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The Unseen Damage

Author: David Abbott
February, 2018 Issue

The fires that raged through Sonoma and Napa counties last October have the potential to create lasting psychological effects on individuals and communities, straining an already stressed mental health delivery system in the North Bay. Though not everyone experiences long-term effects, there are populations vulnerable to life-altering fallout such as anxiety and posttraumatic stress disorder (PTSD).

While many will deal with short-term, lingering anxiety over their losses, PTSD can be cumulative and long lasting. The signs may take months to manifest, sometimes hidden for years, only to show up when some seemingly innocuous trigger sets off a reaction resulting in disruptive behaviors.
“I like to think of anxiety as a symptom: PTSD is a specific cluster of symptoms that can occur after an overwhelming or life-threatening event,” says Michelle Baumgartner, a licensed clinical social worker for Sutter Health in Marin County. “It’s important to separate out an event, like the fires, from a person’s unique response to that event. Not everybody is going to have PTSD.”
The National Center for PTSD, a program of the U.S. Department of Veterans Affairs, describes four main symptoms of PTSD. The first is reliving trauma in the form of flashbacks or nightmares. Trigger events can take the form of news stories about similar tragedies, or sensory reminders such as a car backfiring after a violent gun incident or the smell of smoke after a lethal fire. 
A second symptom is avoidance, which can cause the sufferer to isolate from family, friends and other support groups for fear of having to discuss the traumatic event. Someone suffering this symptom might also avoid crowded places, further distancing themselves from others. 
Increased negative thoughts and feelings associated with PTSD can create sadness or a numbing effect. The sufferer can lose interest in associating with the outside world, become distrustful, or lose the ability to express happiness or other positive emotions. Debilitating feelings of guilt and shame can follow. 
“Humans, as compared to other primates, have this problem of what we call ‘rumination’ where your thoughts get into negative loops that won’t lead you anywhere,” says Mary Burke MD, a psychiatrist for Sutter West Bay Medical Group in San Francisco, who has treated PTSD and attendant psychiatric health issues for more than two decades. “It’s this very rumination that can perpetuate unhelpful anxiety and lead to depression.”
On the other hand, feeling jittery or keyed up, a symptom known as hyperarousal, can affect sleep patterns and concentration. Feeling the need to be on the lookout for danger or sudden anger and irritability can be followed by unhealthy habits such as smoking, drug and alcohol abuse, or even aggressive driving.
Not all who suffer from PTSD are affected by a single catastrophic event, so it can come as the result of accumulated traumatic experiences over a period of time. Those diagnosed with the disorder can face issues that, if not addressed, can cause long-term problems in their lives.
According to the National Center for PTSD, 7 to 8 percent of the population of the U.S. will develop PTSD at some point in their lives. In addition, about 8 million adults have PTSD during any given year. Women are disproportionately affected, as an estimated 10 percent develop PTSD, compared 4 percent for men.

The physical response to trauma

Exposure to trauma in humans is as old as the species itself. In a world fraught with predators and inhospitable climates, early humans developed the same instincts and neurological defenses as other animals to survive.
“As primates, we’ve evolved to know how to handle life’s threatening challenges,” Burke says. “When we see these life-threatening events, our ‘fight-or-flight’ system gets mobilized and you take action that hopefully helps you survive.”
The fight-or-flight response not only sets the brain into motion to find an escape from immediate danger, but an intense physical response takes over the body as well. Surges in adrenaline cause heart rate increases and the stress steroids (glucocorticoids) prepare your body for fight or flight. There can also be alterations to appetite and increased sensitivity to cues about pain. “On an emotional level, you’re going to have a mixture of extreme anxiety and fear and anticipating the worst because that’s protective in the big picture,” Burke says.
“During a life threatening or overwhelming event, the sympathetic nervous system is activated like a gas pedal in a car,” says Baumgartner. “The body then releases the hormones adrenaline and cortisol to prepare for the flight or fight. When action has been taken, and the danger has passed, the parasympathetic nervous system, or brake system, is engaged. A person may then feel numb, shaky and exhausted afterwards. This is a normal stress response.” 

