Systemic Wilderness Adventure Therapy

1

Fraser Island, Qld. 2003
A fresh approach to how we learn and grow. . .
2

Psychological First Aid in Adventure Therapy
Dr. Simon Crisp Clinical Child Adolescent
Family Psychologist Melbourne, Australia
3
Key Learning Objectives

• Ability to DETECT mental health / behavioural /
  personal safety issues
• Confidence in applying a RESPONSE (Psychological
  first-aid)
• Increased knowledge of resources, options and
  REFERRAL processes

4
Jahari Window - knowledge
What you know you know
What you know you dont know
What you dont know you dont know
What you dont know you know
5
Medical First Aid Analogy
First Responder Field staff, Outdoor Educator,
etc.
Paramedic Counsellor
Accident Emergency Team Program Coordinator,
Child Protection,
Surgeon / Physician Psychologist, Mental Health
Service
6
Ways Adolescents Cope

• Non-Productive Coping
• Worrying about the problem
• Using wishful thinking about the problem
• Not coping and becoming ill
• Letting off steam / tension reduction
• Avoidance of the problem
• Self Blaming
• Keeping to oneself / not talking to others
• Seeking spiritual support (ie. Praying to God to
  fix it)
• Depending on a professional and not trying to cope

7
Ways Adolescents Cope cont.

• Productive Coping
• Seeking social support, talk to others (help
  seeking)
• Actions aimed at solving the problem
• Applying themselves to make changes
• Spending time with boy/girl friend
• Improve relationships with others
• Join others with similar concerns
• Focus on the positives of a situation
• Seek relaxing diversions or leisure activities
• Maintain fitness and health physical recreation

8
PREPD anger R eadiness Resources
A ct B
rainstorm C
onsult D ecide
Recap Follow-up
Psychological First Aid
9
Response gt approach engagement

• P.R.E.P.
• P rivacy discretion see how it might look
• R eassuring manner and approach de-role
• E ngage adolescent open up communication
• P roblem define it as a shared concern,
• normalise it, seek collaboration

10
Response gt approach engagement

• Small group discussion
• What are effective ways to PREP adolescents
  before responding with Psychological First Aid?

11
P.R.E.P.

• PRIVACY
• Private place how does this set the scene? What
  messages does this communicate?
• Timing may compromise privacy
• How will a private discussion be perceived?

12
P.R.E.P.

• REASSURING manner approach
• De-role from your usual manner?
• Approach at their level
• Be aware of body language actions speak louder
  than words
• Appear calm and confident instills trust
• Humor to reduce anxiety?

13
P.R.E.P.

• ENGAGE - open communication
• Be patient
• Be an active and interested listener be
  receptive
• Wait until the adolescent is relaxed and more
  open with feelings and information
• If still reluctant acknowledge it and validate /
  normalise it

14
P.R.E.P.

• PROBLEM describe normalise
• Express your concerns simply and directly
• Seek to learn how and if they see a problem
• Be ready to acknowledge differing perspectives
• Seek to find a shared concern
• Outline implications of this concern why it
  deserves attention
• Find leverage for how the client might
  collaborate on the problem

15
PREPD anger R eadiness Resources
A ct B
rainstorm C
onsult D ecide
Recap Follow-up
Psychological First Aid
16
Demonstration of Response

• ? Presentation of all of the stages of Response
  gt
• - 16 year old female student
• - Teacher (Year Level Co-ordinator)
• 25 minutes

17
D angerWhat are common dangers that need to be
assessed?
Psychological First Aid
18
D anger- remove the student from danger or
danger from the student ( medical FA if
necessary)- secure the environment- ensure
supervision- anticipate how the student might
harm you, others or self-harm (in that order)
- risks medium long term
Psychological First Aid
19
D anger questions to ask- Do you feel
unsafe? Should I be concerned?- How much
control do you have over?- What could happen
that might reduce your level of control, or make
you less safe?- Can you easily talk to someone
about feeling unsafe?- Do you have thoughts
about hurting yourself or anyone else?
Psychological First Aid
20
R eadiness - Resources- What are common
reasons why you may be unready to respond?-
What are common resources you or your student may
be able to draw on?
Psychological First Aid
21
R eadiness - Resources ? Readiness am I the
best person? What is my mental state? Am I
adequately prepared? When is the best time for
me, when is the best time for the student? ?
Resources who, or what else can I access what
person or resources can the student access for
themselves (empowerment)
Psychological First Aid
22
R eadiness Resources questions- How do you
feel with me talking to you about this?- What
response do you expect from me?- Have you
spoken to anyone about this before?- Who else
can help you with this?- Who has tried to help
you with this in the past? Was it helpful?
Psychological First Aid
23
A ct within your limits / role / boundaries-
Is it ethical / legal /good practice for me to
intervene?- How far do I go? - What is the
best role for me to take on?- What does my
student expect of me? - Could I compromise my
relationship role with my student?
Psychological First Aid
24
A ct within your limits questions- What
are you expecting I would do in this
situation?- Often there are things that are
best talked about with a counsellor, is this one
of those times?- I wonder if you may feel it is
more private and easier to talk to someone less
involved with you everyday / in the way I am?
Psychological First Aid
25
A ct - How Receptive are you? (Johnson ,2000)

