DISM411 - LECTURE

FUNCTION
What Survivors Need:
PSYCHOLOGICAL FIRST AID KEY POINTS FUNCTION ➢ Soothing human contact
a. Parallel to medical first aid ➢ Validation that reactions are “normal”.
b. Uses skills you probably already have What To Do:
c. Appropriate for all ages ➢ Establish a compassionate “presence.”
d. Consistent with research evidence on risk and resilience following COMFORT ➢ Listen actively.
trauma ➢ Comfort, console, soothe, and reassure.
CRISIS EVENTS ➢ Apply stress management techniques.
• Crisis events – both large-scale and individual ➢ Reassure survivors that their reactions are
➢ occur in every community in the world
• They have physical, social and emotional consequences for those What Survivors Need:
affected. FUNCTION ➢ Social supports/keeping family together
PFA: FIRST-LINE PSYCHOSOCIAL SUPPORT ➢ Reuniting separated loved ones
➢ Connection to disaster recovery services, medical
• PFA is important, first-line psychosocial support for people affected by
care, work, school, vital services.
crisis events.
What To Do:
➢ PFA, like medical “first aid”, is not enough on its own.
➢ Keep survivor families intact.
• Term “PFA” was first coined in the 1940s but its use has increased in
CONNECT ➢ Reunite separated loved ones.
modern-day crisis events.
➢ Reunite parents with children.
WHAT IS PFA?
➢ Connect survivors to available supports.
• Humane, supportive & practical assistance to fellow human beings who ➢ Connect to disaster relief services, medical care.
recently suffered a serious stressor:
a. Non-intrusive, practical care and support
ACTION
b. Assessing needs and concerns
c. Helping people to address basic needs (food, water) What Survivors Need:
d. Listening, but not pressuring people to talk ACTION ➢ Information about the disaster
➢ Information about what to do
WHAT PFA IS NOT?
➢ Information about resources
• NOT something only professionals can do
➢ Reduction of uncertainty
• NOT professional counselling
What To Do:
• NOT a clinical or psychiatric intervention (although can be part of good
➢ Clarify disaster information:
clinical care)
EDUCATE a. what happened
• NOT “psychological debriefing”
b. what will happen
WHY PFA? ➢ Provide guidance about what to do.
• People do better over the long term if they... ➢ Available resources
a. Feel safe, connected to others, calm & hopeful
b. Have access to social, physical & emotional support What Survivors Need:
c. Regain a sense of control by being able to help themselves ➢ Planning for recovery
ACTION
PSYCHOLOGICAL FIRST AID FOR DISASTER SURVIVORS ➢ Practical first steps and “do-able” tasks
OUTCOMES ➢ Support to resume normal activities
• SAFETY ➢ Opportunities to help others
➢ Restoring physical safety and diminishing the physiological stress What To Do:
response ➢ Set realistic disaster recovery goals.
• FUNCTION EMPOWER ➢ Problem solves to meet goals.
➢ Facilitating psychological function and perceived sense of safety and ➢ Define simple, concrete tasks.
control. ➢ Identify steps for resuming normal activities.
• ACTION ➢ Engage able survivors in helping tasks.
➢ Initiating action toward disaster recovery and return to normal
activity. PFA: WHO, WHEN, WHERE?
SAFETY • Who can benefit from PFA?
What Survivors Need: ➢ Boys, girls, women and men who have recently experienced a crisis
SAFETY ➢ Safety event and are distressed.
➢ Security • When should PFA be provided?
➢ Shelter ➢ When encountering a person in distress, usually immediately
What To Do: following a crisis event.
➢ Remove from harm’s way. • Where should PFA be provided?
SAFEGUARD ➢ Remove from the scene. ➢ Anywhere that is safe for the helper and affected person, ideally with
➢ Provide safety and security. some privacy as appropriate to the situation.
➢ Provide shelter. HELPING RESPONSIBLY: ETHICAL GUIDELINES
➢ Reduce stressors. DON’TS
• Don’t exploit your relationship as a helper.
What Survivors Need: • Don’t ask the person for any money or favor for helping them.
SAFETY
➢ Basic Survival Needs • Don’t make false promises or give false information.
What To Do: • Don’t exaggerate your skills.
➢ Provide food, water, ice. • Don’t force help on people, and don’t be intrusive or pushy.
