I really enjoy reading the blog Kellevision.com. She says it like it is and seldom misses the point of what she's writing about. She identifies a problem in programming for homelessness and proposes a set of concepts to help clarify the situation.

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Many of the "barriers" faced by the chronically homeless are not external. They are self-inflicted. Repeatedly failing to pay one's utility bills is not a barrier. It is a behavior. Repeatedly getting into relationships with drug addicts and being evicted because you have allowed your new girlfriend to turn your affordable housing into a crack house is not a barrier. It is a behavior. Choosing to pay your boyfriend's bail instead of the rent is not a barrier, it is a behavior. Consistently refusing to hold down steady employment and being evicted for not being able to pay the rent is not a barrier, it is a behavior.

[..]Lastly, how we label the problem determines how we approach solving it. True social barriers need to be addressed by social services. Better programs need to be designed to specifically address the needs of the mentally ill population. Programs designed to assist the medically disabled need to be accessed. But behaviors require a clinical intervention - therapy. Clients who demonstrate patterns of behavior which result in repeated instances of homelessness need counseling, not social services. The problem is not a social problem. It is an individual problem which requires an individual intervention.

I think it's much more complicated than that. Our world has always had an underclass, a group of individuals who have been largely invisible in the US except during the Depression. These people largely function outside the visible society and economy. They share housing with family and friends, squat in abandoned buildings, and sometimes live under bridges. They live off their housemates or family, work for temp job agencies, borrow, steal, deal drugs, and even engage in formal criminal enterprise. Given our recent policies that have reversed the tax-based redistribution of wealth since FDR, the stagnant wages, disappearing jobs, and ever increasing cost of living, that underclass has become so large it is again visible.

They are chronically under or unemployment and are not collecting Social Security, either because they don't qualify, try though they may to apply, or they haven't the where-with-all to get themselves qualified. This chronic underclass is best described as a sub-culture. They are structurally built into the economy. "Full employment" doesn't include them. Because they have given up on finding work, they no longer register with unemployment offices and so are not counted among the unemployed. Those who are chronically homeless are a sub-group of this sub-culture, and probably represents some of its most dysfunctional members.

By describing the chronically homeless, Kellevision describes most of the common attributes of this subculture.

For the majority of the [chronically] homeless population, homelessness is a lifestyle, not an event.

[..]My purpose here is not to blame the victim, but to talk openly about the severe dysfunction I see in chronically homeless families. Unless we identify the true problem, we will not be able to form a lucid solution. Homeless families typically do not function well on any level. Children are frequently truant from school and display numerous behavior and developmental problems. Dorm rules are constantly broken and there is constant turmoil between the families on the dorm. Relationships are fleeting, intense and severely dysfunctional including domestic violence, substance abuse and exploitative. Interactions with other people are inappropriate or dysfunctional. Most homeless families have burnt all their bridges with every social service agency and with their own families because of their severe dysfunction. Shelter staff often feel like we are running a middle school rather than a homeless shelter. This behavior is what needs to be addressed rather than giving them more money or building more homes.

[..]What are the elements of the homeless mindset? I'm still trying to work this out in my mind, but here are some of them which I see frequently:

• An external locus of control
• the belief that they have no control or responsibility for their choices, actions or behaviors but they are the victim of circumstances
• the belief that the causes for good or bad events in your life are totally outside your control or responsibility
• Sense of entitlement
• the belief that the worlds owes them something and they should be able to collect immediately
• the belief that they should be taken care of by others, by the government or by social service agencies
• the belief that they should be given things they have not earned (i.e. free housing, clothing, food, etc.)
• the belief that others should "help" them (i.e. by paying their unpaid bills or appealing their housing denial)
• Impulsivity
• Poor boundaries
• Emotional immaturity
• Need for instant gratification
• Dependency issues
• Predatory/antisocial behaviors
• Pathological relationships

Certainly, not every member of what I'll call the "underclass sub-culture" share all of these attributes. Each and every person has a story behind their situation. A careful account of their histories, something they usually reluctantly give, chronicles the development of these problems. It's important to discourage a prejudice developing against a whole group of people who are already stigmatized along with the "welfare mother" of the AFDC era. But we are not going to get to a more complete solution without understanding the problem. I suspect that why there is little commentary on this topic.

Kellevision hits on what I believe to be one of the most common roots of dysfunction, repeated traumas throughout their life.

A vast majority of our clients seem to have endured some sort of trauma(s) during their childhood which has(have) halted their emotional development. The result is immaturity, impulsivity, dependency, a sense of entitlement (that someone should take care of them rather than being responsible for themselves), an external locus of control (seeing problems as existing outside of themselves and therefore being outside of their control and/or responsibility), immature relationships and emotional lability. These factors result in behavior which appears erratic and irresponsible.

"Arrested development" is what Kellevision calls it. Indeed, this problem is pervasive and most often multi-generational. There are most often one or more of the following in the family history:

• lifelong repeated exposure to trauma:
  
  
  
  • child abuse and neglect
  
  
  • incest
  
  
  • domestic assault
  
  
  • gang or drug related violence
  
  
  • repeated exposure as a crime victim including assault, rape, and drive by shootings
  
  
  • inconsistent parenting ranging from abusive to no supervision
  
  
  • one or more family member who was murdered
  
  
  
  
• poor performance/attendance at school


• high school drop-out


• parenthood started by mid-teens


• by their twenties, they have several kids with mostly different partners


• sporadic work history and chronic unemployment


• efforts to qualify for Social Security


• family members relying on other families income, so no family member is able to break the pattern of poverty


• chemical abuse


• drug dealing to support a habit


• mental illness


• parents, spouses, brothers, sisters in prison


• criminal activity as income


• crime as a family enterprise

Persons who are members of the underclass see dysfunction as normal. They've never known any different. Many think this is how everyone lives. While they may dream of a good job, they appear to not have the self-discipline to keep a good job. Many of this group might be diagnosed with an anti-social personality DO. Personally, I think this diagnosis is misleading at best. A person earns this diagnosis if their history includes sufficient "anti-social" behavior. This doesn't account for family cultures that teach a confusing mix of conventional and anti-social values. Thus we have neighborhoods that have no constructive relationships with police, believe that justice is against them and label anyone reporting a crime as an informant and not to be trusted. This of course contributes to the chaos in the neighborhood.

In my experience people who get diagnosed anti-social are the ones the clinician don't trust or believe. The whole underclass culture tries to keep their business to themselves. Lying to protect one's family's reputation is encouraged. I suspect while there may be a few classic psychopaths out there, most of those folks who populate our jails are drug abusing, impulsive, underclass members with shut down emotional systems due to repeated chaos and trauma. These folks won't tell you the truth unless they are desperate and already feel they are the lowest of the low. Their judgment is so impaired that they see fear as a weakness they must squelch out. Danger in their world is everywhere and it must be faced, not avoided.

