The alarming news of another military service member going on a shooting rampage killing and wounding other service members on a military base is unnerving. For us Latinos it is especially upsetting to know that Iván López, a Latino, perpetrated the recent Ft. Hood shooting. I do not care for highlighting a person’s ethnicity or culture in these tragic events, but I feel that I have a responsibility as a Latina, a veteran, and a mental health professional to state the obvious that others are already commenting on.


By Xiomara A. Sosa, Clinical Mental Health – Forensic Counselor (Intern)

Founder and Principal, XAS Consulting, LLC

Executive Creator, National Hispanic Mental Health Professionals Network (HMHP)

Hurricane season officially started June 1 and lasts through November. The National Hurricane Center has predicted another busy hurricane season. We have already witnessed devastating tornadoes in Oklahoma. As someone who experienced 9/11up close and personal, I understand intimately how first hand and vicarious trauma from manmade and natural disasters can have an insidious affect on our psychological wellbeing. I was not above it. It was delayed onset for me and I eventually chose to seek help and recovered. I also watched helplessly and lived through the deep personal pain of a loved one battling the damage that came as a result of personal and war zone related trauma. After a long road to recovery for us both, I am now a fierce advocate dedicated to breaking down stigma and advocating for others to seek help when they experience any kind of trauma before it consumes them and their loved ones and causes unnecessary suffering. I now provide disaster mental health services to first and second responders as well as humanitarian workers during emergencies and disasters. And I am beyond proud of my loved one who is now one of the top emergency managers in the field after retiring from an impressive successful Air Force career.

What is a Critical Incident and How Does Culture and Development Affect Survivors?

A critical incident is the actual event that precipitates the trauma. A hurricane is a classic example of a critical incident. I will use my personal experience of living through a hurricane in South Florida. The culture in which this critical incident occurred is the Caribbean, Hispanic and Latin American subcultures living in that part of the country. Many generations of these cultures co-exist, from recent immigrants to those who have been established there as US citizens for decades (James, 2008).

A hurricane is classified as a natural disaster and South Florida is prone to hurricanes. Hurricane season in South Florida begins in June and lasts six months through November. Hurricanes do have a well established and sophisticated warning system in place for the community. However, when a hurricane does hit, many elderly people in the Spanish speaking communities have a tendency to not evacuate when they are asked to by emergency management officials. There are many reasons for this which includes immobility or difficulty with mobility. They also usually do not have transportation, have language barriers and cannot bring themselves to leave their beloved animals, pets or each other behind (James, 2008).

During my experience with one particular hurricane I came across an elderly Cuban American couple. They were in their late stage of life development and had already experienced many hurricane seasons in their homeland of Cuba and in South Florida during their lifetime. This couple escaped the communist regime of Fidel Castro in Cuba and fled to South Florida. They had never returned to Cuba because they were considered political exiles and were not allowed back by their government. Although they experienced hurricane threats in Cuba as young people, they never experienced a tragedy during a hurricane there. However, they have seen destruction, devastation and tragedy in their years living in South Florida, especially when hurricane Andrew devastated the area. That experience profoundly affected them and their response to new trauma. They often refused to evacuate when hurricane warnings were issued because they are afraid that they would have to leave their animals and pets behind and could not bear that thought. They also required transportation, which they did not have, which means they had to rely on public and community services to do so (James, 2008).

As a professional mental health counselor, I adjusted my counseling approach with this couple based on their cultural frame of reference and developmental stage in life. I based my approach on their late life developmental stage. I also considered their cultural needs and I appropriately attended to their language barriers, immobility issues, and their deep rooted attachment to the caring of their animals and pets (James, 2008).

They also required that my approach accommodate the way in which they process stress and information. Perhaps leaving the only home they have known for decades could be too much of a stressful physical change for them. They had the perspective that they would rather stay and protect their humble home and beloved animals and pets rather than leave everything they have behind because of how long it took them to acquire it all. I chose to include in my thinking the possibility of finding shelters where animals and pets are allowed and reassured them that they would be transported back to their home as soon as it is safe to do so. I used very simple language and small steps in trying to reassure them. A lot of patience and seeing the world through their worldview was the most effective approach in this case (James, 2008).

My counseling approach for this critical incident might have been different if the clients were of a different culture. For example, if they were Caucasian, English speaking (monolingual) and living in a more affluent neighborhood. If so, chances are they would have fewer barriers to contend with. They might own a hurricane fortified home that could withstand hurricane winds or have access to transportation to get to a safe place with their animals and pets. They might also have the ability to replace all of their lifelong belongings. This would likely be the case based on a higher socio-economic status. This is not meant as a generalization; however, in South Florida the socioeconomic levels differ quite distinctly between the ethnic communities for the most part, particularly within the Hispanic community. That difference does play a distinct role in how emergency services operate and are delivered. Cultural competency is a necessary part of delivering emergency management services and mental health disaster services (James, 2008).


James, R. K. (2008). Crisis intervention strategies (6th ed.). Belmont, CA: Thomson Brooks/Cole.ISBN: 0495100269

Trauma therapy includes confronting fears and going back to the source of your pain. Here are several strategies to help people who have been through traumatic experiences and painful losses.


