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Trauma Interventions For Survivors of Natural DisastersKathryn Wetzler, Psy.DAdult Staff PsychologistConsortium DirectorKaiser 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 cliniciansCore 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
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
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)
PrazosinAlpha-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
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
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
StrengthsBoth individual and groupBelief systems addressedTrauma-related guilt/atroccitiesStrong empirical support
WeaknessesLabor IntensiveCognitive/Education requirements
Strengths and Weaknesses: Prolonged Exposure
StrengthsStrong empirical support Significant reductions in PTSD symptomsRe-experiencing and hyperarousal symptoms-fear basedAcute PTSD
WeaknessesTreatment attritionOnly individual modalityCardiovascular risksTherapist reactionsNumerous TraumasNot for atrocitiesNot 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