Psychological First Aid: Advanced Concepts in Disaster Stress

Psychological First Aid:Psychological First Aid:Advanced Concepts in Advanced Concepts in

Disaster StressDisaster Stress

Psychosocial Impact Of DisasterPsychosocial Impact Of Disaster

Fear and Distress Fear and Distress ResponseResponse

Behavior Behavior ChangeChange

PsychiatricPsychiatric

IllnessIllness

Sources: Ursano, 2002; Institute of Medicine, 2003

Types of TraumaTypes of Trauma

Individual TraumaIndividual Trauma — — Stress & grief Stress & grief reactionsreactions

Collective TraumaCollective Trauma — — Damages the bonds of Damages the bonds of the communities’ social the communities’ social fabric fabric

Fear and DistressFear and Distress

Individual and Individual and Collective…Collective…

• Emotional impactEmotional impact• Cognitive impactCognitive impact• Physiological impactPhysiological impact• Sensory impactSensory impact• Spiritual impactSpiritual impact

Typical Stress Response PatternsTypical Stress Response Patterns

PhysicalPhysical--Shock symptomsShock symptoms

-Insomnia-Insomnia-Loss of appetite-Loss of appetite-Headaches-Headaches-Muscle weakness-Muscle weakness-Elevated vital signs-Elevated vital signs

EmotionalEmotional-Depressed, anxious-Depressed, anxious

-Numbing-Numbing-Constricted affect-Constricted affect-Guilt, shame, fear-Guilt, shame, fear-Intolerance of fear response-Intolerance of fear response-Global pessimism-Global pessimism

CognitiveCognitive--DistractibilityDistractibility-Duration/Sequence distortion-Duration/Sequence distortion-Declining school work-Declining school work-Recurrent intrusive -Recurrent intrusive recollectionsrecollections-Flashbacks, Nightmares-Flashbacks, Nightmares

BehavioralBehavioral -Clinging, isolation-Clinging, isolation

-Thrill seeking, -Thrill seeking, -Re-enactments of the trauma-Re-enactments of the trauma-Increased substance abuse-Increased substance abuse-Hypervigilance-Hypervigilance-Elevated startle reflex-Elevated startle reflex

Nature of Human StressorsNature of Human StressorsStress further defined as:Stress further defined as:

• Our physical Our physical andand psychological response to these psychological response to these

perceived threatsperceived threats (fight or flight)(fight or flight)

• Our world view has changed, norms, values, past Our world view has changed, norms, values, past

experiences are disruptedexperiences are disrupted

• Can lead toCan lead to Maladaptive CopingMaladaptive Coping strategies for strategies for

both victims and respondersboth victims and responders

• Disables PeopleDisables People

• Causes DiseaseCauses Disease

• Precipitates Mental Precipitates Mental Health DisordersHealth Disorders

• Leads to Substance Leads to Substance abuse, andabuse, and

• Destroys Relationship Destroys Relationship and Familiesand Families

TRAUMATIC STRESSTRAUMATIC STRESS

Is traumatic stress caused by Is traumatic stress caused by “severe” events?“severe” events?

Not always, can be less severe for some but with Not always, can be less severe for some but with greater reactions to the stress for othersgreater reactions to the stress for others

However, However, allall traumatic events have the potential traumatic events have the potential to cause significant damageto cause significant damage

Increased index of traumatic stress is Increased index of traumatic stress is commensurate with the commensurate with the Imprints of HorrorImprints of Horror present present at each scene/eventat each scene/event

Imprints of HorrorImprints of Horror

SightsSights: traumatic injuries, complete devastation: traumatic injuries, complete devastation

SoundsSounds:: explosions, screams, threatening voices explosions, screams, threatening voices

SmellsSmells:: blood, vomit, gasoline, natural gas blood, vomit, gasoline, natural gas

TactileTactile:: wet/dry, hot/cold, sticky, etc. wet/dry, hot/cold, sticky, etc.

TastesTastes:: Burning materials, air-bag powders Burning materials, air-bag powders

The Imprint of Horror...The Imprint of Horror...

Or this….Or this….

Or this….Or this….

