Psychological First Aid: Supporting People in a Disaster
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Transcript Psychological First Aid: Supporting People in a Disaster
In Times of Crisis:
Supporting Others,
Supporting Ourselves
John Gaspari, LCSW
Executive Director
USC Center for Work and Family Life
Center for Work and Family Life
Available Services:
Faculty and Staff Counseling
Faculty, Management and Departmental
Consultation
Critical incident response
Work/Life Support
Family and Dependent Care: Consultation and
Resources
Workplace Health and Wellness Programs
Role Expectations
Are you clear about your the role
expectations you carry as a member of the
CERT?
Can you imagine having any unfulfilled
expectations or disappointments while
functioning in this role?
How might the many other roles you play
at any given time impact your role as a
CERT member?
Unit Objectives
1. Psychological impacts to expect after a
disaster – What happens for people?
2. How to work with the psychological
impacts in your role – Providing
psychological support.
3. Responder stress management and selfcare.
Are We
Psychologically Prepared?
For every physical
injury, there may be 5-6
psychological injuries
This may overwhelm
and impede our
emergency and/or
medical response.
Critical Incident
Exposure to a traumatic event in which
both of the following were present:
The person experiences, 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.
The person’s response involved intense fear,
helplessness or horror. (DSM-IV TR)
Coping Mechanisms
People typically rely on past strategies to
cope with new stressful situations
Past coping mechanisms can be
functional or dysfunctional.
Degree of hardiness (resilience) has been
identified as a characteristic that can
buffer extreme stress in older populations
Children can be vulnerable because they
have no experience or known patterns of
actions as a response to the experience.
Into every life
a little rain must fall …..
But what happens
when there is a
flood?
Psychosocial Impact –
Considerations
Prior experience with a similar
event
Prior trauma
The intensity of the disruption in the
survivors’ lives
The resilience of the individual
Psychosocial Impact –
Considerations
The length of time that has elapsed
between the event occurrence and
the present
•Children/families
Pre-existing vulnerabilities
Man-Caused vs.
Naturally Occurring
Events
•Seniors
•Disabled
•Bereaved
•Health impairments
•Women
Consequences of Critical Incidents
Often include LOSS
Tangible Loss
Loss of loved ones
Loss of home
Loss of material goods
Loss of employment / income
Consequences of Critical Incidents
Often include LOSS
Intangible Loss
Loss of safety / security (real or perceived)
Loss of predictability
Loss of social cohesion/connection/support
Loss of dignity, trust and safety
Loss of positive self-image/self-esteem
Loss of trust in the future, identity,
independence
Loss of hope
Loss of CONTROL
Activity – What if I lost…
You have been given three cards each of three
different colors:
Blue Card - write the name of a person close
to you on each card
White Card - write down one of your favorite
belongings
Pink Card - write down something you enjoy,
an activity, or hobby.
After you have written on each card, place
them face down on the table and shuffle
them around. Close your eyes and pick
three cards.
Activity – What if I lost…
These are the three things you will
have lost in a disaster.
Discuss with the group how you
feel about losing these things or
people
Possible Psychological Reactions
to a Large-Scale Emergency
Many people survive disasters
without developing any significant
psychological symptoms.
For other individuals, the reactions
will disappear over time.
“Just because you have experienced a
disaster does not mean you will be damaged
by it, but you will be changed by it.”
(Weaver 1995)
Grief and Loss
Not an even process
Takes time
Can become stuck in the process
May spawn other problems
Nothing like T & T (Time and Talking)
Supporting
Others
“We’re a community that
believes in
‘love thy neighbor’,
but right now we need to love
our neighbors a little bit more.”
Man talking after devastating
tornados ripped through his
Tennessee neighborhood - 2/08
Role of Disaster Mental Health?
Primarily directed toward “normal” people
who are responding normally to an abnormal
situation
Improve resistance, resilience and recovery.
Identifying those at risk for severe social or
psychological impairment
Identify those in need of additional or special
services.
Role of Disaster Mental Health?
Mitigate post trauma sequelae
May prevent future problems
Helps people to handle problems in a way that
does not create MORE problems
Convey sense of compassion and support for
people.
Psychological Response to Trauma
Key Concepts
Experience has shown that:
No one who sees a disaster is untouched by it.
Most people pull together & function during and
after a disaster, but their effectiveness is
diminished.
Most people do not see themselves as needing
mental health services following a disaster and
will not seek such services.
Psychological Response to Trauma
Key Concepts
Experience has shown that:
Survivors respond to active, genuine interest &
concern.
