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Show a Little Leg

Show a Little Leg

Published May 12th, 2015 in Bon Appetit – Just Plain Good FoodEat for Health

by Tammera J. Karr, PhD

Lamb is a staple food throughout the world including Turkey, Greece, New Zealand, Australia, Africa, and countries of the Middle East. In the U.S., per capita consumption of lamb is much lower than in the rest of the world. Half of all lamb consumed in the U.S. is imported, and within this category of imported lamb, nearly 68% comes from Australia and 30% from New Zealand.

Historically, the best tasting lamb was considered to be “spring” lamb. With modern breeding practices, preparation methods, the amount of fat in lamb has diminished considerably, making it the perfect choice for health-conscious consumers. , Lamb is a very versatile meat and contains one of the most complete amino acid profiles available in protein sources. Lamb is rich in various nutrients, including the proteins, iron, vitamin B12, zinc, selenium, niacin and low in saturated fat.

Among the first animals ever to be domesticated by humans, occurring more than 10,000 years ago, sheep and goats have been pivotal in the development of many cultures. Over 2,000 years ago, the Romans introduced sheep into Great Britain, where lamb remains very popular. Lamb was not introduced into the Western Hemisphere until the early 16th century when the armies of the Spanish explorer Cortés brought sheep with them . It has been a symbol of sacrifice in many religions, including Christianity and Judaism and as a traditional dish on Easter.

Here are some health benefits of Lamb:

  • • Lamb supplies the body with 60.3% of the daily requirement for protein.
  • • The meat contains the minerals;
    • Selenium, a mineral whose deficiency can lead to asthma attacks.
    • Iron, which is an integral component of hemoglobin and aids formation of red blood cells in the body. The form in which iron is present in lamb is easily absorbed by the body.
    • Zinc, which is required by every living cell in the body for healthy immune function, cell division and overall growth.
  • • Vitamin B12, prevents high homocysteine.
    • Promotes a healthy nervous system
    • Supports the formation of red blood cells and prevents anemia. Naturally only in animal foods.
  • • Niacin provides protection against Alzheimer’s disease
    • Necessary for healthy skin
    • Slows the age-related cognitive decline
    • Reduce the risk of osteoarthritis by 50%


Lamb is a source of ‘good fat’ and has less saturated fat than other meats. (Health Benefits of Mutton-Lamb – infosamay.com.) The essential fatty acid omega-3 of lamb depends upon the young sheep’s diet as well as the mother’s diet, when the animals diets are optimum, the results can be a cut of lamb with impressive omega-3s values. Lamb also contains conjugated linoleic acid (CLA). Increased intake of CLA improves immune and inflammatory function, bone mass, blood sugar regulation, reduced body fat, and maintenance lean body mass. Studies show grass-fed lamb contains nearly twice as much CLA as a conventionally fed lamb.
Recommended for those with cardiovascular disease, and diabetes.

A number of ingredients blend well with lamb, including apricots, peaches, plums, yogurt, tarragon,rosemary,  olive oil, aubergine, tomatoes, couscous, quinoa, coriander, fennel,  and French mustard.

I have taken to using this recipe I found on The World’s Healthiest Foods website. It is simple and fast.

10-Minute Rosemary Lamb Chops

Prep and Cook Time: 15 minutes


12 lamb chops
6 TBS fresh lemon or lime juice
3 TBS chopped fresh rosemary,
3 medium cloves garlic, pressed
1/4 tsp Celtic sea salt
1/4 tsp black pepper

Press garlic and let sit for at least 5 minutes to bring out its hidden health benefits.
Mix together lemon juice, rosemary, pressed garlic, salt, and pepper. Rub lamb chops with mixture. Set aside on plate.
Preheat broiler on high heat, and place a stainless steel or cast iron skillet large enough to hold the lamb chops under the heat for about 10 minutes to get very hot (about 5-7 inches from the heat source). Be sure that the handle is also metal.

Once pan is hot, place lamb chops in pan, and return to broiler for about 4-5 minutes, depending on thickness of lamb. Lamb is cooked quickly as it is cooking on both sides at the same time. This is our Quick Broil cooking method.

Serves 4

Thank you Worlds Healthiest Foods for making Lamb so enjoyable and easy !

To Your Good Health and Real Food


Read more at http://lifestyle.iloveindia.com/lounge/benefits-of-lamb-6426.html#RtVM6QEx3yh2TL18.99
See more at: http://lifestyle.iloveindia.com/lounge/benefits-of-lamb-6426.html#sthash.90h2dj6x.dpuf




Karr_TTammera J. Karr, PhD, DAAIM, BCIH, BCHN, CGP, CNC, CNW, CNH, is an author, public speaker, educator, and clinician. Tammera has served as a nutrition advisor for several wellness programs and groups. Additionally she writes a weekly health column, reviews and contributes to national board exams, and is a contributor to online newsletters.

A Native Oregonian, Tammera established an Integrative Medicine Partnership in 2006 and currently works in a clinical setting with DO’s, FNP-C, Bio-Feedback Specialists, and others to provide clients with tools to take control of their health. Tammera provides personalized nutrition consultations, in states not restricted. Her clinical and education practice is ever-evolving to meet the needs of clients, the public and fellow practitioners striving to empower those they meet.

She received her PhD with Honors in Holistic Nutrition from Clayton College of Natural Health and holds national board certifications through the National Association of Nutritional Professionals (BCHN), the American Association of Integrative Medicine (BCIH), American Naturopathic Certification Board (CNW), and the American Association of Drugless Practitioners (CNH). Tammera has served as Committee Chair for the Wellspring School of Natural Health, Holistic Nutrition Education Review Board, 2012-2014.

Tammera became a Certified Gluten Practitioner (CGP) in 2013 through Thomas O’Bryan, DC and theDr.com gluten awareness/education program. In 2012, she became a Diplomate of the College of Biologically Based Practices in the American Association of Integrative Medicine.

Additionally, she serves on the Board of Directors for the National Association of Nutritional Professionals, the Accreditation Commission for the American Association of Integrative Medicine (AAIM) and works as one of many in Oregon promoting National Food Day to communities. Tammera has actively promoted local food awareness and sustainability through her service on the Think Local Umpqua Executive Board, 2010-13.

“Patients with autoimmune diseases should avoid health care professions who make them feel pessimistic about their condition.” Dr. Andrew Weil

 “Every patient carries her or his own doctor inside.”

- Albert Schweitzer (1875 – 1965)

 Please Note:

The information provided in this communication is for informational purposes only and is not intended as a substitute for advice from your physician or other healthcare professional or any information contained on or in any product label or packaging.  You should not use the information in this communication for diagnosis or treatment of any health problem or for prescription of any medication or other treatment.

Consult with your healthcare professional before starting any diet, exercise or supplementation program, before taking any medication, or if you have or suspect you might have a health problem.

You should not stop taking any medication without first consulting your physician.


Tammera J. Karr, PhD, BCHN, BCIH

Certified Gluten Practitioner


Author of “Our Journey with Food”

T, W, Th:  6A Houser Ct ~ Idleyld Park, OR 97447

M:   2031 NE Diamond Lake Blvd. ~ Roseburg, OR 97470

T: 541-430-1078

F: 541-672-1798





The Mindful Path to Self-compassion: Freeing Yourself from Destructive Thoughts and Emotions

The Mindful Path to Self-compassion: Freeing Yourself from Destructive Thoughts

 and Emotions


Written By: Dr. Christopher K. Germer, PhD

Publisher: The Guilford Press, 305 pages


Reviewed By:

Dr. Susan Stuntzner PhD, LPC, CRC, NCC, DCC, FAPA

Assistant Professor

University of Texas – Rio Grande Valley

School of Rehabilitation Services and Counseling

College of Health Affairs


Compassion, self-compassion, and mindfulness have long been spiritual practices of Buddhism and Buddhist psychology.  Remnants of mindfulness and stress reduction techniques have existed in the United States, and evidence of such practices is apparent dating back to the 1970’s, but it has not been until that past 10 years that self-compassion and mindfulness have been more thoroughly considered, examined, and researched.  Much of this increased interest is credited to Dr. Kristen Neff’s research and work on self-compassion and its role in reducing negative thoughts and feelings (i.e., depression, anxiety, self-criticism), and in increasing positive qualities (i.e., forgiveness, better outlook on life) among those who practice and integrate it into their lives.  Further, with the awareness and accessibility of self-compassion and mindfulness, professionals and the individuals served by them are recognizing the implicit value these skills have, as well as the ways such techniques can improve their lives.

The book begins by explaining the tendency people have to resist, suppress, or escape emotional and mental pain.  The author, Dr. Christopher Germer, helps the reader understand that by doing so, people actually create more personal, mental, and emotional pain for themselves.  More specifically, he lays out in an easy-to-understand equation that pain compounded by resistance equates to more suffering (p. 15).  While experiencing pain is a part of the human experience, Germer (2009) explains that “suffering is optional” (p. 16), meaning that people do not need to compound their experiences and make them worse.  Rather than resist our pain, the author indicates that the antidote is to turn toward and face the pain so that people can kindly look at it and care for themselves in a more loving way.  Two components of doing so involve the use of self-compassion and mindfulness.

Self-compassion is a concept and practice that many find initially challenging, particularly within the United States.  It is sometimes perceived as something that people do if they are “weak” or “lazy,” as it may be viewed by some as not holding one’s self accountable or responsible.  However, such beliefs couldn’t be further from the truth.  In the U.S., people are more likely to extend compassion to others, but many are challenged in their ability to be tolerant, kind, forgiving, and accepting of themselves when they are in pain.  Despite this discrepancy, self-compassion is a skill and an approach to life that can benefit any individual.  Germer (2009) also explains the circular relationship of self-compassion and compassion.  He informs the reader that people who are self-compassionate tend to have more compassion for others going through difficult times, and that one does not exclude the other.  Throughout the book, the author encourages people to explore and discover techniques and mantras that work for them in the quest to develop and enhance self-compassion.  Germer (2009) clearly stresses that there is no single right way to develop and enhance self-compassion, and that a part of the journey is discovering what works for each individual.  Further, he provides guidance in how to start with one’s development of self-compassion and then gradually extend it to others (i.e., benefactor, friend, neutral person, difficult person, and groups; pp. 166-178).

One important element of self-compassion is that it does not have to be innate.  Instead, people can learn about, and develop it, regardless of their initial starting points.  Although the exact ways people learn to do that may vary, the author discusses the role of mindfulness and the importance of learning to “anchor” or “quiet” one’s mind and body.  This quieting process helps people learn to “tune in” to themselves, their inner experiences, their breathing, and their personal pain.  Throughout this process, people may learn to meditate, but again, the focus is more on creating stillness within so that people can pay attention to their minds, bodies, souls, and inner experiences.  This process helps people learn about themselves and identify parts that need their love, care, and tender affection.  Mindfulness practices and techniques can aid in helping people focus on their experiences, needs, and on “opening” their awareness to tend and respond to difficulties and challenges (p. 81).

Throughout, the author provides the reader with a number of applications and exercises that can be explored and tried while one is working on the cultivation of self-compassion.  One such exercise is the opportunity to explore and learn about one’s ability to be self-compassionate.  The reader is directed to Dr. Kristen Neff’s website: www.self-compassion.org to complete this exercise.  On her website, Neff has the self-compassion scale she developed as part of her research, and people are provided the opportunity to complete the scale and learn about their abilities to practice and integrate self-compassion in their lives.  Toward the end of the book, readers are again encouraged to revisit and retake the scale to determine if they have improved on their ability to be kind and loving toward themselves.

Another important element for professionals to consider are the barriers and personality styles of each person trying to practice self-compassion.  In Chapter 8, several personality styles (i.e., caregiver, intellectual, perfectionist, workhorse) are discussed, along with an introduction to the potential stumbling blocks associated with each type.  Such information is of value because each person has a different personality and set of circumstances that either aid or hinder the self-compassion cultivation process.  Learning about and being provided with the opportunity to identify which of these apply to one’s own situation enhances the understanding of what might be expected throughout the process.

A final point worthy of mention and relevance to professionals is the illustration of personal and professional stories and examples combined with a number of applied experiences.  Additionally, the latter portion of the book provides the reader with insights about how to measure one’s own progress in practicing and developing self-compassion as well as additional exercises and resources to read, should one want to further his or her ability to be more self-compassionate and to learn about self-compassion.

Professionals wanting to learn more or to integrate self-compassion as a part of their personal or professional practices are encouraged to consider this book.  As stated earlier, the development and cultivation of self-compassion and mindfulness does not require a person to be an expert, but it is a process that can be steadily practiced and improved.  Further, the better professionals understand the value it has in their own life, the more comfortable they may feel in using it with their clients and the people they serve.  This process will be easier for some than others, but Germer (2009) explains that the practice of self-compassion should not be hard or difficult; rather, it is when we “resist” it, or the process of letting thoughts and feelings flow and be what they are, that people tend to get stuck in the process of trying to control or effect the outcome.

About the Reviewer

Stuntzner_SDr. Susan Stuntzner PhD, LPC, LMHP, CRC, NCC, DCC, BCPC, DAPA, FAPA is an Assistant Professor  in the School of Rehabilitation Services and Counseling at the University of Texas – Rio Grande Valley. She currently trains students to become rehabilitation and rehabilitation counseling professionals and to work directly with individuals with disabilities in numerous employment settings. Her research interests include: adaptation and coping with disability, resiliency, self-compassion and compassion, forgiveness and spirituality, development of intervention techniques and strategies, and mentorship of professionals with disabilities. She has written three books pertaining to coping and adaptation and/or resilience-based skills. Her works are entitled, Living with a Disability: Finding Peace Amidst the Storm, Reflections from the Past: Life Lessons for Better Living, and Resiliency and Coping: The Family After.  Dr. Stuntzner has researched and written articles on self-compassion and forgiveness and their potential relationship to the needs of individuals with disabilities. She has also developed two interventions (i.e., resilience, forgiveness) for persons with disabilities to assist them in their coping process. These works are entitled, “Stuntzner and Hartley’s Life Enhancement Intervention: Developing Resiliency Skills Following Disability” and “Stuntzner’s Forgiveness Intervention: Learning to Forgive Yourself and Others”.  Additional information can be found on her website: www.therapeutic-healing-disability.com

Ankle Injury Mechanisms and Integrative Medicine Therapies

Ankle Injury Mechanisms and Integrative Medicine Therapies


Anne J. Yatco, BS, MFA, Forensic Scientist at the Institute of Risk & Safety Analyses (anne@irsa.us, (818) 226-9974 x3)

Kenneth Alvin Solomon, PhD, PE, Post PhD, Chief Scientist at the Institute of Risk & Safety Analyses  (kennethsolomon@mac.com, (818) 348-1133)


The purpose of this article is to show the relationship between the mechanism of an ankle injury (inversion, eversion, etc.) and the most likely result of the injury (sprain, fracture, etc.).  While there are no absolute rules for positively associating each mechanism of injury with a specific type of injury, this article will provide some guidance for those attempting to prove or disprove the relationship between mechanism and injury type.  Furthermore, this article will illustrate common Integrative Medicine treatments for patients with ankle injuries, such as homeopathic remedies, including acupuncture.

Keywords: ankle sprain, ankle fracture, Integrative Medicine, acupuncture, homeopathy

Learning Objectives

Describe the roles of the various anatomical structures of the ankle.
Explain the mechanisms required to injure various anatomical structures of the ankle.
Discuss the common practices in complementary and alternative medicine, also known as Integrative Medicine, used to treat patients suffering from various ankle injuries.