➢ Provide medical care, alleviate pain. • Don’t pressure people to tell you their story.
SUSTAIN ➢ Provide clothing. • Don’t share the person’s story with others.
➢ Provide power, light, heat, air conditioning. • Don’t judge the person for their actions or feelings.
➢ Provide sanitation.
 DISM411 - LECTURE

DO’S LONG-TERM CONSEQUENCES OF UNTREATED CHILDHOOD PTSD

• Be honest and trustworthy. • Significant risk for depression and other psychiatric disorders.
• Respect a person’s right to make their own decisions. • PTSD is highly correlated with the development of drug and alcohol
• Be aware of and set aside your own biases and prejudices. problems.
• Make it clear to people that even if they refuse help now, they can still WHAT ARE EVIDENCE BASED TREATMENTS FOR TRAUMATIZED
access help in the future. CHILDREN?
• Respect privacy and keep the person’s story confidential, as appropriate. • What They Are Not:
• Behave appropriately according to the person’s culture, age and gender. a. Rigid
HOW TO HELP RESPONSIBLY b. Lockstep
• Adapt what you do to take account of the person’s culture. c. Inflexible...
• Respect safety, dignity and rights HOW ARE EBTs SIMILAR TO USUAL TREATMENTS FOR TRAUMATIZED
a. Safety: don’t expose people to further harm, ensure (as best you CHILDREN?
can) they are safe and protected from further physical or • The therapeutic relationship is central.
psychological harm. • Therapist creativity and judgment are valued and critical to success.
b. Dignity: treat people with respect and according to their cultural and • Flexibility is important in how components are adapted for individual
social norms. children and families.
c. Rights: act only in people’s best interest, ensure access to impartial • Cultural, religious, developmental and family values are respected.
assistance without discrimination, assist people to claim their rights
WHAT IS TF-CBT?
and access available support.
• A hybrid treatment model that integrates:
PFA ACTION PRINCIPLES
a. Trauma sensitive interventions
PREPARE b.
1. Look c. Attachment theory
2. Listen d. Developmental Neurobiology (according to many studies, a child’s
3. Link or adolescent’s brain is more resilient, so they are capable of correcting
Prepare • Learn about the crisis event. cognitive and behavioral problems compare to adults)
• Learn about available services and supports. e.
• Learn about safety and security concerns. f. Empowerment Therapy
Look • Observe for safety. g. Humanistic Therapy
• Observe for people with obvious urgent basic needs. WHAT CHILDREN IS TF-CBT APPROPRIATE FOR?
• Observe for people with serious distress reactions. • Children with known trauma history-single or multiple, any type
Listen • Make contact with people who may need support. • Children with prominent trauma symptoms (PTSD, depression, anxiety,
• Ask about people’s needs and concerns. with or without behavioral problems)
• Listen to people and help them feel calm. • Children with severe behavior problems may need additional or
Link • Help people address basic needs and access services. alternative interventions
• Help people cope with problems. • Parental involvement is optimal
• Give information. • Treatment settings: clinic, school, residential, home, inpatient
• Connect people with loved ones and social support. • Group model: CBITS
PEOPLE WHO LIKELY NEED SPECIAL ATTENTION MISCONCEPTIONS ABOUT TF-CBT
(to be safe, to access services) • TF-CBT cannot be used with children when there is no parent/caretaker
• Children and adolescents available.
➢ Especially those separated from caregivers. • TF-CBT cannot be used with children in foster care.
• People with health conditions and disabilities • TF-CBT cannot be used with children with complex trauma or multiple
➢ People who are non-mobile, or who have chronic illness, traumas
hearing/visual impairments (deaf or blind), or severe mental • TF-CBT cannot be used with children who have symptoms other than
disorders. PTSD
➢ Frail elderly people, pregnant or nursing women. • TF-CBT cannot be used with children younger than five or older than 14
• People at risk of discrimination or violence • TF-CBT cannot be used with children with special needs or
➢ Women, people of certain ethnic or religious groups, people with developmental delays
mental disabilities. • TF-CBT cannot be used with children from a variety of cultural
backgrounds
➢ Adaptation for Latino families
➢ Adaptation for Native American families
TRAUMATIC EXPOSURE AMONG CHILDREN AND ADOLESCENTS DIFFICULTIES ADDRESSED BY TF-CBT
• 25% of all girls and 10-12% of all boys experience sexual abuse/assault • CRAFTS
by the age of 18. ➢ Cognitive Problems
• One study (Costello, 2002- Large epidemiological study) suggests that o Not only intellectual. It could be perception, processing, and
25% of all children/ adolescents have experienced a traumatic event problem solving.