• Receptivity
• continuum of psychological closeness to
  clients
• Continuum of Receptivity
•  
• Absent Objective Distant Empathetic
  Sympathetic Identified Fused
• Destructive at risk OK Ideal OK
  at risk Destructive

26
A ct - Boundaries Self Disclosure

• Self disclosure has the potential to confuse /or
  interfere with boundaries
• Immediacy appropriate self-disclosure
• The helping relationship will lead to feelings of
  imbalance for staff - this important
  asymmetry in relationship defines roles of helper
  and recipient of help
• These feelings must be held, and the tendency
  to equalise the relationship must be resisted
• Seek alternative responses to self-disclosure

27
A ct - Keeping Boundaries

• Avoid
• Acknowledging or discussing own mental health
  issues, family issues, drug use, school
  experiences - including telling client of own
  similar issue or problem and how you overcame it
• Expressing personal rather than professional
  feelings about the client
• Telling personal issues partner / spouse, sexual
  or relationship history, family, political or
  religious views

28
A ct - Keeping Boundaries

• Whose needs am I meeting by disclosing?
• Do they really want to know about me,
  or if I can understand their situation?
• Is their question really about themselves?
• Does a personal question about me, result in
  avoidance of own issues?

29

• If I disclose, will the adolescent begin to worry
  about me (role reversal)?
• Could I keep my own personal feelings about my
  issues contained and boundaried within myself?
• Is a adolescent pushing disclosure about wanting
  to equalise or gain more power?

30
When asked a personal question, ALWAYS

• Keep answer general, or in principle
• Describe the concept or reasoning behind your
  answer
• Broaden a question to a discussion about values
  and guidelines for behaviour or relationships
• Remember it is always good to say That is
  personal and I want to keep that private

31
B rainstorm strategies - What can my student
do?- What can I do?- Take a collaborative
problem solving approach
Psychological First Aid
32
B rainstorm strategies questions- What has
worked in the past?- What havent you tired
that might help?- What do you think needs to
happen to take this in a more positive direction?
what do other people think?- If you had more
information, would that make it easier to deal
with?
Psychological First Aid
33
C onsult- with peers / senior / parent /
expert- share responsibility with your
superior- utilize the resources of the parents
or an expert to your students benefit
Psychological First Aid
34
C onsult questions (to yourself)- Do I have
all the pertinent info?- How much do I know
about this type of issue? Have I dealt with this
type of problem before?- Is there something
unique to this situation that suggests I should
consult?- Do my reactions / confidence suggest
that I should get support?- Is specialised
assessment indicated?
Psychological First Aid
35
C onsult Who could you consult to
peer / senior / expert?
Psychological First Aid
36
D ecide- Monitor OR Manage myself OR Refer?
- Re-assess Danger (repeat DRABCD if necessary)
Psychological First Aid
37
D ecide questions (to yourself)- What might
hinder this student accepting referral?- What
can I do to ensure the student follows through?
- How can I ensure that the referee get all the
info?- What are my obligations to parents about
the referral?- What is the best way to review
this? make a plan
Psychological First Aid
38
Response gt termination

• Re-cap Follow-up
• Re-cap
• Key points of information
• Strategies to use
• Plan of action
• Follow-up
• Who / what / when

39
Morning Tea? Something to eat?
40
Specific Problems Anxiety Disorders

• Generalised Anxiety Disorder
• Panic Disorder
• Phobias Social Phobia / Agoraphobia
• Obsessive- Compulsive Disorder (OCD)
• Post-Traumatic Disorder (PTSD)

