A Public Health Model of Crisis Intervention

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A Public Health Model of Crisis Intervention

• Primary Prevention Activities and services
  designed to prevent crisis and reduce risk in
  youth
• Secondary Prevention Activities and services
  implemented in the immediate aftermath of a
  crisis
• Tertiary Prevention Activities and services
  designed to repair crisis related damage
  (pathology) long after the event has occurred

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Primary Prevention

• Goals preparation, improved coping
• Crisis prevention Activities designed to prevent
  crisis events from occurring
• Creating safe and nurturing schools/classrooms
• Identifying at risk youth and promoting social
  skills
• Addressing bullying, depression, alcohol and
  substance abuse, anger management and peer
  mediation

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Primary Prevention

• Crisis preparedness Minimizing the traumatizing
  potential of a crisis
• Critical for crisis plans to address issues such
  as secondary exposure and reunification with
  families
• Provide training
• Drills
• Inform and influence policy
• Plan Set structures for rapid assistance

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Secondary Prevention

• Response
• Key components of early intervention
• Psychological triage
• Responses to trauma
• Psychological first aid
• Recovery
• Long term issues
• Monitoring recovery
• Triggers

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Traumatic events

• Trauma is a sudden, unexpected, dramatic,
  forceful event.
• Overwhelming, uncontrollable experience that
  psychologically impacts victims.
• Creates feelings of helplessness, hopelessness,
  vulnerability and loss of safety.

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NIMH 2002 Report-Early Intervention Reduces Mass
Violence Trauma

• Preparation, planning, education, training and
  evaluation were identified as key components.
• While many survivors will experience some
  symptoms immediately following crisis events, we
  should expect normal recovery for the majority.
• Participation in early interventions should be
  voluntary.

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NIMH 2002 Report-Early Intervention Reduces Mass
Violence Trauma

• Early, brief, focused psychotherapeutic
  intervention can reduce distress among the
  bereaved.
• Some early interventions, especially selected
  cognitive behavioral approaches, appear to be
  effective in reducing acute stress, and may help
  to reduce PTSD and depression.
• For clarity, the term debriefing should be used
  only to describe operational debriefings.

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NIMH 2002 Report-Early Intervention Reduces Mass
Violence Trauma

• Early interventions that involve a detailed
  recall of the event (such as occurs during
  debriefings) may not be helpful and may place
  those with high arousal (e.g., those with
  physical injuries) at greater risk.
• There is no evidence that EMDR is more effective
  than other early psychological interventions.
• Little data was found to guide the optimal timing
  of early interventions.

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NIMH 2002 Report-Early Intervention Reduces Mass
Violence Trauma

• Early screening of trauma survivors was suggested
  to facilitate early interventions. Risk factors
  for adverse outcomes identified included severe
  stress reactions, bereavement, pre-existing
  psychopathology, physical injury, and
  intense/prolonged crisis exposure.
• Follow-up services should be offered to those at
  high risk for adjustment problems.
• Training and certification programs need to be
  developed, sanctioned, and validated by
  professional bodies/organizations.

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NIMH 2002 Report-Early Intervention Reduces Mass
Violence Trauma

• WEAKNESSES
• Report based on a conference with 58 disaster
  experts none represented the schools.
• Two studies addressed school-based interventions
  only 12/78 studies focused on youth.

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NIMH 2002 Report-Key Components of Early
Intervention

• Basic needs
• Psychological First Aid
• Needs assessment psychological triage
• Outreach information dissemination
• Treatments
• Foster resiliency

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Basic Needs

• Safety and security
• Connection with caregivers
• Coping with daily activities
• Abraham Maslow

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Psychological First aid Key concepts

• Protect survivors from further harm
• Identify and provide support for those most
  distressed
• Re-establish social supports
• Keep families together and facilitate reunion
  with loved ones
• Reunite friends, teachers return to school
• Provide information and collaborate with local
  resources

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Psychological First aid Re-establishing social
supports

• Individuals with strong familial and social
  support systems are better able to cope (lower
  levels of traumatic stress reactions)
• Provide assistance to those with inadequate or
  insufficient social support
• Consider how parents/caregivers are coping

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Psychological First aid Re-establishing social
supports

• Reunite students with primary caregivers
• Priority to younger children as they show
  strongest reactions to being separated from
  parents.
• Reunite students with close friends, teachers and
  classmates
• Return to school and familiar routines
• Facilitate communication among families,
  students, community agencies
• Education!

