The European Network for Traumatic Stress Training & Practice .

The European Network for Traumatic StressTraining & 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)

– 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

• 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

Phases

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:– 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.

• Physical: ensure survival, conserve or recover health

• Emotional: Relief, being able to express feelings

• Cognitive: handling the event, its reason and consequences

• Behavioural: adapting behaviour and relationships to changed situation

• Social: make the social systems (school, family, company) function again

Higher Goals of Psychological First Aid

• Simplicity• Innovation• Briefness• Pragmatism• Quick response• Spacial proximity• Building up adequate expectations

Principles of psychological first aid

Definitions of psychological first aid

Psychological first aid: a flexible and individualisedapproach that emphasizes education, reassurance,avoidance of discussion the details of the event, and activeIntervention for only those showing serious symptoms after3 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.

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.

Why is early intervention in the acute phase so important?

“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.”

Psychological Debriefing

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. Sense of Safety

2. Calming

3. Sense of Self- an Community Efficacy

4. Connectedness

5. 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.

• 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:– 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


Sense of Safety

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


Calming

• 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 Sense of Self- and Community Efficacy

• 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.


Connectedness

• 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)


Hope

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 decision-making; 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 non-

intrusive, 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”.


Field Operations Guide – core actions

Psychological First Aid Core Actions:1. Contact and Engagement

2. Safety and Comfort

3. Stabilization

4. Information Gathering: Current Needs and Concerns

5. Practical Assistance

6. Connection with Social Supports

7. Information on Coping

8. Linkage with Collaborate Services



Contact and Engagement:• 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:• 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



Safety and Comfort:• 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:• 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.



Information Gathering:• Advices:• 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



Practical Assistance:• 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:• 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



Information on Coping:• 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


Field Operations Guide - linkage

Linkage with Collaborative Services:

• Provide Direct Link to Additional Needed Services

• Referrals for Children and Adolescents• Referrals for Older Adults• Promote Continuity in Helping Relationships


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. assuming to readily that there is an alliance with a patient when there is none

2. dwelling too long on establishing a relationship when it is already assumed by the patient

Role of helper

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.

The European Network for Traumatic Stress Training & Practice .

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