1. Human Resiliency in Disasters: child, family & community Raija-Leena Punamäki, University of Tampere © Raija-Leena Punamäki 2007

2. Research on Resilience Psychology: Affected but no broken Physics: the capacity of material to absorb energy when deformed -energy recovered Botanics: Bending but does not break or uproot What can we learn about characteristics: individual, family & social ? How to translate this knowledge to intervention, prevention & promotion Types of stresses: –War, atrocities, military violence –single trauma (crises, catastrophes) –child abuse (physical, psychological)

3. © Raija-Leena Punamäki 2007

6. Population Traumatic event During stress After stress Before stress Vulnerability and risk factors Protective and modifying factors Why do children differ in their reaction to stress ? High symptom group Low symptom group From birth Later reactions

7. © Raija-Leena Punamäki 2007 Individual Resilience Factors: Personality: high threshold, curiosity Social skills: enjoy receiving& giving help Feeling of self worth & feeling of control Cognitive capacity, repertoire, flexibility sense of coherence:managable, comprehensive, meaningful Symbolization, imagination, creativity Variety of coping strategies Hobbies, special interests

8. © Raija-Leena Punamäki 2007 Resilience Factors in Family Good child - parent interaction patterns in early childhood/infancy Clear family structures, rules, rituals At least one resilient parent Parents who allow others to help Strong family ties & shared values High socio-economic status Shared emotional expression Laughing & humor

9. © Raija-Leena Punamäki 2007 Resilience Factors in Child’s Network at least one significant other person during childhood feeling of group identity, belonging common shared values between child and society society-structures that support the child’s coping strategies

10. © Raija-Leena Punamäki 2007 Relationship between Trauma and Resilience

11. © Raija-Leena Punamäki 2007 Developmental aspect in war trauma There are not ’war children’: (a) personality (b) age make traumatic experience unique Developmental age (stage) provides both protective self-healing processes and vulnerabilities Cognitive development: memory, attribution, explanations, causality Communication of feelings and expriences developes Peer relationships very important in middle childhood & adolescence

12. © Raija-Leena Punamäki 2007 What one should learn –the uniqueness of a person the most hurting/ provoking experiences the collection of fears before /after the ideas of solution the fantasies of danger, revenge and help the dreams of future the picture of self and others the early important memories The savior, protector, safe place

13. © Raija-Leena Punamäki 2007 Problems among children in war > methods Night-mares –drama- let other child continue story- let dreamer end story Sense of time –drawings - good and bad memories - future, (dramatize future) Loss –make a picture, unfullfilled sentences, read alod, send a letter Sharing coping – strategies - Picture test, story telling (helper, danger, end) dream work

14. © Raija-Leena Punamäki 2007 Mental health problems (MHP) & communal responses in military violence Acute symptoms of depression, aggression, PTSD & dissociation Children at risk: wounded, homeless, poor, low threshold temperement, earlier trauma, accumulated family problems, constitutional A) INTERVENTION MHP Symptom-focused treatment B) PREVENTION MHP Resíliency groups Psychoeducational Family involvement Children & families exposed to trauma with no special vulnerability PROMOTION MH Promotion of healthy conditions: Schoool, healthcare, participation National politics, strategies

15. © Raija-Leena Punamäki 2007 Traumatic events and symptoms Event Psychological mechanisms Expressed symptoms Horror, Threat, Danger *Sensitivity to danger *Biased attention Nightmares Excessive fears Withdrawal & numbing Concentration problems Avoidance & intrusion Impulsive aggression No integration between feeling & knowing *Sensomotor memory *Dissociative states Geralization of fear *Fragmented emotions

16. © Raija-Leena Punamäki 2007 Impact of Traumatic Experience I Social relations Interactions: scapecoting, rigid & reversed roles Family secrets: everybody protects each other Communication fragmented: ”knowing-not- knowing” Mental Health & Psychopathology Posttraumatic stress disorder (PTSD) Depression and PTSD comorbidity Somatic symtoms, difficulty to name pain Dissosiative disorders

17. © Raija-Leena Punamäki 2007 Impact of Traumatic Experience II Emotional processing Fragmented & intrusive emotions (rage, fear) Lack of synchrony between levels (psychological/physiological) Fear dominates Biased either to numbing or escalating of feelings

18. © Raija-Leena Punamäki 2007 Impact of Traumatic Experience III Cognitive activity Memory changes: sensory memory dominanes, less narrative/episodic memories Attention distorted: threat, danger Lack of synchrony & difficulty of reframing Mental flexibility decreases

19. © Raija-Leena Punamäki 2007 Traumatisation and memory Traumatic Sensory & emotional Visual, auditory, kinesthetic, smell, taste Memories unchanged Sensory memory easily recalled : flashbacks Multiple cues for evoke memories Intrusive & uncontrollable Neutral The meaning is constructed Can be verbalized and presented in symbols Memories fade & disappear with time Conscious links between cues & memory Voluntary control

