Psychological First Aid

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Psychological First Aid
A Community Support Model
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Course Objectives

• Enhance immediate and on-going safety
• by providing emotional support.
• Offer practical assistance, and coping skills to
  help deal with the emotional impact of a
  traumatic event.
• Recognize common stress responses in
  children/adults, and provide basic triage skills
  to know when to refer to professional Behavioral
  Health services.
• Recognize the signs and symptoms of personal
  stress and learn self care strategies to increase
  resilience in yourself and others.

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Psychological First Aid

• Recommended as the Standard Acute Behavioral
  Health Intervention by
• National Child Traumatic Stress Network (NCTSN)
• American Psychological Association (APA)
• Centers for Disease Control (CDC)
• Substance Abuse and Mental Health Services
  Administration (SAMHSA)
• National Institute for Mental Health (NIMH)
• National Center for PTSD, Terrorism Disaster
  Branch
• World health Organization (WHO)
• Minnesota Department of Health (MDH)

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Psychological First Aid (PFA)

• Principles and techniques of PFA meet four basic
  standards
• Consistent with research evidence on risk and
  resilience following trauma
• Applicable and practical in field settings
• Appropriate to developmental level across the
  lifespan
• Culturally informed

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MN Psychological First Aid

• A model that
• Integrates public health, community health, and
  individual psychology.
• Includes preparedness for communities, work
  places, healthcare systems, schools, faith
  communities, and families.
• Does not rely on direct services by mental health
  professionals.
• Uses skills you probably already have

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Individual Level What are we trying to do? Get
people to do what is in their best interest AND
Prevent people from doing what is not in their
best interest
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• Health Care System Level
• What are we trying to do?
• Provide care for disaster survivors
• Maintain care for current patients
• Safeguard staff
• Support responders
• Lead effectively in crisis

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• Community Level
• What are we trying to do?
• Promote community health
• Reduce exposure, illness, injury
• Promote pro-social behavior
• Reduce fear-driven behavior
• Safeguard the health care system

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Psychological First Aid Basics

• Expect normal recovery
• Assume survivors are competent
• Recognize survivor strengths
• Promote resilience

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Psychosocial Consequences of Disasters
Fear and Distress Response
Impact of Disaster Event
Behavior Change
Psychiatric Illness
Source Butler AS, Panzer AM, Goldfrank LR,
Institute of Medicine Committee on Responding to
the Psychological Consequences of Terrorism Board
of on Neuroscience and Behavioral Health.
Preparing for the psychological consequences of
terrorism A public health approach.
Washington, D.C. National Academies Press, 2003.
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What is Stress?

• The International Federation of the Red Cross
  defines stress as A very broad term referring to
  the effect of anything in life to which people
  must adjust.
• For instance, anything we consider challenging
  causes stress, even if it is something we
  willingly choose to do.
• The key is that stress requires us to adjust our
  attention and behavior and makes demands upon our
  energy.

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What scares us?

• Than things that are
• In our control
• Easily quickly diagnosable treatable
• Natural
• Survivable
• Managed by a trusted person or organization
• Familiar and routine

• Things frighten us more if they are
• Imposed or Controlled by others
• Hard to treat or rationing required
• Manmade
• Catastrophic or deadly
• Caused by someone or something we dont trust
• Exotic or unusual

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Event is More Stressful or Traumatic When

• Event is unexpected
• Many people die, especially children
• Event lasts a long time
• The cause is unknown
• The event is poignant or meaningful
• Event impacts a large area

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What assists our Emotional Adjustment?

• Acceptance of the disaster and losses
• Identification, labeling, and expression of
  emotions, an
• Regaining a sense of mastery and control.

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Common Physical Reactions - Adults

• Sleep difficulties
• Gastrointestinal problems (Diarrhea, cramps)
• Stomach upset, nausea
• Elevated heart rate
• Elevated blood pressure
• Elevated blood sugar
• With extended stress, suppression of immune
• system functioning

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Common Physical Reactions- Children/Youth

• Headaches
• Stomachaches
• Nausea
• Eating Problems
• Speech Difficulties
• Skin eruptions

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Common Emotional Reactions - Adults

• Fear and Anxiety
• Sadness and Depression
• Anger and Irritability
• Numb, withdrawn, or
• disconnected
• Feeling a lack of involvement
• or enjoyment in favorite activities
• Feeling a sense of emptiness or hopelessness
  about the future

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Common Emotional Reactions Children/Youth

• Anxiety Vulnerability
• Fear of reoccurrence
• Fear of being left alone
• Particularly if separated from family
• Loss of Sense of Safety
• Depression
• Anger
• Guilt

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Common Behavioral Reactions - Adults