The American Association of Integrative Medicine®(AAIM) provides this continuing education credit(s) for certified members, who are required to obtain 30 credits every 3 years to maintain their certification.

Take CEs HERE.

Ankle Injury Mechanisms and Integrative Medicine Therapies


Scope of Paper

A preliminary examination of the anatomy of the ankle, as well as the kinematics that the structures of the ankle generate, will precede a discussion of the types of injuries to the ankle.  Following will be a discussion of the relationship between the type of injury and the mechanism of injury, from both an anatomical point of view and by example.  Finally, we will discuss common Integrative Medicine treatments, which patients with ankle injuries might undergo as part of “whole body” treatments.

Ankle Anatomy

The ankle is formed by the distal tibia, distal fibula, talus, and calcaneus (Figure 1).   Superficially, the ankle’s landmarks are the bony prominences on each side of the ankle known as the medial and lateral malleoli, which are the rounded downward projections at the distal ends of the tibia and fibula, respectively (Figure 2).  The tibia, or shin bone, is the larger and stronger of the two bones of the leg below the knee, and connects the knee to the ankle.  The articular surface of the distal end of the tibia is also known as the plafond, or pilon.  The plafond articulates with the talus; together, they distribute weight bearing throughout the ankle (Small, 2009, p. 314). The fibula, or calf bone, is located on the lateral side of the tibia.  The fibula is connected to the tibia both proximally and distally.  The lower extremity of the fibula projects below the tibia and forms the lateral portion of the talocrural joint.  The fibula maintains ankle mortise stability during weight bearing.  The talus is the second largest of the tarsal bones.  The superior, dome-shaped surface of the body of the talus is known as the trochlea.  The calcaneus, or heel bone, meets the talus in two places: at the posterior and anterior talocalcaneal articulations.  The ankle is surrounded by the articular capsule, which is attached to the borders of the articular surfaces of the malleoli proximally and to the distal articular surface of the talus distally (Norkus & Floyd, 2001, p. 69).


Joints of the Ankle

The ankle is comprised of three joints: the talocrural joint, the subtalar joint, and the distal tibiofibular syndesmosis (Figures 3 and 4).  The talocrural joint, also known as the tibiotalar joint or the mortise joint, is a uniaxial, modified-hinge joint formed by the medial malleolus of the tibia, the lateral malleolus of the fibula, and the talus.  The tibial plafond articulates with the trochlea.  The convex shape of the trochlea allows it to fit snugly into the concave plafond, which stabilizes the ankle mortise, the fork-like structure of the malleoli (Norkus et al., 2001, p. 68).  This is important because the ankle bears more weight per unit area than any other joint in the body (Morrison & Kaminski, 2007, p. 135).  The medial malleolus articulates with the medial aspect of the trochlea, and the lateral malleolus articulates with the lateral aspect of the trochlea.  The talocrural joint allows for dorsiflexion and plantarflexion of the ankle.  The normal range of motion (ROM) for the ankle joint is 30 degrees of dorsiflexion and 45 degrees of plantarflexion.  Normal gait requires only 10 degrees of dorsiflexion and 20 degrees of plantarflexion (Small, 2009, p. 315).  During dorsiflexion, the wider anterior portion of the talus occupies much of the mortise as it wedges itself between the medial and lateral malleoli; this is considered the safest ankle position due to the increased joint stability created by the increased contact of the articular sufaces of the talocrural joint.

The subtalar joint lies just inferior to the talocrural joint.  The subtalar joint is a gliding joint, where the posterior aspect of the talus articulates with the superior aspect of the calcaneus.  The anterior subtalar joint is formed by the head of the talus, the anterior-superior facets, the sustentaculum tali of the calcaneus, and the concave proximal surface of the tarsal navicular.  The posterior subtalar joint is formed by the inferior posterior facet of the talus and the superior posterior facet of the calcaneus.  The anterior and posterior subtalar joints behave like a single ball-and-socket joint.  The subtalar joint averages a 42-degree upward tilt and a 23-degree medial angulation, allowing for inversion and eversion of the ankle (Fong, Chan, Yung, & Chan, 2009, p. 3).

The distal tibiofibular syndesmosis is a syndesmotic joint formed by the joining of the distal fibula and tibia by the anterior and posterior tibiofibular ligaments and the interosseous membrane (Molinari, Stolley, & Amendola, 2009). The distal tibiofibular syndesmosis allows for limited translation and rotation during dorsiflextion and plantarflexion, accommodating for the asymmetric talus (Fong et al., 2009, p. 3).

Ligaments of the Ankle Joint

The talocrural joint is supported by the anterior talofibular ligament, the posterior talofibular ligament, the calcaneofibular ligament at the lateral aspect (Figure 5), and the deltoid ligament at the medial aspect of the ankle (Figure 6).  The anterior talofibular ligament originates from the anterior-inferior border of the fibula and inserts into the neck of the talus.  It prevents anterior displacement and internal rotation of the talus during plantarflexion.  It has the lowest ultimate load, approximately 138.9 N, and it is the weakest of the lateral ligaments, making it the most susceptible to lateral ankle sprains (Fong et al., 2009, p. 3).  The posterior talofibular ligament also connects the talus and the tibia and provides stability to the posterior aspect of the lateral ankle.  The calcaneofibular ligament connects the calcaneus and the lateral malleolus and limits ankle inversion.  It is the strongest lateral ankle ligament.  Injury to the calcaneofibular ligament occurs when the ankle is dorsiflexed and an inversion force is applied.  The deltoid ligament is a flat, triangularly shaped ligament found on the medial aspect of the ankle.  The deltoid ligament has both a deep and a superficial portion.  It is comprised of the anterior tibiotalar, the posterior tibiotalar, the tibiocalcaneal, and the tibionavicular bands.  The deltoid ligament is considered to be the strongest ankle ligament.  During plantarflexion, it prevents excessive eversion and resists talar external rotation.  Injury to the deltoid ligament is uncommon and occurs due to excessive eversion (Norkus et al., 2001, p. 69; Small, 2009, p. 314).

The subtalar joint is supported by the deep ligaments, the peripheral ligaments, and the retinacula, which stabilize the subtalar joint and form a barrier between the anterior and posterior joint capsules.  The three lateral ligaments also prevent excessive inversion and lateral talar tilt at the subtalar joint (Fong et al., 2009, p. 3; Norkus et al., 2001, p. 69).

The anterior and posterior tibiofibular ligaments, along with the interosseous membrane, form a stable roof for the mortise of the talocrural joint and hold the tibia and fibula together (Figures 5 and 6).  These syndesmotic ligaments resist axial and rotational forces against the ankle.  The interosseous membrane also prevents posterolateral bowing of the fibula during weight bearing.  If the tibia’s articulation with the talus is shifted at all, the weight distribution on the talus can be altered, which may lead to early onset arthritis (Fong et al., 2009, p. 3; Molinari et al., 2009, p. 130; Norkus et al., 2001, p. 69; Small, 2009, p. 314).

Muscular Control of Ankle Motion

The following muscles have tendons, which pass behind the malleoli and act as ankle flexors: Peroneus longus; Peroneus brevis; Gastocnemius-Soleus complex; Flexor Hallucis longus; Flexor Digitorum longux; and Tibialis posterior.  The following muscles have tendons, which pass anterior to the malleoli and act as ankle dorsiflexiors:  Tibialis anterior; Extensor Hallucis Longus; Extensor Digitorum Longus; and Peroneus tertius (Martini & Bartholomew, 2000, p. 204-206; Patton, K.T., & Thibodeau, G.A., 2000, p. 228-229).  (Please refer to Table #1 and Figures 7, 8, and 9.)

Tendons of the Ankle

The Achilles tendon is the most notable tendon of the ankle joint.  The Achilles tendon is a large tendon, running from the heel to the calf, shared by the gastrocnemius and the soleus muscles, and it connects both muscles (as well as a third, vestigial muscle called the plantaris muscle) to the posterior calcaneus (Figures 5 and 6).  The attachment of the gastrocnemius and soleus muscles to the calcaneus allows for plantarflexion of the ankle.  The Achilles tendon is a strong, nonelastic, fibrous tissue that can absorb large forces associated with running, upwards of six to eight times the body’s weight (Dubin, 2005, p. 39).

Bursae of the Ankle

A bursa is a sac containing a viscid fluid that helps to reduce friction between moving parts.  Bursae are usually found over bony prominences and beneath tendons.  The bursae with the most clinical significance are the retrocalcaneal bursa, located between the Achilles tendon insertion site and the calcaneus, and the retroachilles bursa, located between the Achilles tendon and the skin (Aldridge, 2004, p. 334).  Injury to the bursae of the ankle is common, and may be concurrent with another injury to the ankle.

Common Ankle Injuries

Common ankle injuries include, but are not limited to, ankle sprains, ankle fracture, arthritis, tendonitis, and bursitis.  Please refer to Table #2:  Mechanisms & Examples of Ankle Injuries.


Ankle Sprains

Ankle sprains are the most common type of ankle injury.  Sprains occur as a result of the stretching or tearing of any of the ligaments surrounding the joints.  Sprains are typically classified as a grade I, II, or III sprain.  A grade I sprain is considered to be a mild sprain, involving stretching or inflammation of a ligament; a grade III sprain, on the other hand, is a complete tear of a ligament.  At this stage, the patient’s ankle will suffer a complete loss of function and motion, as well as mechanical instability (Ardizzone & Valmassy, 2005, p. 65; Wolfe, Uhl, Mattacola, & McCluskey, 2001, p. 93).  The three types of ankle sprains are lateral, medial, and high (syndesmotic).

Lateral ankle sprains are the most common.  The anatomy and biomechanics of the ankle puts the lateral ankle at the highest risk to sustain inversion injuries; in fact, 85% of ankle sprains are caused by an inversion mechanism (Morrison et al., 2007, p. 135).  Lateral sprains often occur from an inversion (or supination) force applied to a foot in plantarflexion.  For example, the common “twisted ankle,” in which the foot rolls inward and the patient lands on the outside of the foot, is a lateral sprain.  The anterior talofibular ligament is injured first and, if the force is great enough, the calcaneofibular ligament follows (Small, 2009, p. 316).

Medial ankle sprains, which are rare, occur when the deltoid ligament is injured during excessive eversion.  The foot rolls outward, and the patient lands on the inside of the foot.  Because the lateral malleolus extends further distally than the medial malleolus, the ankle has a smaller range of eversion than inversion, which accounts for the more common occurrence of lateral ankle sprains.  Deltoid ligament tears are typically associated with ankle fractures (Lynch, 2002, p. 410).

High ankle sprains, or syndesmotic sprains, are far less common than either lateral or medial sprains, accounting for only 1 to 11% of ankle sprains (Small, 2009, p. 317).  High ankle sprains manifest themselves in the separation of the tibia and the fibula, or the widening of the ankle mortise.  External rotation and hyperdorsiflexion are the most common causes of high ankle sprains.  External rotation causes injury to the tibiofibular ligaments, allowing the tibia and fibula to separate; hyperdorsiflexion causes the wide anterior portion of the talus to push the malleoli apart.  High sprains are common in collision sports including football, hockey, and soccer, as well as in skiing.  A blow to the lateral leg while the foot is planted, or a ski that sticks in the snow while turning, can result in external rotation (Figure 10).  Hyperdorsiflexion can occur when a hockey player’s skate is forced into the boards, or when a runner comes to a sudden stop with the foot planted and falls forward (Figure 11) (Molinari et al., 2009, p. 132; Norkus et al., 2001, p. 71-72).


 Ankle Fractures

Ankle fractures are classified as unimalleolar, bimalleolar, or trimalleolar.  Unimalleolar fractures involve injuries to either the medial or lateral malleolus.  Bimalleolar fractures involve injuries to both the medial and lateral malleoli.  A bimalleolar equivalent fracture occurs when the lateral malleolus is fractured and the deltoid ligament is completely ruptured.  Trimalleolar fractures involve a combination of both medial and lateral malleollar fractures and either a posterior malleolar or a posterior tibial fracture.  Mechanisms of unimalleolar, bimalleolar, and trimalleolar fractures include falling forward on top of the foot, falling onto the outside of the foot while the foot is planted (pronation-abduction), and excessive rotational force while the foot is planted.  Pilon fractures (fractures of the articular surface of the distal end of the tibia) are caused by axial loading mechanisms (i.e., falling from a considerable height and landing on one’s feet).

Ankle fractures are classified using two systems: the Danis-Weber classification, and the Lauge-Hansen classification.  The Danis-Weber classification system is based on the level of the fibula fracture.  Type A fractures occur distal to the joint line or ankle mortise (i.e., fractures below the ankle joint); type B fractures occur at the level of the ankle joint; and type C fractures occur proximal to (or above) the level of the ankle joint.  The Lauge-Hansen system is based on the mechanism of injury and pathology: the first part identifies the position of the ankle at the time of injury, and the second part identifies the type of force applied to the ankle.  There are four Lauge-Hansen classification groups:  supination-adduction, supination-external rotation, pronation-abduction, and pronation-external rotation (Small, 2009 p. 317-319).


Ankle Arthritis

Arthritis refers to inflammatory joint disease.  The presenting symptoms of arthritic joints include pain, swelling, stiffness, redness of the skin about the joint, effusion, deformity, and ankylosis (Rogers, 2011, p. 218).  Although the ankle joint is the most commonly injured joint of the human body, symptomatic arthritis of the ankle is nine times less likely than that at the knee and hip, and the ankle joint is rarely affected by osteoarthritis.  The most common causes of the degenerative changes of ankle arthritis are traumatic injuries (fractures of the malleoli, tibial plafond, and talus and ostochondral damage of the talar dome) and abnormal ankle mechanics (ankle instability due to chronic lateral ligament laxity) (Thomas & Daniels, 2003, p. 923).


Tendonitis of the Ankle

Tendonitis (tendinitis) is the inflammation of a tendon, and can affect the ankle joint when any of the tendons associated with the ankle joint, including the Achilles tendon, become inflamed.  Achilles tendonitis, as well as other Achilles tendon injuries, is common among runner and is caused by overuse, improper training, gait abnormalities, degenerative changes, and improper footwear (Dubin, 2005, p. 39). 


Bursitis of the Ankle Joint

Bursitis of the ankle joint is the inflammation of one, or more, of the bursae that surround the ankle joint.  The retrocalcaneal bursa and the retroachilles bursa are common sites of inflammation.  The most common cause of retrocalcaneal and retroachilles bursitis is ill-fitting footwear that irritates the area of the Achilles tendon insertion at the posterior calcaneus (Aldridge, 2004, p. 334).

Mechanism of Injury vs. Injury Type

There are no absolute rules for positively associating a type of ankle injury with a specific mechanism of injury, and vice versa.  For example, a supination-adduction mechanism of injury can result in a unimalleolar, bimalleolar, or trimalleolar fracture, depending on several variables such as the severity and the exact location of the application of the mechanism of injury.  Furthermore, an ankle injury may be associated with a secondary injury.  A working knowledge of the mechanisms of common ankle injuries, however, can lead one to postulate possible mechanisms for specific ankle injuries.

Imagine that a gymnast poorly dismounted from a balance beam, resulting in a trimalleolar fracture of the right ankle, which consisted of a spiral fracture of the distal fibula, an avulsion fracture of the posterior malleolus, and a transverse fracture of the medial malleolus.  Trimalleolar fractures typically occur when there is excessive rotational force while the foot is planted.  This gymnast’s injury can be explained by a supination-external rotation (or supination-lateral rotation) mechanism of injury: when the gymnast landed from her dismount, she rolled her foot inward (supination) as the foot rotated to her right (external rotation).  A rupture of the anterior inferior tibiofibular ligament will also be associated with this stage IV supination-external rotation injury (Arimoto & Forrester, 1980, p. 1060).


