Psychological First Aid: Skills Training For Practical Frontline Assistance

Psychological First Aid Skills for School Crisis Teams
Psychological First Aid
Skills Training for Practical Frontline Assistance

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About the Speaker

Steve Crimando, MA,
steve@bsaonline.net
BCETS, CTS, CHS-V
Consultant/Trainer: U.S. Dept. of Homeland Security; FBI; U.S. Postal Service; NTSB; United Nations, NYPD Counter Terrorism Division; U.S. Military, etc. Member, Board of Directors: International College of the Behavioral Sciences. Diplomate, National Center for Crisis Management. Diplomate, American Academy of Experts in Traumatic Stress. Board Certified Expert in Traumatic Stress (BCETS). Certified Trauma Specialist (CTS). On-scene Responder/Supervisor: 93 and 01 World Trade Center attacks; NJ Anthrax Screening Center; TWA Flight 800; Unabomber Case; Intl kidnappings, hostage negotiation team member; etc. Qualified Expert: to the courts and media on violence prevention and response issues. Author: Many published articles and book chapters addressing behavioral sciences in crisis, disaster and terrorism response.
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Acknowledgements
This training program is based upon the best practices in Psychological First Aid (PFA) identified by several leading international authorities, such as: National Center for Posttraumatic Stress Disorder Disaster Branch of the National Child Traumatic Stress Network The International Federation of Red Cross and Red Crescent Societies National Academies of Science-Institute of Medicine Drs. George Everly & Brian Flynn Zagurski, R., Bulling, D., Chang, R. (2005). Nebraska Psychological First Aid Curriculum. Lincoln, NE: University of Nebraska Public Policy Center.
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Psychologicalfirstaid.com
The primary resource
Available online at: www.ncptsd.va .gov
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Our Agenda
Introduction Foundations of Disaster Mental Health Services What is Psychological First Aid (PFA)? Key Concepts in PFA Delivering PFA Core Actions in PFA PFA Skills Tool Kit PFA Dos & Donts
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Disaster Tolls Escalate

120 natural disasters per year in the early 1980s, which compared with the current figure of about 500 per year The number of people affected by extreme natural disasters has surged by almost 70 percent
174 million a year between 1985 to 1994 254 million people a year between 1995 to 2004
The Oxfam 2008 study was compiled using data from the Red Cross, the United Nations and specialist researchers at Louvain University.
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Changing Disaster Trends

Total number of reported disasters by year (1995 to 2004)
Fatalities Source: EM-DAT, University of Louvain, Belgium

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Population Growth
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Foundations of Disaster Mental Health Services
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Managing the Mental Health Consequences of Disasters

Consequence management in disasters, terrorism and public health emergencies is not limited to the physical consequences. Baseline understanding of the mental health consequences of disasters, terrorism, and other traumatic events. Unique psychosocial impact of CBRN and public health emergencies.
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Ten Key Points About Disaster Mental Health

There are a number of key concepts that all responders/receivers should consider. These include:
1. 2. 3. 4. No one who experiences a disaster or violent event is untouched by it. Only a smaller percentage of the affected population develop PTSD and other long-term mental health problems. Traumatic stress reactions are natural, normal, and expected. They are not to be considered signs or symptoms of a mental illness. Individuals, organizations and communities rebound from disasters/crises in their own time and on their own terms.
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Ten Key Points About Disaster/Crisis Mental Health (Cont.)

5. 6. There is no one-size-fits-all model for disaster mental health intervention. Intervention is not treatment. Mental health treatment, like psychotherapy is intended to create change, the purpose of intervention is to prevent change. Interventions must be phase-specific. Interventions are largely psycho-educational. Interventions must be culturally sensitive.
7. 8. 9.
10. Responders must work within the context of the larger disaster response and recovery effort.
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Common Reactions to Disasters

Emotional Mental Physical Interpersonal
Reactions may last days, weeks, months, or years

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Understanding Behavior: Lewins Equation
Behavior is a Function of Person and Environment
Law Enforcement Sensitive
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Panic in Emergencies
Panic is related to the perception of limited opportunity for escape or availability of critical supplies. Panic is a group phenomena characterized by an intense, contagious fear. Panicked individuals think only of their own needs or survival. Panic is not typical in most disasters.
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Anticipating the Psychological Footprint

Many emergency scenarios (i.e., CBRN, disease outbreaks, etc.) are primarily behavioral emergencies. Example: Sarin gas attack-Tokyo subway 3/95 Psychological casualties to Medical Casualties
4:1
Goinia, Brazil 1987 Cesium-137 release
500:1
Kawana, N., S. Ishimatsu, and K. Kanda. 2001. Psycho-Physiological Effects of the Terrorist Sarin Attack on the Tokyo Subway System. Military Medicine 166:23-6. Becker, Steven. Psychosocial Effects of Radiation Accidents. Medical Management of Radiation Accidents. 2nd ed. Boca Raton, FL. CRC Press. 2001.
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Common Behavioral Response

3 Basic Behavioral Responses Type One: Neighbor-helps-neighbor. Type Two: Neighbor-fears-neighbor. Type Three: Neighbor-competes-with neighbor.
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Applying the Bookends Concept