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Psychological First aid Key concepts

• Children may experience a wide variety of
  reactions and feelings and be influenced by
  cultural and developmental background
• Key normalize reactions
• Most common indicators of distress
• Behavioral changes
• Regression

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Psychological First aidKey concepts

• Inability to understand the permanence of death
• Childrens communication styles differ from
  adults Utilize age appropriate techniques.
• Duration of grief may be extended for years
• Lack of coping skill development

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Fostering Resilience and Recovery

• Foster but do not force social interactions
• Provide training in coping skills, risk
  assessment
• Foster natural social supports and offer family
  interventions
• Look after the bereaved
• Educate on stress responses, traumatic reminders,
  normal vs. abnormal reactions, services available

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Psychological triage
Proximity/Relationships
Out of Vicinity
Direct Exposure
On Site
In Neighborhood
2001 UCLA Trauma Psychiatry Program Dr. Robert
Pynoos
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Psychological triageRisk screening

• Identify and refer acutely traumatized
• Identify vulnerable populations
• Previous trauma
• Previous losses
• History of depression or mental illness
• Establish referral procedures for school and
  community mental health resources

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Traumatic stress reactions

• COGNITIVE
• Confusion
• Memory/time distortions
• Intrusive thoughts
• Academic regression

• SOMATIC
• Sleeping disorder
• Eating disorder
• Hypervigilance startle response

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Traumatic stress reactions

• BEHAVIORAL
• Regression
• Avoidance
• Withdrawal
• Repetitive play
• Aggression

• AFFECTIVE
• Numbness
• Fear
• Anger
• Guilt
• Shame
• Grief

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Post-traumatic stress reactions Exacerbating
factors

• Trauma reminders
• Loss reminders
• Current life stressors or adversities

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Age related reactionsPreschool-2nd grade

• Helplessness and passivity
• Generalized fear abandonment
• Lack of verbalization hinders coping
• Sleep and eating difficulties
• Anxious attachments clinging to parents,
  separation problems
• Regression

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Age related reactionsPreschool-2nd
gradeHelpful Hints

• Provide verbal reassurance and physical
  comforting
• Provide comforting bedtime routines
• Address sleeping problems by providing added
  support at bedtime, e.g., sitting with child
  until they fall asleep, adding stuffed animals

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Age related reactionsSchool age (5-11 years)

• Aggressive behavior at home/school
• Competition with younger sibs
• School avoidance
• Depression and withdrawal from peers
• Regressive behaviors
• Impaired learning and poor concentration in school

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Age related reactionsSchool age (5-11 years)

• Eating/sleeping disturbance
• Retelling and replaying the event
• Concern for victims and their families
• Preoccupation with own actions

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Age related reactionsSchool AgeHelpful Hints

• Patience and tolerance
• Play sessions with adults and peers
• Maintain structure and calm routines at home and
  at school
• Discuss and reinforce safety measures and
  behaviors

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Age related reactionsSchool AgeHelpful Hints

• Use art techniques and journal writing
• Engage them in simple activities that reach out
  to victims and their families
• Teach stress management techniques
• Allow for retelling of the event, responding with
  support and validation of their experience

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Age related reactionsAdolescents

• Detachment, shame and guilt
• Somatic complaints
• Post-traumatic acting out behaviors
• Desires and plans for revenge
• Signs of depression sudden changes mood
  disorder alcohol/substance abuse
  self-mutilation
• Warning Signs homicidal/suicidal thoughts
  (expressed home/school) risk taking behaviors
  giving away possessions

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Age related reactionsAdolescentsHelpful Hints

• Encourage participation in community
  rehabilitation work
• Encourage resumption of social activities,
  athletics, clubs
• Encourage but do not insist on discussion of
  event or fears with peers, families
• Help to understand aggressive behaviors as an
  effort to numb responses coping with anger

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Age related reactionsAdolescentsHelpful Hints

• Maintain structure and routines
• Promote constructive activities to lessen
  feelings of helplessness
• Seek immediate assistance if serious warning
  signs of suicide or violence are observed

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Tips for PARENTS

• Pay more attention, spend more time, be more
  nurturing and comforting.
• Do not be surprised by any significant changes in
  behavior or personality.
• Let them know where you are going, when you will
  be back. Call if out for a long time and
  reassure.
• Let them tell their story. Listen and normalize
  reactions they are having.
• Help them to understand that defiance, aggression
  and risk behavior is a way to avoid feeling the
  pain, the hurt or fear they may have experienced

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Tips for TEACHERS

• Provide added support in response to childrens
  new fears, e.g., night light
• Help children to understand the connection
  between their feelings and behavior as a reaction
  to traumatic experiences
• Find safe ways to express their feelings
  (drawing, exercise, talking).
• Help children identify constructive actions that
  adults can take to help them feel safe and
  actions they can take to make things better at
  school.

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Tertiary Prevention for School Staff

• Monitor the recovery of individuals and community
• Monitor the environment for ongoing threat
• Plan for significant dates such as anniversaries,
  birthdays, graduations.