Integrative Medicine Therapies

Integrative medicine is a “whole-person” approach to treating a patient.  It aims to treat the person and not just the disease (in this case, the ankle injury) by treating the mind, body, and spirit.  As every patient is unique, a thorough understanding of the individual patient is essential and can be achieved through diet journals, patient interviews, and lab testing.  Most integrative medicine programs combine conventional Western medicine with alternative or complementary treatments and therapy, including herbal medicine, acupuncture, prolotherapy, massage, biofeedback, yoga, and stress reduction techniques.  Duke Integrative Medicine’s website states that through a partnership between the patient, physician, and a team of clinical experts, integrative medicine also anticipates possible health issues or risks and promotes prevention to minimize them (Duke Integrative Medicine, 2011).


Supplements and Herbs

According to the University of Maryland Medical Center, some nutrients and herbs help restore damaged tissue, reduce swelling, and provide pain relief: Vitamin C, beta-carotene, glucosamine, chondroitin, calcium, and magnesium promote the healing and rebuilding of tissues.  Pain relief can be achieved with the use of willow bark, cat’s claw, and devil’s claw.  Bromelain, licorice, white willow, Vitamin E, and essential fatty acids such as fish oil or primrose oil reduce inflammation.  White willow, Aescin, and Tumeric reduce swelling.  Vitamin C, beta-carotene, and Vitamin A help improve immune function (Ehrlich, March 7, 2010; March 29, 2010).



Acupuncture originated in China many centuries ago.  Its use spread throughout Asia, and it was introduced to Europe in the 17th century.  Acupuncture aims to heal through the stimulation of anatomical points on the body and involves penetrating the skin with thin, solid, metallic needles manipulated by the hands or by electrical stimulation.  According to the World Health Organiztion (2003), other techniques associated with acupuncture include moxibustion (the burning on or over the skin of selected herbs), laser acupuncture, and acupressure.  According to traditional Chinese medicine, acupuncture regulates the flow of qi, or vital energy, through the body, thus keeping the body in a balanced state (National Center for Complementary and Alternative Medicine, 2011).  The World Health Organization compiled a review and analysis of controlled clinical trials of acupuncture therapy.  The study concluded that acupuncture analgesia works better than a placebo for most kinds of pain, and is highly effective in treating chronically painful conditions.  Acupuncture alleviates pain and reduces muscle spasm; for the treatment of sprains, acupuncture can also improve local circulation, thus speeding up the recovery time (World Health Organization, 2003).



The guiding principle of homeopathy is the principle of similars or “like cures like” in which a disease can be cured by a substance that produces similar symptoms in healthy people.  Another important principle of homeopathic treatments is dilution: the lower the dose of the medication, the greater its effectiveness.  Most homeopathic remedies are so dilute that no molecules of the healing substance remain; even so, the healing substance leaves its imprint or “essence,” and it is this essence that cures the disease.  Homeopaths treat patients based on genetic and personal history, body type, and current symptoms so that remedies are individualized to each patient.  Homeopathic remedies are derived from natural substances that come from plants, minerals, or animals (National Center for Complementary and Alternative Medicine, 2010).  Ehrlich (March 29, 2010), with the University of Maryland Medical Center, lists Arnica (topical or internal), Byronia, Ledum, Rhus toxicodendron, Ruta, and Traumeel as homeopathic remedies for sprains.  Ehrlich (March 7, 2010) also lists Byronia, Phytolacca, Rhus toxicodendron, and Rhododendron, as well as injectable homeopathic medications such as Traumeel, as homeopathic remedies for tendonitis. In the treatment of acute injuries, Traumeel, an inflammation regulating drug, is often combined with Spascupreel (for muscle strains) and Lymphomyosot (for tissue swelling) (Barkauskas, 2007, p. 6).

A case study by Steven Rosenberg, D.P.M., (1998) related his homeopathic treatment of a 45-year-old woman with an ankle sprain.  After a physical examination and evaluation of x-rays of the left ankle, Dr. Rosenberg diagnosed this patient with a 1st degree left ankle sprain.  He treated the patient with multiple subcutaneous injections of Traumeel to all three ligament sites in the lateral aspect of the ankle.  An Unna boot soft immobilization cast was applied to the left ankle to provide stability and compression.  The patient was also given Traumeel (anti-inflammatory), Osteoheel (pain relief), and Lymphomyosot (edema relief) tablets to help decrease the pain, inflammation, and swelling, and Traumeel ointment for topical application.  The following day, the patient had a less painful ankle that could support her weight.  The swelling was decreasing, and she could flex her ankle without pain (p. 280).  This case study shows how conventional techniques (application of the Unna boot) in concert with alternative medicine (homeopathic remedies) can effectively relieve the symptoms of ankle injuries.



Prolotherapy involves a series of injections of irritants, osmotic shock agents, and/or chemotactic agents designed to stimulate low-grade inflammation in injured tissues, specifically ligaments, tendons, and cartilage, which promotes tissue repair and/or growth.

When tissues, such as ligaments, are injured, the common initial response is inflammation, which stimulates substances carried in blood that produce growth factors in the injured area to promote healing.  Ligaments, tendons, and cartilage, however, have poor blood supply and take longer to heal than other tissues.  As a result, incomplete healing of these structures is common.  Traditional treatments for ligament and tendon injuries include anti-inflammatory medications (ibuprofen and Naprosyn), nonsteroidal anti-inflammatory drugs (NSAIDS), or corticosteroids to relieve pain and/or swelling to provide temporary relief.  Gordin (2011) wrote that a study by Dr. Richard Wrenn demonstrated “suppressed fibroblastic reacitons (connective tissue formation) to injury following intramuscular injections of cortisone” (p. 601).  Proponents of prolotherapy argue that by suppressing inflammation and/or fibroblast proliferation and collagen formation, these traditional treatments actually suppress the body’s natural healing process, and the injured tissues do not fully heal.  As a result, many patients suffer from chronic ankle sprains, laxity, or instability due to incomplete healing.

According to Alderman (2007), the use of prolotherapy techniques dates back to Ancient Greece and Hippocrates, who used red-hot needle cautery to treat dislocated shoulders, but the term “Prolotherapy” was by George S. Hackett, M.D., in 1956 as “the rehabilitation of an incompetent structure [ligament or tendon] by the generation of new cellular tissue” (p. 10-11).  Gordin (2011) states that common proliferant solutions used in prolotherapy treatments include dextrose, glycerin, minerals, sodium morrhuate, autologous growth factors, and other pro-inflammatory compounds.  These injected substances irritate the injured ligaments, tendons, or cartilage, which stimulates the formation of collagen (the major component of connective tissue, i.e. ligaments and tendons) via the production of fibroblasts (cells that synthesizes collagen), resulting in tissue growth and repair of injured structures (p. 605-606).

Numerous studies have demonstrated the development and growth of new ligamentous tissue in joints throughout the body using prolotherapy treatment.  A case study by Clive Sinoff, M.D., (2010), documented prolotherapy treatment of a 58-year old man with a 20-year-old ankle injury.  This gentleman injured both ankles due to a fall off a roof.  He had physical therapy for 7 years, underwent arthrodesis of both ankles and the right foot, and utilized therapeutic ultrasound, a TENS unit, and hot foot soaks to only transient, mild relief.  Prolotherapy treatments were started in May 2006 and ended in August 2008 (a total of seven sessions over two years).  By July 2009, the patient reported minimal pain and no longer needed analgesiscs (p. 487-488).


Although the anatomy of the ankle is complex, a careful examination of the individual components of the ankle makes the entire structure easier to understand.  The same process applies to ankle injuries: once the specific functions of the components of the ankle are examined, the mechanisms of injury to those same components become clear.  Through this examination of the ankle and its mechanisms of injury, it is easy to see why people suffer ankle injuries when applied forces cause the components of the ankle to exceed their physical limits. Additionally, through Integrative Medicine, treatment of ankle injuries (and symptoms) can be performed in concert with treatment of the whole patient using alternative and complementary techniques.



(Arnheim & Prentice, 1993; Dox, Melloni, & Eisner, 1993;Kapit et al., 1993)


Abduction: Movement of away from the midline of the body.
Adduction: Movement of toward the midline of the body.
Anterior: Before or in front of.
Distal: Farthest from a center, from the midline, or from the trunk.
Dorsiflexion: Movement of the superior surface of the foot toward the leg.
Eversion: Outward turning of the sole of the foot.
External Rotation: Rotation away from the midline of the body.
Internal Rotation: Rotation toward the midline of the body.
Inversion: Inward turning of the sole of the foot.
Kinematics: The science of motion of the parts of the body.
Lateral: Located on the side; farther from the midline.
Mechanism: The manner in which an effect is produced.
Medial: Relating to the middle; near the median plane.
Plantarflexion: Movement of the forefoot away from the leg.
Posterior: Located behind a structure; relating to the back or dorsal side.
Pronation: Within the ankle, a combination of calcaneal eversion, foot abduction, and dorsiflexion.
Proximal: Nearest to the point of reference.
Supination: Within the ankle, a combination of calcaneal inversion, foot adduction, and plantarflexion.



Figure 1.  Bony anatomy of the ankle (anterior view)


Figure 2.  Bony anatomy of the ankle (posterior view)


Figure 3.  Joints of the ankle (anterior view)


Figure 4.  Joints of the ankle (posterior view)


Figure 5.  Ligaments of the ankle (lateral view)


Figure 6:  Ligaments of the ankle (medial view)


Figure 7:  Muscles of the ankle (lateral view)


Figure 8. Muscles of the ankle (posterior view)


Figure 9.  Muscles of the ankle (anterior view)


Figure 10. Mechanism of a high ankle sprain:  a blow to the lateral leg while the foot is planted


Figure 11. Mechanism of a high ankle sprain:  falling forward onto a planted foot


Table #1

 Muscles of the Ankle

Insertion of tendon Muscle Action
Behind the malleoli Peroneus longus Plantarflexion, eversion
Peroneus brevis Plantarflexion, eversion
Gastrocnemius-Soleus complex Plantarflexion
Flexor Hallucis longus Plantarflexion
Flexor Digitorum longus Plantarflexion
Tibialis posterior Plantarflexion, inversion
Anterior to the malleoli Tibialis anterior Dorsiflexion, inversion
Extensor Hallucis longus Dorsiflexion, inversion
Extensor Digitorum longus Dorsiflexion
Peroneus tertius Dorsiflexion, eversion



Table #2

 Mechanisms & Examples of Ankle Injuries

Injury Mechanism of Injury Examples of How Injury Occurs
Lateral Ankle Sprain inversion and plantarflexion “twisted Ankle”
Medial Ankle Sprain eversion landing on the inside of the foot after jumping
High (Syndesmotic) Ankle Sprain external rotation and hyperdorsiflexion a blow to the lateral leg while the foot is planted, falling forward onto a planted foot
Unimalleolar Fracture supination-adduction, supination-external rotation, pronation-adbuction, and pronation-external rotation falling onto the top of the foot
Bimaleollar Fracture supination-adduction,supination-external rotation, pronation-abduction, and pronation-external rotation falling onto the outside of the foot while the foot is planted (pronation-adbuction)
Trimaleollar Fracture supination-adduction,supination-external rotation, pronation-abduction, and pronation-external rotation excessive rotational force while the foot is planted
Ankle Arthritis posttraumatic degenerative joint disease; may also be osteoarthritic, rheumatoid, or septic in nature prior trauma, age
Tendonitis tight gastrocnemius and soleus muscles, overpronation of the subtalar joint, degeneration overuse of the calf muscles, abnormal stress on the ankle, age
Bursitis irritation of the area of the Achilles tendon insertion at the posterior calcaneus ill-fitting footwear


Alderman, D.  (2007, January/February).  Prolotherapy for musculoskeletal pain.  Practical Pain Management, 7 (1), 10-15.  Retrieved from http://www.prolotherapy.com/ppm2007.pdf

Aldridge, M.D.  (2004).  Diagnosing heel pain in adults.  American Family Physician, 70 (2), 332-338.

Ardizzone, R., & Valmassy, R.L.  (2005). How to diagnose lateral ankle injuries.  Podiatry Today, 18 (10), 65-74.

Arimoto, H. K., & Forrester, D. M.  (1980).  Classification of ankle fractures:  an algorithm.  American Journal of Roentgenology, 135, 1057-1063.

Arnheim, D. D., & Prentice, W. E.  (1993).  Principles of Athletic Training (8th ed.).  St. Louis: Mosby Year Book.

Barkauskas, D.  (2007).  Treating sports injuries—a functional approach.  Journal of Biomedical Therapy, 1(1), 4-8.

Brody, J. E.  (2007, August 7).  Injections to kick-start tissue repair.  The New York Times.  Retrieved from http://www.nytimes.com/2007/08/07/health/07brod.html?_r=2&pagewanted

Dox, I.G., Melloni, B.J., & Eisner, G.M. (1993).  The Harper Collins Illustrated Medical Dictionary. New York: HarperCollins.

Dubin, D.C.  (2005)  Athletes strain to avoid Achilles tendon problems.  Biomechanics, http://www.biomech.com/full_article/?ArticleID=645&month=08&year=2005

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Ehrlich, S. D. (2010, March 7). Tendinitis. Retrieved from http://www.umm.edu/altmed/articles/tendinitis-000163.htm

Ehrlich, S. D. (2010, March 29). Sprains and Strains. Retrieved from http://www.umm.edu/altmed/articles/sprains-and-000157.htm

Fong, D.T.P., Chan, Y., Mok, K., Yung, P.S.H., & Chan, K.  (2009). Understanding acute ankle ligamentous sprain injury in sports.  Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology, 1 (14).  doi:  10.1186/1758-2555-1-14.

Gordin, K.  (2011, May).  Case for prolotherapy.  Journal of Prolotherapy, 3 (2), 601-609.  Retrieved from http://www.journalofprolotherapy.com/pdfs/issue_10/JOP_vol_3_issue_2_may_2011.pdf#page=11

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About the Authors

Solomon_KennethKenneth Alvin Solomon, PhD, PE, Post PhD is Chief Forensic Scientist at The Institute of Risk and Safety Analyses (www.irsa.us) His formal education includes a BS, MS, and PhD in Engineering and a Post PhD each from U.C.L.A. (1971, 1971, 1974, and 1977, respectively).  For the majority of his professional career he was a senior scientist at RAND (Santa Monica, CA) as well as faculty at the RAND Graduate School and Adjunct Professor at U.C.L.A., U.S.C., Naval Post Graduate School, and George Mason University.  He served as a Professional Service Reserve with two police agencies and a Police and Safety Commission.  Dr. Solomon and his staff are engaged in Forensic studies primarily concentrating in accident reconstruction, bio-mechanics, and human factors.


YatcoMs. Yatco obtained a Bachelor of Science degree in Biomedical Engineering with an emphasis in biomechanics from Marquette University in Milwaukee, Wisconsin, and a Masters in Fine Arts degree in Acting from the California Institute of the Arts in Valencia, California.   Her studies included classical mechanics, CAD, physiology, and biochemistry.  She also assisted in research projects through Marquette University’s Biomedical Engineering Department.  Ms. Yatco utilizes her knowledge of classical mechanics, biomechanics, and the mechanics of injury at the Institute of Risk & Safety Analyses to determine the potential for injury in a given accident.