Impact Phase:Impact Phase: Fight or flight Fight or flight Stunned reactionsStunned reactions Cognitive difficultiesCognitive difficulties Helplessness Helplessness Forced dislocationForced dislocation

Responsibility guiltResponsibility guilt

Common Disaster Traumatic Common Disaster Traumatic ReactionsReactions

Recoil/Rescue PhaseRecoil/Rescue Phase• Immediately after disasterImmediately after disaster

DenialDenial Shock/Direction-lessShock/Direction-less Intense GriefIntense Grief Imprints of Imprints of

Horror/FlashbacksHorror/Flashbacks AngerAnger DespairDespair


Recovery PhaseRecovery Phase• Also known as the ‘Honeymoon phase’Also known as the ‘Honeymoon phase’• Grateful to have survivedGrateful to have survived• May hesitate to show distress, griefMay hesitate to show distress, grief• FrustrationFrustration• CNN StressCNN Stress• Sleep disturbances, GI problems, aches/painsSleep disturbances, GI problems, aches/pains• constant fatigueconstant fatigue• Social and Family support erosionSocial and Family support erosion


Potential Long-Term EffectsPotential Long-Term Effects

• Free-floating anxiety and hypervigilanceFree-floating anxiety and hypervigilance• Underlying anger and resentmentUnderlying anger and resentment• Uncertainty about the futureUncertainty about the future• Prolonged mourning/inability to resolve lossesProlonged mourning/inability to resolve losses• Diminished capacity for problem solvingDiminished capacity for problem solving• Isolation, depression, hopelessnessIsolation, depression, hopelessness• Health problemsHealth problems• Significant lifestyle changesSignificant lifestyle changes

Behavior ChangeBehavior Change

• Increased smokingIncreased smoking• Increased alcohol useIncreased alcohol use• Reduced mobilityReduced mobility

• Fear of flying Fear of flying • Fear of travelFear of travel• Sticking close to home Sticking close to home

• Adverse economic consequences that increase Adverse economic consequences that increase psychological distresspsychological distress

Model of Economic Decisions & BehaviorsModel of Economic Decisions & Behaviors

Economic Decisions & Behaviors

Gasoline purchaseWork absence (for childcare)

House purchaseMedical visitsSavingsInsuranceInvestmentFood avoidanceVaccination avoidanceTravel

Attack CharacteristicsWeapon type (CBRNE)

Phase of attack (pre, during, post)

Target (individual, child, urban, rural)

Attack pattern (single, repeated, continuous)

HoaxContaminationNumber of casualties

Economic Costs

$$$

(Ursano)

Psychological & BehavioralMediators (Individual & Aggregate)Belief in exposure to toxic agentOptimismThreat/ Safety perceptionFear of leaving homePsychological distance from attackCritical event (e.g., news report)Distress symptoms

= =

Behavioral Health Impact in Behavioral Health Impact in Disaster ResponseDisaster Response

1.1. Lack of Efficient CommunicationLack of Efficient Communication2.2. Poor CoordinationPoor Coordination3.3. Ambiguous Authority Ambiguous Authority

RelationshipsRelationships4.4. Who Should be in Charge: Who Should be in Charge:

Federal or State Governments?Federal or State Governments?5.5. Counterterrorism versus All-Counterterrorism versus All-

hazard Response hazard Response 6.6. Ambiguous Training StandardsAmbiguous Training Standards7.7. Where is the Learning in Where is the Learning in

Lessons Learned?Lessons Learned?8.8. Performance AssessmentPerformance Assessment9.9. The Geography of PovertyThe Geography of Poverty10.10. Rumor & ChaosRumor & Chaos11.11. Personal & Community Personal & Community

PreparednessPreparedness12.12. Disaster Behavioral Health RoleDisaster Behavioral Health Role

Risks and ImpactRisks and Impact Secondary TraumatizationSecondary Traumatization Increased risk for vicarious Increased risk for vicarious

traumatrauma Risk factors for trauma Risk factors for trauma

increase as physical injuries increase as physical injuries mount and become more severemount and become more severe

Increased likelihood of Increased likelihood of exposure to deceasedexposure to deceased

Lack of confidence in Lack of confidence in governmentgovernment

(Ursano)








Risks and ImpactRisks and Impact First responders hampered by First responders hampered by

inadequate training and inadequate training and equipmentequipment

Frustration & grief more likely Frustration & grief more likely in first responders who feel that in first responders who feel that recovery efforts were poorly recovery efforts were poorly executedexecuted