Events which have clear bookends (i.e.-it is clear when they begin and end; who is in the affected area, who is not) tend to produce acute stress reactions and PTSD-like symptoms. Most natural disasters Many technological disasters Conventional terrorist acts: Bombing, shooting and kidnapping incidents Events which lack bookends and have the element of invisibility (cannot see, smell, hear or taste threatening substances, etc.) result in chronic stress reactions and longterm behavioral consequences Unconventional acts of terrorism: CBRN/WMD Disease outbreaks
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Reactions to Atypical Threats

CBRNs and Public Health crises (i.e., SARS, pandemic influenza, etc.) also result in different responses that are not seen in natural or technological disasters. Those include:

Medically Unexplained Physical Symptoms (MUPS)/Multiple Idiopathic Physical Symptoms (MIPS) Misattribution of normal arousal Sociogenic illness Panic Surge in healthcare seeking behavior Greater mistrust of public officials These reactions further complicate and confuse the public health and medical response to the situation
Pastel, R.H. 2001. Collective Behaviors: Mass Panic and Outbreaks of Multiple Unexplained Symptoms. Military Medicine 166:44-6.
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Reactions to Atypical Threats

Public Health crises (i.e., SARS, pandemic influenza, etc.) also result in different responses that are not seen in natural or technological disasters. Those include: Medically Unexplained Physical Symptoms (MUPS)/Multiple Idiopathic Physical Symptoms (MIPS) Misattribution of normal arousal Sociogenic illness Panic Surge in healthcare seeking behavior Greater mistrust of public officials These reactions further complicate and confuse the public health and medical response to the situation Pastel, R.H. 2001. Collective Behaviors: Mass Panic and Outbreaks of Multiple Unexplained
Symptoms. Military Medicine 166:44-6.
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Case Study Goinia, Brazil 1987
Goinia incident: Equivalent to large-sized dirty-bomb scenario in Manhattan

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Case Study:
Abandoned medical clinic in Goinia contained 1,400 Curie radioactive cesium (Cs 137 ) source
The radioactive sources were stolen, broken opened and dispersed

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Characteristics of CBRN Events:

Fear-inducing Injuries
2005.6.7 Per J. Crapo, Photo on left is where 1 of parents painted the radioactive cesium on himself or herself. W. Dickerson
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Impact of Event
1375 curie Cesium-137 spread throughout a neighborhood External and internal exposure hazards Four victims died within four weeks, 60 over the next decades Twenty victims hospitalized 249 people had detectable external and/or internal contamination 112,000 screened (500 screened for each victim, i.e. 500: 1 ratio) Site remediation took months to complete (October 1987-March 1988)
Ref: IAEA-TECDOC-1009, 1998.
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Neuropsychiatric Casualties
Of first 60,000 monitored: 5,000 had psychosomatic symptoms (8%) rash around neck and upper body vomiting diarrhea 0 (zero) were contaminated!
Ref: Petterson, JS. (1988). Nuclear News, 31:84-90
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The Psychosocial Response

Acute Fear/Stigma
Ambulance drivers abandoning patients Hospital staff/MDs refusing to report to work Pilots refusing to fly individuals from the region Crowd stoning hearse, coffin grave of those killed Discrimination by community
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Neuropsychiatric Casualties
Of first 60,000 monitored: 5,000 had psychosomatic symptoms (8%) rash around neck and upper body vomiting diarrhea 0 (zero) were contaminated!
Ref: Petterson, JS. (1988). Nuclear News, 31:84-90
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The Psychosocial Response

Acute Fear/Stigma
Ambulance drivers abandoning patients Hospital staff/MDs refusing to report to work Pilots refusing to fly individuals from the region Crowd stoning hearse, coffin grave of those killed Discrimination by community
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What is Psychological First Aid?
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What is Psychological First Aid?

Evidence-informed Modular approach Designed to reduce initial distress For immediate aftermath of an event To foster short- and long-term adaptive functioning
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A Working Definition
Psychological first aid (PFA) refers to a set of skills identified to limit the distress and negative behaviors that can increase fear and arousal.
(National Academy of Sciences, 2003)
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Psychological First Aid is.

Psychological first aid (PFA) is as natural, necessary and accessible as medical first aid. Psychological first aid means nothing more complicated than assisting people with emotional distress resulting from an accident, injury or sudden shocking event. Like medical first aid skills, you don't need to be a doctor, nurse or highly trained professional to provide immediate care to those in need.
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Psychological First Aid is Not

Fill in the blank:
The purpose of psychotherapy is to create _______________. The purpose of disaster mental health intervention is to prevent _____________.
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Debriefing Counseling Psychotherapy Mental health treatment
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A Comparison
Medical First Aid
Early assistance provided by those first on-scene Initial assessment of physical impact of event Stabilization of immediate physical wounds Prevention of further physical exposure or injury Maintenance of medical status until professional medical care is available Facilitate transition to trained medical professional when necessary Promote quicker and better physical recovery
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A Comparison
Psychological First Aid
Early assistance provided by those first on-scene Initial assessment of emotional impact of event Stabilization of immediate emotional wounds Prevention of further exposure or emotional injury Maintenance of emotional status until professional mental health care is available Facilitate transition to trained mental health professional when necessary Promote quicker and better emotional recovery
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The ABCs of First Aid Medical

Airway Breathing Circulation
Psychological
Arousal (Reduce) Behavior (Limit) Cognition (Improve)
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Strengths of PFA
PFA includes basic information-gathering techniques for rapid assessment of the survivors immediate concerns. PFA relies on field-tested, evidence-informed strategies that can be applied in a variety of disasters and crisis situations. PFA is appropriate across ages and cultures. PFA includes the use of handouts to provide important information for dealing with postdisaster reactions and adversities.
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When Should PFA be Used?