before 16 years of age and 6% at least one in the previous six months. ➢ Relationship Problems
➢ Affective Problems
POSTTRAUMATIC STRESS DISORDER (PTSD)
➢ Family Problems
Symptoms: ➢ Traumatic Behavior Problems
a. Exposure to traumatic event ➢ Somatic Problems
b. Re-experiencing symptoms
CORE VALUES OF TF-CBT
c. Avoidance symptoms
d. Hyperarousal symptoms • CRAFTS
➢ Components-Based
OTHER PSYCHIATRIC DISORDERS
o depending on the specific case of your client
• High level of comorbidity with PTSD ➢ Respectful of Cultural Values
• Other psychiatric disorders: ➢ Adaptable and Flexible
a. Depression ➢ Family Focused
b. Generalized Anxiety Disorder ➢ Therapeutic Relationship is Central
c. ADHD ➢ Self-Efficacy is emphasized
d. Substance Abuse
 DISM411 - LECTURE

CHILD AND PARENT COMPONENTS TRAUMA NARRATIVE

• Individual sessions for both child and parent • Reasons to directly discuss traumatic events:
• generally parallel child sessions a. Gain mastery over trauma reminders
• Same therapist for both child and parent b. Resolve avoidance symptoms
TF-CBT COMPONENTS c. Correction of distorted cognitions
• PRACTICE d. Model adaptive coping
➢ Psychoeducation and Parenting Skills e. Identify and prepare for trauma/loss reminders
➢ Relaxation f. Contextualize traumatic experiences into life
➢ Affective Modulation COGNITIVE PROCESSING OF TRAUMA
➢ Cognitive Processing • Identify child and parent trauma-related cognitive distortions, from
➢ Trauma Narrative trauma narrative or otherwise.
➢ In Vivo Desensitization • Use cognitive processing techniques to replace these with more accurate
➢ Conjoint parent-child sessions and/or helpful thoughts about the trauma
➢ Enhancing safety and social skills • Encourage parents to reinforce children’s more accurate/helpful
PSYCHOEDUCATION cognitions.
• Goals: • Ex: it’s my fault, I’ll never be like other kids, she’s lost her innocence, you
a. Normalize child’s and parent’s reactions to severe stress can’t trust any men, etc...
b. Provide information about psychological and physiological reactions • Responsibility vs. regret
to stress IN VIVO MASTERY OF TRAUMA REMINDERS
c. Instill hope for child and family recovery • Mastery of trauma reminders is critical for resuming normal
d. Educate family about the benefits and need for early treatment developmental trajectory.
e. PSYCHOEDUCATION GOES ON THROUGHOUT THERAPY! • To be used only if the feared reminder is innocuous (not if it’s still
PARENTING SKILLS dangerous)
• TF-CBT views parents as central therapeutic agent for change. • Hierarchical exposure to innocuous reminders which have been paired
• Goal is to establish parent as the person the child turns to for help in with the traumatic experience. (Related to Systematic Desensitization)
times of trouble. • Therapist MUST have confidence that this will work or it won’t.
• Explain the rationale for parent inclusion in treatment, i.e., not because CONJOINT PARENT-CHILD SESSIONS
parent is part of the problem but because parent can be the child’s • Share information about child’s experience
strongest source of healing. • Correct cognitive distortions (child and parent)
• Emphasize positive parenting skills (praise), enhance enjoyable child- • Encourage optimal parent-child communication
parent interactions. • Prepare for future traumatic reminders
RELAXATION • Model appropriate child support/redirection
• Reduce physiologic manifestations of stress and PTSD. ENHANCING SAFETY SKILLS
• Develop individualized relaxation strategies for manifestations of stress • May be done individually or in joint sessions.
(headache, stomachache, dizzy, racing heart, etc.) • Develop children’s body safety skills.