• Family difficulties
• (physical, emotional abuse)
• Substance abuse
• Being overprotective of family
• Keeping excessively busy
• Isolating oneself from others
• Being very alert at times, startling easily
• Avoiding places, activities, or people that
  bring back memories

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Common Behavioral Reactions- Children/Youth

• Childish or regressive behavior
• May not be deliberate acting out
• Bedtime problems
• Sleep onset insomnia
• Mid-night awakening
• Fear of dark
• Fear of event reoccurrence during night

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Common Cognitive Reactions - Adults

• Difficulty concentrating
• Difficulty with memory
• Intrusive Memories
• Recurring dreams or
• nightmares
• Flashbacks
• Difficulty communicating
• Difficulty following complicated instructions

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Common Cognitive Reactions

• Confusion, memory loss, and disorientation
• Difficulty in concentrating
• May appear as behavioral
• problems in classroom
• School may be where child functions best
• Continuing Structure, sense of control
• Social group

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Common Faith Spirituality Reactions Adults
Children

• Reliance upon faith
• Questioning values
• and beliefs
• Loss of meaning
• Directing anger
• toward God
• Cynicism

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Common Sensory Reactions Adults Children

• Sight
• Sound
• Smell
• Taste
• Touch

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SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors

• PFA TARGET OUTCOMES
• Physical health
• Restore SAFETY
• Psychological health
• Facilitate FUNCTION
• Behavioral health
• Empower ACTION

Source Shultz, Cohen, Watson, Flynn, Espinel,
Smith. SAFETY, FUNCTION, ACTION Psychological
First Aid for Disaster Survivors. Miami FL DEEP
Center 2006.
26
SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors
OUTCOMES
SAFETY
FUNCTION
ACTION
Restoring physical safety and diminishing the
physiological stress response.
Facilitating psychological function and
perceived sense of safety and control.
Initiating action toward disaster recovery and
return to normal activity.
Source Shultz, Cohen, Watson, Flynn, Espinel,
Smith. SAFETY, FUNCTION, ACTION Psychological
First Aid for Disaster Survivors. Miami FL DEEP
Center 2006.
27
SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors
STRATEGIES
SAFETY
FUNCTION
ACTION
SAFEGUARD
COMFORT
EDUCATE
SUSTAIN
CONNECT
EMPOWER
Source Shultz, Cohen, Watson, Flynn, Espinel,
Smith. SAFETY, FUNCTION, ACTION Psychological
First Aid for Disaster Survivors. Miami FL DEEP
Center 2006.
28
SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors
SAFETY
Safety Security Shelter
What Survivors Need
SAFETY
SAFEGUARD
Remove from harms way. Remove from the
scene. Provide safety and security. Provide
shelter. Reduce stressors.
What To Do
Source Shultz, Cohen, Watson, Flynn, Espinel,
Smith. SAFETY, FUNCTION, ACTION Psychological
First Aid for Disaster Survivors. Miami FL DEEP
Center 2006.
29
PSYCHOLOGICAL EXPOSURE RISK ZONES
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Traumatic Stress Risk Factors

• Involving a child
• Human caused disasters
• Loss of life or threat to loss of life
• Extensive widespread damage
• Personal involvement
• Previous history of mental health problems
• Previous significant loss (such as a parent or
  close friend)
• Social isolation (as can be the case with older
  adults)
• Adverse life circumstances such as poverty
• Involvement in rescue and response efforts
• Identification with victims
• National Mental Health Association. (2003).
  Blueprint for responding to public mental health
  needs in times of crisis. PP. 10-11.

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How do you determine emotional trauma exposure-
Psychological Triage

• Assess
• Physical proximity
• Emotional proximity
• Similar previous experience
• Fragile personality
• History of emotional disturbance

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SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors
SAFETY
Basic survival needs
What Survivors Need
SAFETY
Provide food, water, ice. Provide medical
care, alleviate pain. Provide clothing. Provide
power, light, heat, air conditioning. Provide
sanitation.
What To Do
SUSTAIN
Source Shultz, Cohen, Watson, Flynn, Espinel,
Smith. SAFETY, FUNCTION, ACTION Psychological
First Aid for Disaster Survivors. Miami FL DEEP
Center 2006.
33
(No Transcript)
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Sarin Attack on Tokyo Subways

Examined discharged 4023
Hospitalized 984
Severely injured 62
Norwood AE, 2002
Killed 12
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Medical Casualties? Think Behaviorally

• Some disasters provide warning periods
• during which distressed persons surge upon
  healthcare prior to impact.
• For every person who is physically injured or
  directly impacted by a disaster, there are 4 - 10
  secondary victims who experience a significant
  impact on their behavioral health.
• Plan for the accompanying or arriving family.