Immediate aftermath of disasters or terrorism. Typically 0 to 48 hours of the event.
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Where to Use PFA?

On the frontline of a disaster or crisis. Points of Dispensing (PODs) medication or supplies. ERs and Field Hospitals. Shelters, Disaster Recovery Centers, Family Assistance (Reception) Centers. Crisis Hot Lines, Phone Banks. Other community settings.
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Who Should Deliver PFA?

Mental Health Professionals. Para-professionals (i.e.-heath care, school crisis teams, CERT and MRC, Faith-based Relief Workers, etc.) Non-professionals (i.e.-community members, co-workers, etc.)
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Traits of Effective PFA Responders

Capacity to connect with wide range of individuals. Tolerance for symptomatic behavior and strong expression of affect. Capacity for rapid assessment of survivors. Provide care tailored to timing of intervention and context. Working sense of self-capacities. Provide clear, concrete information. Capacity for self-care.
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Essential Attributes and Skills for Responders

Good Listening skills Patient Caring attitude Trustworthy Approachable Culturally competent Empathetic
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Essential Attributes and Skills

Non-judgmental approach Kind Committed Flexible Able to tolerate chaos and ambiguity
(Cont.)
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Exercise
Teach-back elevator pitch exercise Work with a partner. Please follow the instructions provided by the trainer.
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Key Concepts in PFA
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Basic Objectives of PFA

Establish a human connection in a non-intrusive, compassionate manner. Enhance immediate and ongoing safety. Provide physical and emotional comfort. Help survivors identify their immediate needs and concerns. Gather information as appropriate. Offer practical assistance and information.
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Basic Objectives
(cont.)
Connect survivors as soon as possible with family members, friends, neighbors and community resources (social support network). Support adaptive coping; acknowledge coping efforts and strengths; encourage active participation in recovery. Provide information about coping strategies/techniques. Clarify availability of mental health responders; Facilitate linkage to other supports.
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Guiding Principles in Providing PFA

Protect: From further exposure and media. Direct: Be kind, gentle, clear. Connect: With loved ones and information and support.
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Early Psychological Support

Relieve suffering, both emotional and physical. Improve peoples short term functioning. Accelerate the individuals course of recovery.
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Principles of Psychological Support

Do no harm Peer-based approach Recognizes and uses indigenous healing networks and practices Uses trained volunteers Empowers Encourages organizational participation Exercises care with terminology Encourages active involvement Values early intervention Uses viable interventions
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Empowerment
Over-helping can be humiliating and/or create passivity. Quality relief and assistance is based on helping others to gain self-respect and autonomy (empowerment). Abilities and strengths of the recipient are as important as their problems. High degree of organizational participation enhances empowerment
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Active Involvement
Focus on strengths rather than symptoms and deficits. Identify and strengthen coping mechanisms. Actively involve the person in helping to sort out their problems.
Remember: Action Binds Anxiety!
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The PFA Skills Toolbox
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Slowing It Down
Apply the STOP approach:
S it T hink O bserve P lan
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Interpersonal Communication Skills
Non-verbal communication Listening and responding Giving feedback
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Projecting Warmth
Soft tone Smile Interested facial expression Open/welcoming gestures Allow the person you are talking with to dictate the spatial distance between you (This can vary according to cultural or personal differences)
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Increasing Trust and Confidence

General behaviors (depending on culture) to increase trust and confidence:
Face the speaker Display an open posture Keep an appropriate distance Frequent and soft eye contact Appear calm and relaxed
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Communicating Warmth SOLER

S it squarely O pen Posture L ean Forward E ye Contact R elax
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Communication and Empathy (and Safety!)
L-Shaped Stance:
Demonstrates respect Decreases confrontation
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Listening and Responding

Seek to understand first, then to be understood. Concentrate on what is being said. Be an active listener (nod, affirm). Be aware of your own biases/values. Listen and look for feelings. Do not rehearse your answers.
A Good Practice: Ask before you tell.

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Listening and Responding

(cont)
Pause to think before answering. Do not judge. Use clarifying questions and statements. Avoid expressions of approval or disapproval. Do not insist on the last word. Ask for additional details.
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Benefits of Active Listening

Shows empathy. Builds relationships. Helps people acknowledge their emotions and to talk about them instead of negatively acting on them. Clears up misunderstandings between people.
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Guidelines for Responding

Give subtle signals that you are listening. Ask questions sparingly. Never appear to interview the person. Address the content (especially feelings) of what you hear without judging. Focus on responding to what the person is really saying or asking.
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Non-Verbal Communication
Non-verbal can include:
Personal Space Posture Body language
Para-verbal communications refers to : Voice Tone Volume Rate of speech. Para-verbal communication is how we say something, not what we say
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Congruence
Matching words and actions
Denotes trustworthiness Shows others that we care Shows we are in control
Incongruence
Interpreted as being untrustworthy or inauthentic
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Resolving Cultural Conflicts