Risk of injury and death higher Risk of injury and death higher because of lack of training and because of lack of training and length of recovery timelength of recovery time

Feelings of self-efficacy reducedFeelings of self-efficacy reduced

(Ursano)








Risks and ImpactRisks and Impact Special populations at greater Special populations at greater

risk for maladaptive recovery risk for maladaptive recovery following disasterfollowing disaster

Rumors adversely impact Rumors adversely impact effective crisis communication, effective crisis communication, increasing fear, and sometimes increasing fear, and sometimes preventing effective community preventing effective community actionaction

Differences in real and Differences in real and perceived self- and community perceived self- and community efficacy substantially impact efficacy substantially impact ability to recover from disasterability to recover from disaster

(Ursano)

Responder Traumatic StressResponder Traumatic Stress

Characteristics of the RespondersCharacteristics of the Responders

Strong ‘family’ ties with their work Strong ‘family’ ties with their work (role conflict)(role conflict)

Driven internally by high motivationDriven internally by high motivation Risk takersRisk takers Highly dedicatedHighly dedicated Unfamiliar Unfamiliar (Unwilling??)(Unwilling??) with how to unplug with how to unplug

from their dutiesfrom their duties Average to poor dietary habitsAverage to poor dietary habits Used to running on ‘near-empty’Used to running on ‘near-empty’

Pre-eventPre-event planningplanning

CrisisCrisisResponseResponse DuringDuring The The

Critical EventCritical Event

Let-downLet-downPhasePhase

Re-entryRe-entryPhasePhase

Acute Traumatic Acute Traumatic Stress Stress

ManagementManagement

CrisisCrisisStrikesStrikes

Typical Crisis Response PlansTypical Crisis Response Plans

©CISM Perspectives, Inc.©CISM Perspectives, Inc.

Acute Traumatic Stress Mgmt.Acute Traumatic Stress Mgmt.

• Traumatic stress mgmt. of the Emergency Traumatic stress mgmt. of the Emergency Responder Responder duringduring the event the event

• Traumatic stress mgmt. of the person Traumatic stress mgmt. of the person responded to, responded to, duringduring the event the event

• Mitigate/educate on the long term effects of Mitigate/educate on the long term effects of traumatic stresstraumatic stress

Readiness to RespondReadiness to Respond

Understand nature of the requestUnderstand nature of the request Give consideration to your personal situationGive consideration to your personal situation Do not assume that what you are being asked to do is Do not assume that what you are being asked to do is

well thought out and reasonable.well thought out and reasonable. Be certain that what you are asked to do is in keeping Be certain that what you are asked to do is in keeping

with best practice standards and within your training with best practice standards and within your training and expertise.and expertise.

Give consideration to cultural aspects of incident, your Give consideration to cultural aspects of incident, your cultural biases and your ability to provide cultural cultural biases and your ability to provide cultural competent responsecompetent response

Self-Care: Are You Ready…Really?Self-Care: Are You Ready…Really?

Always evaluate your level of readiness to respond.Always evaluate your level of readiness to respond. Do not assume that because you are trained and Do not assume that because you are trained and

experienced and an incident occurs you therefore experienced and an incident occurs you therefore must be ready to respond.must be ready to respond.

Give consideration to your physical and emotional Give consideration to your physical and emotional health.health.

If you have recently encountered a major life If you have recently encountered a major life stressor or are recovering from a serious illness it stressor or are recovering from a serious illness it may be better for you and those who need assistance may be better for you and those who need assistance for you to NOT respond.for you to NOT respond.

PFA VignettePFA Vignette

National Child Traumatic Stress Network National Child Traumatic Stress Network (NCTSN) & National Center for PTSD (NCTSN) & National Center for PTSD (NCPTSD) developed the Video (NCPTSD) developed the Video Responding Responding to Crisis: In the Aftermath of Disasterto Crisis: In the Aftermath of Disaster• Relaxation/breathing vignette – Relaxation/breathing vignette –

Observe PFA concepts while teaching coping skillsObserve PFA concepts while teaching coping skills

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Psychological First Aid: Advanced Concepts in Disaster Stress