Survivors may reject disaster assistance of all
types.
Disaster mental health assistance is often more
practical than psychological in nature.
Social support systems are crucial to recovery.
Psychological Response to Trauma
Key Concepts
While there may be specific disaster-related
stressors, underlying concerns and needs are
consistent across a range of traumatic events.
These include:
A concern for basic survival
Grief and loss over loved ones & loss of valued and
meaningful possessions
Fear & anxiety about personal safety & the physical
safety of loved ones
A need to talk about events & feelings associated with
the disaster, often repeatedly
A need to feel one is a part of the community & its
recovery efforts
Phases of Disaster
Honeymoon
(community cohesion)
llllllllllll
Reconstruction
Heroic
Pre-Disaster
(a new beginning)
Disillusionment
Threat
Warning
EVENT
Inventory
Trigger Events and
Anniversary Reactions
Time
1 to 3 days
1 to 3 years
Honeymoon
(community cohesion)
Survivors may be elated
Happy just to be alive
This phase will not last
Disillusionment
Reality of disaster
“hits home”
Loss and Grief
becomes prominent
What Do You Think?
What main attributes and
skills should a volunteer
have when offering
psychological support?
Essential Attributes and Skills
Good Listening
skills
Patient
Caring attitude
Trustworthy
Approachable
Culturally aware
Empathetic
Non-judgmental
approach
Kind
Committed
Flexible
Able to tolerate
chaos
Intense Emotions
Are often appropriate
reactions following a disaster
Can often be managed by
community responders
Supportive Communication
Supportive communication
conveys:
Empathy
Concern
Respect
Confidence
Activity –
Supportive Statements
What are some supportive
statements that you would
find helpful if you were in
pain, injured, and/or acute
emotional distress.
Do Say…
Can you tell me what happened?
I’m Sorry
This must be difficult for you
I’m here to be with you
Activity –
Unhelpful Statements
What are some statements
that you would find unhelpful
if you were in pain, afraid,
injured, and/or dealing with
tremendous loss.
Avoid Saying . . .
“I understand what it’s like for you.”
“Don’t feel bad.”
“You’re strong/You’ll get through this.”
“Don’t cry.”
“It’s God’s will.”
“It could be worse” or “At least you still
have . . .”
Guiding Principles in Providing
Psychological Support in Your Role
Protect from danger
Be direct and active
Provide accurate information about what
you’re going to do
Reassure
Do not give false assurances
Recognize the importance of taking action
Provide and ensure emotional support
Crisis Intervention
Observe safe practices by showing
concern for your own safety
Remain calm and appear relaxed,
confident and non-threatening
You must look and act calm even if you are
not
Goals of Psychological First Aid
Psychological first aid (PFA) promotes and
sustains an environment of:
SAFETY
CALM
CONNECTEDNESS
SELF-EFFICACY
HOPE
Psychological First Aid
Promote SAFETY:
Help people meet basic needs for food
and shelter, & obtain medical attention.
Provide repeated, simple and accurate
information on how to get these basic
needs met.
Psychological First Aid
Promote CALM:
Listen to people who wish to share their
stories and emotions, & remember that
there is no right or wrong way to feel.
Be friendly & compassionate even if
people are being difficult.
Offer accurate information about the
disaster or trauma, and the relief efforts
underway to help victims understand the
situation.
Psychological First Aid
Promote CONNECTEDNESS:
Help people contact friends and loved
ones.
Keep families together. Keep children
with parents or other close relatives
whenever possible.
Psychological First Aid
Promote SELF-EFFICACY:
Give practical suggestions that steer
people toward helping themselves.
Engage people in meeting their own
needs.
Psychological First Aid
Promote HELP:
Find out the types and locations of
government & non-government services
and direct people to those services that
are available.
When they express fear or worry,
remind people (if you know) that more
help and services are on the way.
Psychological First Aid
DON’T:
Force people to share their stories with
you, especially very personal details
(this may decrease calmness in people
who are not ready to share their
experiences).
Give simple reassurances like
“everything will be ok”, or “at least you
survived” (statements like these tend to
diminish calmness).
Psychological First Aid
DON’T:
Tell people what you think they should
be feeling, thinking or doing now or how
they should have acted earlier (this
decreases self-efficacy).
Tell people why you think they have
suffered by giving reasons about their
personal behaviors or beliefs (this also
decreases self-efficacy).
Psychological First Aid
DON’T:
Make promises that may not be kept
(un-kept promises decrease hope).
Criticize existing services or relief
activities in front of people in need of
these services (this may decrease
hopefulness or decrease calming).