The history of PTSD

Despite its long existence as a human condition, PTSD has only recently been afforded status as a treatable condition. Historical literature and accounts, particularly those pertaining to war, are littered with characters displaying conduct that mirrors modern clinical definitions of PTSD. Consider Shakespeare’s Henry IV, where Lady Percy describes her husband Hotspur’s behavior upon his return from war, including everything from isolation to unwarranted rage and sexual frustration, or Stephen Crane’s Red Badge of Courage, whose protagonist Henry Fleming seals his fate by running from the field of battle in the Civil War.
From the 18th century through the Civil War, what we now know as PTSD was called “nostalgia,” which morphed into “soldier’s heart” and “shell shock” or “battle fatigue” in later wars, according to the National Center for PTSD.
It wasn’t until 1980, in the wake of the Vietnam War, that PTSD made its way into the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Up to WWI, wartime PTSD was usually marked down to cowardice and often ended with a fatal bullet from fellow soldiers. In subsequent American wars, soldiers became too valuable a resource and burgeoning recognition of the disorder allowed affected soldiers to take alternative duty behind the lines in non-combat roles.
The study of war can be instructive to the study of medicine, in part because nearly unlimited military budgets throughout history have led to advances in treatment that in turn have led to higher survival rates for soldiers. 
“Wars are bad for you, but medicine made big leaps,” says Allan Bernstein M.D., a Sebastopol-based neurologist who has worked in the field since 1972. “Public health, surgical techniques, antibiotics, body armor, all this stuff came out of wars.”
For several years, Bernstein taught a class for Osher Lifelong Learning Institute about wars and the resulting medical advances. Modern soldiers have impact monitors built into their helmets to record shock waves from nearby explosions and there are now hi-tech tourniquets and instant blood-clotting agents that are part of a soldier’s basic equipment. 
“You go out in the field and a person gets his arm blown off and is spurting blood, you put this stuff on there and the blood stops,” Bernstein says. 
More and more combat veterans survived throughout the late 20th and early 21st centuries, but they often came home with missing limbs and heads full of disturbing images of death and destruction that could not be shaken. By necessity, recognition and treatment of stress-related injuries had to evolve. 
“People don’t die a lot in Iraq and Afghanistan. They get limbs blown off, they get their heads rattled,” Bernstein says. “The survival rate of soldiers is higher and higher, the survival rate of civilians is worse and worse, so PTSD is two big groups: Group A is soldiers, and group B is civilians.”
What happens to displaced civilians—Syria and Iraq have seen somewhere in the neighborhood of 14 million war refugees in the past two decades—can be instructive for the current situation in the area of the fires, where thousands of people were burned out of their homes and businesses. Additionally, studies of displacements following Hurricane Katrina have become critical to the treatment of survivors of modern natural disasters.

Dealing with the aftereffects

While it’s normal to experience changes in feelings, thoughts or behaviors for days or weeks after a catastrophic event, if symptoms persist or cause disruptions to daily life, it’s important to talk to a doctor or mental health provider. Untreated PTSD will not get better, and can lead to a variety of symptoms including depression, anxiety, problems at work, relationship issues, changes in physical health, alcohol and drug abuse, or possibly thoughts of suicide or harming others.
But Baumgartner cautions against assuming that a single incident can cause PTSD. “We don’t want to label an event a trauma because trauma is an individual’s unique experience of the event, not the event itself,” she says. “If the person’s ability to integrate an emotional experience is overwhelmed, the autonomic nervous system continues to be hyper- or hypo-aroused, or the animal defenses (flight or fight) continue to be engaged, then there is trauma.
Baumgartner, who works at Sutter’s Institute of Health and Healing in Greenbrae, uses a body-oriented talking therapy called Sensorimotor Psychotherapy, which helps people regulate their nervous systems, develop resources, and process traumatic memories in a safe way.
“I want to teach them tools to help them pay attention to their body and what [they] can do to lower any hyper arousal,” she says. “Because this is not a threat right now, but [their] body still feels like it’s a threat.”
To do that, Baumgartner helps her patients track body sensations, such as tightness in the chest or arms, link them to a concurrent emotion or thought, and develop resources for stabilization before processing the traumatic memory. Somatic therapies, as supported by neuroscience research, are an important treatment for trauma.
“It’s still evolving,” Bernstein says. “They talk about aversion therapy, and then go with somebody to walk on a bridge, but there’s some stressors you can’t reapply: you’re not going to reapply sexual trauma, you’re not going to reapply a war…. There are a number of varieties of treatments, but there’s not one that’s absolute.”
The top priority, particularly in the case of the recent fires, is to provide immediate safety and care for victims and to stabilize their lives as soon as possible. 

