ongoing traumatic stress (ots) and post-traumatic stress disorder (ptsd): the impact of cartel...

Ongoing Traumatic Stress (OTS) and Post-Traumatic Stress Disorder (PTSD):

The impact of cartel related violence on the U.S./México border.

Thom Taylor

Agenda

• A brief background to traumatic stress– Post-Traumatic Stress Disorder (PTSD)– Ongoing Traumatic Stress (OTS)

• Preliminary study of OTS in population exposed to violence and insecurity in Ciudad Juárez

• Considerations for U.S./México Border Public Health and Safety communities

TRAUMATIC STRESS BACKGROUND

“Violence and Insecurity” • Extreme increase in cartel and community

related violence in northern México– Cartel related murders (2000+ in past year)– Kidnappings– Car-jackings– Robberies/Extortion (“Cuotas”)– Constant threat

• U.S. not immune• Cartel and army related violence (CARV)

– Psycho-social costs to a community– Increases stress

Caetano, 2009; U.S. Department of State, 2009; Thoumi, 2002; Chan, Air, & McFarlane, 2003

Extreme Stress Reactions• Post-Traumatic Stress Disorder (& Probable PTSD)

– Exposure to traumatic experience (s)– Feelings of fear, helplessness, and/or horror peri-event– Intrusive thoughts/Re-experiencing (1+ symptoms)– Avoidance/numbing to situations (3+ symptoms)– Hyper-arousal (2+ symptoms)– Psycho-social impairment

• Partial PTSD– Threshold for full PTSD may be too high– Impairment still seen (e.g., anger)

American Psychiatric Association (APA), 2000; Berstein et al., 2007; Mitka, 2008; Galea et al., 2003; Stein et al., 1997

Acute Event PTSD: Implicit Assumptions

Identified Traumatic Stress Trends

• Chronic PTSD (> 3 months)• Acute PTSD (> 1 Month)• Resistant• Resilient

APA, 2000; Bonnano, 2004; Norris et al., 2009

Core Trauma Symptoms

Avoidance / Numbing

Re-experiencing / Intrusive Thoughts

Hyper-Arousal

PERI Trauma (Immediate) Considerations• Unpredictable and Un-controllable• Subjective exposure

– Fear– Helplessness– Horror

• Direct forms of Trauma (e.g., assault, terrorism)• Indirect forms of Trauma (e.g., witnessing,

media, trauma by proxy-such as family member)• Subjective interpretation

Breslau et al., 2004; Gray et al., 2004; Gabriel et al., 2007; Suvak et al., 2008; Collimore et al., 2008; Foa & Riggs, 1995; Weathers & Keane, 2007

PRE-Trauma Risk FactorsDemographic risk factors (e.g., female gender)Exposure to multiple traumata (re-exposure)Anxiety disorders rarely present in pure form

– Pre-existing anxiety disorders may worsen traumatic stress after exposure

– Anxiety Sensitivity predisposes to traumatic stress after exposure

• Depression – Unclear if PRE or POST factor– Depression highly comorbid with TS post-event (correlation)– May worsen traumatic stress

Brewin et al., 2000; Ozer et al., 2003; Norris et al., 2003b; Dunner, 2001; Goldenberg et al., 1996; Elwood et al., 2009; Gabriel et al., 2007; Jaycox et al., 2003; Collimore et al., 2008; Breslau et al., 1997; Breslau et al., 1991; Breslau et al, 2000

PRE-Trauma Sources of Coping• Social support strongly buffers against traumatic stress• Coping in uncontrollable situations

– Problem focused (limited in uncontrollable situations)– Emotion-focused

• Active– Self distraction (+ or -)– Venting (+ or -)– Cognitive acceptance of situation/experience ( + or -)

• Avoidance based– Denial ( generally - )– Giving up/feeling hopeless ( - )– Self-blame ( - )– Substance use ( - )

Brewin et al., 2000; Lazarus & Folkman, 1984; Solomon, 1989; Carver et al., 1989

Unique Opportunity

• Virtually no empirical study of psycho-social impact of cartel related violence in the Americas