I have worked with some persons of the underclass who have a clinical presentation of PTSD after many years of participation in gang violence. They know what conventional values are, but they also know what is the law of streets. They are scared and tired of living a nightmare, and want a stable peaceful life but are tortured about what they've seen and what they've done to others over the years. Just seeing a gun sets off flashbacks. They describe their younger years as being "shut off" emotionally, and "not caring" about anyone or anything but money. But now in my office, they are presenting a mostly full range of emotion and a guilty conscience that suggests conventional values. Has their impulsive, "immature brain", associated with anti-social acts, matured into a more conventional pattern? Or is it more accurate to describe them as a product of an anti-social sub-culture? I suspect the latter is more accurate.

Returning to the homeless and Kellevision, she notes the major problem with relationships is homeless people's "picker is broken".

For every person in a homeless shelter with dependency issues we seem to have an predator waiting for them. Half the population seems to be working or receiving some form of assistance and the other half seem to be trying to hook up with them to take advantage of that income....

It is important to realize that single parents contribute to the problem of picking the wrong partner with their own pathology. The single mothers in the family dorm are not simply victims of the men they pick out. There seems to be a predominant attitude of these women that the man should "take care of them". They believe it is just a matter of picking out the right one. The first problem is that their "picker" is broken. They do not pick out a good one. They usually pick out one of the predators roaming the alley behind the shelter. The second problem is that you cannot sit at home expecting to be taken care of in our modern economy. That might have worked in the 1950's, even in the 1970's, but June Cleaver is no more. The modern American household takes two paychecks. Two full-time paychecks. The third problem presents it self when the man expects to be supported by the woman. Even if the woman is working full-time and picks out a man who wants to live off of her, women traditionally earn much lower wages than men. So the family's financial stability is even more shaky.

This predatory - dependent dyad seems to play out in most of their relationships and I wonder if it is not the source of their alienation from their families of origin. A person who constantly expects to be taken care of can be quite tiring. By contrast, a person who is constantly preying on others also becomes quite tiring.

Having grown up in a chaotic home and living a chaotic lifestyle, repeated trauma has numbed their emotions to the point that they are unable to make proper judgments about who is worthy of trust. The predator-prey dyad began in their family of origin where parents exploited the children when they were young, and when the children grow up, they exploit their vulnerable elderly parents. Recently, in my therapy group, one male member admonished a older woman for setting limits with her adult children because they were tacitly supporting her grandchildren for default on a loan she'd co-signed. He felt family was entitled to lean on, effectively use, each other.

Mental illness is often cited as a factor in homelessness. A significant number of homeless clients suffer from debilitating mental illnesses and many researchers sight the high numbers of mental illness in the population. However, each researcher seems to define it in their own way. Some include only the big three Axis I diagnoses (Schizophrenia, Bipolar I and Major Depression). Others include substance abuse (since it is an Axis I diagnosis in the DSM IV) which dramatically inflates the numbers of the "mentally ill". Others include Axis II personality disorders, but only some of them, usually Antisocial Personality Disorder. Still others include Post Traumatic Stress Disorder. In my experience, mental illness is a factor in about 10-20% of our homelessness clients and it is a serious problem. However, it does not explain the other 80%. These 80% use an unusually high percentage of services and monies devoted to the homeless and they are repeat customers.

Here I have to disagree with Kellevision. Everyone I've counseled with substance abuse were running from their feelings about themselves and/or their past. I have found Bipolar DO in significant numbers behind petty criminal activity, gambling addiction, alcoholism, sexual addiction, exotic dancing and prostitution. I participated in a local county survey that identified their most expensive clients. The general profile was bipolar chemically abusive who revolved in and out of the hospital, placements and jail. Personality disorders are mental illness. While many may think the rest of the world is the problem and are not willing to take responsibility, many others are desperate for relief from a horribly chaotic and often traumatic life.

There is a very high incidence of traumatic histories in the homeless community, even before they became homeless, usually during childhood. I believe that a majority of the substance abuse problem in this population is an effort to treat trauma symptoms. However, this can be said of other populations as well, including the substance abuse community. Most trauma survivors manage to maintain housing despite their trauma symptoms. Though trauma symptoms may play a factor in homelessness, I do not believe they are the sole cause.

Sole cause, no, it's the multi-generational underclass sub-culture with it's accompanied fractured families, drug abuse, trauma, predator/prey cycle, and chaotic lifestyles. Trauma comes in forms that are not readily identified. Chaotic events in close proximity in time give the victim the impression they have no control of their fate and so they scramble for every edge in the moment, and anxiously await for the next disaster to strike. Those in the underclass go way out of their way to withhold their histories of trauma and chaos, insisting that they can handle their own problems, and it's none of anyone's business. Or is this simply the accepted cultural method to deal with the shame of their past?

Most homeless clients do not have family support systems. If they did, the family would take them in and they would not be homeless. Many homeless clients come from families who are themselves very nomadic and teetering on homelessness. Some come from families rife with substance abuse, sexual abuse or domestic violence. Others have been rejected by their families for various reasons. These reasons often involve their dependent and/or dysfunctional behaviors.

Underclass families exploit each other until the resources are gone, or the member with resources cut off the leech. Once the underclass has used up their family resources, they become at risk for homelessness. Many have family who died young living violent or drug infested lifestyles, or who are in prison. By this time, they've burned out most of their friends as well. All they can do and meet new vulnerable people and continue a new predictor/prey dynamic.

So what solutions are there for healing the cultural divide? The problem is mostly economic. The underclass lacks a realistic chance for escaping their plight. Oh, sure a few make it, usually through advanced education. But many will hit a ceiling in achievement when they rely too heavily on "temporary feel good" behavior that provides relief from stress, but self-destructively complicates their lives and increases the chances they will fall out of their newly found middle-class status.

The middle-class in America is shrinking, many of the hard working blue collar workers are falling into the underclass from where with a floundering economy, escape will be difficult. Jobs programs, affordable housing, and counseling are sorely needed but remains largely unfunded. What infrastructure is present is actually shrinking with government tax dollars.

Too often the only role models for success are the gang members, drug dealers or pimps who drive fancy cars and flash wads of money. Too many get lost in this dream turn nightmare. But my experiences working with recovering gang members is that many are retrievable when they get desperate enough to escape with the right kind of treatment and patience with their guarded presentations. I work in a Partial Hospital Program (PHP) at an inner city public hospital that is designed to intervene with persons with personality disorders. It's largely based on the Crisis Intervention model that relies on the desperation of the client to inspire commitment, insight and behavior change in therapy. The PHP format is ideal for persons who are suffering from acute exacerbation of substance abuse, PTSD or personality disorder. I call it "mental health boot camp". We have a satisfaction rate of over 90%.