Impact on the community

The Atlas, Tubbs and Nuns fires destroyed 8,679 structures in Napa, Sonoma and Solano counties, scorching nearly 143,000 acres, according to Cal Fire. In Santa Rosa, more than 3,000 homes, 5 percent of its housing stock, were destroyed. In the weeks following the fires that razed entire neighborhoods, the county stepped up its mental health services to address what could prove to be unprecedented need.
There’s been a huge uptick in calls requesting mental health services, says Sonoma County Third District Supervisor Shirlee Zane. “People are experiencing PTSD symptoms as well as dealing with the overwhelming tragedy and the grief that accompanies such a profound loss.”
Zane says that calls doubled in the weeks following the tragic events and she sees long-lasting need throughout the community in the years to come. In addition to setting up emergency crisis stabilization units, mobile support teams and sending health care professionals to local schools, the county worked with local providers, both public and private, receiving grants for training and long-term community care. 
“It’s important that we take a long-term approach to this, because the symptoms of PTSD will most likely hit people who had to flee for their lives,” she says. “They have survived a disaster and a traumatic event, and those are the people who are probably going to have, no doubt some of them, some of symptoms of Traumatic Stress Disorder.” Zane, a former family therapist and hospital chaplain with emergency crisis experience, is acutely aware of the problems the community may face, as she lost her husband Peter Kingston to suicide in January 2011. She worries that, among other things, the suicide rate will spike and other aftereffects will manifest themselves.
“You realize six months later the fire’s gone, your property’s been cleaned up and you’re on the verge of getting decent housing again when suddenly you’re being easily startled or you’re on edge all the time,” says Zane. “You can’t sleep and you’re having angry outbursts.”
Despite the upsurge in need seen by the county, private health care providers such as Kaiser Permente and Sutter Health did not experience an initial rush on mental health services, although Kaiser’s Department of Mental Health and Addiction Medicine Chief, John Mackey M.D, says that could be due to those conversations taking place with personal physicians. “We are starting to see some increase as time passes,” he adds. “The fires have been a regular part of the conversation in primary care, and it may or may not directly relate to the presentation that individual patients are coming in with,” he says. “But it’s an important part of the patient’s life experience, and that becomes a topic of conversation in the visit.”
Kaiser Hospital sits directly in the path of the Tubbs Fire and was evacuated on October 9 as the firestorm raged and almost completely wiped out Journey’s End Mobile Home Park next door. Likewise, Sutter’s three-year-old facility in the Larkfield area was at the center of another part of the firestorm that wiped out surrounding neighborhoods. In total, and including Santa Rosa’s third major health provider St. Joseph Health, local reports show that 406 homes belonging to doctors, nurses, technicians and staff were lost. One in every six doctors lost homes in an industry already struggling to recruit young physicians.
Now that the initial crisis has past, health care professionals say community bonds are more important than ever as the next phase of an ongoing crisis unfolds.
“It’s such a necessity in the middle of suffering to understand why you’re suffering and to be validated and supported,” Mackey says. “It’s, in many ways, the beginning of being able to do something about it. A universal experience makes that easier, of course.”

What is PTSD?