41
Anxiety Process

• Visual stimulus cues the person to appraise the
  situation as either safe OR threat
• Physiological symptoms Perspiration increased
  respiration, blood pressure, etc.
• Cognitive anticipating a catastrophe something
  bad is about to happen loss of confidence or
  self-efficacy memory disturbance attentional
  disruption (over-focus on threat)
  hypervigilance, etc.
• Behavioural agitation restlessness
• AVOIDANCE OF THREATENING SITUATION

42
Gereralised Anxiety Disorder

• Reassure the student things are OK and under
  control
• Be firm, supportive and directive take control
  for the student
• Encourage the student to reality check their
  fears, bring things in to perspective use
  visual cues
• Allow the student to talk through their fears if
  possible
• Gentle distraction and humor can be useful if
  done supportively

43
Panic Disorder

• Acute experiences of heightened anxiety
• Difficulty breathing feelings of chocking or
  hyperventilation trembling or shaking racing
  heart beat dizziness abdominal pain fear of
  loosing control, etc.
• Person may feel they are going to die
• Hyperventilation may appear
• as asthma
• Usually transitory and will
• abate after a few minutes

44
Panic Disorder

• If unsure if a medical condition, treat as one
• Move to quiet and safe location if necessary
• Encourage slow, relaxed breathing
• Reassure and explain what is happening to student
  get them to focus on reassuring using visual
  cues
• Explain that attack will soon pass and they will
  fully recover
• Assure them you will stay until it has passed
• Dont restrict them from moving

45
Psychological First Aid Role Play

• Managing acute anxiety
• In groups of 3, role play the scenario described,
  especially focusing on management of anxiety
  symptoms
• In a large group, discuss how to ensure you stay
  within the limits of your expertise

46
Extreme Anxiety Dissociation

• Usually an adaptive response developed to cope
  with abuse, trauma or extreme anxiety, triggered
  by trauma related stimulus
• Person psychologically disconnects from their
  physical body to avoid uncomfortable sensations
  of fear, anxiety or pain
• Can experience feelings of derealisation and
  depersonalisation
• May have very high pain threshold danger of
  accidental / deliberate self-harm or suicide

47
Dissociation

• May be difficult to tell if it is happening can
  looks as if person is floating and indifferent
• May report being OK or fine and have no
  awareness of their state
• May refuse to move away from danger stay
  stuck or trance-like with fear
• Usually occurs for seconds / minutes and usually
  resolves itself

48
Dissociation

• Assess if person is orientated time/place/person
• Ask how they feel may report nothing, or that
  they are fearful but not show congruent signs
• Gently take charge simple, gentle, firm
  directions, but avoid appearing coercive
• Have them maintain eye contact with you or fix on
  a reassuring visual point

49
Dissociation

• Encourage them to talk about their fears
• not tune out to what I happening
• Move to safer / less stressful location
• Encourage relaxation strategies breathing, etc.
• Normalise their experience affirm their ability
  to put up with the fear

50
Specific problems Depression

• Equally common in both sexes
• Often first noticed
• - fatigue, drop in general performance
• - hopeless and nihilistic themes in verbal
  comments
• - social withdrawal, failure to engage with
  peers
• - friend reports that the student appears sad

51
Depression

• Clinical assessment usually required
• May be in denial that they have a problem, highly
  secretive, avoid interactions, may be expressed
  as irritability or anger
• Hopelessness may make it difficult to motivate
  them towards solving the problem

52
Depression

• Do
• Take seriously
• Persist in talking to adolescent about their mood
• Assume the presence of suicidal thoughts
• Attempt to find out about recent stressors,
  family/peer situation

53
Depression

• Dont
• Take their response that everything is fine on
  face value
• Take sarcasm or anger towards you personally
• Give glib advice snap out of it or list
  reasons why they dont have cause to feel sad
• Raise concerns or comment in the presence of
  others

54
Depression

• Responds best to
• Directness, patience, measured concern
• Closed questions about their mood
• Confidence about how you approach the situation
• Empathy

55
Depression

• When high priority
• Any signs of suicidality, self-harm, high risk
  behaviour
• If no professional involved (that you know of)
• Prior history of depression/suicidality/self-harm
• Recent stressor (especially loss)
• Adolescent rejects help or denies a problem in
  the face of contradictory evidence

56
Suicide and Self-harm

• Continuum of self-harming behaviour
• Deliberate Suicide Attempt Suicide
• Self-harm
• Tension release, Call for help or failed
  Deliberate wish to
• expression of anger serious attempt
  die or accidental etc. death

