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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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”

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

Cognitive Processing Therapy (cont’d.) 12 weekly sessions; 60-90 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

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

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

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

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)

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)

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

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

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

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

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

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

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)

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

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