Kellevision lists a number of problems within the system.

In my humble opinion, our current social services system and is a major factor contributing to the homeless mindset. This is a complicated element to explain. But I think it is important to make an attempt.

I see two major problems with the social services system: 1) the system itself - how benefits are applied and eligibility determined and 2) the people working within the system - the mindset of caseworkers and social workers working with the homeless population.

• The social services system seems to be designed to punish attempts by the poor to achieve independence. Assistance programs penalize people for working "too much" by cutting off benefits when assets accrue. These systems often reinforce irresponsibility and impulsivity while punishing people who try to work and plan ahead.
• Many social services programs seem to "teach" clients to wait until the last minute then create a dramatic "emergency" in order to get help. This fosters the emotionally immature and histrionic displays in emergency rooms.
• Our current welfare system does not allow exchanging work for benefits. Benefits are given away free.
• Caseworkers and social workers have a bad habit of doing things for clients, rather than expecting the client to do it or teaching them how.
• So what have clients learned so far?
  • Don't work too much.
  • Don't plan ahead.
  • Expect someone else to provide you with what you need.
  • Don't take responsibility. Someone else will fix it for you.

The welfare system is complex, cumbersome, and difficult to change into a working entity. The major problem is that it is designed not to serve the poor, but to mollify the political needs of the tax payer. That makes it inherently punitive. As we know from behavioral science, punishment doesn't change behavior. I believe it in fact feeds the cycle similar to the one Kellevision describes above. As long as we put political considerations ahead of evidence-based methods, we'll have a broken system.

Kellevision proposes ideas that I think have significant merit.

I think counseling should be provided liberally. Teach people how to fish. Teach them how their maladaptive behaviors impair their ability to function. Stop rewarding bad behavior. Stop giving away money. Stop cleaning up their messes for them. Stop giving away free stuff.

Once homeless clients are assigned jobs, they would be provided with counseling to address the behavior problems that interfered with their ability to maintain employment. If they failed to come to work due to a poor work ethic, substance abuse problems, domestic violence or other relationship issues, etc. instead of getting fired - again - and having another black mark on their work history, they would be required to participate in counseling or group work to address it.

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Recently, I exchanged messages with Michele Rosenthal, author of the blog, Parasites of the Mind. She asked me a very good question, one that is so much a part of my everyday work, a good long contemplation was needed just to tease out a good answer.

Speaking of inspiring, how do you inspire a client to believe in what he/she is doing? It's so difficult to believe in anything when PTSD has settled its big black cloud on your head.

Any general rules of the game for (self) empowering belief?

Another therapist, Mary Redoutey, joined our discussion and attempted to answer this question. She took the conventional route.

All therapy in essence is self empowered therapy.... The therapist is the partner in the process. I can sit in the chair in my office, can make suggestions, can teach, can do anything as much as I want... and nothing different will happen unless of course the client is present, listens somewhat attentively, suspends negativity long enough to experience a shift in feeling state and/or thoughts or actions.... And the work in the session does not transfer into the client's life unless the client chooses to make the necessary changes.

Essentially, Mary says that therapists don't change people, people can only change themselves. I have commented on a release for a new book that made this point as well. While it is true that what a client brings to therapy may account for much of the effectiveness of therapy, I don't think this is the core of Michelle's question. As I understand her question, she wants to know what the therapist brings to the therapy room.

My first attempt at replying was rooted in my daily routine. I'm always helping people understand how their past experience impinges on their current symptoms.

Consider what happens between mother and child. A child develops their self-concept initially based on how they are treated by their mother. In therapy, the therapist communicates his belief in the client. And if the connection already exists, a seed is planted. But as an adult, only the client can nurture the seed to germination and growth. The therapist can only teach them how.

Generally, when I take this tact, which is common with the childhood trauma survivors I see, I am helping them see the importance of exploring their childhood history and their relationships with their caregivers as a way to understand the origins of their symptoms. This is a much more specific answer that still only partly answers Michelle's question.

I think Michelle wants to know what is the therapists role in motivating a client in each and every step through therapy. In other words, what is the client getting from paid expert advice they can't get from a book? From Michelle's point of view, perceptions of her options are clouded by the rollercoaster existence that accompanies PTSD.

There has been extensive research on this topic. Most recently, much of this research has taken on a ideological fervor endorsing Cognitive Behavior Therapy (CBT). I've written often about my opinion CBT. Suffice it to say, CBT may be the core methodology in helping a client manage their thoughts and building treatment plans, but there is much more to behavior change than changing thoughts. One of CBT's central assumptions is patently false. Not all feelings are produced by or changable by thoughts. Much of our earliest learning occurs before thoughts begin to play a major role in our learning around the age of 8.

Patterson (1989) identified common specific factors recognized by virtually all schools of psychotherapy. He included therapist acceptance, permissiveness, warmth, respect, nonjudgmentalism, honesty, genuineness, and empathy or empathic understanding. Three of these, warmth, empathy, and genuineness have considerable research backing. In a previous article, Patterson (1984) points out:

There are few things in the field of psychology for which the evidence is so strong. The evidence for the necessity, if not the sufficiency, of the therapist conditions of accurate empathy, respect, or warmth, and therapeutic genuineness in incontrovertible.... The fact that specific change occurs in a therapeutic relationship without the addition of so-called specific techniques, such as interpretation, suggestion, instruction, etc., is also evidence of the sufficiency of the relationship by itself.

More recent research has found the competence of the therapist is critical. Verhofstadt et al. 2008, in their article about the value of emotional similarity and empathic accuracy in support giving with couples. They cite:

...mounting evidence that unskilled support can be ineffective or even harmful to the support recipient.... In summary, whereas matching the partner's emotion during a support-seeking interaction may provide a sufficient basis for understanding the partner's current affective state(s) and responding with appropriate emotional support and consolation, understanding the partner's specific thoughts and feelings during a support-seeking interaction may provide a sufficient basis for understanding what kind(s) of help the partner desires and how to provide such help in an acceptable way.

Successful therapists must be able to adapt to their clients' emotional uniqueness and to accurately perceive their thoughts and feelings to provide appropriate support in an acceptable way. Perhaps even more important, therapists must be perceptive and adaptive enough to understand the clients complaint that brought them to therapy and the nature of their quandary beyond the clients' own understanding, or the underlying problems. And having discovered what must be done, therapists must be able to provide the clients insight into their dilemma, provide a rationale for a course of action, and persuade their clients to make changes they are unlikely to find easy or achieve without significant discomfort. Initially, clients are often unable to understand the significance of their problems or nature and potential benefit of the required changes. If they did they wouldn't need therapy!

