3 years of San Bernardino Strong: Personal reflections and lessons on community trauma... and resilience in the face of terrorism

December 2, 2015, changed my community. It changed me.

I was in a San Bernardino County Department of Behavioral Health conference room off Waterman in San Bernardino. It was my third day back to work at DBH after a three week paternity leave for my littlest's birth. A friend leaned over to me and showed me an alert she just received about a possible shooting down the street. We started noticing abnormally numerous sirens. And helicopters.

We quickly discovered there had been a mass shooting nearby--you could see the building from many of our offices. We were on lockdown for hours, as there was a manhunt for the shooters--possibly 4 of them--and there were reports that they were targeting public behavioral health.

Many of us never expected to be a part of the 2016 Presidential Election dialogue. Yet here we were. My community is now part of the list of mass shooting and terrorism locales.

Trauma is legitimately part of that discussion. I'm grateful that we are increasingly and publicly recognizing the impact of trauma on survivors and traditional first responders (e.g., law enforcement, fire fighters, and paramedics).

Today, I want to expand that discussion, recognizing the broader impact of trauma, as well as the critical role of public behavioral health and behavioral health first responders.

What is trauma?

One of the many challenging things about trauma is that it's hard to precisely contain or define it. While we have clinical definitions of trauma to put boundaries on it for diagnostic purposes, our short-term and long-term reactions shape our understanding. What one person experiences as traumatic, another won't. But that doesn't mean it wasn't a trauma.

Here's how trauma is defined according to the last two Diagnostic and Statistical Manuals of Mental Disorders:

Experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. (DSM-IV-TR)

Exposure to actual or threatened death, serious injury, or sexual violence… (DSM-5)

It's easy to recognize trauma when you're faced with actual death, serious injury, sexual violence, etc. It's easy to forget trauma when it's "just" a threat.

Trauma affects more people than we realize

When you start looking at mass casualty events, the number of people impacted grows very quickly. We still tend to prioritize those with primary exposure to actual death. And that makes sense for many reasons. We cannot minimize the impact of this trauma.

Prioritizing trauma can also invalidate the trauma to those who didn't die, weren't physically injured, and may not have seen the actual violence. I would like to encourage any reader to be more aware of a broader impact of trauma.

In the case of San Bernardino, think of the manhunt for the shooters that spanned hours. What kind of trauma on the community was there of so many people looking over their shoulders and searching for a black SUV (not uncommon in Southern California) that may shoot them? What kind of trauma would face people who saw military-grade law enforcement vehicles go down their street and break into a home remotely for fear of explosions? What about those who cleaned up the remains of the bomb making materials in the home that the FBI left? What kind of trauma would be experienced having a massive police chase go past your home? What about the people whose homes were on TV as the shootout happened in front of them?

What about those who were on lockdown for hours with cell phone and internet service bogged down (and therefore minimal information coming through) but with a very real threat of being shot at? Despite the fact that I have decent training in trauma, have provided training in trauma, and have treated trauma, it took two weeks and someone else telling me to realize that this was, in fact, a trauma.

I still experience various forms of hyperarousal with many sirens and helicopters. I know many people who cannot sit with their back to a door in any setting. Many of us enter rooms and look for exits and places to hide. Just last week, an alarm went off in the airport while I was waiting to board, and I started mentally preparing for the worst.

What changes if we label an experience a trauma without attempting to compare traumas? What if we talk about, recognize, and validate the many other ways people experience traumas in these events?

Behavioral health first responders

The County has long had a Community Crisis Response Team, providing 24/7 behavioral health mobile response to the community. The benefit of this kind of infrastructure, service, and expertise cannot be overstated in incidents like this.

Something unique the County did was establish a team of liaisons to survivors and family members of the terrorist attack. I was appointed to oversee one of those teams, serving 96 survivors and close co-workers plus their families. We did not provide counseling or therapy, but rather helped folks navigate life in the aftermath of horror. After trauma, mundane things are not so easy.

We talk about secondary/vicarious trauma/compassion fatigue for behavioral health providers. It's very real. But also remember that most of the CCRT and liaison team members also experienced some level of primary trauma in this incident. Many knew someone who had died, as well.

While behavioral health first responders may not always put themselves in physical danger (although that can be part of the job), why don't we talk about psychological danger?

Dealing with the aftermath of trauma 7 days a week for over a year (and 24/7 for months for many of my liaisons) was the responsibility of many of these folks. Many people put their lives on hold to help others put their lives back together. Was it worth it? Absolutely. Was it hard? Absolutely. And it had real world impacts on our lives.

Is physical danger necessarily worse than psychological danger? Do people die due to psychological danger? (I would definitively say yes.) I would also suggest that this also reflects our cultural bias to emphasize the physical over the psychological.

What would happen if we valued psychological safety to even close to the same degree we value physical safety in culture, in policy, and even in funding?

Public behavioral health is critical

One thing this experience taught me is the significance of the public behavioral health system.

While we have health plans, medical centers, community providers, etc., there really is no institution other than a public agency (namely local government) that has the responsibility and interest to serve every single member of the community.

We may need to consider other ways of structuring services and capacity, but having a community response regardless of insurance makes a huge difference in building baseline community resilience and moving toward community recovery.

In California, we're blessed to have special funding under the Mental Health Services Act, part of which has gone toward stigma and discrimination reduction activities as well as suicide prevention work. I firmly believe that stigma and discrimination reduction as well as baseline suicide prevention foundations help improve people's willingness to seek behavioral health support and prevent additional deaths due to suicide (which is very common in the aftermath of trauma, especially terrorism and mass shootings).

As we build our systems, our funding streams, our policies, and our delivery networks, are we continuing to consider a public health model of behavioral health? We need it not just for these critical incidents, but also for the daily traumas and behavioral health needs that in fact have a much bigger impact on our society.

In honor of those who died three years ago today and the many people who have built resilience and recovery into my community, I ask you to love someone today. We may forget the role of the "little" actions, but they can be the most powerful. I'll leave you with one of my favorite quotes: