Transcript Dia 1 - ESTSS

The European Network for Traumatic Stress
Training & Practice
www.tentsproject.eu
Psychological First Aid
Curriculum for early intervention strategies
after traumatisation
Brigitte Lueger-Schuster
University of Vienna, Department of Clinical
Psychology / Acute Support Vienna
The Problem
• Exposure to traumatic events not only causes medical needs, but
also a broad range of human needs
– relief from pain,
– worries about the event,
– worries about beloved ones, grief, stress and strain.
• Exposure to traumatic events may cause distress and dysfunction,
mainly described in the pathological classification as Acute Stress
Disorder.
• BUT: There is a wide range of psychosocial reactions, which can
lead to disorders.
Definition of Trauma and critical incident
• by the event itself or
• via criteria to assess an event as traumatic (Green, 1990)
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life-treat
threat of bodily integrity,
injury, intentional injury,
confrontation with unthinkable and unbelievable,
to learn about a traumatic event or the danger of being confronted with it,
being guilty of a traumatic event…
• + the loss of beloved ones, missing loved ones or friends, being in
close relation to primary victims (secondary traumatization)
• Traumatizing elements
– physiological strain (pain, starvation, and dehydration),
– exhaustion, surrender,
– Separation, relocation, loss, isolation, dehumanization, uncertainty,
incongruent experience, exposure to the grotesque.
Development of reactions
• Shock, a sense of unreality and fear dominate
• Sights, sounds, smells and feelings persist as images
• As the immediate stress reaction dissipates, longer-term effects
appear.
• Basic assumptions and beliefs are challenged
• Individuals feel vulnerable, helpless and hopeless.
• Griefing for loved ones, griefing for home, for memorabilia, for lost
documents and the neighbourhood are worsening factors
• Often survivors feel guilty or unworthy for surviving.
• A wide variety of emotional disturbances is experienced within the
weeks following traumatic exposure
Time-lines, Phases
• Psychological first aid: 0 to 4 weeks after
exposure
• Early interventions: 4 to 12 weeks after
exposure
• Treatment: 12 weeks after exposure
Phases
• Shalev (2003) describes successive and overlapping stages of the
response to traumatic events (impact – rescue – recovery – back to
life)
• responses are characterized as polymorph and labile in relation to
the circumstances
• early reactions underlay a constant process of adaption and
assimilation, therefore they are labile, occur in divers “pictures” and
react to the ongoing of the event.
• Role of helper varies: from rescue and protection to orientation and
provision of needs to responsivness and sensitive interaction,
ending in concrete and symbolic assistance
Reactions and Symptoms
• Dissociative symptoms
– can be assessed as risk factors for PTSD or
– As dissociative reactions, which are helpful reactions in the sense of self
protection, a kind of psychological surviving-tool.
• intrusive recall
– can be valued as a function in order to “manage” information
– or as a symptom (exhausted memory related to the amygdale activity)
• depressive symptoms
– can be recognized as normal grief reaction and a step to recovery.
• Stress and Extreme Stress theory is homeostatic.
– dynamic interaction between stressor and defending or coping host
– The construct of trauma stresses the breakdown, causing survivors to
potentially carry long-term consequences.
Targets of psychological first aid
• Subjects reqiring special attention
– Children and adolescents, elderly persons, pregnant women, single
parents
– People with chronic illness, people in difficult living conditions
– People with multiple exposure to traumatic events, prior mental healths
problems
– People with special needs (language, legal requirements, no social
net…)
– Directly affected people (survivors) and indirect affected people (family,
friends, helpers…)
• Survivors are active participants in the scenarios
• Helpers should relate to survivors as active recipients and identify
and support their clients’ ways and goals of coping with adversity.
