Coping with Trauma and Psychological First Aid for Disaster Survivors:

Suggestions for American Indians

EMERGENCY EMERGENCY PREPAREDNESS PREPAREDNESS

CONFERENCECONFERENCE

August 9, 2007August 9, 2007Portland, OregonPortland, Oregon

Research Professor

Schools of Nursing and Public Health andCommunity Medicine

FacultyFaculty Northwest Center forPublic Health Practice University of Washington

Randal Beaton, PhD, EMT Randal Beaton, PhD, EMT

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 whichoccurred 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

press)

Types of Disasters- (From Beaton & Bridges, “Disaster Nursing”,in

press)

NaturalNatural Man-made Man-made TechnologicalTechnological

BiologicalBiological

UnintentionalUnintentional Tsunamis, Tsunamis, Floods, Floods, Hurricanes, Hurricanes, Earthquakes, Earthquakes, Wildfires, etc.Wildfires, etc.

e.g., Bhopal, Haz-e.g., Bhopal, Haz-Mat, Case study of Mat, Case study of uranium mining uranium mining industry and the industry and the Navajos (Markstrom Navajos (Markstrom & Charley, 2003) & Charley, 2003)

Epidemic & Epidemic & pandemicspandemics

e.g., 1918-e.g., 1918-1919 global 1919 global Influenza Influenza PandemicPandemic

IntentionalIntentional ““Act of God”Act of God” Chemical, Nuclear, Chemical, Nuclear, Radiological, Radiological, Explosion, Acts of Explosion, Acts of TerrorismTerrorism

BioterrorismBioterrorism

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

Tsunami – MechanismTsunami – Mechanism

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

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 Map of the Exxon ValdezExxon Valdez Oil Oil SpillSpill

Exxon Valdez Exxon Valdez tanker circled with tanker circled with containment boom.containment boom.

Dead murrelet.Dead murrelet.

Oiled sea otter on shore.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 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

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)

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 & Coping & Self-talk in Self-talk in

Apollo Apollo AstronautsAstronauts

Biological reaction to stressUnder 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 Rock

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 worship

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 @ http://www.metrokc.gov/prepare/docs/PR_WaDisPrepHandbk2005.pdf

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

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/business/oem/cert/

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

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 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

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

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

“Positive Illusions” and

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 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

Psychological First Aid (PFA)National Child Traumatic Stress Network

www.NCTSN.org

National Center for PTSD

www.ncptsd.va.gov

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

How Do We Know How to Respond Following Disasters?

Expert Consensus

Experience

Program Evaluation

Customer Feedback

Disaster Research

Trauma 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

Hope Safety

Calming

Connectedness

Self-Efficacy

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:–Sleep–Eating–Decision-making–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 recovery

• Increases people’s beliefs about their capabilities

• Increases self-control of thought, emotions, and behavior

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 outcomesare associated with:• Optimism • Positive

expectancy• A feeling of

confidence in life and/or self

• Strong faith-based beliefs

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 assistanceWhen 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?”

Stabilization

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

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

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 disaster)• Significant developmental concerns about

children or adolescents• 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 disasters