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Hospital Triage Point
Initial Hospital Triage

Psychological Casualties
Searching Family Members
Medical Casualties
Family Center
Support Center
Red
Yellow
Green
Community Behavioral Health resources
Behavioral Triage
Medical Treatment Area
Emergency
Medical/ Surgical Units/ICUs
Patients needing Psychiatric evaluation
Distress
D/C
Community Behavioral Health resources
Behavioral Health
Source Shaw, Shultz, Espinel 2005
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SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors
FUNCTION
Soothing human contact Validation that reactions
are normal.
What Survivors Need
FUNCTION
COMFORT
Establish compassionate presence. Listen
actively. Comfort, console, soothe, and
reassure. Apply stress management
techniques. Reassure survivors that their
reactions are normal and expectable
What To Do
Source Shultz, Cohen, Watson, Flynn, Espinel,
Smith. SAFETY, FUNCTION, ACTION Psychological
First Aid for Disaster Survivors. Miami FL DEEP
Center 2006.
38
Trust Determination Factors In High Concern
Situations
Assessed First 30 Seconds
Listening/Caring/ Empathy 50
Listening/Caring/ Empathy 50
Assessed First 30 Seconds
Competence/Expertise 15-20
Dedication/ Commitment 15-20
Dedication/ Commitment 15-20
Competence/Expertise 15-20
Honesty/ Openness 15-20
Honesty/ Openness 15-20
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Active Listening

• Make it clear that you are listening
• Body Language
• Eye contact
• Distance
• Body orientation
• Facial Expression
• Physical Tension

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Ways of Responding

• Ask mostly open-ended questions
• - Closed Are you feeling better?
• - Open-ended How are you feeling?
• Paraphrase Reflect Feelings
• Avoid giving outright advice
• - Assist with formal problem solving
• - Lets look at all your options.
• Remember your role as supportive helper

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Teach About Normal Symptoms and How to Cope

• Acknowledge the common changes that can occur in
  people who grieve
• Physical Changes
• Emotional Changes
• Cognitive Changes
• Changes in Spiritual Beliefs

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Information on Coping

• Provide the individual with information that may
  help them cope with the event and its aftermath,
  including information about
• Provide basic information about common
  psychological reactions to traumatic experiences
  and losses
• Provide basic information on ways of coping
• Teach simple relaxation techniques (3x3x3)
• Employ Grounding
  

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Adrenaline, Friend or Foe?

• Increase in speed and strength
• Decrease in reaction time
• Increase in sensory acuity
• Freezing and unable to react
• Overreacting
• May act in a way that seems inappropriate for the
  situation (e.g. giggle, yell)

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Agitation

• Sometimes, despite our best attempts at active
  listening, people still become agitated
• Refusal to follow directions
• Loss of control, becoming verbally agitated
• Becoming threatening
• It is usually not personal
• This is their reaction to an UNCOMMON situation,
  and
• it has nothing to do with you

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Alarm Bells/When to Refer

• Harm to self
• Saying they want to
• End it all
• Go to sleep and never wake up again
• Excessive use of substances
• Driving under influence
• In some cases working under influence
• Harm to others
• Child abuse
• Spouse abuse

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Alarm Bells/When to Refer

• Loss of control
• Significant withdrawal (as change in behavior)
• Behavior is unusually (for that individual)
  confused or bizarre
• Unable to care for self (cannot eat, bathe etc. -
  Vulnerable)

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SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors
FUNCTION
Social supports/keeping family together
Reuniting separated loved ones Connection to
disaster recovery services, medical care, work,
school, vital services
What Survivors Need
FUNCTION
Keep survivor families intact. Reunite
separated loved ones. Reunite parents with
children. Connect survivors to available
supports. Connect to disaster relief services,
medical care.
What To Do
CONNECT
48
(No Transcript)
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Connect with Support System

• Connect with community support services
• Attend to children who are separated from their
  parents/caregivers
• Connect with pets

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Hospital Behavioral Health Casualties
EMS Processed Medical Casualties
Self Transported Medical Casualties
Bystanders or Family Members, Friends, Co
workers of Incoming Casualties
Family Members Searching for Missing Loved Ones
Injured, Exposed, Distressed Disaster/ Emergency W
orkers
Psychological Casualties
Media
Volunteers
Onlookers
Distressed Inpatients
Family Members of Inpatients
Distressed Staff
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SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors
ACTION
Information about the disaster Information
about what to do Information about
resources Reduction of uncertainty
ACTION
What Survivors Need
EDUCATE

• Clarify disaster information
• what happened
• what will happen
• Provide guidance about what to do.
• Identify available resources.