Needs of survivors and affected people
• To deal with:
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Disturbing posttraumatic reactions, grief and shattered assumptions
Integrating traumatic experiences and losses
The lack of information about the event and its causes
The lack of information about support (legal, financial…)
Related health problems and persisting health problems
The lack of information about ressources for recovery and treatment
The lack of routines in coping with traumatic turbulences
Sustaining task performance
The feeling of being without protection and help
 Psychological first aid is: psycho and social support in proactive way by
helpers with a specific training in order to answer to these needs.
Shared reality: survivor & helper
• Survivors and witnesses are affected by what they see, hear,
understand, or derive from the news from any source.
• Important, the social context operates as narrated and not as
present: A picture on TV may affect risk perception more than the
experienced traumatic situation.
• Both survivors and helpers are part of that narrative and embedded
in the same social context.
• opportunity for intuitive understanding, empathy and connectedness.
• It can also overwhelm helpers and reduce their efficiency.
Evaluating the early responses:
indicators
• four observable indicators of successful coping:
– Sustained task performance,
– Controllability of emotion,
– Sustained capacity to enjoy rewarding human
contacts and
– Sustained a sense of personal worth.
Higher Goals of Psychological First Aid
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Physical: ensure survival, conserve or recover health
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Emotional: Relief, being able to express feelings
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Cognitive: handling the event, its reason and
consequences
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Behavioural: adapting behaviour and relationships to
changed situation
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Social: make the social systems (school, family,
company) function again
Principles of psychological first aid
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Simplicity
Innovation
Briefness
Pragmatism
Quick response
Spacial proximity
Building up adequate expectations
Definitions of psychological first aid
Psychological first aid: a flexible and individualised
approach that emphasizes education, reassurance,
avoidance of discussion the details of the event, and active
Intervention for only those showing serious symptoms after
3 to 4 weeks – not 3 to 4 days. (p.20)1)
Psychological First Aid is a supportive intervention for use in
the immediate aftermath.
It is designed for delivery by mental health worker or other
helpers to reduce the initial distress caused by traumatic
events. It should foster short- and long-term adaptive
functioning and coping (Nato,2008).
1)Callahan, J. (2009). Emergency Intervention and Crisis Intervention. In P. Kleespies (Ed.),
Behavioral Emergencies. An Evidence-Based Resource for Evaluating and Managing Risk of Suicide,
Violence, and Victimization (pp. 13-32). Washington: American Psychological Association.
Why is early intervention in the
acute phase so important?
Crisis can be the initial period of a much longer
dysfunction. Early response for someone in a stressful and
traumatic situation can prevent a potential ASD from
becoming a much more difficult to treat PTSD. It is also
important to know, when crisis intervention is appropriate:
Only in the acute phase of a critical situation and within a
certain period of time afterwards, however crisis
intervention is not indicated if someone comes to you for
professional help after 3 or even 6 month.
Psychological Debriefing
“More recent RCTs of CISD have shown that this intervention is not
beneficial. Experts have ultimately concluded that CISD is
contraindicated for victims of trauma.
Unlike CISD, psychological first aid does not assume that all trauma
survivors will develop chronic mental health problems, and it is limited to
those who request professional support on the aftermath of a traumatic
stressor.
The intervention aims to enhance the immediate and ongoing safety of
victims and it assists trauma survivors in addressing the current or
anticipated problems in a compassionate, non-intrusive manner.”
McCart, M. R., Fitzgerald, M. M., Acierno, R. E., Resnick, H. S. & Kilpatrick, D. G. (2009).
Evaluation and Acute Intervention with Victims of Violence .
In P. Kleespies (Ed.), Behavioral Emergencies. An Evidence-Based Resource for Evaluating and
Managing Risk of Suicide, Violence, and Victimization (pp. 13-32).
Washington: American Psychological Association.
Most important Components
• Most important components of psychological first aid:
– Attention to basic needs (e.g. safety, food and communication).
– Early interventions (e.g. reducing physiological arousal and
providing information & support).
– Assessing needs and screening (e.g. to ensure immediate needs
are addressed and to identify any additional interventions that
might be required)
– Monitoring the rescue and recovery environment (e.g. monitoring
media coverage and the services being provided).