Time Line Treatment of Pain

Alternative Fascinating Case History

Time Line Treatment of Pain

Dollie Mercedes
PhD, DD, MBA, Master Practitioner NLPtm,
Trainer EduKtm, Dx Thought Field Therapy,
Board Certified Professional Counselor,
American Psychotherapy Association

Productive Transitions
Santa Rosa. California

In integrative healing, there are many modalities.  Some techniques speak to certain individuals, and other techniques serve others.

I have used Neuro Linguistic Programming, NLPtm for many years along with several other energy techniques and found effective results.  In certain cases, I used an advanced NLPtm technique called Time Line Therapytm. (Developers discussed the process in their book, Time Line Therapy and the Basis of Personality, James & Woodsmall, 1988.)

Indicators that one should use this technique are that a patient’s problem has been long-term and does not seem to connect to an obvious trauma or event that would explain his or her discomfort.  Several cases have involved unexplained physical pain.  One of the more dramatic cases follows.

In the spring of 1987, a young man in his 30s was referred to me by his mother.  He had had “head pain” all his life.  All examinations had found no trace of any physical cause.  After the intake and probing questions, I chose to use the time line process.  As stated, there seemed to be no obvious cause that he or the family could recall.  His mother had cued me that this condition existed all his life, and the family had consulted medical personnel to examine him with no cause or solution found.

The first step is to find out how the client perceives the time relationship in his/her life.  I ask questions to determine where (in what direction) the thoughts of past and present seem to come from.  Most often, the past comes from behind and the present moves toward the front.  In other cases, the past may be toward the left, etc.  The key to this process is rationalizing some key event – that is, take the emotional hook out of it – as a way of neutralizing the memory.

After establishing the patient’s time line in his mind, I guided him to travel above the line toward his past until he was aware of the very first time some emotional event happened to cause the head pain.  One of the first questions I ask when guiding a client is, “Was the very first time before, during, or after your birth into this life?”

The patient’s head was bowed, his eyes open.  His mouth said “before,” but no sound came out.  When asked a second time, with the instructions to take whatever came up, he again mouthed the word “before.”  Finally, he spoke it out loud.  When I probed, he told me it was three lifetimes ago.

When I asked him to describe from above what he saw (I do not see things for others, they see and describe what they experience), he described a scene from his death in one of those former lifetimes wherein he was being scalped.

I guided the process down through the clearing process and brought it up and forward above his time line to the present, and then onward into the future.  Then I instructed him to return to the present and “be here now.”

The next day, his mother asked how the appointment went.  He said, “I don’t know if I believed that stuff.”  After his mother asked about the head pain, he responded, “It’s gone.”

His mother commented, “Does it matter whether you believe it or not?”

There is no head pain to this day.

Treatment for Survivors of Natural Disasters

Treatment for Survivors of Natural Disasters

Lauren T. Bradel, MA
Northern Illinois University
Kathryn M. Bell, PhD
Capital University

Correspondence: Lauren T. Bradel, MA, Department of Psychology, Northern Illinois University, DeKalb, IL 60115. Email: ltbradel@gmail.com. Phone: 218-760-3387.
Correspondence: Kathryn M. Bell, PhD, Assistant Professor, Psychology Department, Capital University, Columbus, OH 43209. Email: kbell626@capital.edu. Phone: 614-236-6439.


Natural disasters such as floods, earthquakes, tornadoes, and hurricanes can lead to significant psychological (and physical) impairment in populations both directly and indirectly exposed to the disaster. Although not everyone who survives a natural disaster responds aversively, a relatively large number of people do. In adults, stress reactions following a natural disaster may range from heightened anxiety and an increase in the frequency of nightmares to debilitating post-traumatic stress and severe depression. Of individuals exhibiting severe aversive reactions to natural disasters, many fail to utilize available mental health care services for one reason or another. Treatment approaches and strategies for enhancing treatment utilization among natural disaster survivors are discussed.

Keywords: trauma, natural disaster, PTSD, treatment

Learning Objectives:
1. Raise the audience’s awareness of psychological problems commonly experienced by natural disaster survivors
2. Increase the audience’s knowledge of factors related to the development of psychopathology following natural disasters
3. Improve the audience’s understanding of treatment barriers for natural disaster survivors and provide suggestions for overcoming these barriers
4. Enhance the audience’s understanding of evidence-based approaches to treating survivors of natural disasters

Program Level: Beginners

Prerequisites: None

Target Audience:
Psychologists who currently work with or may in the future work with survivors of natural disasters According to the National Comorbidity Survey, nearly 19% of men and 15% of women report having experienced a natural disaster, or naturally-occurring catastrophe that is not man-made, at some point during their lifetimes (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Research has indicated that, for survivors, natural disasters tend to result in slightly fewer negative psychological outcomes than man-made disasters, such as plane crashes and acts of terrorism (David et al., 1996). In spite of this, natural disasters have been shown to lead to significant psychological impairment in adult survivors. Multiple studies have shown an increase in psychopathology following natural disasters that may linger for years following the event (Boe, Holgersen, & Holen, 2010; van Griensven et al., 2006).

AAIM members can take the CE test HERE


Psychopathology Following a Natural Disaster


Post-traumatic stress disorder (PTSD) and posttraumatic stress symptoms have been shown to be one of the most prominent psychological conditions to develop following a natural disaster (David et al., 1996; Mason, Andrews, & Upton, 2010; Schoenbaum et al., 2009). PTSD and posttraumatic stress symptoms can result from exposure to a traumatic event and cause significant distress or impairment. PTSD is characterized by the development of intrusive recollections of the event, avoidance of stimuli associated with the event, and hyperarousal that persist for more than one month (American Psychiatric Association [APA], 2000).

Prevalence rates of PTSD and posttraumatic stress symptoms following a natural disaster vary across a number of studies. In a study by Tobin and Ollenburger (1996) , survivors of a flood were interviewed by telephone approximately four months after the natural disaster occurred. Nearly 71% of survivors reported experiencing some posttraumatic stress symptoms, with 25% of survivors reporting a high level of posttraumatic stress symptoms. Additional studies have also shown that individuals with preexisting psychological disorders may be at an increased risk for developing PTSD or posttraumatic stress symptoms following a natural disaster (Boe et al., 2010; McMillen, North, Mosley, & Smith 2002; Tobin & Ollenburger, 1996).


Research indicates that major depression often accompanies posttraumatic stress symptoms in survivors of natural disasters (McFarlane & Papay, 1992; North, Kawasaki, Spitznagel, & Hong, 2004). In a study conducted by Başoğlu, Kiliç, Şalcioğlu, and Livanou (2004), 16% of survivors who were at the epicenter of an earthquake in Turkey met diagnostic criteria for comorbid PTSD and depression. Ruminating, or constantly turning something over in one’s mind, related to symptoms of depression and posttraumatic stress has also been shown to increase the likelihood of developing depression following a natural disaster (Nolen-Hoeksema & Morrow, 1991). McLeish and Del Ben (2008) found that one month after Hurricane Katrina, depression scores in an outpatient population significantly increased, but PTSD scores remained unchanged.


Anxiety is another common psychological outcome following natural disasters, and it can come in several forms. In studying earthquake survivors in Turkey, Karanci and Rustemli (1995) found that survivors experienced a range of anxiety varying between phobic anxiety, somatization, and hostility, and many individuals’ symptoms were still chronic at a 16 month follow-up. Likewise, McFarlane and Papay (1992) found that survivors of a natural disaster experienced the development of both phobias and panic disorders following the event. Further, individuals suffering from high levels of general anxiety prior to the disaster were at an increased risk for experiencing higher-than-normal levels of post-disaster anxiety (Tobin & Ollenburger, 1996).

Substance Use

To date, research is inconclusive regarding how substance use changes in survivors of natural disasters, although many studies indicate that, as a whole, general substance use increases. For example, Parslow and Jorm (2006) found that survivors of a major bushfire in Australia significantly increased their tobacco use following the disaster—regardless of posttraumatic stress symptomology. Conversely, Beaudoin (2011) found that alcohol use following Hurricane Katrina significantly increased, but tobacco use did not. Beaudoin hypothesized that tobacco use did not increase because of the recent emphasis on publicizing tobacco’s adverse effects. In a third study, North and colleagues (2004) found no significant differences in pre- and post-disaster alcohol use in a sample of male flood survivors.

Although findings relating to natural disasters and substance use are relatively inconclusive, an abundance of research has supported the idea that surviving a traumatic experience, in general, is significantly related to increased substance use (Fetzner, McMillian, Sareen, & Asmundson, 2011; Khoury, Tang, Bradley, Cubells, & Ressler, 2010). Furthermore, Jacobsen, Southwick, and Kosten (2001) found that a diagnosis of PTSD often predicts substance use in trauma survivors. In a sample of individuals who had survived various traumatic experiences, Breslau, Davis, and Schultz (2003) did not find that PTSD preceded trauma survivors’ substance use, but they found that individuals did significantly increase nicotine use following the traumatic event. The authors hypothesized that PTSD and substance use disorders may be influenced by shared risk factors—other than trauma exposure—and this is why increased drug and alcohol use were not found to increase after the trauma.

Correlates of Psychopathology Following a Natural Disaster


Several factors have been shown to influence the impact natural disasters have on an individual. Exposure to the disaster may be one of the most important risk factors for developing posttraumatic stress reactions (Kessler, Galea, & Jones,2006). Multiple studies have shown that the greater the degree of exposure to a natural disaster, the more likely the development of negative mental health outcomes (Galea, Nandi & Vlahov, 2005; Nolen-Hoeksema & Morrow 1991; Rhodes et al., 2010; Thompson, Norris, & Hanacek, 1993). In a study focused on earthquake survivors, Bland, O’Leary, Farinaro, Jossa, and Trevisan (1996) found that individuals’ psychological outcomes were directly positively correlated to the magnitude of personal consequences relating to the earthquake.

Likewise, several studies have indicated that relocation is related to negative psychological outcomes. Weems and colleagues (2007) found that individuals needing to evacuate during Hurricane Katrina exhibited significantly more posttraumatic stress symptoms than those who did not relocate. Similarly, in a study conducted in the United Kingdom, Mason, Andrews, and Upton (2010) found that having to relocate following a natural disaster, in addition to suffering high levels of exposure to the disaster, was a significant predictor of the development of psychopathology. Specifically, individuals needing to vacate their homes were, on average, two times more likely to meet diagnostic criteria for PTSD, anxiety, and/or depression. Davis, Grills-Taquechel, and Ollendick (2010) report similar findings, noting that individuals displaced by Hurricane Katrina experienced significantly higher levels of psychopathology than non-displaced individuals. In fact, they found housing to be one of the top stressors related to the hurricane.

Loss may also play a role in the development of mental health problems following the disaster. For example, loss, in general, has been shown to be significantly related to an increased likelihood of suffering negative mental health outcomes (Mason et al., 2010). Similarly, in a study looking at flood victims, Tobin and Ollenburger (1996) found that temporary or permanent loss of employment due to the flood was significantly related to individuals experiencing increased levels of stress. Death of a loved one during the natural disaster was also shown to increase stress levels. Research following Hurricane Katrina also showed that watching exposure to the hurricane in the form of excessively watching television coverage of the disaster and a loss of electricity were predictive of negative psychological outcomes (McLeish & Del Ben, 2008).

Social Support

Social support has been shown to be an important factor influencing the development of stress related to natural disasters (Galea et al., 2005; Lowe, Chan, & Rhodes, 2010). Kwon, Maruyama, & Morimoto (2001) found that low social support is associated with a higher likelihood of developing PTSD following a natural disaster. They also found that individuals perceiving greater social support prior to the disaster experienced less psychological distress, experienced fewer stressors, and perceived more social support following the natural disaster which, in turn, was related to lower post-disaster psychological distress. Subsequent to Hurricane Katrina, multiple studies reported that a high level of perceived pre-disaster support, emotional support throughout the disaster, and post-disaster companionship provided through sources such as churches and community centers were all predictive of fewer negative psychological outcomes as compared to individuals who did not receive those types of support (Ruggiero et al., 2009; Weems et al., 2007).

Preexisting Health Conditions

Natural disaster survivors with a prior history of trauma exposure or preexisting psychological condition may be more likely to develop PTSD than those with no preexisting trauma history or psychological condition (McMillen et al., 2002). For example, in a study conducted in the United Kingdom, flood survivors who had experienced a prior flood were at an increased risk of developing symptoms of posttraumatic stress and anxiety (Mason et al., 2010). The authors surmised that this relationship between prior disaster exposure and psychopathology may have been the result of the propensity of survivors to fear the reoccurrence of another exposure, and therefore, resulted in increased anxiety. Likewise, natural disasters can exacerbate pre-existing psychiatric symptoms and may also trigger the development of additional symptoms, such of depressive symptoms (McLeish & Del Ben, 2008; Schoenbaum et al., 2009). Similarly, individuals with poor physical health prior to the disaster may be as much as two to four times more likely to meet diagnostic criteria for PTSD, anxiety, or depression following exposure to a natural disaster than someone who was physically healthy prior to the disaster (Mason et al., 2010).

Individual Characteristics

Gender has also been shown to be associated with the likelihood of developing stress reactions to a natural disaster, including PTSD. Mason and colleagues (2010) found that, on average, female survivors of natural disasters scored higher on PTSD, anxiety, and depression scales than male survivors. Preliminary research suggests that low-income single mothers may be particularly vulnerable to the development of stress reactions (Lowe et al., 2010). Studies have also shown that factors such as neuroticism, guilt, problems with concentration, and obsessive traits are directly positively related to the development of PTSD following exposure to a natural disaster (Carr et al., 1997; Chen et al., 2001; Kuo et al., 2003; McFarlane, 1988).


The tendency to interpret a disaster in a negative way has been shown to be related to negative psychological outcomes (Tobin & Ollenburger, 1996). In a study looking at risk and resiliency factors following a hurricane, Lowe and colleagues (2010) found that individuals who appraised the disaster negatively were at an increased risk for negative psychological outcomes following the disaster than those who did not evaluate the hurricane as negatively. In fact, appraisals of the event were stronger predictors of posttraumatic stress than exposure to the disaster itself. Similarly, Ruggiero et al. (2009) found that, in individuals affected by the 2004 Florida hurricanes, extreme fear during the hurricanes was a strong predictor of individuals’ overall health.


Notably, suicide is not among the prevalent psychological consequences of natural disasters. Research has shown that, although psychological distress may increase following a disaster, suicide rates do not necessarily increase as well (Kessler et al., 2006). For example, Krug et al. (1999) tracked suicide rates in various countries affected by natural disasters and found relatively no change in suicide rates. Similarly, Kessler et al. (2006) found that suicidality (ideation and suicide plans, but not attempts) was actually lower following Hurricane Katrina than before. Findings such as these suggest that factors other than just trauma exposure and psychopathology may play a role in individuals’ decisions to commit suicide. In fact, research on man-made disasters suggests that some aspects of post-disaster personal growth may actually be beneficial and protect against suicide in individuals with a clinically significant mental illness (Mezuk et al., 2009). Future research is needed to examine post-disaster personal growth and its impact on suicide risk among individuals exposed to natural disasters.