Any life-threatening or traumatic event, either experienced or observed, can lead to PTSD. Such events include:
Sexual or physical assault
The violent or accidental death or injury of a loved one
Injurious or automobile accidents that involve fatalities
Natural or man-made disasters (from fires to terrorist attacks) or any event associated with feelings of lost control
For information or help seeking information or mental health services in Sonoma County, go to or In Napa County, go to 

First Responders & Post-traumatic Stress

While the mental and emotional health of residents affected by the October fires is an ongoing concern, the health of police, fire and emergency medical professionals is equally important. Once stigmatized within the ranks, posttraumatic stress issues is now treated as any other on-the-job injury, which only benefits first responders and the public they serve. 
“Ten-plus years ago people didn’t want to talk about this kind of thing,” says Lieutenant Ron Klein, a 17-year veteran of the Petaluma Police Department. “If you’re a police officer or firefighter you had to be tough. The old adage, ‘Rub some dirt on it. It’ll be okay,’ was the common theme.”
Klein and other members of the PPD, many of whom live in areas threatened by the fires, joined other first responders that night to help evacuation efforts. Many worked to help neighbors and save the houses of friends and family. In the heat of battle they carried on, often not knowing if they would have a home awaiting their return. Even Klein’s Skyhawk home in eastern Santa Rosa was under threat as he worked throughout the night. He was one of the lucky ones, as two members of his department lost homes to the firestorm.
When they arrive on the scene of a catastrophic, violent or tragic event, first responders carry both implied and definite authority and an expectation to go above and beyond human capacity to witness human tragedy most people rarely see. But as human beings, there is often a point where repeated exposure takes its toll.
The resulting trauma can manifest itself in any number of posttraumatic injuries, PTS or PTSD, leading the emergency responder to seek help through a number of resources that have become available in the past generation.
“There’s a lot of different thoughts in the psychological world right now and it depends on who you speak to,” Klein says of the difference between PTS and PTSD. “What I’ve learned is PTS tends to be more of a short-term thought process where you may relive events that you experienced.”
There’s also a tendency to avoid the term “disorders” in favor of “injuries.” But whether it is a short-term problem—or one that requires mental health services and time away from the job—resources are available through state-mandated Employee Assistance Programs (EAP) administered through public agencies.
In the case of the PPD, the EAP is provided through the City of Petaluma to all municipal employees and their families, while county employees, such as deputy sheriffs, have access to EAPs as well as in-house psychologists under contract to counsel officers who need extra help.
Even volunteers such as members of the Sebastopol Volunteer Fire Department, which mobilized to fight the October fires, have access to Sebastopol’s EAP in addition to the modest stipends received for training and responding to calls, according to Sebastopol Fire Chief Bill Braga
Braga says his volunteers were at the front lines the night of October 8 after spending the day working the department’s yearly pancake breakfast fundraiser, so it was a long, long day for most of them. Members of his department were also affected by the plight of their neighbors. “We’ve all been touched by this,” he says.
All psychological services are confidential and there is also Critical Incident Stress Management (CISM) offered through the Sonoma County Fire Chief’s Association.
Should a first responder get to the point where posttraumatic issues become debilitating, it is treated like any other injury received on the job. The employee may receive disability insurance for time away from work, and upon return, job options are available away from the front lines to ease back into the flow.
Peace Officers Standards and Training, a state commission that regulates police departments, requires training throughout policing organizations on PTS injuries. Care for local police received a boost in 2015 with the release of a study by the Obama Administration after an upsurge in officer suicides nationwide. The Report on 21st Century Policing outlines “six pillars of support”—the sixth being officer health and wellness—that outlines what departments throughout the state are already implementing.
“California tends to be a progressive state,” Klein says. “I would say we’re definitely the head of the spear when it comes to officer wellness.”
All in all, it is a more humanizing way to look at first responders. “There’s no superhuman power that you [acquire] when you become a police officer, firefighter or emergency room nurse,” Klein says. “You are a human being. You have feelings. You have emotions. You have families.”




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