• Limited knowledge of real-time (daily) impact– Memory distortion after the fact (e.g., months,

years, melding of traumas? Such as in VHA situation)

– More refined understanding of impact of ongoing traumatic situations

Nisbett & Wilson, 1977; Wolfer, 1999

Preliminary Study of Ongoing Traumatic Stress

1. Assess Ongoing Traumatic Stress (OTS)2. Examine impact of factors commonly

associated with PTSD in:1. Ongoing (daily) Traumatic Stress2. Ongoing (daily) Re-experiencing symptoms3. Ongoing (daily) Avoidance symptoms4. Ongoing (daily) Hyperarousal symptoms

METHODS

Participants• N = 121 (N days = 816)• Inclusion Criteria

– Travel/live in Cd. Juárez at least 3 days/week– Internet access at least every 24 hour period– Bilingual– UTEP student

• Comfort with online survey; anonymity/confidentiality• Post-hoc advantage; could still recruit after UTEP travel ban

• Compensation: $40USD giftcard to Target OR 4 experimental credits

Measures: Main OutcomeAll measures professionally translated and

back-translated with subsequent native Spanish speakers’ input on items

Post-traumatic Stress Disorder Checklist (PCLS)– Specific event-adapted for CARV: “…violencia

relacionado con el narcotrafico u hostilidad y maltrato militar.”

– Past 30 day Acute PTSD (α = .89)Adapted version for daily traumatic stress for past 24 hours (PCLSD): α range = .91 - .94

Brislin, 1970; Liu, 2002; Weathers et al., 1993 Ruggiero et al., 2003; Orlando & Marshall, 2002

Background MeasuresLife Events Checklist (LEC) documents 17

traumatic events often associated with PTSD Experienced Directly (direct)Witnessed (indirect)Learned of/Heard about (indirect)

Depression, Anxiety, and Stress Scale (DASS)Depression (α = .86)Anxiety (α = .78)General Stress (α = .85)

Gray et al., 2004; Lovibond & Lovibond, 1995; Crawford & Henry, 2003; Daza et al., 2002

Background Measures ContinuedMulti-dimensional Scale of Social Support

(MSPSS)Family (α = .89)Friends (α = .96)Significant Other (α = .92)

Brief COPE coping measure (BCOPE); Carver encourages malleability given nuances of coping

• Problem Focused Coping (α = .78)• Emotion Focused Active Coping (α = .73)• Avoidance Coping (α = .76)

Zimet et al., 1988; Carver et al., 1997, Schneider et al., 2007; Perczek et al., 2000

Daily Assessment

• Completed online >24 hours for 7 days• PCLSD (daily traumatic stress)• Time-varying explanatory covariates

– Travel to CJ (# hours) – Reasons for being in CJ (family, friends,

business, antro/club/bar)– Perceived degree of exposure to violence

(fear, helplessness, horror)

Lemonade out of Lemons• Drop out rarely positive outcome, but allows

unique analysis in present study• 20% did not return for follow-up• Unique opportunity in trauma study

– Avoidance unpleasantness drop-out?– Re-experiencing unpleasantness drop-out?– Hyper-arousal unpleasantness drop-out?

Informative Drop-Out• Diggle-Kenward Selection Model (DKSM)

– Single covariate entered due to estimation complexity: Past 30 day traumatic stress (PCLS)

– Survival indicator from daily reports 3 to 4 constrained to be 0; no drop-out in interval

– To allow estimation, only intercept allowed to co-vary with past 30 day acute PCLS scores

• Drop-out unassociated with traumatic stress, all Zs < |.65|, all ps > .52

• Take Home Point: Preliminary support that asking about trauma on a daily basis does not make it worse for those assessed.