Factors Related to Treatment

Treatment Utilization

Few studies have been conducted looking at mental health service use following natural disasters. Most existent research looking at treatment utilization focuses on service use following Hurricane Katrina. For example, in a telephone survey of Hurricane Katrina survivors by Wang and colleagues (2007), only 16% of respondents had used mental health services following the hurricane. Furthermore, only 4% of respondents were currently seeing a mental health professional whereas 11% were regularly visiting a general medical practitioner. In another telephone study, Wang and researchers (2008) found that 23% of respondents with preexisting mental health issues who used mental health services prior to the hurricane had either reduced or terminated treatment after Katrina. Of those individuals receiving treatment after the hurricane, nearly 65% were being treated by a general medical practitioner as opposed to a mental health professional. Polusny and colleagues (2008) report similar findings with tornado survivors, noting that participants were significantly more likely to seek treatment from a general medical practitioner than a mental health care professional.

Wang and colleagues (2007) report a dropout rate for psychotherapy of nearly 60% following Hurricane Katrina. Of those who sought treatment but discontinued, the authors found that drop out was for a number of reasons including financial limitations (22%); lack of enabling factors, such as transportation (42%); feeling their psychological concerns were not severe enough to justify seeking treatment (50%); and feeling as though their psychological concerns would resolve naturally over the course of time (52%). In a study of individuals with at least five symptoms of depression, Nutting, Rost, Smith, Werner, and Eliot (2000) reported similar findings with 57% of participants beginning treatment but only 17% completing treatment. Dissimilar to Wang and colleagues (2007), Nutting et al. (2000) attributed the high drop-out rate to severe physical problems that, likely, detracted from individuals’ interest in seeing treatment of psychological concerns.

Characteristics Influencing Healthcare Utilization Following a Natural Disaster

Various demographic variables have been shown to be related to the mental health services individuals receive following a natural disaster, including Hurricane Katrina. Studies looking at correlates of healthcare utilization following natural disasters have found that women are significantly more likely to seek services than their male counterparts (Rosen, Matthieu, & Norris, 2009; Roy-Byrne, Joesch, Wang, & Kessler, 2009; Wang et al., 2007; Wang et al., 2008). Furthermore, being a member of a minority group is related to significantly less healthcare use than White individuals, and being a member of a minority group has also been shown to be a significant predictor of treatment drop-out (Roy-Byrne et al., 2009; Wang et al., 2007). Multiple studies show that individuals who are middle-aged are the most likely age group to receive healthcare services following a natural disaster; the elderly and children are the least likely to receive proper healthcare (Rosen et al., 2009; Roy-Byrne et al., 2009; Wang, 2007). Additionally, individuals who are married, currently co-inhabiting with a partner, or have been married at some point in life are more likely to seek healthcare services than individuals who do not fall into one of those categories (Roy-Byrne et al., 2009; Wang et al., 2007).

Education and socioeconomic status are also significant predictors of healthcare service utilization after a natural disaster. Roy-Byrne and colleagues (2009) found that following Hurricane Katrina, individuals with a high school education and below were less likely to receive adequate healthcare services than those with more extensive education. Similarly, individuals with modest incomes prior to the hurricane were less likely to receive healthcare services than individuals with extremely low incomes or more substantial incomes (Roy-Byrne et al., 2009; Wang et al., 2007). Also related to education and income, individuals with no health insurance were less likely to receive healthcare than individuals who had coverage (Wang et al., 2007; Wang et al., 2008).

Research exploring pre-disaster health as a potential predictor of who will receive healthcare services—and specifically, physician referrals—following a natural disaster has been inconclusive. In a study by Rosen and colleagues (2009), results indicated that individuals who experienced significant disaster-related loss were more likely than those who had not experienced a significant disaster-related loss to receive referrals for healthcare services. Likewise, individuals who suffered from a disability prior to the natural disaster are often more likely to receive a referral than individuals who did not have a prior disability (Rosen et al., 2009). Conversely, Rosen and researchers (2009) found that individuals suffering from pre-disaster mental illness were less likely to receive a referral for post-disaster assistance than individuals not previously suffering from a mental illness.

Enabling resources are also important factors in determining whether or not individuals seek healthcare services after a disaster. Facilities must be available, individuals need access to transportation to make use of available services, travel times must be reasonable, and potential clients need to have the knowledge of how to use the services available to them (Wang et al., 2008). Given the risk for resource loss during a natural disaster (e.g., loss of electricity, telecommunications, transportation), it is no wonder that some survivors are unaware of available resources and/or may not have the means to access these resources even though they might otherwise be interested in utilizing these resources.

Not only do demographic variables and resources predict healthcare utilization, but attitudes towards healthcare services are also a significant predictor of use following a natural disaster. Low perceived need, or the belief that symptoms will diminish over time, is a common factor that prevents individuals from seeking post-disaster services (Wang et al., 2007; Wang et al., 2008). Similarly, individuals’ perceptions of their own symptoms and how they are still able to function may influence if they judge their problems as severe enough to require help from a mental health professional (Polusny et al., 2008). Stigma and the belief that treatment is useless—although this belief is less common than low perceived need—are other reasons that individuals may avoid seeking healthcare services after a disaster (Wang et al., 2007; Wang et al., 2008).

Specific psychiatric symptoms may also influence one’s decision to seek treatment and from whom they seek that treatment. For example, individuals suffering from PTSD Cluster C (avoidance) symptoms are more likely to use post-disaster healthcare than individuals suffering from other posttraumatic stress symptoms (Polusny et al., 2008). Findings also indicate that individuals may be more likely to seek services from a general practitioner rather than a mental health provider following exposure to natural disaster. Researchers from this study hypothesized that survivors experiencing a greater number of PTSD avoidance symptoms may avoid mental healthcare because they fear treatment will focus on the traumatic event (Polusny et al., 2008).

Current Treatment Methods

Critical Incident Stress Debriefing

Critical Incident Stress Debriefing (CISD), a group-based method of psychological debriefing (PD), has become common practice following various types of traumatic events. The goal of CISD is, generally, to minimize the adverse psychological impact of traumatic events through a brief intervention immediately following the event. Specifically, Mitchell (1983) explains that CISD is usually applied in seven phases: introduction, facts, thoughts/impressions, emotional reactions, normalization, planning for the future, and disengagement (as cited in Wei, Szumilas, & Kutcher, 2010). Recent research, however, suggests that this practice may be less beneficial and more harmful than originally believed.

Many mental health professionals are experiencing growing concern over the use of PD. Rose, Bisson, & Wessely (2003) articulate this concern in their review of PD procedures, referring to PD as an example of a commonly-used intervention that lacks the evidence to support its use. The authors identify an absence of randomized control trials examining group PDs, but note that the few studies that have investigated this intervention provide little evidence supporting the notion that PD is useful as an early psychological intervention or may help protect against psychopathology following trauma. Devilly and Cotton (2004) report similar findings, stating that there are no reliable studies demonstrating the efficacy of CISD and arguing that it is an ineffective response to critical incident. Indeed, Adler and colleagues (2008) conducted an empirical study of the effectiveness of CISD in veterans and found that CISD failed to reduce post-trauma symptoms relative to individuals undergoing no treatment.

Several factors may contribute to the possible ineffectiveness of PD including CISD. It has been suggested that debriefing may occur too early post-trauma to accurately predict morbidity. Research has indicated that debriefing may be associated with adverse effects for certain individuals because it may lead to secondary traumatization through its use of imaginal exposure shortly after the traumatic event (Rose et al., 2003). Debriefing may also increase survivors’ expectations of developing psychological distress to the traumatic event when, if not for the debriefing, they may have only experienced normal distress levels. In other words, debriefing may increase individuals’ awareness of their distress, and in turn, increase overall distress (Rose et al., 2003). Furthermore, Devilly, Gist, and Cotton (2006) suggest that debriefing may lead individuals to circumvent social support from family or friends because of the belief that professional help will be more beneficial to recovery. This is problematic because research has shown that inadequate levels of social support are related to poorer psychological outcomes following multiple types of trauma, including natural disasters (Kaniasty & Norris, 1995; Ozer, Best, Lipsey, & Weiss, 2003; Polusny et al., 2011).

Despite growing evidence that PD may do more harm than good, some individuals maintain their belief that PD is important to implement following a traumatic event. For example, Walsh (2009) supports the use of PD—specifically for workers assisting with relief efforts following a traumatic event. According to Walsh, PD provides a way for individuals sharing a similar experience to connect and support one another throughout the recovery process.
Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is another common treatment for survivors of natural disasters. In CBT, the client and therapist meet approximately 8-12 times to engage in various exposure, behavioral, and cognitive exercises to address the client’s maladaptive trauma-related beliefs and reduce the client’s emotional disturbance following trauma (Foa et al., 2000). Maladaptive trauma-related beliefs are inaccurate thoughts that may develop following exposure to a natural disaster, including those involving assimilation (i.e., altering new information about the traumatic event into preexisting beliefs, such as “Bad things only happen to bad people – therefore, I must be a bad person because this bad event happened to me.”) or over accommodation (i.e., changing one’s beliefs about the self or world to increase feelings of safety or control, such as “I must always be on guard to keep bad things from happening again in the future.”). A common goal of CBT is accommodation, in which the client balances beliefs with the reality of the traumatic event (see Resick, Monson, & Chard, 2007 and Sobel, Resick, & Rabalais, 2009 for further details).

There are several variations of CBT including: exposure therapy, systematic desensitization, stress inoculation training, cognitive processing therapy, cognitive therapy, assertiveness training, biofeedback and relaxation training, and different combinations of the methods listed above. Research has demonstrated that CBT is one of the most beneficial treatments for trauma survivors, with the exposure component, or imaginal exposure to the event itself, thought to be a large factor in its success (Foa, Rothbaum, Riggs, & Murdock, 1991; Foa et al., 1999; Foa, et al., 2000). Furthermore, studies show that CBT typically has the best outcomes when it begins two to six weeks following the trauma and is completed in five to nine sessions (Devilly et al., 2006).

Preliminary research suggests that CBT may be appropriate for the treatment of PTSD and posttraumatic stress symptoms (Hamblen et al., 2009). Specifically, Hamblen et al. (2009) conducted a study investigating the effectiveness of Cognitive Behavior Therapy for Post-disaster Distress (CBT-PD) following Hurricane Katrina, a ten session CBT intervention provided at least 90 days post-disaster to address the client’s cognitive, behavioral, and emotional reactions to trauma. The use of CBT-PD was related to significant reductions in participants’ distress and worked equally well for individuals suffering from both moderate and severe stress levels. The percentage of participants experiencing severe distress decreased from 61% (pre-treatment) to 14% (post-treatment). This reduction in stress was maintained at 5 months post-treatment when researchers followed-up with participants.

Suggestions for Treatment

Although there has been a significant amount of research conducted looking at psychological outcomes and treatments for survivors of natural disasters—especially following Hurricane Katrina in 2005—there is still much work to be done. Specifically, the efficacy of various treatments, such as CBT, need to be tested with survivors of natural disasters. Likewise, new guidelines must be established and implemented so that responses to natural disasters are quicker and more people have access to the necessary psychological services.

Eliminating Psychological Debriefing/Critical Incident Stress Debreifing

Currently, PD/CISD is the treatment that seems to receive the most criticism—primarily due to the lack of empirical evidence supporting its use (i.e., Devilly and Cotton, 2004). Belaise, Fava, and Marks (2005) propose moving beyond PD/CISD and, instead, focusing more on the potential effectiveness of well-being therapy (WBT) in which individuals learn to focus on incidents of emotional well-being. Specifically, he says randomized control trials are needed to test this therapy because, during preliminary investigations, trauma survivors have responded particularly well to the exposure and cognitive restructuring components of WBT.

Similarly, Tuckey (2007) suggests investigating other interventions that are financially and logistically feasible for organizations to implement as an alternative to PD/CISD. Wei and colleagues (2010) also suggest eliminating PD/CISD because of the lack of evidence supporting its effectiveness and, instead, implementing five empirically supported intervention principles: promotion of a sense of safety, promotion of calm, promotion of a sense of self- and community efficacy, promotion of connectedness, and promotion of hope.

Implementing PFA, or psychological first aid, is another alternative to PD/CISD that has been proposed (Vernberg et al., 2008; Wei et al., 2010). The PFA Guide is available to psychologists needing to provide relief for disaster survivors (see Vernberg et al., 2008 for a more detailed description of PFA). PFA is guided by the approaches most consistently supported by empirical research so that they can be disseminated, employed, and further studied. There are eight core actions outlined in PFA: (1) contact and engagement, (2) safety and comfort, (3) stabilization, (4) information-gathering, (5) practical assistance, (6) connection with social supports, (7) information on coping, and (8) linkage with collaborative services. PFA also discusses several implications for practitioners including how to utilize current knowledge, suggestions for working with various groups, the evolution of training and available materials, self-care of healthcare providers, the need to recruit PFA providers, and the importance of evaluating current practices.

Focusing on the Efficacy of Cognitive-Behavioral Therapy in Natural Disaster Survivors

Although numerous studies have supported the effectiveness CBT in treating trauma survivors (i.e., Foa et al., 2000), much more research is needed. Specifically, research must be conducted evaluating CBT’s effectiveness in survivors of natural disasters; most existent research focuses on assault survivors and, generally, survivors of violence. What little research on implementing CBT with natural disaster survivors does exist focuses on adolescent populations (i.e., Shooshtary, Penaghi, & Moghdam, 2008). Further research is needed to test the effectiveness of CBT in adult survivors of natural disasters.

Implementation of Telehealth

Telehealth is an emerging method of delivering long-distance healthcare to clients unable to access local healthcare services. Telehealth is being applied in a variety of settings including primary care and specialty consultation. It is also being implemented to assist with medical logistics, coordinating transportation, and monitoring remote patients (Simmons et al., 2008). In a study looking at adults diagnosed with depression, the use of telehealth was shown to significantly reduce symptoms of depression at 6 months as well as improve mental functioning at both 6 weeks and 6 months (Hunkeler et al., 2000). Assuming the infrastructure is available, this may be a beneficial approach to employ in disaster situations because it can make reaching survivors and providing services easier (Simmons et al., 2008).

Telehealth could assist aid workers in being able to provide resources sooner to survivors of natural disaster. Schoenbaum and colleagues (2009) suggest using telehealth to reach individuals affected by natural disasters immediately after the disaster. Using telehealth would allow for the provision of long-distance mental health services to shelters via working telephone lines. Likewise, telehealth would be useful when individuals are unable to or encouraged not to leave their homes (Simmons et al., 2008). However, this leads to the need to consider variables such as accessibility, affordability, and applicability of this type of assistance following a natural disaster (Devilly et al., 2006).

Additional Recommendations

Be Discriminative

When treating individuals who have survived a natural disaster, mental health professionals need to distinguish between psychopathology and typical stress reactions (Ginzburg, 2008; Whaley, 2009). It is not uncommon for natural emotional distress to be mistaken for mental illness following a natural disaster. It is important that mental health professionals consider an individual’s overall functioning following the disaster to help guide decisions about diagnosing potential psychopathology (Whaley, 2009).

Likewise, mental health professionals must exercise caution not to “medicalise” distress symptoms. In other words, professionals should focus on not drawing unnecessary attention to symptoms that are typical of “normal” distress following a natural disaster. By drawing attention to symptoms unnecessarily, clients may become overly-focused on their symptoms and begin to experience more distress symptoms than they otherwise would have (Rose et al., 2003).
As Ginzburg (2008) points out, individuals who are diagnosed with a mental illness following a natural disaster may not have these diagnoses removed once symptoms begin to remit. As a result of maintaining their diagnoses, psychotherapy and/or medication may not be adjusted as necessary. This error can lead to the development of unnecessary distress once mental health relief workers begin to leave and mental health resources potentially become scarce. In order to avoid this unnecessary distress, it is important that mental health professionals are cognizant about re-assessing patients throughout the course of treatment to track the status of their disorder. Similarly, it is important that physicians treating survivors express the importance of frequently meeting with mental health professionals in order to receive the proper treatment following a natural disaster.

