Coping with Trauma and Psychological First Aid for

Report
Coping with Trauma and Psychological First Aid
for Disaster Survivors:
Suggestions for American Indians
EMERGENCY
PREPAREDNESS
CONFERENCE
August 9, 2007
Portland, Oregon
Randal Beaton, PhD, EMT
Research Professor
Schools of Nursing
and Public Health and
Community Medicine
Faculty
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 D09HP08334-01-00Disaster & Environmental Health Nursing
(R. Beaton, PI)
Special Thanks
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Linda Frizzell, E. Cherokee & Lakota
June Strickland, Cherokee
Ticey Casey, Siletz
Iris HeavyRunner PrettyPaint, Blackfeet
Jay LaPlante, Blackfeet
National Child Traumatic Stress Network
and the National Center for PTSD
Learner Objectives
1. To identify various ways of coping with
traumatic events including disasters
2. To examine some existing coping
strategies in American Indians as well as
other 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 press)
Natural
Man-made
Technological
Biological
Unintentional
Tsunamis,
Floods,
Hurricanes,
Earthquakes,
Wildfires, etc.
e.g., Bhopal, HazMat, Case study of
uranium mining
industry and the
Navajos (Markstrom
& Charley, 2003)
Epidemic &
pandemics
e.g., 19181919 global
Influenza
Pandemic
Intentional
“Act of God”
Chemical, Nuclear,
Radiological,
Explosion, Acts of
Terrorism
Bioterrorism
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 life events that
challenge 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
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 Exxon Valdez Oil Spill
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 harbor seal, 250 bald
eagles and 22 orca whales
• Impact on fishery, fishing, seafood, sports
fisheries & tourism industries- economic
and lifestyle impacts in Alaska Natives
• Protracted litigation
Coping may also be viewed from a
variety of perspectives
•
•
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Individual
Family
Community
Tribal
In many cases trauma and disaster impact(s) 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 (and families/
communities/tribes) employ to master,
tolerate or minimize threats associated
with stressful events.
(after Taylor et al, 2002)
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”
Tiet et al (2006)
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; e.g. exercise may
be an adaptive coping strategy even
though it does not solve “the problem”
• Maladaptive coping: ineffective coping
which neither reduces stress nor resolves
the situation.
(Beaton & Murphy, 2002)
Empirical investigation of coping in Puget
Sound Firefighters (Beaton et al, 1999)
H. Simpson
Very difficult to measure “sense of humor” in fire service
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
Apollo
Astronauts
Little empirical data are available to guide
recommendations 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
JUNE STRICKLAND, RN, PhD
OBSERVATIONS
• Water is very important to coastal peopleto go to and walk by the water
• Plateau people drink water and wash face
with water under stress
• Prayer songs sung to one’s self or others
• Prayer is generally a part of the way for all
• Families may use talking circles in crisis
• Youth talk of going to the mountains
Benchmark Mountain 9/01/06
Sacred Places: Siletz Medicine Rock
Canoe Journey
• Since 1997 the Canoe Journey has been
hosted by different tribes each summer
and is now attended by 6,000 people daily
during the celebration and potlatch
• Incorporates safety, strength, traditional
regalia, language, song, plants & food.
• The canoe journey gives meaning & is a
unifying force for Indian Nations & culture
Skokomish Tribe
Tribal healers & elders
Medicine persons and tribal elders possess
• Wisdom and compassion
• Sacred knowledge
• Leadership in times of stress; Nisqually
earthquake example
Contrast with non-Indian culture:
youth & celebrity worship
Iris HeavyRunner PrettyPaint’s
Worldview Philosophy(2003)©
Lens through which we learn to nurture, protect and dream
Used with
permission of Iris
HeavyRunner
PrettyPaint
Traditional Native Culture & Resilience (from
HeavyRunner PrettyPaint & Morris, 1997)
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Sacredness of all creation
Sharing material possessions
Cooperation vs. competition
Harmony & balance- maintained by not
imposing on an individual’s rights & beliefs
• Humor
• Oral traditions
Gathering of Native Americans
(GONA) -LaPlante
• Four day gathering of Native Americans
who want to become change agents &
leaders
• GONA is a safe place for communities to
share, heal and plan for action
• GONA offers hope, encouragement, a
framework and presents a prevention model
based on traditional native cultural values
Conceptual Model of Nursing in Native
American Culture (Struthers & Lowe, 2003)
Holistic model that incorporates a number of
elements in nursing care with American
Indians including:
• Trust
• Respect
• Spirituality
• Traditions and
• Connections
Additional 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 Indians—Western approaches to care
have not been embraced by American Indian
populations and most forms of mental health
treatment have yielded disappointing results
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 (in my opinion)
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 Washington DOH 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 (if you don’t already
know them)
• Join a community emergency response team
such as CERT.
• UW CERT webpage site
http://www.washington.edu/admin/business/oem/cer/
CERT for Tribal Nations
• In Nov. of 2002 members of five Midwest
tribes– the Kickapoo Tribe in Kansas, the
Omaha Tribe of Nebraska, the Prairie
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 to Coping
with Trauma & Disaster
• 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 effective 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 (Tedeschi et al, 1998)
• Meditation & spiritual practices
• Maintain a hopeful outlook. There is very,
very little downside to optimism
Some “Unrealistic” Optimism may
actually be adaptive
• 50% of marriages fail within five years
(perhaps even higher rates of divorce in
American Indians), 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)
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
“You’ve lost
your home,
your job and
your pet–how
do you feel
about that?”
Sigmund Freud
Some Basics
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Expect normal recovery
Assume survivors are competent
Recognize survivor strengths
Promote resilience
Offer practice solutions
Five Empirically-Supported Early
Intervention Principles
Promotion of Psychological Sense of Safety &
Comfort
• 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 outcomes
are associated with:
• Optimism
• Positive expectancy
• A feeling of confidence in
life and/or self
• Strong faith-based
beliefs
Summary and Conclusions– Coping
with Trauma and Disaster
• American Indian tribes and peoples have 500
years of experience coping with trauma
• Historical trauma has been considered a “risk
factor” for adverse trauma outcomes but it
may also serve as a source of strength &
resolve
• 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
possess a number of protective traditions,
rituals and ceremonies as well as other
cultural sources of resilience which are
consistent with the principles and actions of
Psychological First Aid (PFA) including:
- connectedness
- hope and
- self-efficacy
Resilience in American Indian Tribes and
Individuals in the Face of Trauma & Adversity
• “Resilience is not a new concept to our
(American Indian) people.
• It is an ancient principle of a philosophy of
American Indian life
• It teaches: “stand strong…try hard…and
never give up”
Iris HeavyRunner PrettyPaint, 2006
University of Montana

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