for Assessment for CCP Counseling Interventions

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for Assessment for CCP Counseling
Interventions

• Deborah DeWolfe, Ph.D., MSPH

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Population Exposure Model
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Dimensions of Trauma Exposure

• Threat to life and limb
• Severe physical injury
• Receipt of intentional harm/injury
• Violent/sudden loss of a loved one
• Causing death or severe harm to another

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Dimensions of Trauma Exposure

• Unexpected and uncontrollable danger
• Witnessing injuries, death, carnage
• Experiencing panic or dissociation
• Prolonged recovery effort
• Learning of exposure to a noxious agent

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Survivor Risk Factors

• Prior or pre-existing mental health or substance
  abuse problem
• Prior unresolved trauma or loss
• Low socioeconomic resources
• Female gender
• Ethnic group membership

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Survivor Risk Factors

• Family instability and conflict
• Lack of social support
• Presence of children in the home
• Age in middle years (40-60 years)

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Resilience Factors

• Belief in own capability to cope
• Minimal avoidance coping and blaming
• Perceived and actual social support
• Adequate socioeconomic resources
• Positive buffers self-efficacy, perceived
  control, self esteem, hope and optimism

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Key Question
How can we promote resilience in vulnerable and
highly exposed individuals?
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Model of Responses to Trauma Bereavement
Rage Anger Blame
Anxiety Intrusions
Reconstructing A New Life
Disbelief Outcry Heroism
Hypervigilance
Reclaiming Life
Searching for Meaning
Event
Coming to Terms with New Realities
Numbing
Avoidance
Isolation Loneliness Depression
Shock Denial Disorientation
Sadness Despair Guilt
0 to 7 Days TIME
2 to 5
Years
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How Much is Too Much?
Avoidance
Anxiety, Arousal
Sadness, Depression
Manageable
CCP
Maladaptive Thoughts
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Cognitive Reactions

• Intrusive thoughts, images
• Recurring dreams, nightmares
• Memory and concentration difficulties
• Difficulty making decisions
• Damaging cognitive distortions
• Rumination about trauma and losses

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Emotional Reactions

• Anxiety, fear about safety
• Irritability, anger, rage
• Sadness, grief, depression
• Re-experiencing aspects of the trauma
• Numbness, disconnection
• Hopelessness and despair
• Survivor guilt, self doubts

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Physical Reactions

• Agitation, hyperarousal
• Fatigue, exhaustion
• Gastrointestinal distress
• Tightness in throat, chest
• Headaches
• Worsening of health conditions

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Behavioral Reactions

• Sleep problems
• Jumpiness, easily startled
• Hypervigilance
• Avoidance of reminders
• Increased family conflicts
• Isolation, social withdrawal

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Ethical Considerations

• Understand meaning and implications of assessment
  outcomes
• Assure that appropriate and effective MH
  interventions to address outcomes are available
• Balance time required, level of intrusion, and
  risk of trauma restimulation with immediate
  helpfulness to survivors and families

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Life Functioning Questions

• How is person functioning at home, work and
  socially?
• How has persons health been impacted?
• How has person changed since the event?

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Therapeutic Assessment

• Establish rapport and connection
• Explore trauma and loss exposure and experience
• Examine current trauma symptoms
• Identify meanings and hot spots
• Explore trauma, loss, mental health and substance
  abuse histories
• Identify coping strengths and capabilities

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Disaster Counseling Interventions

• Deborah DeWolfe, Ph.D., MSPH

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MH Provider Competencies

• Can-do problem-solving approach
• Establishes rapport easily
• Able to sit with pain, grief, tears, anger,
  anxiety, frustration, anguish
• Culturally sensitive and competent
• Understands boundaries and limits
• Takes good care of own mental health

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Key Concepts of Disaster Mental Health
Intervention

• First, do no harm
• Avoid mental health labels
• Assume competence and capability
• Be flexible, practical, empowering
• Respect differences in coping
• Focus on strengths
• Fit services to the community

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Range of Disaster Mental Health Interventions

• Psychological First Aid
• Community Outreach
• Crisis Intervention
• Psychoeducation
• Psychological Debriefing
• Mental Health Consultation
• Brief Individual Counseling
• Group Counseling

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Model of Responses to Trauma and Bereavement
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Underlying Assumptions

• The majority of survivors and family members will
  successfully recover without MH assistance.
• A significant minority will experience PTSD,
  depression, anxiety and distress and may benefit
  from MH intervention.