1. Be aware that culture may be a factor. 2. Be willing to work on the cultural issues. 3. Be willing to talk about how the other person's culture would address this problem. 4. Develop a solution together. 5. If there is confusion or a misunderstandingtalk about it and learn from each other.
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Seek Assistance
Loss of control. Becoming threatening. If the person becomes threatening or intimidating and does not respond to your attempts to calm them, seek immediate assistance.
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Personal Safety in PFA

Observe safe practices by showing concern for your own safety Remain calm and appear relaxed, confident and non-threatening Three rules for personal safety:
Never sacrifice safety for rapport; Leaving one minute too soon, always better than one minute too late; If you have to run, dont run from danger, run toward safety!
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Delivering Psychological First Aid
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Guidelines for Delivering PFA

Politely observe first; Dont intrude. Ask simple, respectful questions to determine how you can help. Offering practical assistance (food, water, blankets, etc.) can create the PFA opportunity. Be prepared for survivors to either avoid you or flood you with contact.
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Guidelines for Delivering PFA

(Cont.)
Speak calmly. Be patient, responsive and sensitive. Speak slowly, in concrete terms; avoid acronyms or jargon. Acknowledge whatever positive steps the survivor has done to keep safe. Give information that directly addresses the survivors immediate needs and goals. Provide information that is accurate, timely and age-appropriate.
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Keep in Mind
The goal of PFA is to:
Reduce distress and arousal Assist with current needs Promote adaptive function
The goal is NOT to:

Elicit details of the traumatic experience or losses. Debrief, by asking for details.
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Behaviors to Avoid
Do not make assumptions about what survivors are experiencing or what they have been through. Do not assume that everyone exposed to a disaster will be traumatized. Do not pathologize. Most reactions are understandable and expectable. Do not patronize or talk down to survivors, focus on helplessness, weakness, mistakes or disabilities. Do not assume survivors want to or need to talk to you; a compassionate presence can be calming, supportive and help people feel safer and better able to cope. Do not speculate or offer possibly inaccurate information.
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Core Actions in Psychological First Aid
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PFA Core Actions

1 2 3 4 5 6 7 8 Contact and Engagement Safety and Comfort Stabilization Information Gathering Practical Assistance Connection with Social Supports Information on Coping Linkage with Collaborative Services
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Population Exposure Model

A: Community victims killed or seriously wounded, bereaved family members, loved ones, close friends B: Community victims exposed to incident and scene, but not injured C: Bereaved extended family and friends, residents in the disaster zone who lost homes, First Responders and Recovery Workers, ME, service providers working with families D: Mental Health and Crime Victim Assistance providers, Government Officials, Media. E: Groups that identify with the target-victims group, businesses with financial impacts, community-at-large
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A B C D E
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Contact and Engagement

The goal of this action, Contact and Engagement, is to respond to contacts initiated by survivors, or to initiate contacts in a nonintrusive, compassionate, and helpful manner. It is about how a responder approaches and initiates a PFA contact with a distressed individual.
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Contact and Engagement:
Sample Dialog Between Responder and Survivors
Hi. Im Bob. Im part of the county disaster response team. Im checking in with people here at the shelter to see how theyre doing after the flood and to see if I can help in any way. Is it OK if we talk for a few minutes? Can I ask you name? Can I call you Doris, or would you prefer Mrs. Williams? Before we talk, is there any thing you need right now, Mrs. Williams? Juice or water? Have you had a chance to eat yet since you arrived at the shelter? (Response) Good. Well, lets sit for a few minutes and talk.
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Contact and Engagement: Review

Introduce yourself. Ask about immediate needs. Maintain the highest level of confidentiality possible in the post-disaster setting. Use the active lurking approach.
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Safety and Comfort

The goal of this action is to enhance immediate and ongoing safety, and provide physical and emotional comfort.
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Safety and Comfort: Strategies

Do things that are active (rather than passive waiting), practical (using available resources), and familiar (drawing on pass experience). Get current, accurate, up to date information, while avoiding survivors exposure to information that is inaccurate or excessively upsetting. Get connected to practical resources. Get connected with others who have shared similar experiences.
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Ensuring Immediate Physical Safety

Find appropriate officials who can resolve safety concerns beyond your control (threats, weapons, etc.) Remove hazards from your service area (broken glass, overturned furniture, spilled liquids, etc.) that could cause someone to slip or fall. Make sure children have a safe and supervised area to play. Be aware of potential persecution of individuals or groups due to ethnic, religious or other affiliations or identities.
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Ensure Physical Safety
(Cont.)
Inquire about the need for medication. Ask if the survivor has a list of current medications or where this information can be obtained. Keep a list of survivors with special needs to they can be checked on frequently. Contact relatives, if they are available, to further ensure nutrition, medication and rest.
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Threat of Harm to Self or Others

Look, listen and feel (intuitively) for signs that a person may hurt themselves or others. Expressing anger/hatred toward self or others. Extreme agitation. Seek immediate support for containment and/or management of risk by medical, EMT, law enforcement or security personnel.
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Shock
Signs of Shock:
Pale Clammy skin Weak, rapid pulse Lightheaded, dizzy Irregular breathing Dull, glassy eyes Unresponsive to communication Lack of bladder/bowel control Restless, agitated, confused
Seek immediate medical support.