Rubin, 1976; Molenberghs, Michiels, Kenward, & Diggle, 1998; Diggle & Kenward, 1994

Approach to Analysis: • Multi-level modeling

– Specified Expectation-Maximization in Maximum Likelihood; robust to MAR

– Grand Mean centered variables – Standardized (N~0,1) covariates to give common scale to

psychological factors• OPTS dependent variable (PCLSD)

– Condition on demographics, LEC, DASS, MSPSS factors, BCOPE sub-scales

– Time varying covariates • Presence in CJ (hours)• Perceived exposure to violence occurring (fear, helplessness, and

horror)Snijders & Bosker, 1999; Gardiner, Luo, & Roman, 2009

PRELIMINARY STUDY RESULTS

Demographic Highlights

VariablePossible Range Mean SD Med. Min. Max.

Days in Cd. Juárez, Chih per week 0 to 7 4.84 1.81 4 1 7

Days in El Paso, TX per week 0 to 7 4.73 1.56 5 1 7

Family who live in Cd. Juárez, Chih (%) 0 to 100 67.31 30.18 80 0 100

Friends who live in Cd. Juárez, Chih (%) 0 to 100 60.79 31.76 70 0 100

Age (years) -- 21.62 3.40 21 18 44

PTSD Checklist Past 30 day Score (PTSD) 17 to 85 43.87 13.71 43 18 85

Sample Continuous Characteristics

VariablePossible Range Mean SD Med. Min. Max.

Days in Cd. Juárez, Chih per week 0 to 7 4.84 1.81 4 1 7

Days in El Paso, TX per week 0 to 7 4.73 1.56 5 1 7

Family who live in Cd. Juárez, Chih (%) 0 to 100 67.31 30.18 80 0 100

Friends who live in Cd. Juárez, Chih (%) 0 to 100 60.79 31.76 70 0 100

Age (years) - 21.62 3.40 21 18 44

PTSD Checklist Past 30 day Score (PTSD) 17 to 85 43.87 13.71 43 18 85

Sample Continuous Characteristics

SD

Continuous Variable Range Mean Overall Betw. Within

Hours each day in Cd. Juárez 0 to 24 11.87 9.00 6.74 6.39

Daily traumatic stress level 17 to 85 32.30 13.50 11.74 6.11

Peri-traumatic experiencesFear 0 to 6 1.91 1.85 1.44 1.16Helplessness 0 to 6 1.93 1.89 1.49 1.20Horror 0 to 6 1.58 1.83 1.47 1.11

Coping via substance use 0 to 6 0.49 1.15 1.10 0.54

Sample Daily Characteristics

Sample Daily Characteristics Cont.Categorical Variable Overall % Between % Within Avg. %

Daily Traumatic Stress Risk Category

Limited (PCL less than 34) 60 81 74

Moderate (PCL of 34 to 43) 21 52 41

Clinical (PCL greater than 44) 19 37 52

Reasons for being in Cd. Juárez: Family

No 25 55 46

Yes 75 93 81

Reason for being in Cd. Juárez: Friends

No 67 92 72

Yes 33 75 46

Reason for being in Cd. Juárez: Business

No 92 99 93

Yes 8 26 30

Reason for being in Cd. Juárez: Antro/Bar

No 95 100 96

Yes 5 19 23

PREDICTING ONGOING (DAILY) TRAUMATIC STRESS RESPONSE SYMPTOMS

Multi-Level Model Predicting Ongoing Traumatic StressTime Invariant Covariates B 95% CI p

Female 0.02 -0.20 - 0.24U.S. Resident vs. citizen 0.04 -0.16 - 0.25Income (ref. is Less than 15,000USD)

15,001 to 30,000USD 0.01 -0.23 - 0.2630,001 to 45,000USD 0.04 -0.26 - 0.3445,001USD to 60,000USD 0.11 -0.24 - 0.45More than 60,000USD -0.01 -0.53 - 0.52

Prior Trauma Exposure (Life Events Checklist)Heard about (Indirect) -0.04 -0.14 - 0.06Witnessed (Indirect) 0.02 -0.08 - 0.12Directly experienced -0.01 -0.12 - 0.10

Psychological Symptoms (DASS-21)Depression -0.06 -0.22 - 0.10Anxiety -0.04 -0.18 - 0.10General Stress 0.18 -0.01 - 0.37 0.07