There is only one experience that I find cuts through virtually any dark cloud, and that is the touch of human empathy. When people who are overwhelmed by pain suddenly find someone who seems to understand how they feel, they no longer feel alone and abandoned by the world. A skilled therapist can provide more than the usual kind of empathy. After years of exploring the human condition, the therapist reaches within the client's experience that at least begins to provide some meaning to explain and place in context her experience.

Preston and de Waal (2002) describes the nature of human interaction as involving an exchange of complementary emotional and thought messages. These shared representations allow people to adjust their responses based on the communicated states of others suited to relieve each others' distress. (Cited in Gruhn et al., 2008)

Grillion et al. (2008) describe the emotional exchange between client and therapist and the unique skills required of the therapist.

When the context becomes safe enough for the client to lower his or her defenses, the alteration of regulatory structures becomes possible. The therapist's own self-regulatory movements reveal his or her inner states to the client. Much like the "good enough mother", the therapist's efforts to regulate his or her own inner states show the client that he or she is in contact with the client. Personal therapy for therapists helps to extend the range of experience that they can draw upon in their work with clients (Schore, 2006, cited in Grillion et al. (2008). According to Amini et al. (1996) the most effective interventions are based on the therapist's awareness of his or her own physical, emotional, and ideational responses to the client's veiled messages.

Accordingly, when the therapist has increasingly expanded self-integration and awareness in regard to his or her state of mind with respect to attachment, then he or she has a larger capacity for assisting clients to achieve integration and awareness. This understanding derives from the primary attachment relationship within the developmental psychobiological perspective in which parents who have secure or "earned" secure states of mind with respect to attachment function in certain ways (including attunement and sensitivity) with their infants that result in attachment security in their children. Therefore, from an attachment point of view, the more secure the therapist is, the greater the likelihood is that he or she can assist clients with achieving greater security (Beebe, 1998, cited in Grillion et al. (2008). Therapist self-awareness broadens "clinical intuition", which is referred to as the art of psychotherapy (Bugental, 1987; Schore, 2006; cited in Grillion et al. (2008).

Thus the relationship of between therapist and client is perhaps the second most important aspect therapy, right behind client characteristics and motivation. So it is critically important that the client has a good relationship with the therapist. Clients must be willing to shop around to make sure there is a good match. Cooper (2008, quoted in Croft, 2008) makes research based recommendations for finding the right therapist.

Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process.

References

Croft, Alison. (2008, October 17). Clients, Not Practitioners, Make Therapy Work. Press release by the British Association For Counselling & Psychotherapy on a new book Cooper, Mick (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. In Medical News Today. Retrieved May 1, 2009, from http://www.medicalnewstoday.com/articles/125815.php.

Grillon, C., Pine, D., Lissek, S., Rabin, S., & Vythilingam, M. (2009). Increased Anxiety During Anticipation of Unpredictable Aversive Stimuli in Posttraumatic Stress Disorder but not in Generalized Anxiety Disorder Biological Psychiatry DOI: 10.1016/j.biopsych.2008.12.028

Grühn, D., Rebucal, K., Diehl, M., Lumley, M., & Labouvie-Vief, G. (2008). Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion, 8 (6), 753-765 DOI: 10.1037/a0014123

Patterson, C. H. (1984). Empathy Warmth And Genuiness In Psychotherapy: A Review Of Reviews. Psychotherapy, 21, 431-438

Patterson, C. H. (1986). Foundations For A Systematic Eclectic Psychotherapy. Psychotherapy, 29, 427-435

Verhofstadt, L., Buysse, A., Ickes, W., Davis, M., & Devoldre, I. (2008). Support provision in marriage: The role of emotional similarity and empathic accuracy. Emotion, 8 (6), 792-802 DOI: 10.1037/a0013976

Trauma recovery is a major part of what psychotherapists do. There is much made about the traumatic effects of major disasters like the Typhoon in Myanmar, the Tsunami in the Indian Ocean, Hurricane Katrina, the war in Iraq, and the tragic events of 9/11. There have been many reports about the walking psychologically wounded from these events. There has been considerable effort to training emergency responders in "Psychological First Aid".

Does everyone who was traumatized need therapy? The answer is a resounding "No". There is research to show that many if not most people adjust to trauma as a matter of course. It's as if their own built in coping mechanisms are sufficient for recovery. So, unless there are symptoms of "Acute Stress Disorder" treatment is not indicated and could do more harm than good.

PsyBlog

These techniques are in line with the 'hydraulic theory' of the emotions - a popularly held view of how the emotions work. In this view, people's emotions work in the same way as a pressure cooker. Emotions build up inside until the mind can no longer contain the pressure. Then steam is 'let off', releasing the pressure inside and improving the mood.

[..]People who choose not to let off steam in this way are popularly seen as being in denial, and this denial is often seen as pathological. Dr Seery's study extends these criticisms to attack the broader idea that talking about a traumatic event soon after it has occurred is usually beneficial. Mounting evidence suggests that those who do not talk about a traumatic event are simply more resilient, rather than being in a state of pathological denial.

Mental Health America has released a list of advice for holiday shoppers in view of the tradegies in Omaha.

Reuters

Mental Health America developed tips to help individuals ease anxieties they may feel in the wake of this tragedy. Individuals looking for information and support can visit www.mentalhealthamerica.net or call Mental Health America at (800) 969-6642.

• Know that tragedies, like mall shootings, are rare. -- Develop a personal safety plan to ensure your wellbeing in a similar situation.
• Limit television viewing. Watching or reading news about the event over and over again will increase your stress.
• Talk about it. By communicating with others about the event, you can relieve stress and realize that others share your feelings.
• If you feel depressed, anxious or angry, talk to friends, family, ministers or others around you. Likely, other people are experiencing similar feelings.
• Ask for help when you need it. If your feelings of anxiety and worry do not subside or become so intense that they interfere with your daily life, don't try to cope alone. Talk with a mental health professional, spiritual adviser or other person who can help. Seeking help is not a sign of weakness.

CBS has followed up on a study last March that I wrote about here. CBS sought to fill the void for available statistics from the VA. The sad story is that suicide is a much more common outcome than most think for all kinds of trauma. Combine that with a culture that sees emotion as weakness, we have a set up for our young soldiers.

Trauma survivors have a painful road before then can find recovery. Prolonged exposure treatment is one of the few approached that has shown reliable outcomes. In other words, reliving the trauma until the intensity of symptoms subside is the best path to health.