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Provide Information About Response Activities

To help reorient and comfort survivors, provide information about: What to do next. What is being done to assist them. What is currently know about an unfolding event. Available services. Common stress reactions. Self-care, family care, and coping. Use your judgment about whether and when to present information.
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Promote Social Engagement

Facilitate group and social interaction as appropriate. Promote sameage/near-age peer interaction with children and teens. Encourage neighborhelping-neighbor support to reduce social isolation.
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Children Separated from Parents/Caregivers

Reconnect children with parents/caregivers they may have been separated from is a priority. Ask unaccompanied children for basic information (name, parent/caregiver names, sibling names, address, school, etc.). Provide children with accurate, easy to understand information about who will be supervising them and what to expect next. Do not make promises that they will see their caregiver soon.
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When a Family Member is Missing

This is one of the most difficult experiences for a family. Families often experience:
Denial Worry Hope Anger Shock Guilt
The American Red Cross has established a Disaster Welfare System to support family communication and reunification. Their Safe and Well website has tools and services to help locate loved ones during emergencies. This resources can be access through:
www.redcross.org
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Missing Persons
When a loved one is missing:
Be prepared to spend extra time with worried family members. Use compassionate presence, just being there to listen to hopes and fears. Be honest in giving information and answering questions. Inform the appropriate authorities. If family members wish to leave the safe area to search, inform them of the current conditions in the search area.
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Missing Persons
(Cont.)
When authorities need additional information, they may interview the family. It is best to limit young children from this process. Encourage family members to be patient, understanding and respectful of each others thoughts and feelings until there is more definite news.
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When a Family Member or Close Friend has Died

Acute grief reactions are likely. Survivors may feel sadness, anger, guilt over the death. You should remember: Treat bereaved children and adults with dignity, respect and compassion. Grief reactions vary person to person. There is no single correct way to grieve. Grief puts people at risk for substances (legal and illegal). Make survivors aware of these risks, the importance of self-care and availability of professional help.
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Helping Families After a Loss

Discuss how family and friends will each have their own reactions. Explain that there is no right or wrong way to feel or act and there is no normal period of time for grieving. Discuss how culture and religious beliefs influence grieving. Explain that children may only show their grief for short periods of time each day, and otherwise engage in play and positive activities. This does not mean their grief is not as strong as other family members.
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Stabilization
The goal of this action is to calm and orient emotionally overwhelmed survivors.
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Emotionally Overwhelmed Survivors

Most individuals affected by disasters will NOT require stabilization. You should be concerned about reactions that are intense, persistent and interfere with the survivors ability to function.
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Watch for these Signs

Looking glassy eyed, vacant or lost. Unresponsive to verbal questions or commands. Disoriented (aimless, confused behavior). Uncontrollable crying, hyperventilating, rocking or regressive behavior. Uncontrollable physical reactions (shaking, trembling). Frantic searching behaviors. Feeling incapacitated by worry, anxiety. Engaging in risky or dangerous behavior.
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When People are Overwhelmed

Enlist available family and/or friends to assist. Decrease stimulation: find a quiet place to talk, speak softly and quietly. Ask what the person is experiencing (i.e.possible flashbacks, feeling the event is still ongoing, etc.). Address the persons concern, dont simply try to convince the person to calm down or feel safe.
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Steps for Stabilizing

Respect the persons privacy; give them a few minutes before you intervene. Let people know you are available, and that you will stop back. Stay near by, keep busy. Remain quiet, calm and present, rather than adding additional stimulation. Offer support on specific manageable feelings, thoughts or reactions. Give information that orients the survivor to the surroundings, what will be happening, what steps he or she may consider.
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Orienting Overwhelmed Survivors

Use these points to help survivors understand their reactions: Intense emotions may come and go in waves. Shocking experiences can trigger strong, upsetting alarm or startle reactions. Sometimes the best way to calm down is by using a relaxation technique (breathing, muscle relaxation, walking, etc.) Friends and family are important sources of support for calming.
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Stabilization Techniques
If the person is extremely agitated, shows a rush of speech and appears to be losing touch with their surroundings or is experiencing persistent, intense crying, it may be helpful to employ: Grounding techniques Relaxation techniques Entrainment Techniques
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Beginning a Stabilization Technique

Begin each stabilization technique by: Asking the person to listen to you and look at you. Finding out if the person knows who they are, where they are and what is happening around them (are the oriented). Asking him/her to describe the surroundings, and say where you both are. This initial step may be enough to help ground and re-orient the survivor.
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Grounding Technique
Introduce the technique by saying: After a frightening experience, you can find yourself overwhelmed with emotions or unable to stop thinking about or imaging the what happened. You can use a method called grounding to feel less overwhelmed. Grounding works by turning your attention back to the outside world. Heres what you do
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Grounding Instructions
1. Sit comfortably with your arms and legs uncrossed. 2. Breathe in and out slowly and deeply. 3. Look around you and name five nondistressing objects that you can see. For example, you could say, I see the floor, I see a shoe, I see a table, I see a chair, I see a person. 4. Breathe in and out again slowly and deeply.
(Continued)
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Grounding Instructions (Cont.)