NATO (2008). Psychological Care for People affected by Disasters and Major Incidents. A Model for
Designing, Delivering and Managing Psychological Services for People Involved in Major Incidents,
Conflict, Disasters and Terrorism. Non-binding Guidance. NATO Joint Medical Committee.
Most important components
• Most important components of psychological first aid
– Outreach and information dissemination (e.g. by information leaflets,
websites & media interviews).
– Technical assistance, consultation & training (e.g. improving the
capacity of organisations to provide what is required to re-establish
community and family networks).
– Fostering resilience, coping & recovery (e.g. psychoeducation)
– Triage (e.g. identifying vulnerable and high-risk individuals & groups,
and arranging referral for specialist help if needed)
– Treatment (e.g. formal treatments including pharmacotherapy)
NATO (2008). Psychological Care for People affected by Disasters and Major Incidents. A Model for
Designing, Delivering and Managing Psychological Services for People Involved in Major Incidents,
Conflict, Disasters and Terrorism. Non-binding Guidance. NATO Joint Medical Committee.
Elements of Trauma Intervention
Five empirical supported intervention principles:
1.
2.
3.
4.
5.
Sense of Safety
Calming
Sense of Self- an Community Efficacy
Connectedness
Hope
Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., Friedman, M.,
Gersons, B. P. R., de Jong, J. T. V. M., Layne, C. M., Maguen, S., Neria, Y., Norwood, A. E., Pynoos, R. S.,
Reissman, D., Ruzek, J. I., Shalev, A. Y., Solomon, Z., Steinberg, A. M. & Ursano, R. J. (2007). Five essential
elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70 (4), 283-304.
Elements of Trauma Intervention
Sense of Safety
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Negative post-trauma reactions tend to persist under conditions of
ongoing threat or danger.
If safety is introduced, these reactions show a gradual reduction
over time.
Even if the threat continues, those that can maintain a relative
sense of safety, have considerably lower risk of developing PTSD
on the following months.
Intervention strategies:
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interrupting the post-traumatic stimulus generalization, reality
reminders, teaching contextual discrimination in the face of trauma
and loss triggers, assisting in developing more adaptive cognitions &
coping skills, grounding techniques.
Intervention must include a social systems perspective.
Controll rumors
Elements of Trauma Intervention
Calming
Extremely high levels of emotionality, may lead to panic attacks,
dissociation, and may portend later PTSD.
• Prolonged states of heightended emotional responding may lead to
agitation, depression & somatic problems.
• Heightened heart rate in the early post-trauma phase has been
demonstrated to be associated with long-term PTSD symptoms.
• Given such problems, it is important that intervention include the
essential ingredient of calming. Treatments for calming range from
direct to indirect approaches.
– Direct approaches: For those with severe agitation, „racing“ emotions or
extreme numbing reactions.
– Techniques: Therapeutic grounding, Breathing Retraining, deep muscle
relaxation, medication, Stress inoculation training (SIT),
• Counter-productive ways of calming: benzodiazepines, wrong
informations
Elements of Trauma Intervention
Sense of Self- and Community Efficacy
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Self efficacy: individual has the belief that actions lead to positive outcome
Collective efficacy: Sense that one belongs to a group that is likely to
experience positive outcomes.
Trauma-related self-efficacy pertains to the perceived ability to regulate
troubling emotions and to solve problems (relationships, restoration of
property, relocating, job retraining, and other trauma-related tasks)
Intervention:
– encourage active coping and good judgment about when and how to cope
– Childhood intervention: Teaching children emotional regulation skills when faced
by trauma reminders and enhancing problem-solving skills.
•
Critics: 1. Self- and collective efficacy require behavioral repertoires and
skills (self-efficacy beliefs that are not reinforced by ongoing successful
action quickly compromise). 2. Empowerment without resources is
counterproductive and demoralizing.
