Psychological First Aid

1. Psychological First Aid A Community Support Model

2. 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.

3. 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)

4. 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

5. 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…

6. 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

7. Health Care SystemLevel: • What are we trying to do? • Provide care for disaster survivors • Maintain care for current patients • Safeguard staff • Support responders • Lead effectively in crisis

8. 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

9. Psychological First Aid Basics • Expect normal recovery • Assume survivors are competent • Recognize survivor strengths • Promote resilience

10. 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.

11. 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.

12. 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 don’t trust • Exotic or unusual

13. 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

14. 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.

15. 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

16. Common Physical Reactions- Children/Youth • Headaches • Stomachaches • Nausea • Eating Problems • Speech Difficulties • Skin eruptions

17. 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

18. 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

19. 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

20. 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

21. Common Cognitive Reactions - Adults • Difficulty concentrating • Difficulty with memory • Intrusive Memories • Recurring dreams or nightmares • Flashbacks • Difficulty communicating • Difficulty following complicated instructions

22. 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

23. Common Faith & Spirituality Reactions– Adults & Children • Reliance upon faith • Questioning values and beliefs • Loss of meaning • Directing anger toward God • Cynicism

24. Common Sensory Reactions– Adults & Children • Sight • Sound • Smell • Taste • Touch

25. 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 harm’s 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. DIRECT EXPOSURE (eye witness) ON SITE (eye witness) IN NEIGHBORHOOD OUT OF VICINITY PSYCHOLOGICAL EXPOSURE RISK ZONES

30. 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.

31. 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. Sarin Attack on Tokyo Subways Examined & discharged 4023 Hospitalized 984 Severely injured 62 Norwood AE, 2002 Killed 12

34. 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.

35. Hospital Triage Point Initial Hospital Triage Medical Casualties Psychological Casualties Searching Family Members Red Yellow Green Support Center Family Center Behavioral Triage Community Behavioral Health resources Emergency Medical Treatment Area Medical/ Surgical Units/ICUs Distress Patients needing Psychiatric evaluation D/C Community Behavioral Health resources Behavioral Health Source: Shaw, Shultz, Espinel 2005

36. 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.

37. 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% Competence/Expertise 15-20% Dedication/ Commitment 15-20% Dedication/ Commitment 15-20% Honesty/ Openness 15-20% Honesty/ Openness 15-20%

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

39. 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

40. 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

41. 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”

42. 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)

43. 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

44. 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

45. 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)

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

49. 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 Workers Psychological Casualties Media Volunteers Onlookers Distressed Inpatients Family Members of Inpatients Distressed Staff

50. 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 What Survivors Need: ACTION 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.