What To Do
Source Shultz, Cohen, Watson, Flynn, Espinel,
Smith. SAFETY, FUNCTION, ACTION Psychological
First Aid for Disaster Survivors. Miami FL DEEP
Center 2006.
52
Practical Assistance

• Offer practical assistance and information to
  address students immediate needs and concerns.
• Identify the most immediate need(s)
• Clarify the need(s)
• Discuss an action response
• Act to address the need

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It is OK to

• Recommend substitute precautions that are
• more useful,
• less burdensome or
• less likely to backfire
• If you dont know an answer, say I dont know
  but I might be able to help you find out.
• Or, Im not sure what to do, but I will be
  happy to help you find someone who does.

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Not OK to suggest that

• Lets talk about something else.
• You should work toward getting over this.
• You are strong enough to deal with this.
• I know how you feel.
• Youll feel better soon.
• You did everything you could.
• You need to relax.
• Its good that you are alive.

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Model of Responses to Trauma Bereavement, CMHS,
1994
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SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors
ACTION
Planning for recovery Practical first steps
and do-able tasks Support to resume normal
activities Opportunities to help others
What Survivors Need
ACTION
Set realistic disaster recovery
goals. Problem solve to meet goals. Define
simple, concrete tasks. Identify steps for
resuming normal activities. Engage able survivors
in helping tasks.
What To Do
EMPOWER
Source Shultz, Cohen, Watson, Flynn, Espinel,
Smith. SAFETY, FUNCTION, ACTION Psychological
First Aid for Disaster Survivors. Miami FL DEEP
Center 2006.
57
Promoting Resilience

• Everyone who experiences a disaster is touched
  by it
• We have the ability to bounce back after a
  disaster to a New Normal
• Resilience can be fostered
• One goal of Psychological First Aid support
  resilience in ourselves and others

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Compassion Fatigue

• There is a cost to caring. We professionals who
  are paid to listen to the stories of fear, pain,
  and suffering of others may feel, ourselves,
  similar fear, pain and suffering because we
  care.
• Compassion fatigue is the emotional residue of
  exposure to working with the suffering,
  particularly those suffering from the
  consequences of traumatic events.
• Charles R. Figley, Ph.D.

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• INCREASE YOUR RESILENCY
• How we perceive, label and
• Interpret our experiences, how we think
  about the events in our lives, and what we
  predict for the future effects our current
  functioning!
• When we anticipate negative
• or painful outcomes, we increase
• the probability of a stressful
• response.

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Personal Resiliency Plan

• Focus beyond short term
• Know your unique stressors and Red Flags for
  further assistance
• Know unique stressors of the event extent of
  damage, death, and current suffering
• Demystify/de-stigmatize common reactions
• Select from menu of coping responses
• Monitor on-going internal stress

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Developing Disaster Resilience

• Personal Family Preparation
• Recognize pre-existing stress
• Develop healthy coping skills
• Participate in preparedness exercises drills
• Educate yourself on your school, city, and
  county response plans and your response role in a
  crisis situation
• Make pre-emergency individual and family
  response plans

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SAFETY, FUNCTION, ACTION
Psychological First Aid for Disaster Survivors
SAFETY
FUNCTION
ACTION

• SAFEGUARD
• Goal SAFEGUARD
• survivors from
• harm and
• offer protection.

COMFORT Goal COMFORT support, validate, and
orient distressed survivors.
EDUCATE Goal EDUCATE and inform survivors
about the disaster, available options for
action, and resources for support.

• EMPOWER
• Goal EMPOWER survivors
• to take first steps toward
• disaster recovery and foster
• self-efficacy and resilience.

• CONNECT
• Goal CONNECT
• survivors to
• family, friends, and
• social supports,

• SUSTAIN
• Goal SUSTAIN
• survivors
• by providing
• basic needs.

Source Shultz, Cohen, Watson, Flynn, Espinel,
Smith. SAFETY, FUNCTION, ACTION Psychological
First Aid for Disaster Survivors. Miami FL DEEP
Center 2006.
63

• Nancy Carlson
• Behavioral Health Preparedness Coordinator
• Minnesota Department of Health
• Office of Emergency Preparedness
• 625 Robert Street North
• St. Paul, MN 55155- 0975
• Phone [phone]
• Cell 651-247-7398
• Fax [phone]
• Nancy.J.Carlson_at_health.state.mn.us
• MDH Behavioral Health Web Sites
• www.health.state.mn.us/oep/planning/mhimpact.html
• www.health.state.mn.us/mentalhealth/mhep.html
• www.health.state.mn.us/emergency/