Social Support (MSPSS)Family -0.03 -0.15 - 0.10Friends -0.10 -0.23 - 0.03Significant Other 0.14 0.01 - 0.27 <.05

CopingProblem focused -0.06 -0.21 - 0.09Active emotion focused -0.05 -0.20 - 0.10Avoidance based 0.11 -0.01 - 0.24 0.08

Acute Post-Traumatic Stress Disorder 0.42 0.29 - 0.54 <.01Time Varying Covariates

Hours in Cd. Juárez -0.01 -0.06 - 0.04Reason for being in Cd. Juárez

Family 0.11 0.00 - 0.22 <.05Friends 0.04 -0.05 - 0.12Business 0.15 0.01 - 0.28 <.05Club/Bar/Antro -0.06 -0.24 - 0.12

Peri-event exposure reactionsFear 0.11 0.03 - 0.19 <.01Helplessness 0.15 0.08 - 0.21 <.01

Horror 0.14 0.06 - 0.22 <.01

Multi-Level Model Predicting Ongoing Re-Experiencing SymptomsTime Invariant Covariates B 95% CI p

Female -0.17 -0.38 - 0.04U.S. Resident vs. citizen -0.10 -0.29 - 0.09Income (ref. is Less than 15,000USD)

15,001 to 30,000USD 0.07 -0.16 - 0.3030,001 to 45,000USD 0.12 -0.16 - 0.4045,001USD to 60,000USD 0.24 -0.08 - 0.56More than 60,000USD 0.09 -0.41 - 0.59

Prior Trauma Exposure (Life Events Checklist)Heard about (Indirect) -0.02 -0.12 - 0.07Witnessed (Indirect) -0.09 -0.18 - 0.01 0.07Directly experienced 0.00 -0.11 - 0.10

Psychological Symptoms (DASS-21)Depression -0.10 -0.25 - 0.05Anxiety 0.00 -0.14 - 0.13General Stress 0.16 -0.02 - 0.33 0.08

Social Support (MSPSS)Family 0.00 -0.12 - 0.12Friends -0.08 -0.20 - 0.04Significant Other 0.08 -0.04 - 0.20

CopingProblem focused -0.02 -0.16 - 0.13Active emotion focused -0.05 -0.19 - 0.09Avoidance based 0.09 -0.03 - 0.21


Hours in Cd. Juárez 0.01 -0.05 - 0.06Reason for being in Cd. Juárez

Family 0.01 -0.11 - 0.14Friends 0.07 -0.03 - 0.18Business 0.00 -0.17 - 0.16Club/Bar/Antro 0.00 -0.21 - 0.22

Peri-event exposure reactionsFear 0.10 0.00 - 0.19 0.06Helplessness 0.17 0.09 - 0.25 <.01

Horror 0.21 0.12 - 0.30 <.01

Multi-Level Model Predicting Ongoing Avoidance SymptomsTime Invariant Covariates B 95% CI p

Female -0.03 -0.30 - 0.24U.S. Resident vs. citizen 0.09 -0.16 - 0.34Income (ref. is Less than 15,000USD)

15,001 to 30,000USD -0.08 -0.38 - 0.2130,001 to 45,000USD -0.21 -0.57 - 0.1545,001USD to 60,000USD 0.10 -0.32 - 0.52More than 60,000USD -0.30 -0.93 - 0.34

Prior Trauma Exposure (Life Events Checklist)Heard about (Indirect) -0.04 -0.17 - 0.08Witnessed (Indirect) 0.01 -0.11 - 0.13Directly experienced -0.02 -0.16 - 0.11

Psychological Symptoms (DASS-21)Depression -0.01 -0.21 - 0.18Anxiety -0.07 -0.24 - 0.11General Stress 0.15 -0.08 - 0.38

Social Support (MSPSS)Family -0.02 -0.17 - 0.14Friends -0.12 -0.27 - 0.04Significant Other 0.16 0.01 - 0.32 <.05

CopingProblem focused -0.05 -0.23 - 0.14Active emotion focused -0.08 -0.26 - 0.11Avoidance based 0.09 -0.06 - 0.24