Elements of Trauma Intervention
Connectedness
• Social connectedness provides opportunities for social support
activities (e.g. practical problem solving, emotional understanding &
acceptance, sharing of traumatic-erxperiences) and leads to
community-efficacy.
• Connections to loved ones is an important coping strategy. Social
support is related to better emotional well-being and recovery
following any trauma.
• Negative social support (e.g. minimizing problems or needs,
unrealistic expectations regarding recovery, invalidating messages)
is strongly correlated to long-term post-trauma distress.
• Intervention:
– 1. Identifying those who lack strong social support and who are likely to
be more socially isolated; 2. Keeping them connected, training people
how to access support; 3. Providing formalized support where informal
social support fails.
Elements of Trauma Intervention
Hope
• Definition of hope: Hope is a positive, action-oriented expectation
that a positive future goal or outcome is possible.
• But: Difference between Western action-oriented view of hope and
religious hope, which is not action-oriented.
• Strong evidence for the central importance of retaining hope
following mass trauma.
• Interventions can range from individual to group to mass media
messaging (e.g. CBT, guided self-dialogue, decatastrophizing,
benefit-finding)
Field Operations Guide - preparations
The Field Operations Guide gives advices for the preparations to
deliver Psychological First Aid:
• Entering the Setting: Importance of clearly defined roles and decisionmaking; effective entry depends on having as much information about the
setting as possible
• Providing Services: identify those who may need support.
• Psychological First Aid is designed for working with individuals and families,
but many components can be used in group settings as well.
• Maintain a calm presence
• Be sensitive to Culture and Diversity
• Be aware of At-Risk Population: Children, separated from parents; injured
people…
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E. &
Watson, P. (2006). Psychological first aid: field operations guide 2nd edition. National Child
Traumatic Stress Network and National Center for PTSD.
Field Operations Guide –
precise instructions
The Field Operations Guide provides precise instructions
for first responders and other relief workers:
• Basic Objectives: e.g. “Establish a human connection in a nonintrusive, compassionate manner”; “Calm and orient emotionally
overwhelmed or distraught survivors”.
• Professional Behavior: e.g. “Operate only within a framework of an
authorized response system.”; “Be visible and available”.
• Guidelines for Delivering Psychological First Aid: e.g. “Speak slowly,
in simple concrete terms; don´t use acronyms or jargon”.
• Behaviors to avoid: e.g. “Do not “debrief” by asking for details of
what happened”.
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E. &
Watson, P. (2006). Psychological first aid: field operations guide 2nd edition. National Child
Traumatic Stress Network and National Center for PTSD.
Field Operations Guide
– core actions
Psychological First Aid Core Actions:
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Contact and Engagement
Safety and Comfort
Stabilization
Information Gathering: Current Needs and Concerns
Practical Assistance
Connection with Social Supports
Information on Coping
Linkage with Collaborate Services
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E. &
Watson, P. (2006). Psychological first aid: field operations guide 2nd edition. National Child
Traumatic Stress Network and National Center for PTSD.
Field Operations Guide – core actions
Contact and Engagement:
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Introduce Yourself/Ask about Immediate Needs: e.g. Describe your role;
explain that you are there to see if you can be of help; speak softly and
calmly.
Confidentiality: Maintain the highest level of confidentiality possible.
Safety and Comfort:
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Ensure Immediate Physical Safety
Providing Information about Disaster Response Activities and Services
Attend to Physical Comfort
Promote Social Engagement
Attend to Children who are Separated from their Parents/Caregivers
Protect from Additional Traumatic Experiences and Trauma Reminders
Help Survivors Who Have a Missing Familiy Member
Help Surviors When a Family Member or close friend has died
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E. &
Watson, P. (2006). Psychological first aid: field operations guide 2nd edition. National Child
Traumatic Stress Network and National Center for PTSD.
