (floor effect) Still, depression assessment likely always warranted when assessing traumatic stress in general Sample applies for other anxiety disorders May 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

Coping with Ongoing Traumatic Stress Problem-focused coping difficult in uncontrollable/unpredictable situations Adaptive routes/variation of routes to go somewhere in the city Others examples from your perspective? Active/emotion-focused coping may not fully compensate for OTS Coping may be very diverse in OTS Are some strategies helpful in one context of ongoing violence, while harmful in others? Many of you see coping first-hand Riolli & Savicki, 2010; Bonanno, 2004; Lazarus, 2000; Bal et al., 2003; Ullman, Filipas, et al., 2007

Family, Familiarity, Stability Decision to move/stay in Cd. Juárez? Separation from loved ones and familiarity Family may still be exposed even if one individual family member is safe. “For better or worse…” (the family unit) Resource loss worsens traumatic stress Psycho-social resources (e.g., friends) Kids can do a little better here—from research perspective Older adults can be vulnerable to effects of displacement Physical resources/access Extortion (“Cuotas”) Example: IMSS Note 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 connection Alim et al., 2008; Rivera et al., 2008; Hobfall et al., 2009; Wyshak, 1994; Fozdar, 2009

Social Support Strongest buffer to Post-Traumatic Stress Applies to retrospective reports Potentially more accessible when exposure is acute vs. ongoing May be more nuanced in Ongoing violence Supporting others in uncontrollable and unpredictable ongoing stressors may be difficult Larger families may have resources spread across many individuals Provider vs. receiver? Brewin et al, 2000b; Bradley et al., 2005; Kwak, 2003; Szapocznik & Kurtines, 1993; Monson et al., 2009

“For better or worse…”

“For better or worse…”

Community Support Opportunity Regional attention to traumatic stress A need (Cartel violence, Veterans of OEF/OIF) An opportunity to be a “Star” community for helping those affected by traumatic stress Psychological/Psychiatry is important, but not the only answer: Limit mental health stigma and shame Promote autonomy: “feeling in control” Potential nuances of exposure therapy In a way, this is community wide problem focused coping Particularly noteworthy as men did not differ from women in being affected Social 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

http://www. arabellaadvisors. com/pages/HIGO2009_conflictresolution http://www.arabellaadvisors.com/pages/HIGO2009_conflictresolution.html 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

Creative Community Support Promote predictability May be limited in Cd. Juárez (ideas?) El Paso/U.S. side of the border Educate on traumatic stress and the range of people affected-builds empathy Streamline policies/systems to accommodate range of victims’ needs Limit daily stressors: “the daily grind” Wears down mental resources Unprepared when crisis occurs Behavioral economists, I/O psychologists, and combat deployed clinicians Sutton, 2010; Hobfoll et al., 2007; Wei et al., 2010; Bryan, 2010

In a crisis, which battery do you want? 1. 2. Psycho-neuro-immunological example (e.g., flu); Remember-Traumatic stress is a bio-psycho-social problem 3. 4.

Preventing “low power” Address daily stressors of patients/clients/staff Is a action/policy a barrier, a benefit, or both for the Patient/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 staff Support the supporters Remember, 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.”

Focus on “Small Wins” Big changes are rare and when they do occur, there is sometimes a backlash Find ways to make “small wins” Recognize small wins as wins none-the-less Reinforces future action that can promote future “small wins” Promotes self-efficacy May promote community efficacy Small wins add up. Bryan, 2010

Limitations and Strengths of Present Study Threshold for impairment in PCLS may be different for this group Sensitivity and specificity Need for focus on psycho-social impairment criterion Convenience/snowball sampling may limit generalizability of findings Low statistical power due to large inter-individual variability Strengths Daily level longitudinal assessment; not feasible in many cases Professionally back-translated measures

Conclusions Moderate to high levels of ongoing traumatic stress a likely reality for many with close ties to Cd. Juárez Risk factors and buffers commonly associated with PTSD nuanced in Ongoing (Daily) Traumatic Stress Community can do a lot to indirectly help those affected by trauma “Small Wins” Creative opportunities for community support?

One Final Note

The Future of Cartels When substance use revenues change, cartels may not disappear or even become weaker (VERY ADAPTIVE) Example: 1920s-1930s Chicago U.S. Gangs May move in to other activities that traumatize the population Human/body trafficking (sex, labor, organs) Consideration of (illegal) supply chains Partnerships with other dangerous entities We need to consider the future of cartels to prevent future traumatization of our loved ones and friends.

Spanish Trauma Questionnaires National PTSD Center Post-Traumatic Stress Disorder Checklist Life Events Checklist http://www.ptsd.va.gov/professional/pages/assessments/assessment.asp Contact me if you have questions on other scales: tjtaylor@miners.utep.edu

Acknowledgements Dr. Cooper Dr. Byrd Dr. Cohn Dr. Eno Louden Dr. Morera Hispanic Health Disparities Research Center, Grant No. 1P20MD002287-03 A Smoke Free Paso del Norte, Grant No. 26-8113-17 Areli Guajardo and Ivan Torres Cisco Salgado and José Cabriales Prevention and Treatment in Clinical Health Lab Victoria A. Garcia and Richard Ford, Ph.D. .

Thank you!

Time permitting, I would like Questions A 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?