Family 0.11 -0.01 - 0.22 0.07Friends 0.00 -0.09 - 0.09Business 0.29 0.15 - 0.44 <.01Club/Bar/Antro -0.10 -0.30 - 0.10

Peri-event exposure reactionsFear 0.13 0.04 - 0.22 <.01Helplessness 0.13 0.05 - 0.21 <.01

Horror 0.06 -0.03 - 0.14

Multi-Level Model Predicting Ongoing Hyperarousal SymptomsTime Invariant Covariates B 95% CI p

Female 0.08 -0.14 - 0.31U.S. Resident vs. citizen 0.02 -0.19 - 0.23Income (ref. is Less than 15,000USD)

15,001 to 30,000USD 0.05 -0.19 - 0.3030,001 to 45,000USD 0.24 -0.06 - 0.5445,001USD to 60,000USD -0.07 -0.41 - 0.28More than 60,000USD 0.21 -0.32 - 0.74

Prior Trauma Exposure (Life Events Checklist)Heard about (Indirect) -0.03 -0.14 - 0.07Witnessed (Indirect) 0.10 0.00 - 0.20 <.05Directly experienced -0.03 -0.14 - 0.08

Psychological Symptoms (DASS-21)Depression -0.08 -0.24 - 0.08Anxiety -0.07 -0.21 - 0.08General Stress 0.21 0.02 - 0.40 <.05

Social Support (MSPSS)Family -0.05 -0.17 - 0.08Friends -0.07 -0.20 - 0.06Significant Other 0.13 0.00 - 0.25 0.06

CopingProblem focused -0.07 -0.22 - 0.08Active emotion focused -0.04 -0.19 - 0.11Avoidance based 0.15 0.02 - 0.27 <.05



Family 0.12 -0.01 - 0.25 0.07Friends 0.08 -0.02 - 0.19Business 0.06 -0.11 - 0.22Club/Bar/Antro -0.02 -0.24 - 0.20

Peri-event exposure reactionsFear 0.06 -0.04 - 0.16Helplessness 0.15 0.07 - 0.24 <.01

Horror 0.13 0.03 - 0.22 <.01

DISCUSSION

Ongoing Traumatic Stress

• Border significantly affected by OTS and PTSD– Present sample might objectively be considered of

less risk (many protective factors/buffers)– Still, sample evidenced both PTSD and OTS scores

warranting concern• Assessing for PTSD can potentially help to reduce

OTS• Yet, common prior factors associated with long

term traumatic stress (PTSD) less impactful at daily levelmore nuanced?

Diamond et al., 2010; Mineka & Zinbarg, 2006; Ozer et al., 2008; Ursano et al., 2009

Evidence for Ongoing Traumatic Stress• Objective exposure (i.e., less time in Cd. Juárez) does

not reduce OTS• Very strong subjective component

– Strong peri-event subjective reactions to exposure observed– Assessment of “real time” reactions important

• Valid Anticipatory fears: the future as important as past– Unpredictability– Uncontrollability– Fear, helplessness, and horror on a daily basis– Reinforced avoidance and generalizing of fearful

situations/psycho-social states

Diamond et al., 2010; Hobfoll et al., 2009

What is not there that “should be?”

• Gender (female) unassociated with Ongoing Traumatic Stress in the present sample– Variability (model ICCs) HUGE– Other important factors to assess nested within

gender• Not “only a Mexican problem”

– Socio-economic status not explanatory either– U.S. and Mexican citizens integrated in to both

sides of border are significantly affected

Kessler et al., 1995, Ozer et al., 2008

Past/Future Exposure Considerations• Evidence for resilience from past traumata

– Much exposure already in these young adults– Little impact on traumatic stress when

accounting for other factors identified in traumatic stress literature

• Still, fear regulation strongly disrupted in traumatic stress; differentially to other anxiety disorders

• Long-term impact from short term OTS?

Bonanno, 2004; deRoon-Cassini et al., 2010; Norris et al., 2009; Dutton & Greene, 2010; Etkin & Wager, 2007; Wilson & Freer, 2010; Ginzburg et al., 2010

Other Factors to Consider: Psycho-Accumulation of Trauma?