CBS News

In 2005, for example, in just those 45 states, there were at least 6,256 suicides among those who served in the armed forces. That’s 120 each and every week, in just one year.

Dr. Steve Rathbun is the acting head of the Epidemiology and Biostatistics Department at the University of Georgia. CBS News asked him to run a detailed analysis of the raw numbers that we obtained from state authorities for 2004 and 2005.

It found that veterans were more than twice as likely to commit suicide in 2005 than non-vets. (Veterans committed suicide at the rate of between 18.7 to 20.8 per 100,000, compared to other Americans, who did so at the rate of 8.9 per 100,000.)

One age group stood out. Veterans aged 20 through 24, those who have served during the war on terror. They had the highest suicide rate among all veterans, estimated between two and four times higher than civilians the same age. (The suicide rate for non-veterans is 8.3 per 100,000, while the rate for veterans was found to be between 22.9 and 31.9 per 100,000.)

There is some good news from the Virginia Tech tragedy. The community of mental health providers pieced together a model crisis response program of trained volunteers to support, identify and refer to professional help people suffering from the trauma.

Psychiatric News

To provide her local community with support after the deadliest mass shooting in U.S. history, a mental health professional calls on a cadre of trained volunteers to address the mental health needs of those affected.

Community Disaster Response Coalition President Dorinda Miller, Ph.D., disseminates information about disaster mental health services offered by her organization at a fair in Blacksburg, Va.

When the first shots rang out on the Virginia Tech campus in Blacksburg on April 16, one phone call to the New River Valley Community Disaster Response Coalition (CDRC) launched a carefully synchronized plan that would ultimately extend much-needed support to thousands of people whose lives were affected by the shootings.

"People have a hard time believing that a disaster will ever affect them," said Dorinda Miller, Ph.D., in an interview with Psychiatric News.

Miller, along with several others, created the CDRC in 2002 with funds from the American Psychiatric Foundation. The goal was to meet the mental health needs of people affected by disaster in the New River Valley, an area that encompasses four mountainous counties and includes Blacksburg, Va., home of Virginia Tech.

When the deadliest mass shooting in U.S. history took place in the quiet college town, Miller, together with an entire community of trained volunteers, was ready to spring into action. Miller noted that the genesis of the New River Valley CDRC began with the 9/11 terrorist attacks.

At the time, she was providing mental health relief services at the Pentagon with the Red Cross and said she realized that there was no way one agency could hope to meet the disaster mental health needs of an entire community and that she would need to form partnerships with other agencies in the New River Valley, where she ran A-Kee Inc., a nonprofit organization dedicated to providing the community with disaster-relief mental health services and education.

Her goal was to develop a program that would provide consistent disaster mental health training to local mental health clinicians and community members and forge partnerships with local emergency and rescue teams.

Miller worked with colleagues Amy Forsyth-Stephens,M.S.W., and Harvey Barker, Ph.D., the head of the New River Valley Community Services Center, a mental health agency, to develop a disaster mental health protocol.

In doing so, she sought guidance from local county emergency coordinators and the emergency planner for Virginia Tech. She then began recruiting volunteers to train them to provide disaster mental health services by using a curriculum she developed.

The daylong training, according to Miller, educates volunteers about crisis-intervention techniques, good-listening techniques, symptoms indicating an individual needs to be referred to a mental health clinician in the community, confidentiality of victims and family members, and ways to take care of themselves under stressful situations. Trainees also learn about how disasters affect certain populations, such as children, the elderly, and people with various types of disabilities.

Training typically takes place three or four times a year and is free, according to Miller.

I think it's probably a human trait that we seek the simplest solution to a problem even when more complex and proven methods are well known. Even scientists seem to do this, even in their area of study!

Our culture seems to have decided thousands of years ago that negative emotions are bad and should be avoided. Everywhere in the psychological literature is examples of researchers seeking to find ways to help people avoid psychological pain.

Has it occurred to anyone that psychological pain has a purpose? For those of us that believe we evolved to be human beings, we have to assume that most attributes that make us human in some way enhance our survival, or that trait would have been selected out of the gene pool. Negative emotions help us. I make that assumption and help people make sense out of their misery, rather than find ways to avoid it. Misery is the single most powerful motivation for change.

Here is a good example. Surviving a traumatic event involves recurring "flashbacks" of the trauma that persist for sometimes many years. So in keeping with the tradition of helping people avoid their "flashbacks", we have this report from New Scientist.

"It might be the case that people with memory disturbances have to gain some control over the memory representation by remembering it and trying a different emotional response to the memory before successful suppression," he adds.

A drug targeting specific brain regions might eventually boost the ability to suppress, said John Gabrieli, at the Massachusetts Institute of Technology, Cambridge, US.

For a mother haunted by the memory of her son's suicide, he said, "it is hard to imagine that you would ever get her to forget that the event occurred. But the more you could weaken the memory in any dimension, the better it would be."

Ok, lets try the assumption that flashbacks are somehow helpful. Just how is it helpful for the mother in the example above is haunted by memories of her son's suicide? It's a challenging stretch to the assumption surely. But how is it we would expect there be a way to somehow "forget" the memory? That seems impossible without brain damage and considerable collateral damage to other structures and abilities.

What is there in the psychological literature that might explain recurrent unpleasant memories? Recall that phobia is treated by "exposure", gradually introducing the anxiety or fear provoking stimulus while the patient tries to relax. There is good research to say this works pretty well.

What if the flashbacks were the human body's attempt to provide it's own crude exposure treatment? What if the patient were advised to sit with his feelings, talk about the experience with a trusted counselor and to make sense of the experience in his current life. Might this be a way to find meaning in the seemingly meaninglessness of traumatic event?

Indeed, there are examples of research showing how exposure therapy is effective for PTSD.

Here is an even sillier example.

Monitor on Psychology

So, again, this suggests that verbalizing an emotion may activate the right ventral lateral prefrontal cortex, which then suppresses the areas of the brain that produce emotional pain.

"[In talk therapy] we tend to focus primarily on content and enhanced understandings and changed understandings," said Lieberman. "But it's not entirely irrelevant that they all involve putting feelings into words."

Duh! Talk about being blind to anything not in front of your face!

Ever wondered why some people survive a major stress or trauma better than others? There really is no magic. People who in general have healthy lifestyles and attitudes survive trauma better than others. People who in particular have unhealthy attitudes about stress, themselves and life in general are much more likely to suffer stress related symptoms.

Here are a list of ten traits of healthy POWs from the Vietnam War. This information is not just for soldiers, it's for all of us.