20. © Raija-Leena Punamäki 2007 Cognitive capacity predicts PTSD ( N=65; Qouta et al. 2005)

21. © Raija-Leena Punamäki 2007 Impact of Traumatic Experience IV Psychophysiological Hippocampus volume decrease & Amygdala activity intensifies > Integration of new experiences as a part of old memory >> > fragmented and intrusive experience & difficult to reframe HPA-hypothalamic-pituitary-adrenal axis >>> Regulation of stress hormone Loss of stimulus discrimination a) acoustic startle response, b) low threshold to sound intensifies >>> uncontrollable fear

22. © Raija-Leena Punamäki 2007 Traumatization is about failure in integration Cognitive-emotional domains Either emotions overwhelming or absent In dissociation, feeling, thinking and sensory experience separated Past and present Traumatic memory ’split’ from personal history Sleeping and waking Nightmares break the dreaming, reality inrudes

23. © Raija-Leena Punamäki 2007 Research questions: trauma & children’s dreaming How does exposure to war trauma associate with remembering dreams? How does trauma impact dream content and structure? Which dream characteristics associate with good mental health? What kind of dream structure & dream content can protect child mental health from negative impact of war trauma? Can dreaming compensate for daily life traumatic & dangerous experiences?

24. © Raija-Leena Punamäki 2007 Method of dream studies Participants 413 Palestinian children (6-16 years) Trauma group n=279 living in Gaza (military violence) Control group n=144 living in Galilee (non- violence) 121 Kurdish children Northern Iraq (7-15 years) Orphan Children n=60 Children from intact families n=61 Measure tools: (a) 7-night dream diary: “Last night I dreamt…” (b) Multidimensional mental health (c) reports on evening-morning emotions (d) coping by unfinished sentences

25. © Raija-Leena Punamäki 2007 Trauma affects dreams I Dream content: Persecution dreams, sense of falling, physical vulnerability Kurdish children dream about death; Orphans about their parents Dream structure: Lack of narratives (”I dreamt about a dog”, ”Somebody was chasing me”) Lack of emotional expression (both negative & positive: ”I fall down because of a killed body, and walked away”) Many somatic feelings & action dreams (”I was running to escape, but my feet were glued to the ground”; ”I shouted for help but no voice came from my mouth”)

26. © Raija-Leena Punamäki 2007 Trauma & dreaming II Exposure to trauma increases recall of dreams in the morning > Human mind works actively during the night Symbolic, narrative, and emotional dreams protect the child mental health Dreams that ’break’, lack narrative are harmful Dreaming shows a compensatory function: Children with active and heroic coping during the day, reported helpless and fearfull dreams

27. © Raija-Leena Punamäki 2007 Protective dream Symbolic, emotional & fantasy Last night I dreamt that water had dried from the see. I was walking in the middle of the dried see. Suddenly I saw a huge fish in front of me, and I got frightened.... He said: I talk to you, because I want to protect you from the anger of other fish and from the rageful see. I said to him... The fish asked me to hurry up, because the see was just sleeping, and when it wakes up it will get back its real nature. (Girl 13, Gaza) Vulnerable dream Repeats reality & behavioral, document I saw in my dream that the occupying soldiers were having my brother in the street and beating him with baton. Till his bones were crashed from the severe beating…I started screaming hoping that my family would go out and to defend him. But nobody answered me because nobody could hear me. I went to the occupying soldiers…, while they were all the time beating me. As to get rid of me… (Girl 13, Gaza)

28. © Raija-Leena Punamäki 2007 Orphan girl 16 years (Kurdistan) 2 nd night :I dreamt that my mother hit me because I went to the room at that time my mother wash herself and my hand became green coloured. My mother told me "you are very good because your hand became green, but now you are more afraid", but I was not afraid. 3 nd night I dreamt that my mother wear a white dress, she talk nice things, then she cried & then I told her: "Why do you cry?" - she said: "where are you?" - I said I am in my grandmother's house. 4 nd night I dreamt that the fire rains; me with my mother & my sister in a room, near a cup. Suddenly a man entered the room & I asked about this fire which rains - he answered that this is the end. 5 nd night I dreamt that my father stand in the grave & I told him: "why did you die so early?" He said "you die also and everyone should die whether early or late".