• Re-exposure assumes a somewhat linear process• Psycho-accumulation, potentially quadratic?

Depression, Anxiety, General Stress, and Traumatic Stress

• In ongoing traumatic stress, depression may or may not be present– Few depression symptoms overall (floor effect)– Still, depression assessment likely always warranted

when assessing traumatic stress in general• Sample applies for other anxiety disorders• May meet criteria for multiple anxiety disorders (e.g., GAD)

• General stress may be one area where we can intervene for those exposed to OTS (more later)

Breslau et al., 1991; Breslau et al, 2000; Collimore et al., 2008; Breslau et al., 1997

Coping with Ongoing Traumatic Stress• Problem-focused coping difficult in

uncontrollable/unpredictable situations– Adaptive routes/variation of routes to go somewhere

in the city– Others examples from your perspective?

• Active/emotion-focused coping may not fully compensate for OTS

• Coping may be very diverse in OTS– Are some strategies helpful in one context of ongoing

violence, while harmful in others?– Many of you see coping first-hand

Riolli & Savicki, 2010; Bonanno, 2004; Lazarus, 2000; Bal et al., 2003; Ullman, Filipas, et al., 2007

Family, Familiarity, Stability • Decision to move/stay in Cd. Juárez?

– Separation from loved ones and familiarity– Family may still be exposed even if one individual family

member is safe.– “For better or worse…” (the family unit)

• Resource loss worsens traumatic stress– Psycho-social resources (e.g., friends)

• Kids can do a little better here—from research perspective• Older adults can be vulnerable to effects of displacement

– Physical resources/access• Extortion (“Cuotas”)• Example: IMSS

Alim et al., 2008; Rivera et al., 2008; Hobfall et al., 2009; Wyshak, 1994; Fozdar, 2009

Social Support• Strongest buffer to Post-Traumatic Stress

– Applies to retrospective reports– Potentially more accessible when exposure is acute

vs. ongoing• May be more nuanced in Ongoing violence

– Supporting others in uncontrollable and unpredictable ongoing stressors may be difficult

– Larger families may have resources spread across many individuals

• Provider vs. receiver?

Brewin et al, 2000b; Bradley et al., 2005; Kwak, 2003; Szapocznik & Kurtines, 1993; Monson et al., 2009

Focal Individual

Social Support Models in Traumatic Stress

Tacit Assumption: Unidirectional Model (e.g., sexual assault)

Social Support Network Member 2

Social Support Network Member 3 Social Support

Network Member 4

Social Support Network Member …N


“For better or worse…”

Focal Individual


Bi-Directional Model (e.g., combat deployment, death of a loved one)



Network Member 4



Focal Individual


Mixed Directionality Model (e.g., Ciudad Juárez residents)



Network Member 4



“For better or worse…”

Focal Individual


Community Level Social Support



Network Member 4



Community Support

Community Support Opportunity

• Regional attention to traumatic stress– A need (Cartel violence, Veterans of OEF/OIF)– An opportunity to be a “Star” community for helping

those affected by traumatic stress• Psychological/Psychiatry is important, but not the

only answer:– Limit mental health stigma and shame – Promote autonomy: “feeling in control”– Potential nuances of exposure therapy

Joseph, 2010; McCart et al., 2010; Jones, 2007; Diamond et al., 2010; Litz et al., 2002; Rose et al., 2002; Shalev et al., 2004; Milliken et al., 2007; Bradley et al., 2005

PTSD

Exposure Therapy Paradigm Traumatic Event

Presumed Safe Situation Reality

Perception

Level

Generalized fears of surroundings and

reoccurrence of event(s)

Timeline

Relaxation and (Imaginal) Exposure

Therapy

PTSD

Exposure Therapy in Ongoing Traumatic Stress

Traumatic Event(s)

Unsafe Situation Reality

Perception

Level

Timeline

Traumatic Stress

Traumatic Stress

Generalized fears of surroundings and

reoccurrence of event(s)

Relaxation and (Imaginal) Exposure

Therapy

?