Psychiatry News

Charney and Steven Southwick, M.D., a professor of psychiatry at Yale University, identified personality traits associated with resilience in 250 American POWs during the Vietnam War who were held captive for up to eight years and subjected to torture and solitary confinement. Remarkably, years after their release, they had a lower-than-expected incidence of depression and PTSD. To determine how these men, mostly pilots, handled such a dire experience yet in many cases came out stronger than before, they videotaped interviews with them and conducted a battery of neuropsychological tests along with neuroimaging.

In two other studies, they interviewed a group of women who had suffered severe trauma, especially sexual and physical abuse, and a group of people who showed courage and resilience while facing serious medical problems. They found that the same characteristics of resilience in the POWs were present in these other two groups. Charney indicated that these studies will be described in a book he wrote to be published soon by Houghton Mifflin titled The POW Response: A Prescription for a Resilient Life.

Based on the results of the three studies, Charney described the following 10 psychological characteristics that people can work toward to increase resilience:

• Be optimistic. Optimism is strongly related to resilience, and it can be learned through CBT. Optimists usually have decreased autonomic arousal, use more adaptive coping strategies, and seek supportive personal relationships during crises. "Even in the worst of times resilient people remain optimistic," Charney said. Women with this disposition have shown a better response to a diagnosis of breast cancer, while men have a lower rate of hospital readmission after coronary artery bypass surgery.


• Develop cognitive flexibility or the ability to restructure knowledge in adaptive ways to changing demands. It is the basis of psychotherapy for traumatized people, Charney explained. Research has shown that this trait reduces PTSD after combat and speeds recovery after loss of a family member or natural disaster. "Resilient POWs regarded their years in captivity as horrendous, but they learned valuable things about themselves that they would not have learned any other way, which prepared them to face challenges later in life," Charney said. He explained that cognitive flexibility is linked to neurobiological mechanisms such as memory consolidation.


• Develop a personal moral compass or shatterproof set of beliefs. Doing so helps people get through adversity. Many victims of Hurricane Katrina and 9/11 attributed their survival to faith, either through religion or spirituality. "Many POWs never lost their faith and prayed every day," Charney said. After being freed, one man refused to attend a "coming-out party" until he found a priest and had confession.


• Be altruistic. Coping with extreme stress is often made easier by helping others. "Altruism is underrated and needs to be used more often as a therapeutic tool," he asserted. The belief in a survivor mission can be a lifesaver to traumatized people. He said Mothers Against Drunk Driving, one of the the world's largest crime-victim organizations, is indispensable to many women who lost a loved one in a car accident. Similar groups were formed after 9/11. Researchers are now looking at neural circuits related to moral decision making and altruism.


• Find a resilient role model in a mentor or a heroic figure. This is important "because imitation is a powerful mode of learning," Charney said. "Heroic figures inspire us to greatness even though they might not achieve success." He noted that the ill-fated British explorer Ernest Shackleford failed to reach the South Pole, but his leadership qualities and perseverance during the expedition made this one of the greatest survival stories of all time.


• Learn to be adept at facing your fears. Resilient POWs were found to have this trait, which boosted their resilience and self-esteem, Charney said. "So recognize that fear is normal and can be used as a guide." He recommends learning and practicing skills needed to get through one's fears. He said the neurobiological underpinning is well known in terms of extinction and stress inoculation.


• Develop active coping skills. Resilient individuals do this and create positive statements about themselves in relation to a threat. They also seek active support from others. Charney reported that by training young female Rhesus monkeys to adapt to stress, that is, to become inoculated against it, and cooperate rather than resist during blood collection, Stanford researchers Karen Parker, Ph.D., and David Lyons, Ph.D., helped explain the differences in the biology behind these two types of coping skills." They reported their findings in the September 2004 Archives of General Psychiatry. Similar human experiments are now under way.


• Establish and nurture a supportive social network. The value of this was seen dramatically after 9/11 and Hurricane Katrina. "After a disaster we don't need psychiatrists running around talking with people," Charney asserted. "Intense debriefing doesn't help. What helps is having family members and close friends share the experience with victims, because very few people can go it alone." He said it's not enough simply to attend a support group and talk with other people. During times of stress, emotional strength comes from close, meaningful relationships.


• Keep fit. Exercise not only is good for physical well-being but also enhances brain health and plasticity. Charney cited findings for this notion from the 2002 study "Exercise: A Behavioral Intervention to Enhance Brain Health and Plasticity" by Carl Cotman and Nicole Berchtold published in Neuroscience.


• Have a sense of humor and laugh frequently, according to Richard Wender, M.D., chief of family medicine at Thomas Jefferson University Hospital in Philadelphia. Humor narrows the gap between doctors and nurses and between them and patients, especially children, who often feel helpless and forlorn, and helps them cope with their illness.

Charney recommends developing resilience by training regularly in areas that engage emotions, intellect, morals, and physical endurance and by overcoming challenges. He believes such training affects what type of adults young people develop into and suggests that it could be part of high-school health education.

The tragedy of Katrina continues in resources stretched beyond capacity with no relief in sight. This nation needs to take another look at relief efforts on the Gulf coast.

washingtonpost.com

Hurricane Katrina left more than gutted houses and empty streets along the Gulf Coast. The most devastating impact of the storm, which killed thousands of people and destroyed entire towns, can be seen in the desperate faces of people more than a year later, survivors and rescue workers said in a panel discussion Wednesday.

[...]The panel was part of an annual Carter Center symposium on mental health policy. This year's focus is on the psychological effects of Hurricane Katrina. Panelists said mentally ill patients are still unable to get treatment and medicine because so few services are available in New Orleans and other damaged cities. But the storm also triggered mental problems -- most commonly depression and anxiety -- in people who had never before had them.

Wellborn's unit handles all calls to police involving mentally ill people. With just two of the city's 11 hospitals operating, officers can take only the most serious cases in for medical attention, he said.

Law enforcement agencies in New Orleans and neighboring Jefferson Parish say they are answering more calls than before the storm about domestic abuse, drunkenness and fights. Involuntary commitments to mental hospitals are up from last year, and the number of suicides in Orleans Parish has tripled.

James Cooper, who works for the Extra Mile, which recruits volunteers for the Louisiana Department of Health and Hospitals, said he is frustrated that the federal government has done little to help pay for mental health services for hurricane survivors. And mental health professionals have nowhere to turn for help with their own anxiety from the storm, he said. "It's so hard for them to deal with what they had to go through, and then to deal with clients all day long," Cooper said.