The 12 Core Concepts, developed by the NCTSN Core Curriculum Task Force, are now available on the NCTSN website. The Concepts serve as the conceptual foundation of the Core Curriculum on Childhood Trauma and provide a rationale for trauma-informed assessment and intervention. The Concepts cover a broad range of points that practitioners and agencies should consider as they strive to assess, understand, and assist trauma-exposed children, families, and communities in trauma-informed ways.

From the Desk of
Elizabeth Grady, LPCS, NCC
2013 LPCANC President

Disaster Distress Helpline Offers Immediate Crisis Counseling

Call 1-800-985-5990 or text “TalkWithUs” to 66746.

The recent shooting at the Sandy Hook Elementary School in Newtown, Connecticut, continues to bring out strong emotions across the Nation. The Disaster Distress Helpline, 1-800-985-5990, can provide immediate counseling to anyone who needs help in dealing with the many issues and problems that might arise from this tragedy.

Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), the Helpline immediately connects callers to trained and caring professionals from the closest crisis counseling center in the nationwide network of centers. Helpline staff will provide confidential counseling, referrals, and other needed support services.

The Disaster Distress Helpline is a 24-hours-a-day, 7-days-a-week national hotline dedicated to providing disaster crisis counseling. The toll-free Helpline is confidential and multilingual, and available for those who are experiencing psychological distress as a result of natural or man-made disasters, incidents of mass violence, or any other tragedy affecting America’s communities.

Our texting service also is available to Spanish speakers. Text “Hablanos” to 66746 for 24/7 emotional support.

TTY for Deaf/Hearing Impaired: 1-800-846-8517

The Helpline also can be accessed online at

Resources on Coping

Helping your children manage distress in the aftermath of a shooting

Managing your distress in the aftermath of a shooting

Tips for Talking With and Helping Children and Youth Cope After a Disaster or Traumatic Event

Helpful Hints for School Emergency Management: Psychological First Aid (PFA) for Students and Teachers: Listen, Protect, Connect – Model & Teach Listen, Protect, Connect – Model and Teach Psychological First Aid for Teacher and Students

After a Loved One Dies – how children grieve and how parents and other adults can support them

School Crisis Guide: Help and Healing in a Time of Crisis

Disaster Distress Helpline

Resources For Reporting Accurately on Mental Illness Mental Illness in the News in Post Shooting Events

Resources developed by the University of Washington on how journalists can and should best cover mental illness This is a printable PDF version:

This is an HTML version:

Resources developed by the University of Washington on how journalists can and should best cover mental illness This is a printable PDF version:
This is an HTML version:


How to Manage Trauma: Warning Signs and Ways to Talk to Your Doctor

 70% of adults in the U.S. have experienced some type of traumatic event at least once in their lives. That’s 223.4 million people. In public behavioral health, over 90% of clients have experienced trauma. Trauma is a risk factor in nearly all behavioral health and substance use disorders.

Trauma occurs when a person is completely overwhelmed by certain events or extreme circumstances. People suffering from trauma often respond with intense fear, horror, or feelings of helplessness. In some cases, the extreme stress brought on by trauma overwhelms a person’s capacity to cope. But people can, and do, recover from traumatic experiences every day. Here is an infographic explaining some of the warning signs of trauma, and some helpful tips on how to seek treatment and talk to your doctor.

Traumatic experiences are quite common, and survivors must in some way emotionally process and integrate these unwanted and painful events. Successful processing yields a realistic perspective in which the traumatic experience is in the past, reducing the person’s sense of current threat. Many trauma survivors accomplish this over time via natural mechanisms of recovery and do not require treatment. When this process is impeded or the natural processing is insufficient, posttraumatic stress disorder (PTSD), depression, and other problems frequently result.

Studies continue to show that PTSD is a common condition, with prevalence in the general US population of about 8%. Prevalence of PTSD in the active military and veteran population is even higher: Among US active duty service men and women returning from current military deployments, PTSD is estimated as high as 14-16% and among US veterans of the wars in Iraq and Afghanistan, estimates range from 4% to 17% (see Hoge et al., 2004; Richardson et al., 2010).

Given the impact of PTSD on individuals and families affected by this condition, dissemination and implementation of effective treatments is a very high priority.

Psychological treatments are aimed at helping the PTSD sufferer to process and integrate traumatic experiences. Cognitive behavioral therapies have extensive and strong empirical support and often result in remission or a decrease in the severity of PTSD, and decreased severity of depression and anxiety. All effective CBT interventions, which commonly include exposure (imaginal and in vivo), cognitive therapy, or skills training (e.g., stress inoculation; affect regulation and interpersonal effectiveness training), help the survivor to become less afraid of or threatened by trauma memories and reminders and of PTSD symptoms themselves, and to feel more competent and better able to cope. Theorists of exposure and cognitive approaches agree that treatment must in some way access or activate trauma memories, thoughts, and feelings, while providing corrective information that serves to modify the person’s unrealistic expectations of harm and danger and to reduce excessive negative emotion.