Note: Relaxation training can be helpful in ongoing traumatic stress situations per Diamond, G. M., Lipsitz, J. D., Fajerman, Z., & Rozenblat, O. (2010). Ongoing traumatic stress

response (OTSR) in Sderot, Israel. Professional Psychology, Research and Practice, 41, 19-25. doi:10.1037/a0017098

Creative Community Support• Promote predictability

– May be limited in Cd. Juárez (ideas?)– El Paso/U.S. side of the border

• Educate on traumatic stress and the range of people affected-builds empathy

• Streamline policies/systems to accommodate range of victims’ needs

• Limit daily stressors: “the daily grind”– Wears down mental resources– Unprepared when crisis occurs

Sutton, 2010; Hobfoll et al., 2007; Wei et al., 2010; Bryan, 2010

In a crisis, which battery do you want?

1. 2.

3. 4.

Preventing “low power”• Address daily stressors of patients/clients/staff

– Is a action/policy a barrier, a benefit, or both for the• Patient/client?• Staff?

– Can the action/policy be adapted to reduce “the daily grind?”– Can benefit not just the individual patient/client, but also the

system and staff• Support the supporters

– Remember, there is a hierarchy many systems– “____________ flows downhill.”– You fill in the blank (can be positive or negative word)

• After presentation, I am interested in hearing your perspectives on how to prevent “low power.”

Focus on “Small Wins”• Big changes are rare and when they do

occur, there is sometimes a backlash• Find ways to make “small wins”

– Recognize small wins as wins none-the-less– Reinforces future action that can promote

future “small wins”• Promotes self-efficacy• May promote community efficacy

– Small wins add up.

Bryan, 2010

Limitations and Strengths of Present Study

• Limitations– Threshold for impairment in PCLS may be different for

this group• Sensitivity and specificity • Need for focus on psycho-social impairment criterion

– Convenience/snowball sampling may limit generalizability of findings

– Low statistical power due to large inter-individual variability

• Strengths– Daily level longitudinal assessment; not feasible in many

cases– Professionally back-translated measures

Conclusions• Moderate to high levels of ongoing traumatic

stress a likely reality for many with close ties to Cd. Juárez

• Risk factors and buffers commonly associated with PTSD nuanced in Ongoing (Daily) Traumatic Stress

• Community can do a lot to indirectly help those affected by trauma– “Small Wins”– Creative opportunities for community support?

ONE FINAL NOTE

The Future of Cartels• When substance use revenues change, cartels may

not disappear or even become weaker (VERY ADAPTIVE)– Example: 1920s-1930s Chicago– U.S. Gangs

• May move in to other activities that traumatize the population– Human/body trafficking (sex, labor, organs)– Consideration of (illegal) supply chains– Partnerships with other dangerous entities

• We need to consider the future of cartels to prevent future traumatization of our loved ones and friends.

Spanish Trauma Questionnaires

• National PTSD Center– Post-Traumatic Stress Disorder Checklist– Life Events Checklist– http://

www.ptsd.va.gov/professional/pages/assessments/assessment.asp

• Contact me if you have questions on other scales: [email protected]

http://www.ptsd.va.gov/professional/pages/assessments/assessment.asp



mailto:[email protected]

Acknowledgements• Dr. Cooper• Dr. Byrd• Dr. Cohn• Dr. Eno Louden• Dr. Morera• Hispanic Health Disparities Research Center, Grant No.

1P20MD002287-03• A Smoke Free Paso del Norte, Grant No. 26-8113-17• Areli Guajardo and Ivan Torres• Cisco Salgado and José Cabriales• Prevention and Treatment in Clinical Health Lab• Victoria A. Garcia and Richard Ford, Ph.D.• .

Thank you!

Time permitting, I would like

• Questions• A discussion of problem focused coping from

your eyes?• To hear about possible “Small wins” in

change/adaptation of activities and policies you think could help your organization to help those affected by trauma?

ongoing traumatic stress (ots) and post-traumatic stress disorder (ptsd): the impact of cartel...

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