Wellborn said many police officers in New Orleans have not sought help for the trauma they suffered from rescuing stranded residents and policing essentially lawless streets. Officers are having trouble controlling their tempers and are getting into altercations with people on routine calls. MORE

Post Traumatic Stress Disorder (PTSD) is one of the more debilitating disorders associated with experiencing intense trauma such as a rape or living in a war zone. PTSD has been associated with symptoms of nightmares, flashbacks, extreme anxiety, inappropriate anger and violent behavior, and feelings of disconnection from family and friends. It has been associated with permanent changes in the associated with memory impairment and exaggerated startle response. Many stress related symptoms such as headaches, dizziness, chest pain and anxiety attacks also are common. Long-term studies of veterans associate PTSD with long-term health disorders thought to be associated with stress.

A survey in mid-2004 by the military of 82nd Airborne paratroopers coming back to Fort Bragg from serving in Iraq suffered from post-traumatic stress disorder at almost the same rate as Vietnam War veterans. The rate reported for the paratroopers was 17.4%. The New England Journal of Medicine reported 16 percent of Iraq veterans reported symptoms of post-traumatic stress disorder, major depression or severe anxiety. A national study of Vietnam veterans determined in 1988 that the prevalence of PTSD was about 15 percent with a lifetime incidence of 30 percent. Newsweek September 5, 2005 issue reported:

Alfonso Batres, who heads the Department of Veterans Affairs' (VA) Readjustment Counseling Service, believes the rate is [...] growing. So far this year some 14,000 vets have sought counseling at the 207 community vet centers he oversees. About 27 percent of them, he explains, report such symptoms. "The numbers coming in are escalating," says Batres, who stresses that his data are anecdotal.

In October of 2005, USA Today reported:

almost 1,700 servicemembers returning from the war [the first ten months of 2005] said they harbored thoughts of hurting themselves or that they would be better off dead. More than 250 said they had such thoughts "a lot." Nearly 20,000 reported nightmares or unwanted war recollections; more than 3,700 said they had concerns that they might hurt someone or "lose control with someone."

The lesson's of Vietnam suggests at least a 30% rate of lifetime incidence of PTSD, so Iraqi veterans should expect the same. But worse, the Pentagon is sending back to Iraq individuals who already are being treated for mental disorders. Therefore the incidence and intensity of symptoms may well increase. Some studies have found that incidence rates of 54% can occur. Studies of some Bagdad neighborhoods finds a prevalence of 90% of residents with some sort of mental disorder.

The Department of Defense sponsors an on-line Mental Health Self-Assessment tool for members of the military. Here is the details.

Military life, especially deployments or mobilizations, can present challenges to service members and their families that are both unique and difficult. Some are manageable, some are not. Many times we can successfully deal with them on our own. In some instances matters get worse and one problem can trigger other more serious issues. At such times it is wise to check things out and see what is really happening. That's the purpose of these totally anonymous and voluntary self-assessments.

These questions are designed so you can review your situation with regard to some of the more common mental health issues. The screening will not provide a diagnosis - for that you need to see a professional. But, it will tell you whether or not you have symptoms that are consistent with a condition or concern that would benefit from further evaluation or treatment. It will also give you guidance as to where you might seek assistance.

A Yahoo! News article gives this preview.

Program users can do self-assessments for depression, bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, and alcohol abuse.

Questions include:

• Have you lost pleasure in the things you used to enjoy?
• Do you have trouble eating or sleeping?
• Does your mood fluctuate between overly "high" to sad and hopeless?
• Are you keyed up and anxious all the time?
• Are you having nightmares about something that happened in the past?
• Do you suffer from unexplained aches and pains?

When they've completed the self-assessment, users are provided with information about where they can go for a full mental health assessment.

If you are an Iraqi veteran and you are stuggling to adjust to your return from Iraq or Afghanistan, seek help. This screening tool is only a beginning. You are the best judge if you need help. If you find yourself changed, unable to find sufficient meaning or joy in your life, be sure to seek help. Your commitment to our country has already included great sacrifice, you need not suffer anymore than you have to. Mental health treatment in the right hands can be very beneficial.

Dare To Dream MH Library - Psychologist Driven to Help Hurricane Victims

The Red Cross doesn't have enough mental health people in its data base, volunteering. I got an e-mail from the American Psychological Association, saying the Red Cross needs mental health volunteers. This was sent to every licensed member of the APA.

Looking for a way to contribute to your skills to disaster relief? Call your local Red Cross. Click the link above to read of her experiences.

Boston Globe

IRAQ VETERAN Daniel Cotnoir learned that Baghdad rules don't apply in Lawrence (Mass.). The former Marine sergeant, who was named 2005's ''Marine of the Year" by the Marine Corps Times newspaper, was charged earlier this month with two counts of armed assault with intent to murder after firing a shotgun near a crowd of revelers outside his home. He had already reported their noise to police and, when a glass bottle shattered his bedroom window, Cotnoir allegedly feared for the safety of his wife and children.

As a Marine officer from 1999 to 2003, I led platoons in Afghanistan and Iraq. Following two combat tours, I left active duty to go to graduate school, thinking I could seamlessly return to normal life. But even with a loving family, supportive friends, and solid future prospects, homecoming derailed me for a year. I woke up to nightmares, shook uncontrollably during Fourth of July fireworks, and felt myself switch into ''combat mode" when challenged. After a driver cut me off on my morning commute and I envisioned gutting him with my car key, I recognized classic symptoms of post-traumatic stress disorder.

According to the American Psychiatric Association, the disorder may result when people survive events ''that involved actual or threatened death or serious injury." Combat stress disorder, in its simplest form, is the persistence into civilian life of behavior that was necessary to survive in battle: hyper-vigilance, fear of crowds, aggression.

None of us can know what Cotnoir was thinking before he pulled the trigger, but he is certainly an eligible candidate for the stress syndrome, and I see in his actions the anguish I felt after my own homecoming. What makes this so tragically significant is that Cotnoir is not alone.

A study at the Walter Reed Army Medical Center in Washington found that at least 17 percent of Iraq veterans experience anxiety, depression, or post-traumatic stress disorder. 425,000 American troops have served in Iraq since March 2003, which means that more than 70,000 may be suffering from psychological trauma. Indeed, its visible manifestations are growing. The divorce rate for Army officers has tripled in the past three years, and the National Coalition for Homeless Veterans reports that its affiliates helped 67 veterans of Afghanistan or Iraq in 2004.