• Focused breathing/mindfulness/meditation • Develop a safety plan which is responsive to the child’s and family’s
• Progressive, other muscle relaxation circumstances and the child’s realistic abilities.
• Physical Activity • Practice these skills outside of therapy.
• Yoga, singing, dance, blowing bubbles • For sexually abused children, include education about healthy sexuality.
• “If it’s not fun, you’re not doing it right”. • For children exposed to DV (Domestic Violence), PA (Physical Abuse), CV
AFFECTIVE MODULATION (Children Violence), may include education about bullying, conflict
• Feeling Identification resolution, etc.
➢ Accurately identify and express a range of different feelings EMPIRICAL SUPPORT FOR TF-CBT
o Board games (e.g.,Emotional Bingo) • 6 completed randomized controlled trials (RCT) using comparison
o Feeling brainstorm treatments, conducted in Pittsburgh, New Jersey and across both sites.
o Color My Life or person • >500 sexually abused/multiply traumatized children, 3-18 years old
➢ Traumatized children may have restricted range of affect expression • 2 ongoing RCTs for children exposed to sexual abuse or domestic
➢ End on a positive note. violence as primary traumas, ages 4-12 years old.
COGNITIVE PROCESSING • All of the 6 completed studies supported the superiority of TF-CBT over
• Help children and parents understand the cognitive triad: connections other active treatments for traumatized children with regard to
between thoughts, feelings and behaviors, as they relate to everyday improvement in a variety of domains: PTSD, depression, anxiety,
events. (this is related in ABC in CBT lecture last semester) internalizing, externalizing, sexualized behaviors, shame, abuse-related
• Help children distinguish between thoughts, feelings, and behaviors. cognitions.
• Help children and parents view events in more accurate and helpful
ways.
• Encourage parents to assist children in cognitive processing of upsetting
situations, and to use this in their own everyday lives for affective
modulation.
 DISM411 - LECTURE
TEACHING RELAXATION TECHNIQUES TO DISASTER WORKERS
• Disasters workers have a deep commitment to working long hours
without breaks and may quickly dismiss suggestions about using time to
relax.
GUIDELINES:
1. Inquire about how long they have been on the job and about
previous disaster experience.
2. Inquire about how coping styles (how he/she see their fellow
workers coping, what he/she typically does to relax).
3. Inquire about unexpected stressors.
4. Inquire about sleeping patterns and level of fatigue.
5. Provide rationale for relaxation, first validating fatigue and its effects.
Discuss disaster workers’ general vulnerabilities (e.g., inability to stop
working or thinking about the disaster).
6. Begin instruction and demonstration of techniques (e.g., muscle
relaxation, conscious breathing, autogenics, visualization, etc.).
Remember, the circumstances and settings that you will be teaching
in are, more often than not, far from ideal. You may have from five
to fifteen minutes to demonstrate the value of relaxation. The
challenge is to efficiently facilitate the experience of relaxation in the
midst of chaotic environments.
STRESS MANAGEMENT
• Stress management is key to emergency management. Successful stress
management is built on prevention and planning, a solid understanding of
roles and responsibilities, support for colleagues, good self-care, and
seeking help when needed.
• Crisis response professionals may be repeatedly exposed to unique
stressors during the course of their work. Successful implementation of
any stress management plan requires overcoming some obstacles and
barriers, including priority setting, resource allocation, organizational
culture, and stigma.
STRESS REDUCTION STRATEGIES
• Reduce physical tension by using familiar personal strategies (e.g., take
deep breaths, gentle stretching, meditation, wash face and hands,
progressive relaxation).
• Pace self between low and high-stress activities.
• Use time off to “decompress” and “recharge batteries” (e.g., get a good
meal, watch TV, exercise, read a novel, listen to music, take a bath, talk to
family).
• Talk about emotions and reactions with coworkers during appropriate
times.
DEBRIEFINGS
• Debriefings are structured group meetings or discussions about a
traumatic event involving persons who normally work together.
• Occasionally, it may be necessary to combine various groups of
emergency response personnel together for a debriefing but this should
only be done when all of the parties were involved together in the same
incident.
• Debriefings are designed to mitigate the impact of such an event and to
assist persons to recover as quickly as possible from the stress arousal
associated with the particular event.
OVERVIEW
• A Critical Incident Stress Debriefing (CISD) is one type of debriefing
which integrates crisis intervention strategies with educational techniques.