29. © Raija-Leena Punamäki 2007 Aims in therapy: Fragmented & broken dreams to complete narrative Exploring and expressing emotions, especially the absent or numbed feelings Facing the horror & monsters in safe place Change the end of the dream story Change the position of the dreamer (victim – hero, active-passive, helped-helped) Form a friendship with your dreams Rehearsal the painful experiences until neutralized Dreams as symbolic material

30. © Raija-Leena Punamäki 2007 Mental health problems (MHP) & communal responses in military violence Acute symptoms of depression, aggression, PTSD & dissociation Children at risk: wounded, homeless, poor, earlier trauma, family problems, low threshold temperement, poor coping A) INTERVENTION MHP Symptom-focused treatment B) PREVENTION MHP Resíliency groups Psychoeducational Family involvement Children & families exposed to trauma with no special risk factors & vulnerability C) PROMOTION MH Promotion of healthy conditions: School, healthcare, participation National politics, strategies

31. © Raija-Leena Punamäki 2007 Gaza Community Mental Health Programme: Example of two preventive interventions ’Clients’ view: Mothers: Biology does not protect Parents: Worry about adolescent’s future I Enhancing healthy interaction with mother-child dyads in extreme destruction II Trauma & Resiliency focused intervention with adolescents

32. © Raija-Leena Punamäki 2007 Developmental ’tasks’ during the first year of life 0-6 mo Integration of sensories: eye, move Emotional attunement & arousal 6-12mo Attachment style & Mother-child int.  Secure  Insecure-avoidant  Insecure-Ambivalent  Disorganized

33. © Raija-Leena Punamäki 2007 Attachment style & in child development Emotions  Recognition own & others feelings  Regulation of affect  Expressing emotions, syncrony Cognitions  memory: episodic, semantic & procedural  thinking, causal relations & attribution Social relations  Thurst in self & others, support seeking  Group membership, sharing

34. © Raija-Leena Punamäki 2007 Impact life threat on attachment Main early risks: 1) Fear in mother’s eyes 2) Maternal PSTD-intrusive & dissociative states of mind Strong correlation between human interaction & sensory, psychological and physiological development Attachment problems: either too little or too much emotional self-regulation:’inhibited vs disinhibited’ Insufficient recognition of social cues Long-term elevated cortisol level (HPA) refer to constantly high arousal and stress

35. © Raija-Leena Punamäki 2007 Developmental ’tasks’ during the adolescence Early adolescence 11-13 years Peer-group & friends important Temp. regression of emotional accuracy High sophistication in thinking & solving Adolescence 14-17 years Growth spurts Intimate relationships High moral sophistication Temporary increase in aggression

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37. Combine interventions & preventions Symptom management & trauma healing –deals with information, understanding & integration –procedes pre-designed order –addresses painful memories, symptoms and coping Resilience-building -groups –deals with fantasy –adresses resources –addresses problems directly only by members initiative Therapy –groups & individual –addresses problems and resources –processoriented, -not pre-designed

38. © Raija-Leena Punamäki 2007 Conclusion: War trauma can be healed Apply & tailor ’manualized, evidence- based preventive interventions’ on well-defined problem Developmental science: sensitivity period Intervention & Prevention science: Mode & focus of intervention Be aware of philosophy

39. © Raija-Leena Punamäki 2007 Study III Adult Attachment & Cognitive- Emotional Processing of trauma

40. © Raija-Leena Punamäki 2007 ” Fatherhood of a national hero” Oslo agreement (Israel & PLO, 1993): 8 000 political prisoners released Motivation for seeking psychological help: * anger & intrusive memories harm intimate relationship * feeling failure in being a father: outsider * numbing of feelings (not so much for PTSD) The ’big question’ how to process trauma-related emotions

41. © Raija-Leena Punamäki 2007 Adult Attachment & emotions Secure-balanced Access to both negative & positive feelings Access to both emotions & cognition Insecure-dismissing Distrust emotions; minimizes feelings Emphasis on analytic & cognitive mode Insecure-preoccupied Distrust cognitions, ignores information Emotions overwhelming

42. © Raija-Leena Punamäki 2007 Multilevel Model of Emotions (N.Fridja) a) Domains of emotions Behavioral: action readiness Cognitive: appraisal & metacognitions Affective: feelings, mood Physiological level: arousal b) Intensity and valence of emotions c) Content & autobiographical meaning

43. © Raija-Leena Punamäki 2007 Study Hypotheses : Emotional processing of trauma is biased among insecurely attached individuals: Dismissing use predominantly cognitive modes Preoccupied use predominantly emotional feeling states

44. © Raija-Leena Punamäki 2007 Secure individuals use balanced emotional-cognitive processing Exposure to trauma activates the attachment-specific emotional processing

45. © Raija-Leena Punamäki 2007 Participants 153 Palestinian men, Gaza Political prisoners Released accord. Oslo agreement 19-50 year-olds (29.4+5.7) Education: 33% university 37%, secondary, 7% primary school Local clinics

46. © Raija-Leena Punamäki 2007 The Association between Trauma Exposure & Posttraumatic Growth according to Attachment Security 3.8 3.6 3.4 3.2

47. © Raija-Leena Punamäki 2007. 1.8 1.4 1 0.6 0.2 The Association between Trauma & Negative Emotions according to Avoidant Attachment

48. © Raija-Leena Punamäki 2007 Figure 1. Child Resilience and Father’s Mental Health problems according to child gender

49. © Raija-Leena Punamäki 2007 Figure 2. Child resiliency according to birth weight

50. © Raija-Leena Punamäki 2007 Figure 3. Child Resilience and Mother’s Child Rearing Practices according to Child Gender