5. Next, name five non-distressing sounds that you can hear. For example, I hear a woman talking, I hear myself breathing, I hear someone typing, I hear a door closing, I hear a cell phone ringing. 6. Breathe slowly and deeply. 7. Next name five non-distressing things that you can feel. For example, I can feel the wooden armrest of this chair, I can feel my toes inside my shoes, I can feel my back pressing against my chair, I can feel the blanket I am holding, I can feel my lips pressing together. 8. Breathe in slowly and deeply.
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Relaxation Techniques
There are several types of relaxation techniques helpful for deceasing arousal. The most useful in the immediate post-disaster environment are: Breathing Progressive muscle relation Although visual imagery can be an effective relaxation technique in normal conditions, survivors who close their eyes and attempt to picture pleasant or calming images may find themselves overwhelmed with visual images of the disaster.
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Breathing Exercise Instructions

You can use a script like this to guide a survivor during a breathing exercise: 1. Picture that you are going around a box or square, and as you go around the square you will breathe, or hold your breath or exhale slowly on the count of three on each of the four sides of the square. 2. Begin by following my voice and now taking two deep breathes, filling your lungs all the way down to your belly. Do that two times. 3. Lets start to go around the square. Breath in, on my count, one-thousand-one, onethousand-two, one-thousand three.
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Breathing Exercise Instructions

(Cont.)
4. Now hold your breathe, one-thousand-one, one-thousand-two, one-thousand three. 5. Now breathe out slowly, one-thousand-one, one-thousand-two, one-thousand three. 6. Now wait, one-thousand-one, one-thousandtwo, one-thousand three. 7. And now repeat, breathe in, one-thousandone, one-thousand-two, one-thousand three.
Repeat five times, slowly and comfortably. Do this as many times each day as needed.
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Breathing Technique Diagram

Begin Inhale Box breathing is an autogenic technique to calm physiological arousal.
Wait
3-4 seconds each side
Hold
Exhale
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Entrainment Techniques
Entrainments techniques involve using your behavior and communications in a way that influences the survivors behavior. This technique can be helpful in calming a loud, agitated individual or someone who is frantic and speaking excessively or uncontrollably fast.
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Entrainment
If the survivor is speaking very loudly, begin by speaking a little more loudly than you normally do (not as loud as the survivor); Slowly and incrementally, begin to lower your volume in order to influence the survivor to lower their volume. If the survivor is speaking very quickly, begin by speaking a little more quickly that you normally do; Slowly and incrementally, begin to slow your pace in order to influence the survivors pace of speech.
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PFA Core Actions

1 2 3 4 5 6 7 8 Contact and Engagement Safety and Comfort Stabilization Information Gathering Practical Assistance Connection with Social Supports Information on Coping Linkage with Collaborative Services
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Information Gathering: Needs and Current Concerns
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The goal of this action is to identify needs and concerns, gather additional information, and tailor PFA interventions.
BSA
113
Information Gathering
PFA interventions must be flexible and adapted to the specific individual, their needs and concern. Although a formal assessment is not necessary, you may ask about: Need for immediate referral. Need for additional services. Offering a follow-up meeting. Using PFA components that may be helpful.
BSA
114
Information Areas
Nature/severity of the experience Death of a loved one Concerns about postdisaster conditions; ongoing threats Separation from loved ones; concerns for their safety Physical, mental illness, need for medications. Losses (Home, school, neighborhood, business, property, pets) Extreme feelings of guilt or shame Thoughts of causing harm to self or others Availability of social supports Prior drug and alcohol use Prior exposure to trauma or death of loved ones Specific concerns about impact on children/development
BSA
38
121
Extreme Feelings of Guilt or Shame

Extreme negative emotions can be very painful, difficult and challenging, especially for children and teens. Listen carefully for signs of guilt or shame. To clarify, you may say: It sounds like you are being really hard on yourself about what happened. It seems like you feel that you could have done more. For those experiencing guilt or shame, provide emotional comfort, reassurance and information on coping with these emotions.
BSA
122
Thoughts about Causing Harm to Self or Others

It is a priority to get a sense of whether an individual is having thoughts about causing harm to self or others. To explore these thoughts and feelings, ask questions like: Sometimes situations like these can be very overwhelming. Have you had any thoughts about harming yourself? Have you had any thoughts about harming someone else? For those having such thoughts, immediate medical or mental health assistance is needed. Stay with the survivor until the appropriate personnel arrive and assume management of the survivor. BSA
123
Availability of Social Support

Family, friends, and community support can greatly enhance the ability to cope with distress and postdisaster adversity. Ask about social support with questions like: Are there family members, friends, or community agencies that you can rely on for help the problems that you are facing as a result of the disaster? For those lacking adequate social support, help them connect with available resources and services, provide information about coping and social support, and offer a follow-up meeting.
BSA
39
124
Prior Drug and Alcohol Use

Exposure to trauma and post-disaster adversities can increase substance abuse, cause relapse, or lead to new abuse. Get information by asking: Has your use of alcohol, prescription medications, or drugs increased since the disaster? Have you had any problems in the past with alcohol or drug use? Are you currently experiencing withdrawal symptoms from drug use? For those with potential substance abuse problems, provide information about coping and social support, link to appropriate services, and offer a follow-up meeting. Those experiencing withdrawal should be referred for medical assistance.
BSA
126
Youth and Developmental Concerns