It was originally developed by Dr. Jeffrey T. Mitchell. CISD is the debriefing
protocol most widely used today and it is the technique which will be
outlined in this workbook.
• CISD was designed to be applied among public safety, disaster response,
military and emergency response personnel but it can be used with
virtually any population, including children, when it is employed by a
skilled intervention team.
• A debriefing is not psychotherapy, nor is it a substitute for
psychotherapy. Instead, it is meant to provide an opportunity for
ventilation in a structured and supportive environment. The core focus of
a debriefing is the relief of stress in normal, emotionally healthy people
who have been exposed to a traumatic event. The debriefing is not
intended to resolve psychopathologies or personal problems that existed
before the traumatic incident being debriefed.
• Debriefings usually take 2 to 3 hours; marathon debriefings indicate one
or more of the following problems:
1. That the incident was a very traumatic one;
2. That too much time was spent on the fact and thought phases;
3. The team was inexperienced or unfamiliar with the debriefing
process;
4. The quality of team leadership was poor.
CONTRAINDICATIONS
• Contraindications
➢ Debriefings are not indicated in the following situations:
a. For use after routine events;
b. For a debriefing to be conducted in the absence of a mental health
professional;
c. For a debriefing to be conducted if too much time has passed since
the traumatic incident;
d. For use in mediating management-employee conflicts;
e. For use as a substitute for psychotherapy.
TIMING
• Debriefings must be held when the participants are emotionally "ready"
to accept the benefit from them. This often occurs within 24 to 72 hours
after exposure to a traumatic incident. However, some traumatic
incidents, especially disasters or line-of-duty deaths require a much longer
waiting period since the shock, numbing or denial mechanisms may last
for weeks after the traumatic event.
REASONS FOR THE THERAPEUTIC EFFECTS OF DEBRIEFINGS
1. Early intervention: Prevents the concretization of traumatic
memories.
2. Opportunity for catharsis: This ventilation of emotions leads to
reduced stress arousal.
3. Opportunity to verbalize the trauma: The opportunity to verbally
reconstruct and express specific traumas, fears and regrets leads to
reduced stress arousal.
4. Structure: Superimposes an orderly process with a finite beginning
and a finite end upon the chaos of a traumatic event.
5. Group support: The group experience provides numerous healing
factors which are intrinsic to the group process.
6. Peer support: Peers can most effectively eradicate the myth of
uniqueness and can suggest more appropriate stress management
techniques.
7. Stress education: Allows for a better understanding of available skills
to cope with stressful situations.
8. Persons in need of further care can be more
readily identified.
 DISM411 - LECTURE

FORMAT OF A DEBRIEFING
• The Mitchell model of debriefing (CISD) is a 7-stage intervention with • As debriefing becomes a more common intervention, workers are
the following stages: increasingly understanding the effects of stress.
1. Introduction 5. Symptom a. Defining traumatic stress
2. Fact 6. Teaching b. Common stress reactions
3. Thought 7. Re-entry c. Factors associated with adaptation to trauma
4. Reaction d. Self-care and stress management

• The final phase of the debriefing is allotted to discussing unfinished

issues, reactions to the debriefing, a summation of the debriefing, and the
• Originally developed by Jeffrey Mitchell (1983) to mitigate the stress referral process.
among emergency first responders, critical incident stress debriefing LARGE GROUPS DEBRIEFING PROTOCOL
(CISD) is now a widely used protocol with victims and providers of all kinds
• Occasionally, circumstances require that you provide a “debriefing” to a
(e.g., teachers, clergy, administrative personnel) in a wide range of
large number of workers and adjustments to the formal debriefing
settings (e.g., schools, churches, com- munity centers).
protocol are necessary. The protocol for large group debriefing involves a
• Two types of protocols are commonly used: an initial debriefing
modification of the process and con- tent of the eight steps used in formal
and a .
debriefings.
•The rationale for this process is that providing early intervention,
involving opportunities for catharsis and to verbalize trauma, structure,
group support, and peer support are therapeutic factors leading to stress
mitigation.