Some studies indicate that virtually everyone who experiences trauma experiences some difficulty with traumatic stress. Post Traumatic Stress Disorder is a highly specific diagnosis, so specific that many people who are disabled by the trauma don't fit the diagnosis. That's, in part, appropriate given that traumatic stress often serves as the triggering event in a major mental illness. Repeated trauma can lead to the chronic maladjustment of personality disorders. How ever some people recovering from trauma fit into the DSM IV-TR diagnostic criteria of Adjustment Disorder, Panic Disorder or Generalized Anxiety Disorder but not PTSD. That is a problem because the diagnosis doesn't carry with it the presumed cause and that can present a problem in future treatment episodes. The roots of the problem can get lost in the pile of paperwork and a client's understandable reluctance to discuss the details of his/her history over and over again.

My own professional practice suggests traumatic stress is the number one reason a person seeks treatment. In other words, trauma is either a precipitant or a major part of a treatment seekers mental health history. We need a better understanding of the effects of traumatic stress and research on effective treatment. Traumatic stress certainly warrents more attention in the DSM standards of diagnosis.

A number of people maybe wondering just how we can best help children and their parents who have faced the disaster in New Orleans. Here is an approach that has produced convincing research results treating children and their families. Contact the authors for more information. The link is below.

SAMHSA

Trauma-Focused Cognitive Behavioral (TF-CBT) is a psychotherapeutic intervention designed to help children, youth, and their parents overcome the negative effects of traumatic life events such as child sexual or physical abuse; traumatic loss of a loved one; domestic, school, or community violence; or exposure to disasters, terrorist attacks, or war trauma. It was developed by integrating cognitive and behavioral interventions with traditional child abuse therapies that focus on enhancement of interpersonal trust and empowerment. The program can be provided to children 3 to 18 years of age and their parents by trained mental health professionals in individual, family, and group sessions in outpatient settings. It targets symptoms of posttraumatic stress disorder (PTSD), which often co-occurs with depression and behavior problems. The intervention also addresses issues commonly experienced by traumatized children, such as poor self-esteem, difficulty trusting others, mood instability, and self-injurious behavior, including substance use.

Families all over the Gulf Coast are experience the trauma of a natural disaster. Families all over America are watching the events unfold on the nightly news. Certainly the trauma of being present in the event is potentially the most damaging. But watching such catastrophic events unfold even on TV can have some effects, especially on children and adolescents.

Talking about traumatic stress among family members have the effect of rallying the primary circle of support for its members. Sometimes the comfort of the support of your immediate family is enough, sometimes it is not. Here is some guidelines from the American Psychological Association about when to seek help.

Individuals with prolonged reactions that disrupt their daily functioning should consult with a trained and experienced mental health professional. Psychologists and other appropriate mental health providers help educate people about normal responses to extreme stress. These professionals work with individuals affected by trauma to help them find constructive ways of dealing with the emotional impact.

With children, continual and aggressive emotional outbursts, serious problems at school, preoccupation with the traumatic event, continued and extreme withdrawal, and other signs of intense anxiety or emotional difficulties all point to the need for professional assistance. A qualified mental health professional can help such children and their parents understand and deal with thoughts, feelings and behaviors that result from trauma.

Here are some suggestions to help you cope with trauma. Many of these approaches will be helpful for the more quiet effects of vicarious trauma experienced through the television.

- Give yourself time to heal. Anticipate that this will be a difficult time in your life. Allow yourself to mourn the losses you have experienced. Try to be patient with changes in your emotional state.
- Ask for support from people who care about you and who will listen and empathize with your situation. But keep in mind that your typical support system may be weakened if those who are close to you also have experienced or witnessed the trauma.
- Communicate your experience in whatever ways feel comfortable to you - such as by talking with family or close friends, or keeping a diary.
- Find out about local support groups that often are available such as for those who have suffered from natural disasters, or for women who are victims of rape. These can be especially helpful for people with limited personal support systems.
- Try to find groups led by appropriately trained and experienced professionals. Group discussion can help people realize that other individuals in the same circumstances often have similar reactions and emotions.
- Engage in healthy behaviors to enhance your ability to cope with excessive stress. Eat well-balanced meals and get plenty of rest. If you experience ongoing difficulties with sleep, you may be able to find some relief through relaxation techniques. Avoid alcohol and drugs.
- Establish or reestablish routines such as eating meals at regular times and following an exercise program. Take some time off from the demands of daily life by pursuing hobbies or other enjoyable activities.
- Avoid major life decisions such as switching careers or jobs if possible because these activities tend to be highly stressful.

Here are some suggestions about how to care for your children.

The intense anxiety and fear that often follow a disaster or other traumatic event can be especially troubling for children. Some may regress and demonstrate younger behaviors such as thumb sucking or bed wetting. Children may be more prone to nightmares and fear of sleeping alone. Performance in school may suffer. Other changes in behavior patterns may include throwing tantrums more frequently, or withdrawing and becoming more solitary.

There are several things parents and others who care for children can do to help alleviate the emotional consequences of trauma, including the following:

- Spend more time with children and let them be more dependent on you during the months following the trauma - for example, allowing your child to cling to you more often than usual. Physical affection is very comforting to children who have experienced trauma.
- Provide play experiences to help relieve tension. Younger children in particular may find it easier to share their ideas and feelings about the event through non-verbal activities such as drawing.
- Encourage older children to speak with you, and with one another, about their thoughts and feelings. This helps reduce their confusion and anxiety related to the trauma. Respond to questions in terms they can comprehend. Reassure them repeatedly that you care about them and that you understand their fears and concerns.
- Keep regular schedules for activities such as eating, playing and going to bed to help restore a sense of security and normalcy.

An expert from Purdue offers additional suggestions courtesy of AScribe Newswire

If parents have had a conversation with their children about the tragedies surrounding Hurricane Katrina, they need to remember once is not enough, says a child development specialist at Purdue University. "Parents have expressed difficulty in explaining what happened in this and other large-scale public tragedies to their children, but it's important that they realize parents don't need to have all the answers," said Judith Myers-Walls, associate professor of child development and family studies. "This is a great opportunity to teach kids coping mechanisms. By being honest, parents can show their kids how to cope with being afraid."

Myers-Walls recommends the following actions for parents, teachers and other caring adults when children have questions about the hurricane's effects:

- Don't assume that the kids don't know about it.
- Be available and "askable."
- Share your own feelings.
- Help children use creative outlets, such as art and music, to express their feelings.
- Reassure young people, and help them feel safe.
- Support children's concern for people they don't know.
- Look for feelings beyond fear.
- Help children and youth find a way to think about the event and move forward.
- Take action and get involved in positive action to help alleviate others' suffering.

Don't underestimate the effects of trauma. In my experience, trauma is one of the leading contributers to mental health disabilities. Repeated trauma is one of the most common causes. Even once the effects of trauma have led to the long-term effects of post-traumatic Stress Disorder, while a significant life disruptor, successful treatment is possible when the person commits to placing a high priority on treatment.