Field Operations Guide – core actions
Safety and Comfort:
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Attend to Grief and Spiritual Issues
Provide Information about Casket and Funderal Issues
Attend to Issues Related to Traumatic Grief
Support Survivors Who Receive Death Notofication
Support Survivors Involved in Body Identification
Help Caregivers Confirm Body Identification to a Child or Adolescent
Stabilization:
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Stabilize Emotionally Overwhelmed Surviors
Orient Emotionally Overwhelmed Survivors
The Role of Medications in Stabilization: Medication may be necessary
when survivors experience extreme agitation, anxiety or panic, psychosis
or are dangerous to self or others.
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E. &
Watson, P. (2006). Psychological first aid: field operations guide 2nd edition. National Child
Traumatic Stress Network and National Center for PTSD.
Field Operations Guide – core actions
Information Gathering:
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Advices:
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Nature and Severity of Experiences during the Disaster
Death of Loved One
Concerns about Immediate Post-Disaster Circumstances and Ongoing
Threat
Separation from or Concern about the Safety of Loved Ones
Physical Illness, Mental Health Conditions, and Need for Medication
Losses (Home, School, Neighborhood, Business, Personal Property,
Pets)
Extreme Feelings of Guilt of Shame
Thoughts about Causing Harm to Self or Others
Availability of Social Support
Prior Alcohol or Drug Use
Prior Exposure to Trauma and Death of Loved Ones
Specific Youth, Adult, and Family Concerns over Developmental Impact
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Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E. &
Watson, P. (2006). Psychological first aid: field operations guide 2nd edition. National Child
Traumatic Stress Network and National Center for PTSD.
Field Operations Guide – core actions
Practical Assistance:
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Offering Practical Assistance to Children and Adolescents
Identify the Most Immediate Needs
Clarify the Need
Discuss an Action Plan
Act to Address the Need
Connection with Social Supports:
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Enhance Access to Primary Support Persons (Family and
Significant Others)
Encourage Use of Immediately Available Support Persons
Discuss Support-Seeking and Giving
Special Considerations for Children and Adolescents
Modeling Support
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E. &
Watson, P. (2006). Psychological first aid: field operations guide 2nd edition. National Child
Traumatic Stress Network and National Center for PTSD.
Field Operations Guide – core actions
Information on Coping:
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Provide Basic Information about Stress Reactions
Review Common Psychological Reactions to Traumatic
Experiences and Losses
Talking with Children about Body and Emotional Reactions
Provide Basic Information on Ways of Coping
Teach Simple Relaxation Techniques
Coping for FamiliesAssisting with Developmental Issues
Assist with Anger Management
Address Highly Negative Emotions
Help with Sleep Problems
Address Alcohol and Substance Abuse
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E. &
Watson, P. (2006). Psychological first aid: field operations guide 2nd edition. National Child
Traumatic Stress Network and National Center for PTSD.
Field Operations Guide - linkage
Linkage with Collaborative Services:
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Provide Direct Link to Additional Needed
Services
Referrals for Children and Adolescents
Referrals for Older Adults
Promote Continuity in Helping Relationships
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E. &
Watson, P. (2006). Psychological first aid: field operations guide 2nd edition. National Child
Traumatic Stress Network and National Center for PTSD.
Role of helper
It is important to notice, that the role of the
interviewer or clinician is expected to be a helping one
There can be two types of errors conducted by the
interviewer in an emergency situation
1.
2.
assuming to readily that there is an alliance with a patient when there is
none
dwelling too long on establishing a relationship when it is already
assumed by the patient
Guidelines and
recommendations
• Psychological Care for People Affected by Disasters and Major
Incidents (NATO, 2008)
• Five Elements of Mass Trauma Intervention (Hobfoll et al., 2007)
Psychological First Aid. Field Operations Guide – 2nd Edition
(Brymer et al., 2006)
• Callahan, J. (2009). Emergency Intervention and Crisis Intervention.
In P. Kleespies (Ed.), Behavioral Emergencies. An Evidence-Based
Resource for Evaluating and Managing Risk of Suicide, Violence,
and Victimization (pp. 13-32). Washington: American Psychological
Association.