• Emergency workers may be members of highly trained teams, victims
INITIAL DEBRIEFING PROTOCOL (IDP)
trying to help those who have been more seriously affected, or
• The protocol for an initial debriefing (IDP) generally consists of eight bystanders.
steps:
MANY TYPES OF HELPERS RESPOND TO EMERGENCIES:
1. Preparation 5. Reaction phase
1. Search and rescue workers 7) Clergy
2. Introduction 6. Symptom phase
2. Fire and safety workers 8. Mental health and social service
3. Fact phase 7. Teaching phase
personnel
4. Thought phase 8. Re-entry phase
3. Transport drivers 9. Elected officials
4. Medical personnel and 10. Volunteers who staff shelters,
• Make necessary arrangements with incident commander or rescue team paramedics (EMTs) provide mass care, assess and
managers and obtain information about the conditions of the rescue repair the infrastructure
operation and if there are particular concerns about individual workers. 5. Medical examiner and staff 11. Media professionals
• Try to limit each debriefing group to 8-10 workers, but anticipate as 6. Police, security, and
many as 20-30 workers. The greater the number of workers attending, the investigators
less time each person has to actively participate.
• The number of debriefings that workers should attend is best guided by
HELPING THE HELPERS
the length and conditions of the rescue operations and the degree of
worker exposure to traumatic stimuli. • Rescuing and aiding survivors, and the tasks of body recovery,
• Arrange to work with a co-debriefer and discuss respective roles. identification, and transport are but a few of the stressors that con-
• Arrange for a private quiet room for 2 to 4 hours. tribute to high levels of emotional distress among disaster workers
• Those in attendance should not be on call. Have educational/referral (Uranso, R.J., McCaughey, B.G., & Fullerton, C.S. 1994).
handouts ready. • Disaster mental health work with helpers requires a broad clinical
• Schedule time for post debriefing discussion with co-debriefer. background and specific knowledge of stress reactions, post-trau- matic
stress disorder, crisis intervention, the nature of emergency work, stress
management, and other intervention protocols appropriate to the disaster
• Review confidentiality: Personal disclosures are to be held in strict environment.
confidence by the group.
• Explain group rules: Inform attendees that no one is required to talk, but
participation is encouraged. Agree on length of time. • Generally, disaster work is a combination of negative and positive
• Facilitate participant introductions: Depending upon the number of experiences.
workers in attendance, worker introductions may include name, role, • Experiences may involve profound feelings of grief, despair,
hometown or vicinity, and whether or not there has been previous helplessness, horror and repulsion.
experience with debriefing. OCCUPATIONAL HAZARDS
➢ Exposure to unpredictable physical danger
➢ Encounter with violent death and human remains
• Depending on the number of workers in attendance, the next phase of
➢ Encounter with suffering of others
the debriefing is asking participant/volunteers to describe from their own
➢ Negative perception of cause of the disaster
perspective what happened, where they were, what they did, and what
➢ Negative perception of assistance offered victims
they experienced sensorily (perception of sights, smells, sounds).
➢ Long hours, erratic work schedules, extreme fatigue
➢ Cross cultural differences between workers and community
• In this phase, workers are asked to describe their cognitive reactions or ➢ Inter-agency/intra-organizational struggles over authority
thoughts about their experience. In many instances, there are several ➢ Equipment failure and perception of low-control
events within the entirety of the rescue experience that make a ➢ Lack of adequate housing
memorable impact. Target most prominent thoughts. ➢ Encounter with mass death
➢ Encounter with death of children
• In this phase, workers are encouraged to discuss the emotions they ➢ Role ambiguity
experienced during the course of the operations. ➢ Difficult choices
➢ Communication breakdowns
➢ Low funding/allocation of resources
• In this phase, workers stress reactions are reviewed in the context of ➢ Negative perception by community
what they experienced at the scene, what stress reactions have lingered, ➢ Weather conditions
and what they are experiencing in the present. ➢ Over-identification with victims
➢ Human errors
➢ Time pressures
➢ Perceived mission failure
 DISM411 - LECTURE

PERSONAL SITUATION/STRESSORS
➢ Personal injury
➢ Injury or fatality of loved ones, friends, associates
➢ Property loss
➢ Pre-existing stress
➢ Low level of personal and professional preparedness
➢ Stress reactions of significant others
➢ Proximity to scene of impact
➢ Self-expectations
➢ Prior disaster experience
➢ Negative perception/interpretation of event
➢ Low level of social support
➢ Previous traumatization