Source: Center for the Study of Traumatic Stress
Anxiety
A state of intense apprehension,
uncertainty and fear
Results from anticipating a
threatening event
Intense anxiety = “fight or flight”
Agitation
Sometimes, despite our best
attempts at active listening, people
become agitated
It is usually not personal
This is their reaction to an
extremely abnormal situation, and
it has nothing to do with you
The Energy Curve
Agitation
Anxiety
Tension Reduction
Baseline
Elements of Escalation
Challenging authority or questioning
Refusal to follow directions
Loss of control, becoming verbally
agitated
Becoming threatening
Elements of Escalation
Challenging Authority or Questioning
Answer the question
Repeat your request in a neutral tone of
voice
Remember that an ounce of prevention
is worth a pound of cure
Elements of Escalation
Not Following Directions
Do not take control, help the individual gain
control of him/herself
Remain professional
Consider restructuring your request
Give the person time to think about your
request
Seek Assistance
Loss of Control, Becoming Verbally
Threatening
Verbal Vomit
If the person becomes threatening or
intimidating and does not respond to
your attempts to calm them, seek
immediate assistance
Elements of De-escalation
Establish a relationship
Introduce yourself if they do not know you
Ask the person what they would like to be
called
Don't shorten their name or use their first
name without their permission
With some cultures, it is important to always
address them as "Mr." or "Mrs.", especially if
they are older than you
Elements of De-escalation
Use concrete questions to help the
person focus
Use closed ended questions (yes/no)
If the person is not too agitated, briefly
explain why you are asking the question
• For example:
I'd like to get some basic information from you
so that I can help you better. Where do you
hurt?
Elements of De-escalation
Come to an agreement on
something
Establishing a point of agreement will help
solidify your relationship and help gain their
trust
Positive language has more influence than
negative language
Active listening will assist you in finding a
point of agreement
Elements of De-escalation
Speak to the person with respect
This is communicated with:
Words
Para-verbal Communication (how we
say the words – e.g. tone, pitch)
Non-verbal behavior
Use of words like please and thank
you
Elements of De-escalation
Don't make global statements about
the person's character
Use “I” statements
Lavish praise / support /
encouragement is not believable
Responder Stress and
Well-Being:
Helping the Helpers
Adrenaline, Friend or Foe?
Increase in speed and strength
Tunnel vision – eyes revert to default survival
position.
Reduced Near, peripheral, depth
Hearing muted
Changes in reaction time
Freezing and unable to react
Overreacting
Increase in sensory acuity
Slow motion time
May act in a way that seems inappropriate for
the situation (e.g. giggle, yell)
Psychological Response to Trauma
Survivors’ Needs and Reactions
People often experience strong and
unpleasant emotional and physical
responses following exposure to traumatic
events (e.g. disasters).
These may include a combination of:
•Fear & anxiety
•Grief & loss
•Shock
•Hopelessness
•Loss of Confidence
•Mistrust
•Sleep disturbances
•Physical pain
•Confusion
•Shame
•Shaken faith
•Aggressiveness
Possible Physiological
Symptoms
Loss of appetite
Headaches, chest pain
Diarrhea, stomach pain, nausea
Hyperactivity
Increase in alcohol or drug consumption
Nightmares
Inability to sleep
Fatigue, low energy
Possible Emotional/Psychological
Symptoms
Irritability, anger
Self-blame, blaming others
Isolation, withdrawal
Fear of recurrence
Feeling stunned, numb, or overwhelmed
Feeling helpless
Mood swings
Sadness, depression, grief
Denial
Concentration, memory problems, confusion
Relationship conflicts/marital discord
More Typical Reactions…
Fear of darkness
Fear of being alone or of crowds or strangers
Sensitivity to loud noises
Somatic complaints
Guilt, anger, grief
Reliving past traumas
Main point – Disaster stress is a
normal response to an abnormal
circumstance. If symptoms persist,
they must be treated.
C. Fasser, 2004; B. Young, 2006
Possible Psychological Reactions
to a Large-Scale Emergency
For most people, things get
better with time…
Possible Psychological Reactions
to a Large-Scale Emergency
For some, however, the reactions may
evolve and even worsen.
*Victims of Hurricane
Katrina: Significant increase in
serious mental health problems
two years post Katrina (PTSD,
suicidality, depression, anxiety,
substance abuse, domestic
violence) across all racial and
socio-economic groups.