57
Suicide and Self-harm

• Signs
• Depressed, anxious, angry, agitated, mood swings,
  concentration or memory problems
• Often high risk-taking behaviour
• Poor coping, may have eating disorder,
  personality problems
• May be aggressive towards others
• Sometimes have difficulty being assertive

58
Suicide and Self-harm

• Do
• Always take seriously, regardless of frequency
• Gently persist in talking to adolescent about
  self-harming behaviour / suicidal thoughts
• Assume even fleeting thoughts can be deadly
• Affirm telling someone is best thing to do

59
Suicide and Self-harm

• Dont
• Avoid or put off investigating the issue, or hope
  it will subside with time
• Convey anger, disgust, or a punitive attitude
• Believe you can tell the students real
  motivation, ie. just trying to get attention

60
Suicide and Self-harm

• Remain non-judgmental
• Encourage verbalisation of feelings
• Affirm your role is to keep student safe from
  harm
• Set clear limits about not tolerating self harm
  in your presence (if necessary)

61
Suicide and Self-harm

• Dont reinforce/reward the behaviour accidentally
  give a neutral response
• Dont attempt to physically restrain if actively
  self-harming move away, avoid watching, but
  remain in close proximity
• Ensure student is directly supervised at all
  times if suicidal
• Seek expert consultation as soon as possible

62
Psychological First Aid Role Play

• Managing suicide / self-harm risk
• In groups of 3, role play the scenario described,
  especially focusing on engagement, building
  rapport and direct questions about mood and
  suicidal thoughts
• In a large group, discuss how to ensure you stay
  within the limits of your expertise

63
Psychological First Aid Role Play

• Key points
• Develop sufficient rapport to allow student to
  open-up
• Normalise the adolescents experience
• Ask direct, closed questions to determine risk
  factors
• Ensure you have a clear plan student adherence
  to it
• Plan for follow-up or monitoring

64
Acute Stress PTSD

• Definition of Psychological Trauma
• An adverse psychological reaction to a stressful
  and extraordinary event
• Eg.s
• Accident, near accident, injury, death
• Assault, threat of harm, extreme behaviour
• Self harm, threats of self harm, suicide
  gestures, completed suicide
• Natural disasters and extreme environmental
  conditions
• Observing or in any way being a witness to any of
  the above

65
Comfort Zones Trauma
66
Trauma

• Typical (normal) Stress Response Symptoms
• Shock, disbelief
• Heightened arousal, fear
• Hopelessness, abandonment
• Flight or escape behaviour
• Protective postures
• Holding others
• Family oriented behaviours
• Heroic behaviour
• Time distortion brief, suspended
• Emotional shutting down
• Panic is rare

67
Acute Stress Disorder PTSD

• Acute Stress Disorder
• Occurs within 2 days to 4 weeks post incident
• lt20 of people are likely to experience it
• 75 of ASD continue onto PTSD

68
Acute Stress Disorder PTSD

• Acute Stress Disorder - Features
• Persistent dissociation
• Re-experiencing of the event (e.g. flashbacks)
• Avoidance of being reminded of the traumatic
  event
• Regressed behaviour
• Increased arousal startle response,
  hypervigilence
• Derealisation, depersonalisation, dissociative
  amnesia

69
Acute Stress Disorder PTSD

• Post Traumatic Stress Disorder
• Post Acute Stress Disorder gt 4 weeks
• lt 15 of all survivors develop PTSD
• Symptoms may worsen with time
• Likely to seriously effect functioning school,
  family, peers, adult relationships
• Can be foundation to depression, substance
  abuse, self-harm, suicide

70
Managing Critical Incidents

• Ensure physical safety
• Take personal inventory
• Take charge
• Seek and give personal support
• Develop a routine
• Balance activity and restore normalcy
• Establish links to social supports ASAP

71
Trauma Reactions of Adolescents

• Withdrawal
• Depression
• Less responsible, more demanding - regress
• Rebellious, competitive
• Frustrated angry
• Physical complaints

72
Traumatic Events

• Needs of Adolescents
• Education about the crisis what happened and why
  
• Talk about their feelings / frustrations
• Encouragement to re-engage in activities and
  socialise
• Encouragement to become actively involved in
  getting things back to normal

73
Traumatic Event Hypothetical

• Managing a traumatic incident
• In groups of 3, discuss how to manage the
  scenario described. Plan your response in points
  and chronological order.
• In a large group, discuss what action you
  planned, what order you would apply them and why?

74
Round Up

• Hows your Jahari Window?
• Outstanding questions?
• Most helpful thing?
• Where to now?