Prolonged exposure (PE; Foa, Hembree, Rothbaum, 2007) for PTSD has amassed considerable empirical support and is one of the primary treatments being rolled out by the U.S. Department of Veteran’s Affairs and the Department of Defense. While PE is a highly effective treatment, clinicians are sometimes concerned about whether it is an appropriate treatment for individuals with PTSD resulting from certain types of trauma or for those clients whose trauma narratives and current experience are dominated by emotions other than or in addition to fear: guilt, shame, anger, grief, and sadness. This is understandable – exposure-based treatments were designed for amelioration of excessive and/or unrealistic fear, not excessive guilt or anger. Experienced trauma therapists know that fear is but one of the emotional responses to trauma that are important to address in treatment. And most likely all would agree that facing trauma memories and reminders, and dealing with the feelings that result, are of prime importance.

Clinicians are also sometimes concerned that repeated revisiting of some trauma memories, particularly those associated with guilt or shame or anger about what occurred or what one did or did not do during the trauma, will be ineffective or will result in increased negative emotion. Many years of using and studying PE have yielded a rich understanding of emotional processing of traumatic memories via imaginal and in vivo exposure. Imaginal exposure – repeatedly revisiting trauma memories in imagination – and discussing and processing this experience with the therapist is a potent and efficient means of helping the PTSD sufferer to 1) fully access all of the salient information – facts, emotions, thoughts, behaviors, environment – within the trauma memory, 2) contextualize and understand his or her reactions and experience of the trauma and its aftermath, and 3) achieve a realistic perspective on the traumatic event and one’s behavior during it, as well as the impact it has had and will have in the future.

These outcomes are clearly illustrated in the case of a veteran treated with PE whose traumatic experience involved a deadly engagement with the enemy in which several of the men under his command were killed, despite his considerable and courageous efforts to lead this mission successfully and to save lives. The veteran presented for treatment about 5 years after this event with severe PTSD and depression, and he was suffering from extreme guilt and self-blame for the death of his men. In imaginal exposure he revisited the memory of that painful day in which these men under his command were killed and he was shot at while trying to render them aid. He was given a recording of this first imaginal exposure to take home and asked to listen to it daily before the next session, which he did.

During the review of his homework in the following session, the veteran reported that he had listened to the recording of his imaginal exposure frequently, as requested, and that he had done much ‘soul-searching’. He realized that he had done his job as best he could, and that if he had not done his job well, even more people would have died. Moreover, the veteran reported that thinking this over and listening to the session repeatedly had led him to accept that there was probably nothing that he could have done differently, and that he was beginning to feel a lessening of the “guilt and shame and the blame” he held on to for years after the death of his men. The veteran seemed relieved as he told his therapist that even though he had done everything in his power to bring everybody home, it was just not possible, and not up to him. He ended by saying that he was realizing through this process that he needed to try to let this go and to forgive himself.

This case is a good reminder that our powers of recovery are strong, and that when these powers have stalled or been impeded, they can be unleashed or facilitated by good, trauma-focused psychotherapy so that healing can proceed. Prolonged exposure and cognitive therapy, often primed by imaginal revisiting of the trauma memory as suggested by Ehlers and Clark (2000), are powerful and effective procedures that activate these forces and promote a reorganization of the trauma-related information that is more accurate and whole, an acceptance of what has happened, and a reduction of anxiety, guilt, anger, sadness, and other emotions that have dominated the person’s current experience, and result in reduction of PTSD and other trauma-related disorders.


Ehlers, A., & Clark, D.M. (2000). A Cognitive Model of Persistent Posttraumatic Stress Disorder. Behaviour Research and Therapy, 38, 319-345.

Foa, E. B., Hembree, E. A. & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences. New York: Oxford University Press.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.

Richardson, L. K., Frueh, B. C., & Acierno, R. (2010). Prevalence estimates of combat-related post-traumatic stress disorder: Critical review. Australian and New Zealand Journal of Psychiatry, 44, 4-19.

Elizabeth A. Hembree, PhD
Department of Psychiatry, Perelman School of Medicine
University of Pennsylvania

The messages that people in crisis send themselves become very negative and twisted, in contrast to the reality of the situation. Dilemmas that are constant and grinding wear people out, pushing their internal state of perception more and more toward negative self-talk until their cognitive sets are so negative that no amount of preaching can convince them anything positive will ever come from the situation. Their behavior soon follows this negative self-talk and begets a self-fulfilling prophecy that the situation is hopeless. At this juncture, crisis intervention becomes a job of rewiring the individual’s thoughts to more positive feedback loops by practicing and rehearsing new self-statements about the situation until the old, negative, debilitating ones are expunged. Cognitive Behavioral Therapy (CBT) seems most appropriate after the client has been stabilized and returned to an approximate state of precrisis equilibrium. Basic components of this approach are found in the rational-emotive work of Ellis (1982), the cognitive-behavioral approach of Meichenbaum (1977), and the cognitive system of Beck (1976) (James 14-15).