Rabins, Kass, Rutkow, Vernick, and Hodge (2011) recommend implementing advanced planning for responses to both natural and man-made disasters. Specifically, they recommend planning to first treat individuals who are particularly vulnerable to negative outcomes as a result of the disaster. For example, individuals who have preexisting mental health conditions and individuals reporting newly-emerging psychological symptoms should be treated before individuals not meeting those criteria. By implementing this advanced planning in the chaos following a disaster, mental health care providers would be able to systematically and efficiently triage care.

Implement Early Screening

The implementation of early screening, or looking for an illness that has not yet become apparent in a specific population, has been suggested by multiple mental health care professionals as a way to better-respond to the mental health care needs of natural disaster survivors. Others disagree with this recommendation, arguing that it will not be as effective as many individuals believe. For example, Brake and colleagues (2009) suggest that screening for adverse reactions, such as PTSD and acute stress, following a natural disorder is of no benefit. First, the authors state that early screening is futile because stress reactions within the first month after a natural disaster are “normal.” Furthermore, they allege that screening may lead to the “medicalization” of these normal stress symptoms. Additionally, Brake and colleagues (2009) state it is not cost-effective to screen natural disaster survivors, the literature has not yet identified an ideal time to conduct this screening, and screening is too inaccurate to be effective.

Contrary to the viewpoint Brake and researchers (2009) express, many mental health professionals view early screening following disasters as beneficial. For example, Ruggiero and colleagues (2009) recommend that disaster responders screen for depression as soon as survivors seek help for health-related concerns. Similarly, Koopman, Classen, and Speigel (1994) recommend using early screening measures that identify symptoms most predictive of future psychological disorders, such as dissociative experiences, immediately following the disaster. Preliminary research has supported the implementation of early screening procedures. In a study following survivors of an oil rig explosion in the North Sea, Holgersen, Klöckner, Boe, Weisaeth, and Holen (2011) concluded that an early screening intervention would have been able to identify survivors most at risk for developing long-term adverse effects.

In areas of trauma other than natural disaster, psychologists have begun creating measures to serve as quick, comprehensive ways to identify individuals who are most at risk for developing adverse reactions. For example, Winston, Kassam-Adams, Garcia-Espana, Ittenbach, and Cnaan (2003) developed the Screening Tool for Early Predictors of PTSD (STEEP). This instrument assesses individuals who have experienced a trauma, such as severe personal injury, within the past month. The STEEP is intended to help health professionals allocate resources, taking into account who has the greatest need for them. The measure was tested at a Level I trauma center, and was predictive of posttraumatic stress symptoms in approximately 90% of cases. Although this measure was not tested with a sample of natural disaster survivors, this is a type of early screening intervention that mental health professionals dealing with natural disaster survivors may want to consider creating and implementing in the future.

Get to Know Your Clients

The better a clinician can get to know his/her clients, the better he/she will be at providing the appropriate treatment for those clients (Ginzburg, 2008). Specifically, information on clients’ culture, including culturally-normative behavior, can be extremely valuable in determining a treatment path and making healthcare recommendations for clients. It is also important to be aware of the client’s personal needs and not make assumptions. For example, do not make assumptions that a client’s presenting problems will be directly related to the disaster he/she recently experienced. As advised by Whaley (2009), it may be beneficial to directly address any personal feelings of guilt or responsibility the client has relating to the event and help him/her reframe any events that were out of the client’s control. Once feelings of responsibility have been addressed, it may then be useful to get the client to focus on his/her own needs following the natural disaster.

Learning about a client’s family and friends can be beneficial in identifying a social support network following a natural disaster. Multiple studies have indicated that social support is an important factor for determining resilience following trauma (Galea et al., 2007; Lowe et al., 2010). Providing clients with information about where to connect with other survivors so they can communicate their feelings and responses to the disaster with individuals in similar situations can be important in helping them receive further support, learn self-help strategies, and develop contacts for further assistance (Devilly et al., 2006; Walsh, 2009).

To reiterate, it is crucial for the therapist to create a relationship with the client in which he/she feels comfortable revealing personal information that may prove useful during therapy. During Hurricane Katrina, some clinicians recommended that their clients stay with family to alleviate some of their stress (Whaley, 2009). However, this advice was often useless because many individuals’ families lived in close proximity to the disaster zone, and they, too, experienced a great deal of stress and loss. Had clinicians been more familiar with their clients, they could have provided more useful recommendations. However, instead of providing constructive recommendations, many clinicians only reminded their clients of the substantial loss they and their families were experiencing.

Consider the Health of Other Professionals—And Yourself!

Vicarious traumatization (VT), or the development of PTSD-like symptoms and changes in trauma-related cognitions in individuals not directly affected by a traumatic event, may develop among some professionals working with natural disaster survivors (as cited in Elwood, Mott, Lohr, & Galovski, 2011; Figley, 1995). VT can include general distress and a disruption of one’s beliefs and schemas (Farrell & Turpin, 2003). Symptomatic responses—especially intrusive thoughts related to the trauma—are more likely to develop than cognitive changes among mental health workers (Farrell & Turpin, 2003).

According to Figley (1995) VT is especially common in trauma-focused professionals, such as psychotherapists, but can affect anyone involved in helping an individual overcome a trauma including friends, family, and caregivers (as cited in Elwood et al., 2011). Research has indicated several predictors of VT including having a trauma history, experiencing life stress, suffering from mental illness, having a lack of social support, having achieved low educational attainment, being young, and implementing negative coping strategies, such as substance use (Lerias & Byrne, 2003). Argento and Ilaria (2011) found that role clarity and job support at one’s workplace were also inversely related to the development of VT in rescue workers.

Ginzburg (2008) noted the importance of paying attention to how fellow mental health professionals who are working with natural disaster survivors are faring. It is imperative to remember that professionals are also being exposed to and impacted by the devastating effects of natural disaster they are witnessing. Similarly, individuals in other service positions, such as police officers and firefighters, may display aversive reactions to the traumatic event (Ginzburg, 2008; Marmar, Weiss, Metzler, & Delucchi, 1996; Walsh, 2009).

According to data collected by Ginzburg (2008), several months after Hurricane Katrina, nearly 27% of firefighters contacted by the researcher’s team reported symptoms of depression, and 22% reported posttraumatic stress symptoms. Likewise, 26% of police officers reported depression symptoms and nearly 19% displayed posttraumatic stress symptoms. In a similar study following an earthquake in China, nearly 7% of military first responders met the diagnostic criteria for PTSD six months after the disaster (Wang et al., 2011). Walsh (2009) recommends that all organizations—both government and volunteer—provide trauma training for their workers who may someday respond to a disaster situation. For example, in a study by Fullerton, McCarroll, Ursano, and Wright (1992), firefighters reported significantly less stress responding to an emergency situation when they felt they had received the proper training prior to the event.
A lot about VT is still unknown, and further research must be conducted investigating predictors, symptoms, and prevention related to VT (Farrell & Turpin, 2003). Ellwood and colleagues (2011) recommend that employers work to provide more treatment options for trauma workers. They also recommended that trauma workers receive more training about how to respond to traumatic events, and they should also be more educated about VT.

Concluding Comments

Each year, natural disasters cause individuals significant emotional distress in the form of posttraumatic stress symptoms, depression, anxiety, substance use, and other adverse effects. Survivors of natural disasters who are women, suffer from preexisting mental health issues, interpret the disaster in a negative way, suffer extreme exposure to the disaster, and have low social support are the most likely to develop negative psychological outcomes following the event. Female Caucasian individuals who are middle-aged, have high or extremely low educational attainment, have access to transportation and technology, and do not hold negative attitudes towards mental healthcare are the most likely to receive treatment after a natural disaster.

Currently, there are two primary methods used to treat survivors of natural disaster who are suffering adverse effects: CISD/PD and CBT. Research exploring both therapies has consistently indicated that CBT is the superior treatment method, and several studies have even suggested that CISD/PD be abolished altogether. Furthermore, many mental health professionals believe that the current treatment methods, alone, are not sufficient. Researchers suggest that other treatments, such as WBT, PFA, and telehealth be explored further. Additionally, it is important for trauma workers to keep in close contact with their clients as well as pay attention for signs of VT in both themselves and other professionals. Much work is still needed in the area of psychological treatment for natural disaster survivors. Considering the large number of natural disasters occurring around the world in recent years, it is imperative that this area of psychology be given more attention than it has in the past. Consequently, new interventions must be implemented so that natural disaster survivors experience the fewest long-term negative psychological outcomes possible.


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Authors’ Biographies

Lauren T. Bradel, MA

BradelLauren is a fourth year clinical doctoral student at Northern Illinois University.  Lauren received her Bachelor’s degree from the University of St. Thomas in St. Paul, Minnesota and her Master’s degree from Northern Illinois University.  As an undergraduate, Lauren worked with Dr. Melissa Polusny at the Minneapolis Veterans Affairs Medical Center where she assisted with research focused on soldiers returning from Iraq and Afghanistan.  At Northern Illinois University, Lauren has worked with Drs. Holly Orcutt, Kathryn Bell, and Alan Rosenbaum.  Her primary research interests include identification of risk factors for intimate partner violence perpetration and the identification of risk factors for developing psychopathology following trauma.


Kathryn M. Bell, PhD

BellDr. Bell is an assistant professor within the Psychology Department at Capital University. She received her doctorate in clinical psychology at Western Michigan University and completed her clinical internship in the Behavioral Sciences Division of the National Center for PTSD within the Boston VA Medical Center. Dr. Bell completed a two-year clinical research postdoctoral fellowship through The Warren Alpert Medical School of Brown University and served as an assistant professor for three years within the clinical psychology program at Northern Illinois University. She has published extensively in the areas of trauma and interpersonal violence.

Chemophobia & Other Food Nonsense

Chemophobia & Other Food Nonsense

Published May 5th, 2015 in Alternative Perspective, Eat for Health, What’s in the News

by Tammera J. Karr, PhD

I’m about to make a confession – There are times I have no clue as to what to write this column on. This week was just one of those times. The clock was ticking, and the deadline was at hand, and still I had no inkling, shimmer or clue. Then I picked up the mail and began looking through a Food Product Journal for “Innovation, Ingredients, Science, and Compliance.” One of our long time friends told me years ago that it was important to know both sides of the story, that way your enemies never catch you unawares.

This holds true for the world of food also.

As I thumbed through the pages, I saw the word “Chemophobia”, this halted me and required a closer examination – to which head shaking and laughter ensued. “Chemicals are Chemicals, whether found in nature or made by man. But, consumer advocates are sounding the alarm concerning the perceived dangers of artificial flavors.” “Nothing is more indicative of this chemophobia in today’s foodscape than the growing preference for natural versus artificial flavors.” The article goes on to detail how unstable natural flavors are compared to synthetic, that stabilize and preserve while saving cost for the manufacture;” the author stated.


So I thought I’d look at the listed synthetic food flavors in the article….

Terpenes: “The name “terpene” is derived from the word “turpentine”. A range of terpenes have been identified as high-value chemicals in food, cosmetic, pharmaceutical and biotechnology industries. Chemical synthesis of terpenes can be problematic because of their complex structure, and plants produce very small amounts of these valuable chemicals, making it difficult, time-consuming, and expensive to extract them directly from plants. Research into terpenes has found that many of them make ideal natural agricultural pesticides. Terpin hydrate, an expectorant and humectant, is used in the treatment of acute or chronic bronchitis and related conditions. Terpenes are used by termites to attack enemy insects.
Ok that doesn’t sound horrible – well until you get to the termites that is. So in essence we are using fake tree sap made from yeast to make food, medicines, perfumes and pesticides.

Glutamic acid: glutamic acid is known as glutamates. In neuroscience, glutamate is an important neurotransmitter that plays the principal role in neural activation. In 1908 Japanese researcher Kikunae Ikeda of the Tokyo Imperial University identified brown crystals left behind after the evaporation of a large amount of kombu broth as glutamic acid. Professor Ikeda termed this flavor umami. He then patented a method of mass-producing a crystalline salt of glutamic acid, monosodium glutamate.

Warning: people with kidney or liver disease or those with neurological diseases, including ALS or Lou Gehrig’s disease, and epilepsy, should not take glutamic acid without consulting a physician. According to a 2010 article in “Neuron Glia Biology,” people who cannot metabolize glutamic acid properly can develop problems associated with a number of neurological conditions, including epilepsy. MSG can cause symptoms ranging from headache and flushing of the skin to chest pain. The effects are potentially dangerous palpitations, shortness of breath, and swelling of the throat, a sign of anaphylaxis, says MedlinePlus.

So of the two chemical compounds listed, one may not be so bad, and the other may be life threatening for some. Sounds a little like Russian Roulette to me.

While this and several other articles suggested we, the consumers, are a bit daft in the head, and are easily lead astray by “food advocates” The rest of the journal was dedicated to Consumer Market trends and how to score big with “Clean Labels”. Here is some of the shared information I found interesting.

a.) 53% of consumers who bought a gluten free food or beverage did not know it was GF.
b.) Since 2013, there have been over 2400 new food and drink launches sporting a “no additives or preservatives” claim.
c.) Almond milk has surpassed soy milk and accounts for 55% of the alternative beverage market.
d.) More than 70% of adults purchased foods or beverages with clean-label package claims in 2012.
e.) The gluten free market reached over 23 billion in 2014
f.) Due to the lack of clarity around the definition of “natural” consumers are targeting foods with clean and simple labels.

So it would seem, while I might be a mad-hatter for wanting clean food, the industry is delighted over the money I’m willing to spend for it. And don’t think for a moment they are not working to get an even bigger market share of local foods and produce, after all the largest funder for this journal is ConAgra.

To Your Good Health and Information



Thimmappa, R.; Geisler, K.; Louveau, T.; O’Maille, P.; Osbourn, A. (2014). “Triterpene biosynthesis in plants”. Annu Rev Plant Biol. 65: 225–57. doi:10.1146/annurev-arplant-050312-120229. Retrieved 19 January 2015.
Augustin, J.M.; Kuzina, V.; Andersen, S.B.; Bak, S. (2011). “Molecular activities, biosynthesis and evolution of triterpenoid saponins”. Phytochemistry 72: 435–57. doi:10.1016/j.phytochem.2011.01.015. Retrieved 19 January 2015.



Renton, Alex (2005-07-10). “If MSG is so bad for you, why doesn’t everyone in Asia have a headache?”. The Guardian. Retrieved 2008-11-21.
“Kikunae Ikeda Sodium Glutamate”. Japan Patent Office. 2002-10-07. Retrieved 2008-11-21.



Lucy Postolov, Licensed Acupuncturist and Herbalist

About Lucy Postolov, LAc, Licensed Acupuncturist and Herbalist    

Postolov-LucyThe American dream is often defined by a ‘rags to riches’ story. In Lucy Postolov’s situation, she left behind Russian culture, intelligent and educated family members and career achievement to pursue spiritual and political freedom. Lucy Postolov was born in 1960 in Tashkent, capital of Uzbekistan, at that time one of the republics of Soviet Russia. By the time she was 23 she had earned her medical degree from Tashkent Medical School and later completed her residency in neurology. Always interested in Oriental Medicine, Lucy received her post medical specialty in Acupuncture and Acupressure. Being a strong willed woman, Lucy yearned for more out of life for herself and her family. In 1989, the government allowed Lucy, her husband Tony, and their 4-year-old daughter Annie to leave the country with two suitcases each – minus any valuables – and $90 per person. With only one distant relative in the United States, they arrived in California with a hopeful eye on an uncertain future.