Survivors can be very upset when the disaster or its aftermath interferes with upcoming special events, including important developmental activities (ex.birthdays, graduation, start of school or college, marriage, vacation). For information about this ask: Where there any special events coming up that were disrupted by the disaster? For those with developmental concerns, provide information about coping and assist with strategies for practical help.
BSA
127
Other General Concerns

It is also useful to ask general open-ended questions to make sure that you have not missed any important information. You can ask, Is there anything else we have not covered that you are concerned about or want to share with me? If the survivor identifies multiple concerns, summarize these and help to identify which issues are most pressing. Work with the survivor to prioritize the order in which concerns should be addressed.
BSA
40
128
Practical Assistance
The goal of this action is to offer practical help to survivors in addressing immediate needs and concerns.
BSA
129
Exposure to disaster, terrorism and post-event adversities is often accompanied by a loss of hope. Those who are likely to have more favorable outcomes are those who maintain one or more of the following characteristics: Optimism (because they can have hope for their future). Confidence that life is predictable. Belief that things will work out as well as can reasonably be expected. Strong faith-based beliefs. Positive belief (ex.- Im lucky. Things usually work out for me.) Resources, including housing, employment, financial.
BSA
130
(Cont.)
Providing people with needed resources can increase a sense of empowerment, hope, and restored dignity. Therefore, assisting the survivor with current and anticipated problems is a central component of Psychological First Aid. Survivors often welcome a pragmatic focus and assistance with problem-solving.
BSA
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131
Steps in Offering Practical Assistance

Step 1: Identify the Most Immediate Need If a survivor has identified several needs, focus on one of them at a time. Collaborate with the survivor helping them select the most urgent issues.
BSA
132
(Cont.)
Step 2: Clarify the Need Talk with the survivor to specify the problem. If the problem is understood and clarified, it will be easier to identify next steps.
BSA
133
(Cont.)
Step 3: Discuss an Action Plan Discuss what can be done to address the concern or need. If the survivor is stuck, you can offer a suggestion. Tell survivors what they can realistically expect if you are aware of resources and procedures.
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134
(Cont.)
Step 4: Act to Address the Need Help the survivor take action. Example: Help the set up an appointment for needed services or assist him/her in starting their paperwork. Note: Do not do for the survivor, but rather do with. Avoid creating a dependency. Promote self-efficacy and empowerment.
BSA
Connection with Social Supports
135
The goal of this action is to help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources. BSA
136
Forms of Social Support

Social support is related to emotional well-being and recovery following disasters and terrorism. People who are well connected to others are more likely to engage in receiving and giving support.
Emotional Support Social Connection Feeling needed Reassurance of Self-Worth
Reliable Support Advice and Information Physical Assistance Material Assistance
BSA
43
137
Fostering Social Support

Enhance access to primary support persons (i.e.-family members, significant others, etc.) Encourage use of immediately available supports persons. Discuss both seeking and giving support Model support with the survivor.
BSA
138
Barriers to Social Support

If individuals are reluctant to seek support, there may be reasons, such as: Not knowing what they need (feeling that they should) Feeling embarrassed or weak. Feeling guilty to receive when others are in greater need. Not knowing where to turn for help. Thinking, No one can understand what I am going through. Fearing that people will be angry or made to feel guilty if they are asked for help.
BSA
139
Modeling Support (Cont.)

As a provider of support, you can model positive supportive responses, such as: From what youre saying, I can see how you would be (Reflective comment) Am I right when I say that you (Clarifying comment) Are there any things that you think would help you to feel better? (Empowering comment/question) If appropriate, consider passing along the handout, Connecting with Others: Seeking Social Support and Giving Social Support
BSA
44
140
Information on Coping
The goal of this action is to provide information about stress reactions and coping to reduce distress and promote adaptive functioning.
BSA
141
Providing Information
Various types of information can help survivors manage their stress reactions and deal more effectively with problems. Such information includes: What is currently known about the unfolding event. What is being done to assist them. What, where, and when services are available. Post-disaster reactions and how to manage them. Self-care, family care, and coping.
BSA
142
Provide Basic Information about Stress Reactions

Briefly discuss common stress reactions experienced by survivors, including the three types of reactions: Arousal Avoidance Re-experiencing Avoid pathologizing these reactions. Recognize and encourage positive reactions (i.e.appreciating life, family and friends; strengthening spiritual beliefs or social connections).
BSA
45
143
Information about Trauma Reminders

It is useful for survivors to understand and anticipate the impact of reminders in triggering reactions. These include: Trauma Reminders: Sights, sounds, smells, etc. associated with the traumatic event. Loss Reminders: Sights, sounds, smells, etc. associated with a lost loved one, pet, or property. Change Reminders: People, places, things, activities, that remind the survivor of how life has changed since the disaster.
BSA
144
Other Reactions
Other kinds of reactions include: Grief Reactions Traumatic Grief Reactions Depression Physical Reactions
Responders should consider using the handout, When Terrible Things Happen, as well as the Tips series (Ex: Parent Tips for Helping Adolescents)
BSA
145
Discussing Positive and Negative Forms of Coping

The aim of discussing both the positive and negative forms of coping is to: Help survivors consider different coping options. Identify and acknowledge their personal coping strengths. Think through the negative consequences of maladaptive coping actions. Encourage survivors to make conscious goaloriented choices about how to cope. Enhance a sense of personal control over coping and adjustment.
BSA
46
146
Information on Ways of Coping

