Coping with Trauma and Psychological First Aid for Disaster

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					Coping with Trauma and Psychological First Aid
            for Disaster Survivors:
      Suggestions for American Indians


                          August 9, 2007
                         Portland, Oregon
   Randal Beaton, PhD, EMT
Research Professor
  Schools of Nursing
 and Public Health and
 Community Medicine

Northwest Center for
Public Health Practice
University of Washington
          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)
             Special Thanks
•   Linda Frizzell, E. Cherokee & Lakota
•   June Strickland
•   Ticey Casey, Siletz
•   Joe Finkbonner
•   Jay LaPlante, Blackfoot
•   National Child Traumatic Stress Network
        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
           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
    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
          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‖
          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)
 Types of Disasters- (From Beaton
  & Bridges, ―Disaster Nursing‖,in
                Natural           Man-made             Biological

Unintentional   Tsunamis,         e.g., Bhopal, Haz-   Epidemic &
                Floods,           Mat, Case study of   pandemics
                Hurricanes,       uranium mining       e.g., 1918-
                Earthquakes,      industry and the     1919 global
                Wildfires, etc.   Navajos (Markstrom   Influenza
                                  & Charley, 2003)     Pandemic
Intentional     ―Act of God‖      Chemical, Nuclear,   Bioterrorism
                                  Explosion, Acts of
Mental Health: Are we ready?
      Ready for what?
 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
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
The six-story Four Seasons apartment building in
Anchorage was completely destroyed.
Tsunami – Mechanism
Close-up view of tsunami damage along
the waterfront at Kodiak.
         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
   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
Map of the Exxon Valdez Oil
Exxon Valdez tanker circled with
containment boom.
Dead murrelet.
Oiled sea otter on shore.
  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
      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
     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)--
  Problem- vs. Emotion Focusing
• 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
 Approach & Avoidance Coping
• Approach coping– making plans,
  confronting difficult situations, trying hard
  to work things out & focusing on the
• Avoidance coping— Social withdrawal,
  trying to avoid and/or not think about the
  problem, avoid confrontations and conflict
  & even emotional numbing (avoiding one’s
  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)
     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
Coping &
Self-talk in
  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)
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
Skokomish Tribe
Importance of nature and
resources: Siletz hatchery
Sacred Places: Siletz Medicine
             The Journey
• Puget Sound canoe journeys promote
  tribal cohesion & sense of community
Skokomish Tribe
      Tribal healers & elders
• Wisdom and compassion
• Sacred beliefs and customs
• Contrast with non-Indian culture & youth
    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
 Preventive Approaches to Coping
           with Disaster
• Disaster planning- everybody and every
  family needs a family disaster plan.
Washington State Disaster Preparedness
  Handbook is available @
 This includes concrete suggestions for
  helping children adjust after a disaster
 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.
  Other Preventive Approaches to
  Foster Individual & Community
• Survival and Red Cross Training– learn
  CRP and basic survival skills
• Join a community emergency response
  team such as CERT.
• UW CERT webpage site
    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
• Identify steps to prepare yourself and your family for a
     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
     Preventative Approaches
• An ounce of prevention is worth a ton of
• 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
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
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,
• Meditation & spiritual practices
• Maintain a hopeful outlook. There is very,
  very little downside to optimism
  ―Positive Illusions‖
Creative Self-Deception
 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.
     Fostering Resilience in the
• 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
  Psychological First Aid (PFA)
National Child Traumatic Stress Network
       National Center for PTSD
                        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

This approach to disaster survivors’ mental health has been
  adopted by:
• American Red Cross
• Medical Reserve Corps
• Community Emergency Response Teams (CERT)
• Among others
How Do We Know How to Respond Following
        Customer        Disaster
        Feedback        Research

  Experience                Research

                ―You’ve lost your
                 home, your job
                  and your pet–
                 how do you feel
                   about that?‖

Sigmund Freud
Five Empirically-Supported Early
         Intervention Principles
        Promotion of Psychological Sense of Safety

• Reduces biological aspects of
  traumatic stress reactions

• Positively affects thoughts that
  inhibit recovery
                                            Promotion of Calming

• Reduces anxiety, high arousal,
  numbing, or strong emotions

• Supports better:
   –Performance of life tasks

• May reduce the probability of long-term
  psychological difficulties
                               Promotion of Self-Efficacy

• Encourage disaster survivors to
  play an active role in their own

• Increases people’s beliefs
  about their capabilities

• Increases self-control of
  thought, emotions, and
                               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
                               Instilling Hope

Favorable outcomes
are associated with:
• Optimism
• Positive expectancy
• A feeling of confidence in
  life and/or self
• Strong faith-based
                        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)
                                     Some Basics

   Expect normal recovery
   Assume survivors are competent
   Recognize survivor strengths
   Promote resilience
                                      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
                                  Safety and Comfort

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

3: Calm and orient emotionally-
                 Information Gathering: Current Needs
4: Identify immediate needs and concerns,
    and gather additional information, and and Concerns
   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
• Immediate developmental impact
• Availability of social support
• Prior alcohol or drug use
• Prior exposure to trauma and death of loved
                                        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
                         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.
                                     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
                     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?
        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
•   Significant developmental concerns about children or
•   When the survivor asks for a referral
•   Medication evaluation?
                  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
             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