Lucy was 29 years old when she arrived in America and she had to begin all over again. Her medical qualifications and those of her surgeon husband were not recognized in the U.S. While Tony retrained as a psychiatrist, Lucy supported her family by working as a lab technician at the California Cryobank. Working full-time, Lucy was also attending Emperors College of Oriental Medicine to obtain her master’s degree in Oriental Medicine. Her average week would be eighty hours but she felt fulfilled since she was doing something meaningful.

After completing her master’s degree in three years, she started an Oriental Medicine practice at a West Los Angeles Clinic, treating patients while continuing to work as a consultant at the Cryobank where she spearheaded the Stem Cell Program, years ahead of its time. Her success in her private practice allowed her to open her own Acupuncture/Herbology treatment center, The Postolova Acupuncture Group located in Brentwood. In 1999, Lucy continued her commitment to a holistic approach to healing by taking a position as consultant/acupuncturist with the ground-breaking Department of Integrative Medicine at the prestigious Cedars-Sinai Medical Center. In 2000 she was the first licensed acupuncturist to be granted full privileges at the world-renowned Cedars-Sinai Medical Center.

In 2010, Lucy received Board Certification in Integrative Medicine by the American Association of Integrative Medicine.

Lucy’s passion for helping others has her working with a wide variety of health issues including cancer, infertility, weight loss, menopause, neurological disorders, addiction etc. She has been certified by NADA (National Acupuncture Detoxification Program) and works successfully with many different types of addiction.  In 2001, she released a meditation CD for patients with cancer pain. Her work with oncology patients was recognized by the Israel Cancer Research Fund and she was honored with the “Woman of Action” award in 1998. She has also appeared on numerous news programs as an expert in Traditional Oriental Medicine and has been featured on the KCET program Healthweek and ABC’s Good Day L.A. In 2008, Lucy contributed a chapter to the book “Guidebook of Sexual Medicine”.

Hundreds of Lucy’s patients were able to make their biggest dream come true, have a child. Lucy works with infertility patients, when Western OBGYN gave up and she’s also working with many famous fertility doctors, hand in hand.

Lucy is an expert when it comes to female disorders. Polycystic ovaries, Endometriosis, fibroids and many hormonal disorders.

Lucy’s special desire to empower women with a sense of their own well being compelled her to help them revitalize their appearance using natural methods. She appreciated the importance for women of all ages to feel good about themselves and the way they look. She’s one of the first healthcare practitioners who started using Arasys, a revolutionary system for face rejuvenation and body inch /weight loss . Designed by the inventor of the pacemaker, this system is very popular in Europe and a well kept secret in the United States. Many of Lucy’s patients have been using the Arasys system with extraordinary results. It is Lucy’s hope to be able to bring this product to all women.

Lucy lectures both internationally and nationwide. She has been invited to speak in Paris and here in the USA at UCLA, Tulane School of Medicine, Cedars-Sinai Medical Center, Tower Oncology Cancer Research Foundation, Cancer Support Community / Benjamin Center and many others.

She is on the Physician Advisory Board for the Cancer Support Community. In 2012, Lucy was invited as an Independent Consultant for Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute. In 2015, she was recognized by the Los Angeles Business Journal as a ‘Woman Making a Difference’.

Lucy’s work is a testimony to not only the vital treatments she offers, (support of cancer patients, infertility, inch and weight loss, facial rejuvenation (Arasys) and many others.) but to her ability to understand the best of what Chinese and Western medicine has to offer. She works hard and she knows what it means to live fully and how to make a difference.

Dr. Juan Paolo Bellosillo

Dr. Juan Paolo Bellosillo ND, MCL, DWMS, DAAIM, MAURP


BellosilloDr. Juan Paolo Bellosillo, was named after and blessed by the late Saint John Paul II in the Philippines Nunciature and has embarked on Preventive Medicine Campaign through Medicine and Media, showing compassion and nobility in service with every beat of his heart.

He had finished his schooling from the Ateneo De Manila University Loyola Schools in Economics, which included additional concentrations in Natural Sciences, Math, Law and Foreign Languages. Subsequently, he pursued his Masters at the School of Urban and Regional Planning as University Scholar in the University of the Philippines while juggling work in wellness and healthcare. He has undergone and survived two near death experiences, that took him to the Emergency Room brought about by progressed arteriosclerosis and atherosclerosis of the heart. Consequently, he pursued his Natural Medicine and Energy Medicine at the IFP Institute Official School of Naturopathy and Natural Sciences and graduated Magna Cum Laude.

The desire to prevent the growth of mortalities due to heart attacks from house to community, to city, to region, and eventually, nationwide gave him the perseverance and determination to study in Germany’s International Academy for Homotoxicology to augment his arsenal against acute, chronic and degenerative diseases. He also pursued his continuing naturopathic doctor education in the areas of preventive cardiology, nutrition, anti-aging medicine, sports medicine through the University of Bridgeport, US. Moreover, he furthered his knowledge in Metabolic Cardio treatment through the Institute for Integrative Medicine supplemented by the teachings of his Uncle, Dr. Adolfo Bellosillo the former president of the Philippine Heart Association. Having gone through training and education in sports and nutrition, he supports athletes and the general public; fueling their performance in competitive races or the race of life. He too was educated and trained under the Philippine Red Cross in the areas of life support and first aid. He was President of his class composed of 70 nurses and allopathic doctors. Combined with Tactical Medicine through a Multi Jurisdictional Task Force program (US), he led a team of Coast Guard Auxiliary and First Responders in a Medical Psychological Mission in the heart of Tacloban Leyte, during Typhoon Yolanda-Haiyan.

Dr. Pao, as he is fondly called in television, has gone from resource speaker to hosting stints in some TV programs such as Doctor’s on TV, Rise and Shine, Good Morning Kuya as well as an Eco Travel Show in Studio 23, ABS-CBN. He uses television to educate, reach out to people and inform them of the ways and means to avoid diseases as well increase their quality of life, an application of public involvement and participation metrics.

He manages his profession and advocacies in providing quality healthcare and wellness on the individual level, organizational level (corporate: Nutra, Pharma Healthcare, ICT-BPO, Distribution-Logistics, Hospitality Tourism, Schools, Retail, Real Estate-Development), and city levels. He has served through establishing programs and multi-medical system centers from Northern Luzon (La Union) down to Quezon City and as way South to Bicol’s Legaspi. For this reason he was given awards and recognition in the City Levels especially when disasters struck, Asian Achiever award in Naturopathy and Dangal ng Bayan Award.

Notably, he has successfully aided in the reversal of hypertension, cardiac insufficiency, diabetes, atherosclerosis, arteriosclerosis, chronic kidney diseases and the like through using combined whole medical systems and integrative medicine methods- Holistic Medicine.

To date, he holds a Diplomate in Naturopathy and Energy Medicine in the IFP, First Filipino Diplomate in Whole Medical Systems and Diplomate in Integrative Medicine in the American Association of Integrative Medicine. Furthermore he holds an International Membership with the World Society of Interdisciplinary Anti-aging Medicine, membership with the Philippine Stem Cell Society, membership with the Philippine Institute of Environmental Planning, membership in the Philippine Society of Biochemistry and Molecular Biology, Registered Triathlete with the Triathlon Association of the Philippines and was granted membership in the prestigious American Board for Certification in Homeland Security. He believes security in health is affected by the quality of security we have at home and in our homeland. Security about Him and for Him, is another story to be shared.

He serves the movers and shakers in the Philippine society in the areas of private and public hierarchies including key positions in law enforcement, congress, business and humanitarian. John Paul the II had a noble heart and this has inspired Dr. Pao in his vocation and profession to help one and all: “Live a Legacy”.

The Flu and Prevention

The Flu and Prevention

Published April 14th, 2015 in Alternative PerspectiveAlternative Therapies

by Tammera J. Karr, PhD

This year, that flu “vaccine will only reduce your risk of ending up in the doctor’s office with the flu by about 23 percent. The vaccine was developed nearly a year ago in February, 2014, and it’s not an ideal match for H3N2, the strain of the virus prevalent this season. That mismatch — along with H3N2’s reputation for causing higher hospitalization and mortality rates — led the Centers for Disease Control and Prevention to predict a severe flu season this year.

That prediction has been borne out, with more flu-related doctors’ office visits this year than last year. In Virginia, flu activity remains high after peaking in late December, according to the state health department. As the air gets drier, it sucks the moisture out of those mucus droplets. As the droplets shrivel and crystallize, the reduction in water increases the concentration of salts and proteins and changes the acidity.” (http://www.sciencedaily.com/releases/2015/02/150202105403.htm_br)

Linsey Marr, a professor in the Charles E. Via Jr. Department of Civil and Environmental Engineering at Virginia Tech, is obsessed with flu transmission. “Marr found that between 50 percent and 98 percent humidity, the virus doesn’t survive well — the droplets dry out just enough to be inhospitable. But at very low humidity — like you’d find indoors in the winter — droplets can dry out completely, preserving the virus-like microscopic beef jerky.”

“As recovering flu victims struggle back to work and school, and new cases keep cropping up, the question on everyone’s mind is: What can people do about it?”

  • Washing your hands, is a start, and then there is the tried and true home remedies of garlic, onions, bone broths and a diet rich in real foods versus processed foods.
  • Optimal vitamin D3 levels (optimal levels fall between 65ng/ml & 85ng/ml), vitamin C rich foods and naturally fermented healthy bacterium rich foods, also improve your ability to ward off viruses. If you can’t handle fermented foods increase your probiotic supplement use.
  • Getting out from under florescent lights also improves your body’s ability to fight viruses, along with the use of cheap air filters to reduce airborne molds and dander that weaken your immune response.
  • Use a humidifier on your wood stove to improve the humidity during flu season in your home.
  • Change out air filters in your heating system even if you think they don’t need it to improve air quality in your work and home.
  • And lastly, a good night’s sleep makes a world of difference. You should wake feeling rested, not run over by a truck. If you don’t feel rested consider your bed may be the problem before you run off to the doctor for a sleeping pill.

To Your Good Health and Information –



Reasons Why Winter Gives Flu a Leg Up Could Be Key to Prevention. (n.d.). Retrieved from http://www.newswise.com/articles/reasons-why-winter-gives-flu-a-leg-up-could-be-key-to-prevention_br
Reasons why winter gives flu a leg up could be key to … (n.d.). Retrieved from http://www.sciencedaily.com/releases/2015/02/150202105403.htm_br

Depression School: A 3-Session Group Crisis Stabilization Intervention

Depression School: A 3-Session Group Crisis Stabilization Intervention

Jolene Oppawsky, PhD, LPC, ACS, DAPA
University of Phoenix


The rapidly changing mental health care environment has many treatment and financial implications for therapists and clients.  The changes place new and acute demands on providers and caregivers to meet clients’ needs with time-limited, innovative therapies without compromising care.  Innovative perspectives in clinical practice should stimulate research on practical therapeutic interventions developed by clinicians who depend on their own creativity and resourcefulness to help clients.

In this article, we present the process and protocol of Depression School, an innovative 3-session depression group for crisis stabilization of depressed clients.  Also included are examples of the clients’ written work, a tangible form of accountability, the results of a before-and-after Beck Depression Inventory taken by each client as evidence of the initial depth of depression and successful treatment.



The rapidly changing mental health care environment has acute implications for therapists and clients.  The number and nature of authorizations for therapy have changed.  Due to economical considerations, authorizations of brief treatment models, with a reduction of the number of therapy sessions, have increased.  There has also been an increase in authorizations for group therapy, although the evidence that group therapy is more cost effective than individual therapy is still debated (McCrone, A. et al, Shapino, J. 1982, MacKenzie, C. & Ray, K., 1995, Tucker, M. & Oei, T. P.S. 2006).  Additionally, hospitalization authorizations by HMOs for mental health problems have decreased.  These changes place new and acute demands on therapists to meet their clients‘needs without compromising care.

It is far beyond the scope and purpose of this article to review the ever-growing amount of financial research and clinical-use literature on the above topics.  It is the author’s hope that this perspective in clinical practice will stimulate research on practical therapeutic interventions developed by clinicians who depend on their own creativity and resourcefulness to help clients.

In the following article, this author and facilitator of the group presents the instructions and process for facilitating a 3-session depression group and gives the protocol for facilitating the group.  The group, whose members were selected by the intake therapist, agreed to participate in this innovative crisis stabilization treatment.  The group was named Depression School by the initial clients, and the name stuck.  The group members met weekly for crisis stabilization of their depression before they were transferred to five sessions of individual therapy.  Also included in this article are examples of the clients’ written work and a tangible form of accountability, the results of a before-and-after Beck Depression Inventory ( Beck, A. T., Rial, W. Y., & Rickets, K. 1974;  Burns, 1992 ) taken by each client as evidence of the initial depth of depression and positive treatment outcomes.  An additional bonus is that the clients can use this instrument at home to gauge their moods and ward off depression.

After the 3-session group, the clients participated in five weekly sessions of individual therapy as a time-limited treatment and were then discharged.  Treatment was completed in eight weeks (60 days).

Depression School

Building the Group

Depression school is a name coined by the first group of clients who participated in a new and innovative three-session crisis stabilization group therapy model for depression as part of an eight-session therapy plan developed by this author, as a time-limited treatment.  The remaining five sessions were individual sessions.  This name, Depression School, has been accepted by all subsequent groups conducted by this therapist/writer resulting in a permanent name for this writer’s groups on depression.  The group members can be a mix of ages, races and sexes, or women’s and men’s groups can be formed.  Groups of children and adolescents can also be established.  Extremely psychotic clients would not be appropriate for this model because of the level of group participation necessary to make the workbooks and interact effectively with the other clients in developing their own treatment.

The Beck Depression Inventory

BDI usage

The BDI is actively used today in numerous statistical efficacy studies, among many others, (Enrichd Investigations, 2003; Thompson, L.W., Coon, D. W., Gallagher-Thompson, D., Sommer, B.R., & Koin, D., 2001).

BDI results in Depression School are gathered to judge therapy outcomes and to help the clients use this instrument at home to gauge their depression if they are using The Feeling Good Book (Burns, D., 1992).  The intent of using the BDI in Depression School is not to obtain statistical data, but rather to be used at home by clients to help make them active participants in their treatment.  It also gives them a preventative tool to help them manage their moods.

Each client should have two scores, one score from the beginning of therapy, and one after the third session.  Each client’s BDI results are put on individual graphs and added to their workbook.

The Process

The group’s goal was established by this therapist/writer, that of understanding, managing and defeating depression through group effort, and the objectives were defined.

Group objectives

  • To gain an understanding of depression and develop a group definition of depression
  • To explore, as a group, your old ways of handling depression that have not been helpful (“bummers”)
  • To understand, through group sharing, the circumstances that brought you to therapy
  • To develop and explore, as a group, new ways of dealing with depression
  • To try these new ways in real life


Session one

The first session starts with an introduction by the therapist about his or herself and about the upcoming group work, followed by an invitation for the clients to introduce themselves and make a short statement about what they would like to accomplish individually and as a group.  The Beck Depression Inventory (BDI) is then explained and given to each client.