You can discuss a variety of ways to effectively cope with post-disaster reactions and adversity: Talking to others for support. Getting needed information. Getting adequate rest, nutrition and exercise. Engaging in positive distracting activities (i.e.hobbies, sports, reading, etc.) Trying to maintain a normal schedule to the extent possible. Using the breathing exercises discussed in the Stabilization section.
There are many more.
BSA
147
Maladaptive Coping Actions

There are also ineffective coping actions, including: Using drugs or alcohol to cope. Withdrawing from activities. Withdrawing from friends and family. Working too many hours. Getting violently angry. Overeating or undereating. Doing risky or dangerous things.
Not taking care of yourself.
There are many more.
BSA
148
Other Coping Issues

Survivors may also benefit by addressing other coping issues, such as: Age/Developmental issues. Anger Management. Highly Negative Emotions (Guilt and Shame). Sleep Problems Alcohol and Substance Use
BSA
47
149
Collaborative Services
The goal of this action is to link survivors with available resources at the time or in the future.
BSA
150
Provide Direct Links to Needed Services

Responders should do what they can to ensure effective linkage with needed services. Examples of situations requiring referral include: Acute medical problems that require immediate attention. Acute mental health problems the require immediate attention. Worsening of a pre-existing medical, emotional, or behavioral problem. Treat of harm to self or others. Cases involving domestic, child, or elder abuse (be aware of local reporting laws). When survivors ask for referrals.
BSA
151
Making a Referral
When making a referral: Summarize your discussion with the person about his/her needs and concerns. Check for the accuracy of your summary. Ask about the survivors reaction to the suggested referral (ex.- How do you feel about connecting with Agency A?). Give written referral information, or if possible, make the appointment right then and there.
BSA
48
Module Five
Understanding & Preventing Secondary Traumatic Stress
152
Crisis Counselor Self-Care

Compassion Fatigue (Figley, 1992) is an occupational hazard in trauma intervention providers Additional supervision and attention to transference and counter transference issues is advised Internal support may be a productive means of team member ventilation and validation
153
Vulnerabilities of Crisis Counselors

Cumulative stress from hearing disaster stories Not Understanding how much listening and talking help Feeling overwhelmed by the depth of grief, anger or frustration expressed by survivors Over-identification or enmeshment with survivors Unrealistic expectations of reliving emotional pain
154
49
When Counselors Need Help

Take on the anger and frustration of the survivor Counselor begins to take on the system Refer anyone who shows strong emotions to higher levels of care Cannot end helping relationship when goals have been met Performing concrete services that the survivor could or should do for themselves Work too much overtime Survivors call them at home
155
Burnout
A state of extreme dissatisfaction with ones clinical work, characterized by: 1) excessive distancing from survivors; 2) impaired competence; 3) low energy; 4) increased irritability; 5) other signs of impairment and depression resulting from individual, social, work environment and societal factors
Figley, C., 1994
156
Compassion Fatigue
A state of tension and preoccupation with the individual or cumulative trauma of ones clients as manifested in one or more ways: 1) re-experiencing traumatic events; 2) avoidance / numbing of reminders; and 3) persistent arousal.
Figley,C., 1994
157
50
Burnout or Compassion Fatigue?

Unlike burnout, the traumatized professional experiences: Faster onset of symptoms Faster recovery from symptoms Sense of helplessness and confusion Sense of isolation from supporters Symptoms disconnected from real causes. Symptoms triggered by additional events
158
159
Dos and Donts of Psychological First Aid
BSA
160
Dos & Donts

Promote Safety
Help people meet basic needs for food, shelter, and obtain emergency medical attention. Provide repeated, simple and accurate information on how to obtain these.
BSA
51
161
Dos & Donts

Promote Calm
Listen to people who wish to share their stories and emotions and remember there is no wrong or right way to feel. Be friendly and compassionate even if people are being difficult. Offer accurate information about the disaster or crisis event, and the assistance available to help victims understand their situation.
BSA
162
Dos & Donts

Promote Connectedness
Help people quickly connect with friends or loved ones. Keep families together. Keep children and parents or other close relatives together when ever possible.
BSA
163
Dos & Donts

Promote Self-Efficacy
Give practical suggestions that steer people towards helping themselves. Engage people in meeting their own needs.
BSA
52
164
Dos & Donts

Promote Hope
Find out the types of help available to people and direct people to those services. Remind people (if you know) that more help and services are on the way when they express fear or worry.
BSA
165
Dos & Donts

Force people to share their stories with you, especially very personal details (this may decrease calmness in people who are not ready to share their experiences). Give simple reassurances like everything will be OK or at least you survived (statements like this diminish calmness).
BSA
166
Dos & Donts

Tell people what you think they should be thinking or feeling or how they should have acted (this decreases self-efficacy). Tell people why you think they have suffered by alluding to personal behaviors or beliefs of the victims (this also decreases self-efficacy).
BSA
53
167
Dos & Donts

Make promises that may not be kept. Criticize existing relief efforts or existing services in front of people in need of these services (this undermines hope and calmness.
BSA
168
Closing Activities
Q & A Evaluations Certificates
BSA
54

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Psychological First Aid Skills for School Crisis Teams