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Underlying Assumptions

• Recovery involves reclaiming and reconstructing
  ones life - finding a new normal, which occurs
  gradually over years.
• Brief counseling support can assist individuals
  as they negotiate the working through process.

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Support, Problem-solving, Crisis Intervention

• Explore disaster experience
• Identify priority needs and problems
• Assess functioning and coping
• Intervene immediately when at risk
• Assist with problem-solving
• Reinforce positive coping strengths

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Goals of Brief Trauma Counseling

• Stabilize emotions and regulate distress
• Confront and work with realities associated with
  the event
• Understand and manage trauma symptoms and grief
  reactions
• Develop a sense of meaning regarding traumatic
  event
• Come to acceptance
• Reclaim and reconstruct life - move on

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Stabilize Emotions and Regulate Distress

• Targeted interventions (e.g., for sleep,
  intrusive images, startle reactions, avoidance,
  social isolation)
• Psychoeducation on traumatic stress and grief
  reactions
• Relaxation techniques
• Positive behaviors encouraged social, exercise,
  self care, pleasant activities
• Referral for pharmacological interventions

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Confront and Work with Realities

• Tell thoroughly trauma and loss experience -
  paced appropriately
• Explore feelings, reactions, thoughts and
  meanings during and since event
• Identify and work with hot spots images,
  beliefs, self doubts
• Incorporate exposure techniques writing,
  retelling, guided imagery, in vivo

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Pacing Addressing Trauma
The survivor may feel secure to progress to
dealing with the trauma only when confident that
the counselor is not only genuine, empathic, and
warm, but also capable of understanding the
significance of the trauma, bearing to hear of
it, and able to help the traumatized person
manage the affect that it evokes.
(p. 112, Raphael and Wilson,
1993)
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Understand and Manage Trauma and Grief Reactions

• Encourage capacity for self-observation
• Provide psychoeducation on coping with trauma and
  loss
• Assist with identifying, labeling, validating and
  connecting emotions and reactions
• Anticipate risk circumstances and plan coping
  strategies

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Goals for Bereavement Counseling

• Accept the reality of the loss
• Experience the pain of grief
• Adjust to a life in which the deceased is missing
• Withdraw emotional energy and invest in a new
  relationship (Worden, 1982)

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Goals for Bereavement Counseling (6 Rs)

• Recognize the loss
• React to the separation
• Recollect and re-experience the deceased and the
  relationship
• Relinquish the old attachments to the deceased
  and the old world
• Readjust to move adaptively into the new world
  without forgetting the old
• Reinvest in life (Rando, 1993)

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Traumatic Grief

• Overlay of trauma reactions on mourning process
• Alternate between trauma-based and grief
  reactions
• Avoidance of reminders of the deceased
• Intrusive recollections of scenes of death
• Nightmares of trauma vs dreams as alive
• Counseling validates, supports and intervenes
  with both processes

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Multi-disciplinary Network

• Crime Victim Services
• Faith-based Assistance
• Longer-term Psychotherapy
• Psychiatry and Pharmacology Intervention
• Substance Abuse, Domestic Violence, and Family
  Support Services

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Group Counseling

• Support Groups
  
• Brief Counseling Intervention Groups

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Benefits of Group Intervention

• Opportunity to tell trauma story and have it
  witnessed
• Expression, validation and normalization of
  reactions and feelings with others who went
  through event
• Education on reactions and coping
• Resource information sharing
• Encouragement for healthy coping
• Fostering hope and sense of control

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Support Groups

• Homogeneous (e.g., bereaved parents, bereaved
  spouses with children, emer- gency workers,
  evacuees, unemployed)
• Time-limited (4-8 meetings)
• Sharing personal stories related to 9/11
• Psychoeducation on trauma and grief processes
  and coping strategies
• Focused group discussion
• Problem-solving immediate concerns

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Brief Counseling Intervention Groups

• Time-limited (6-10 meetings)
• Sharing personal stories related to 9/11
• Structured with psychoeducation, coping practice,
  and homework exercises
• Focused group discussion
• Exposure techniques to aid integration
• Activities to promote healthy coping
• Looking to the future finding meaning, purpose
  and reclaiming life