Helpers
Responders are, by definition, exposed to
a critical incident
They may experience critical incident
stress because of the work they do
Often have a feeling of not having done
enough
Are sometimes overwhelmed by the needs
of the community
Need to cope with their own fears
Challenge to Helpers
Being part of the collective crisis
Repeated exposure to grim experiences
Carrying out physically difficult, exhausting
or dangerous tasks
Lacking sleep and feeling fatigued
Facing the perceived inability to ever do
enough
Challenge to Helpers (cont.)
Facing moral and ethical dilemmas
Being exposed to anger and lack of
gratitude
Being detached from personal support
systems
Feeling frustrated by policies and
decisions by supervisors
Feeling guilt over access to food, shelter,
etc.
Categories of Reactions
After the Incident
•ASD / PTSD
•Grief
•Depression
•Resilience
Mental Health
and Illness
Distress
Responses
•Fear / worry
•Sleep disturbance
•Altered productivity
•Avoidance (emotional)
•Substance abuse
•Risk taking
•Over Dedication
Human
Behavior in
High Stress
Environments
Loss and Grief – Signs of Trouble
Avoiding or minimizing emotions
Using alcohol or drugs to self-medicate
Using work or other distractions to avoid
feelings
Hostility and aggression toward others
Stress
A state of physical
and/or
psychological
arousal
Often brought
May
be
expressed
about by a
perceived threat or differently by
different people /
challenge
cultures
Coping with Stress
Coping is a way to prevent, delay,
avoid, or manage stress
Coping mechanism categories:
Changing the source of stress
Changing the view of the situation
Tolerating the stressor until it passes or
becomes less troublesome
Examples of Coping
Seeking help from others or offering to help
others
Using natural support systems
Talking about their experiences and trying to
make sense of what happened
Hiding until the danger has passed
Seeking information about the welfare of loved
ones
Gathering remaining belongings
Examples of Coping (cont.)
Beginning to repair the damage
Burying or cremating the dead
Following religious or cultural practices
Setting goals and making plans
Using defenses like denial
Remaining fearful and alert to further
danger
Thinking long and hard about the event
What Are Your
Preferred Approaches to
Managing Stress?
Do you practice ‘stress
management’ regularly?
Self-Help Techniques
Know the normal reactions to stressful events
Be aware of your tension and consciously try to
relax
Use the buddy system
Talk to someone you trust and with whom feel at
ease
Listen to what people close to you say and think
about the event
Reconcile expectations with results
Self-Help Techniques (cont.)
Work on routine tasks if it is too difficult to
concentrate on demanding duties
If you cannot sleep or feel too anxious,
discuss this with someone you can trust
Express your feelings in ways other than
talking:
Draw
Paint
Play music
Journal
Self-Help Techniques (cont.)
Do not self-medicate
Go easy on yourself
Avoid inflated or
perfectionistic
expectations
Seek professional advice
if reactions continue
Cognitive/Behavioral Approaches
to Stress Reduction
Adequate Rest
Exercise / Movement
Diet / Balanced Nutrition
Enough H2O
Moderate Chemical Use
Laughter / Tears
Time Away From Work Role
Cognitive/Behavioral Approaches
to Stress Reduction
Religious / Spiritual
Relaxation Techniques / Breathing
Yoga
Meditation
Social Support / Discuss Feelings
Allow yourself to receive as well as
give
Cognitive/Behavioral Approaches
to Stress Reduction
Play: Hobbies / Personal Interests
Exposure to Nature
Biofeedback
Massage / Human Touch
Sex
Professional Assistance
Medication
What Else Works for You???
Team Well-Being
CERT team leaders:
Provide pre-disaster stress management training
Brief personnel before response
Emphasize teamwork
Encourage breaks
Provide for proper nutrition
Rotate staff
Phase out workers gradually
Arrange for a intermittent and post-event
debriefing
Conduct follow-up with CERT team members
Critical Incident Stress Debriefing
(CISD)
Debriefing / Defusing:
is a specific technique designed to assist
responders in dealing with the physical or
psychological symptoms that are generally
associated with trauma exposure.
allows those involved with the incident to
process the event and reflect on its impact.
allows for the ventilation of emotions and
thoughts associated with the crisis event.
provided as soon as possible but typically no
longer than the first 24 to 72 hours after the
initial impact of the critical event.
No Macho (Wo)Man,
No Pity Party
Do not create an expectation
there will be a problem, but
when there is a problem,
go get help.
Lt. Col Dave Grossman (ret.)
When you come to the edge
of all that you know,
You must believe in
one of two things;
There will be earth
on which to stand,
or You will be given wings.
Anonymous
Questions / Discussion