After the BDI is taken, the clients are asked to described their depression to the group, generate a group definition, and develop a motto.  Clients also share with the group what happened in childhood and along life’s way to set the stage for depression.  The therapist, co-therapist or selected group member should record the definition and motto.  Recording a few key words of the clients’ descriptions of depression and what happened in childhood is also necessary.  After generating lists of current and childhood experiences, which the clients feel caused their depression, the group members extract main themes from the information.  The designated scribe also records these.  These records are then used in the development of the group’s workbook.  Computers may be used, which are especially welcomed and effective when working with teenagers.  This means that client writings are generated right in the group.  Kelly (1990) and Oppawsky (2001) suggest that client writings in therapy can enhance cognitive awareness for clients.  For homework, the clients are asked to think about how their workbooks could be embellished with art work, photographs, or poems, and to bring anything they would like included in their workbooks to the next session.  The process of this type of group usually initiates a significant amount of group interaction and the clients are asked to give and receive feedback and support from their peers.  Personal items help clients share personal information and help them discover or elaborate on any negative or positive thoughts.  The clients are encouraged to discover the universality of any items brought in for their workbooks, such as a photograph of a client as a child laughing, playing, or with siblings or family, or of a pet.  This task helps clients discover just how well they can identify with others.  This connectivity also helps bridge social and cultural lines leading to positive cross-cultural interactions within the group (Oppawsky, 2009).

Session one should close with an exploration of any issues arising from the session and a safety check, meaning a danger-to-self and a danger-to-others check and an affirmative statement from each client about him or herself.

Session two

The group opens with a short round-about with each client telling about his or her week.  Then, clients are invited to explore old ways of dealing with depression that have been counterproductive or have not worked, and generate a bummer list.  The word bummer to describe this list was client-initiated, and has stuck.  This part of the group work usually generates significant interaction among members and this interaction should be encouraged.  Again, the bummers are recorded for the workbook.

After the bummer list is generated, the group is invited to explore and develop new ways of dealing with depression and to generate a new ways list.  This list may be made up of things that have worked for the clients in managing their depressive moods in the past, or things that they would like to try.  Accepted cognitive behavioral techniques, such as negative thought stopping, journaling, and identifying triggers that lower moods, can be introduced by the therapist (Corey, 2001).  These are also recorded for the workbook.  After generating the new ways list, each client contracts to try a new way in vivo in the next week.

Again, session two closes with an exploration of any issues arising from the session or during the week, a safety check, and an affirmative statement by each client about him or herself.

Session three

Session three starts with group members sharing how they made out using new ways during the past week.  This usually generates significant group interaction.  Group support is imperative if some of the members were not successful in adopting a new way.  If a client was not successful, the client selects another new way to be tried in vivo in the following week.

Clients are then asked to retake the BDI and compare their results to their initial BDI.

A group discussion of their results follows, again with group and therapist support if  a client’s mood has not improved, and encouragement and support if it has improved.

The clients are then asked to make their workbooks with supplies usually provided by the therapist and/or agency.  Some supplies that are useful are colored construction paper for the cover and yarn or colored thread to bind the workbook.  The clients often bring pictures or poems to develop cover pages.  Often, pictures are included inside the workbook, as well.  Children and teenagers like to put their own pictures on the front of their workbooks or draw a cover picture.  This writer usually generates copies of the individual BDI results, the objectives, the group motto, the bummer list, and the new ways list on the computer and then provides them to the clients for their workbooks.  Frequently, a group member will do this as homework.

The group closes with each member giving another member a positive affirmative of something he or she has observed about the member during the three weeks.  An exploration of any issues arising from the group or during the group’s duration follows.  A safety check is made, and the clients are transferred to their individual therapists for their remaining five individual therapy sessions.  The group members are encouraged to take their workbooks with them to their first sessions of individual therapy.

Suggestions for Follow-up

Each client is transferred from Depression School to individual therapy.  After five sessions of individual therapy, all clients are usually discharged having attained their treatment goals and with moods that are continuing to improve.  The clients are asked in individual therapy to make a commitment to monitor their moods at home and continue using the new ways developed in Depression School in individual therapy and after discharge.  The clients are usually encouraged by the individual therapist to join a self-help depression group or a bereavement group in the community.  A list of community resources should be given.


Therapists should initially assess the clients for danger to others and/or dangers to self.  These assessments should be done throughout the duration of therapy as well.  Clients who are suicidal, or have vague threats of harming others, can participate in this innovative model with proper precautions such as no-suicide and no-harm-to-others contracts.  Clients who have active intentions to harm themselves or others are not appropriate for this group.  Clients who become seriously suicidal in the group with a plan and/or means to commit suicide, or trigger a Tarasoff response, should be referred out of group to appropriate services.  Occasionally, some clients may experience deepening depression or mental decompensation while in group and should be transferred immediately to more intensive care.

Vignette Protocol of a Depression School Therapy

The following is the protocol of an authentic Depression School that includes the group’s definition of depression, the motto of the group, the themes from the group, the bummer list, the new ways list, and the results of the BDI, pre and post-treatment.

Client Selection

All the eight participants – five women and three men of different ethnic backgrounds, White, African American, and Hispanic, and ranging in age from 25 to 58 – had a psychiatric diagnosis of Major Depression, severe or moderate, determined during his or her biopsychosocial intake assessment at an outpatient crisis intervention and brief treatment facility.  All participants had denied suicidal ideation or homicidal ideation during intake.  All clients had had previous suicidal ideation but had made no attempts.  Some had had vague thoughts of harming others in the past but with no plan or intent.  All signed no-harm contracts.  All the participants had refused medication.  Each client was granted eight sessions of brief treatment by his or her mental health provider and agreed to participate in this innovative plan for therapy.

The group’s definition of “a depressed person” was: “one who is not able to deal with things in life, who feels down all the time, who is not able to make decisions, has mood swings, is angry, who is tired all day, and wants to kill/hurt someone.”

Their mottos were: “Find your own life,” and “Depressed people are sensitive, we feel, it hurts, it is risky – but we wouldn’t have it any other way, but without depression, look inside, listen to self.”

After generating lists of current and childhood experiences, which the clients felt had caused their depression, main themes were extracted from the list by the group members.  The following themes were generated by the group:

  • Loss of love
  • Loneliness
  • Financial problems
  • Threatened autonomy
  • The need for unconditional love, unconditional acceptance


A bummer is something used to try to deal with depression that has not worked.  Sharing bummers with each other helped the group avoid unsuccessful coping methods.  Group support also helped clients relinquish steadfast bummers.  The following were examples of bummers generated by the group.

  • Drinking and drugs
  • Not crying
  • Anger – gets you nowhere
  • Letting people back/drive you into a hole, not standing up for yourself
  • Denial
  • Sleeping all the time, boredom
  • Hurting yourself or others
  • Fighting and domestic violence
  • Losing sight of yourself and your needs
  • Hooking up with people or getting married to someone you don’t love out of feelings of being needy
  • Making wrong decisions
  • Settling for less
  • Not being able to accept reality
  • Letting depression immobilize you
  • Running from a situation
  • Setting yourself up for bad things
  • Engaging in work activities that don’t have anything to do with your dream, staying in a bad job, or poor work atmosphere
  • “Absorbing shit” instead of dealing with people

New ways

The new ways list contained examples of things that group members had successfully used   in the past to manage and defeat depression, or ones they wanted to try.  Each client selected a new way from the list and made a commitment to try a new way between the second and third session.  Each client also committed to relinquishing his/her bummers and using new ways during individual therapy and after discharge.  The new ways were:

  • Crying and grieving, grief work
  • Activities such as music, church, art, reading helpful and powerful books, hobbies, fitness, participating in groups, such as Divorce Recovery or Parents without Partners
  • Do something innovative despite not having the money
  • Validate yourself and your feelings, don’t let yourself be put on the back burner (take affirmative action)
  • Reach out to others
  • Make a plan and carry it out
  • Take time out for yourself , enjoy time to yourself

BDI  results

The BDI results were gathered to judge therapy outcomes and to help the clients use this instrument at home to gauge their depression if they were using The Feeling Good Book.  Each client had two scores, one score from the beginning of therapy, and one after the third session.  All the clients were in the moderate, severe, or extreme depression categories initially except one client with mild mood disturbances.  All responded to the therapeutic effects of this group intervention with improvement in mood.  Six out of eight clients showed more improvement in mood on inventories than the other two.  The client who scored in the mild mood disturbance category reported that she was feeling better, and her score did not rise within the category.  Each client’s BDI results were put on individual graphs and added to their workbooks.

Discussion of Depression School and the Vignette

The Beck Depression Inventory (BDI) was designed as a standardized tool to assess the depth of depression and is widely used throughout the United States and Canada as well as abroad (Corey, 2001).  It is a formal screening tool for depression with good reliability and validity (Beck, Rial, & Rickets, 1974).  A review of evidence-based studies shows that both the BDI and the BDI-SF (Short Form) are used (McFarland, K., 2005).  The BDI and the assessment scale are published in Burn’s (1992) self-help book, making it an accessible and affordable resource for clients.  Many clients come to therapy with the book or have the book at home.  Many mental health centers have the book available for clients and therapists to use, and it is also readily available in most public libraries.

In Depression School, the depth of depression for each client was assessed in the first few minutes of therapy.  The initial results stressed each client’s reality without disputing or prescribing their symptoms.  The final BDI was a tool of accountability of therapy, a tangible product of what really went on in therapy, as well as a measure of positive outcome.

The rapidly changing mental health environment, in which the number of therapy sessions is reduced, should awaken therapists to a need for innovative and new ways to increase the effectiveness and efficiency of therapy, as well as aid in the accountability of therapy without compromising care.  Enrolling depressive clients in crises in a weekly 3-session Depression School for crisis intervention and stabilization before they are transferred to individual therapy is warranted.

In Depression School, clients were viewed as active agents who were able to derive meaning out of what they were going through and were helped to take action to modify their depression.  Their written work and BDI results enriched this model by encouraging processes of self-expression, which were documented.  Additionally, clients’ written work helped the clients understand their therapy and the therapeutic process.  Their workbook became a tangible form of accountability for them.  The universality of the group members’ problems and their interactive approach to understanding, managing, and defeating their depressions helped the clients to acquire effective strategies in dealing with their moods in a timely fashion.  Indeed, all clients in the vignette, except one with initially mild mood disturbances who retained the same results, showed improvement.  Six clients out the eight showed more improvement in their moods than the other two.  Depression School, as a crisis intervention/stabilization therapy, with its goals of helping clients understand, manage, and defeat depression, worked for these clients.  By divorcing themselves from bummers and using new ways, the Depression School actually became a coping skills program for clients in crisis and paved the way for successful individual therapy.

After the three sessions, the eight clients who participated in the group and were presented in the vignette were transferred to five sessions of individual therapy, wherein the clients’ problems past and present problems leading to depression were explored in depth.  Their commitments to understanding, managing, and defeating depression were reaffirmed.  All the clients’ BDI scores improved by the end of the three sessions with the exception of the one client whose BDI showed mild mood disturbances initially.  Her BDI stayed in that range.

At the time of discharge, after eight sessions (3 group sessions and 5 individual sessions), all clients were in the mild mood disturbances range of the BDI, substantiating significant improvements in their moods.  The one client who was in the mild mood disturbance range initially reported that she felt significantly better having moved higher within her range.  The clients were discharged by mutual client/therapist agreement with treatment completed.

Research Possibilities and Multiplication Factors

Serious psychotherapy is a blend of art and science.  Experienced therapists understand that the need for brief treatment modalities calls for creative and innovative interventions.  These therapists also know that they must use what works.  This model of treatment was designed by this writer from her significant experiences practicing psychotherapy in agency settings in Arizona, where resources and the number of sessions allowed to clients are limited.  The use of this innovative and creative practice illuminated the need for research on this group model.  It is the author’s hope that this perspective in clinical practice will stimulate research on practical therapeutic interventions developed by clinicians who depend on their own creativity and resourcefulness to help clients.  For example, on this group model, statistical tests on the results of the BDI could be done to determine if the changes the clients’ recorded were statistically significant.  The number of group sessions compared to individual sessions was arbitrarily picked by this writer based on her experience with and need for brief therapies.  Further research on the exact number of group versus individual sessions needed to stabilize moods could be researched.  Furthermore, the use of this model with children and adolescents could be practiced and researched.

This writer has since successfully conducted many 1-3 session Depression Schools with medicated and non-medicated adult clients with major depressions, dysthymia, and bipolar disorder.  After stabilization, these clients were transferred to various services, such as meds only groups, case management services, primary care physicians, self-help groups, and to individual therapies of different lengths of time.




Beck, A. T., Rial, W.Y., & Rickets, K. (1974). Short form of depression inventory: Cross-validation.  Psychological Reports, 34(3), 1184-1186.

Burns, D.  (1992). Feeling good  The new mood therapy.  New York: Avon Books.

Corey, G. (2001). Theory and practice of counseling and psychotherapy.  Pacific Grove, Ca: Brooks/Cole Publishers.

ENRICHD Investigators. (2003). Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The enhancing recovery in coronary heart disease. Patients (ENRICHD) randomized trial.  Journal of the American Medical Association, 289, 3106-3116.

Kelly, P.  (1990).  The uses of writing in psychotherapy.  New York:  Haworth Press.

MacKenzie, C. & Roy, K. (Eds.), (1995). Effective use of group therapy in managed care.  American Psychiatric Publication on Clinical Practice No. 29. British Columbia: Clinical Practice Publisher.

McCrone, P., Weeramanthri, T., Knapp, M., Rushton, A., Trowell, J., Miles, G. Kolvin, I.  (2005). Cost-effectiveness of individual versus group psychotherapy for sexually abused girls. Child and Adolescent Mental Health, 10(1), 26-31.

McFarland, K., (2005). Battling late-life depressions: Short term psychotherapy for depression in older adults-A review of evidence-based studies since 2000.  Annals of the American Psychotherapy Association, 8(4), 20-27.

Oppawsky, J. (2001).  Client writing: An important psychotherapy tool when working with adults and children.  Journal of Clinical Assignments, Handouts, and Homework in Psychotherapy Practice, 1(4), 29-40.

Oppawsky, J. (2009). Grief and bereavement. A how-to therapy book for use with adults  and children experiencing death, loss and separation. Bloomington, IN: Xlibris Press.

Shapiro, J. ( 1982). Cost effectiveness of individual versus group cognitive behavior therapy for problems of depression and anxiety in an HMO population.  Journal of Clinical Psychology, 38(3), 674-677.

Thompson, L.W., Coon, D.W., Gallagher-Thompson, D, Sommer, B. R., & Koin, D. (2001). Comparison of desipramine and Cognitive/behavioral therapy in the treatment of elderly outpatients with mild-to-moderate depression.  American Journal of Psychiatry, 9(3), 225-240.

Tucker, M. & Oei, Tian P.S. (2006). Is group more cost effective than individual cognitive  behavioral therapy?  The evidence is not solid yet.  Behavioural and Cognitive Psychotherapy, 35(1), 77-91.


 About the Author

Oppawsky_JoleneJolene Oppawsky, PhD, a Diplomate Psychotherapist, Licensed Professional Counselor in Arizona, and an Approved Clinical Supervisor is a University of Phoenix faculty member and supervisor in the graduate counseling program in Tucson, Arizona. Formerly, she taught for Boston University in their graduate overseas counseling program. She has taught psychology and psychotherapy at the University of Warsaw twice and at the University of Lithuania. She does psychotherapy on a contract basis in Tucson, Arizona. She has several professional publications to her credit.