amul&’systemicpsychosocial supportmodelforrespondingto...
TRANSCRIPT
A Mul&-‐Systemic Psychosocial Support Model for Responding to
Disasters and Mass Violence
Gilbert Reyes, PhD Affiliate Member
Na&onal Child Trauma&c Stress Network (NCTSN) Disaster Relief Chair
Trauma Psychology Division (56) of APA
The previously scheduled program has been interrupted for this breaking news story:
APA Stunned by Revela&ons in the Hoffman Report. On Eve of Annual Conven&on, Crack Team of Trauma Psychologists Deployed to Toronto to Heal the Survivors
Learning Objec&ves
Par&cipants will be able to: 1). Itera&vely map the “dose of exposure” terrain in the aWermath of a disaster. 2). Dynamically map the currently and readily available resources for responding to the an&cipated psychosocial needs. 3). Match exis&ng resources to the an&cipated and manifest psychosocial support needs with cultural sensi&vity and responsiveness to change across &me.
Presenter Background Early Career: • Faculty at the Disaster Mental Health Ins&tute, Univ. of S.
Dakota – Major Product: Handbook of Interna&onal Disaster Psychology (Edited 4 Vols.)
– Ac&vi&es: Research and Training Consulta&ons with World Health Organiza&on (WHO), Interna&onal Society of Red Cross and Red Crescent Socie&es (IFRC), etc.
– Rapid Assessment of Refugee Mental Health Needs – Development of Trainers and Training Curriculum for Community-‐Based Psychological Support
– Major Experiences: 1999 – Tornadoes (Oklahoma); 1999 – Hurricane (N. Carolina); 2000 – Terrorism (Kenya); 2000 – Massive Flood (Venezuela); 2001 – Na&onal PFA Conference (Cuba); 2001 – Terrorism (New York); 2002 – Consulta&on at IFRC (Switzerland); 2002 – IFRC Training of Easter European Delegates (Hungary)
Presenter Background Mid-‐Career: • Faculty Administrator at Fielding Graduate University (now
adjunct faculty) – Main Product: Encyclopedia of Psychological Trauma (Lead Editor, with Elhai & Ford)
– Ac&vi&es: Member of the NCTSN • Terrorism and Disaster Center
– Hurricane Katrina Research – Manual for Working with Displaced Popula&ons – Disaster Research Training Program
• UCLA – Na&onal Center for Child Trauma&c Stress – Terrorism and Disaster Network – Psychological First Aid (Development and Training) – Skills for Psychological Recovery (Development and Training) – Task Force on the Core Curriculum on Childhood Trauma
– Research: Wildfire Research Team (UCSB & Univ. of Iowa)
Personal Lessons Learned • Almost nothing in graduate school (clinical psychology) prepared me for
the American Red Cross model of Disaster Mental Health (RC – DMH) – Paramilitary aitudes and culture (“swaggering lifers”) – Reliance on heroics rather than servant leadership and robust
adap&ve personnel systems (just like in the movies) – S&gma&zed iden&ty of DMH mission and personnel – Small army of licensed mental health clinicians (advance to the
rear) – Minimal workforce training and prepara&on (intro to RC and intro
to DMH) – Minimal grasp of “community psychology” and “public health
model” – No clear and consistent model of service delivery or outcome
objec&ves – Inadequate feedback loops for program evalua&on or product
improvement – Inadequate efforts to mi&gate occupa&onal hazards (i.e.,
secondary or vicarious trauma&c stress, and compassion fa&gue)
Current ARC-‐DMH seems improved
Current ARC-‐DMH seems improved
Current ARC-‐DMH seems improved
Literature Review Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P., (2006). Psychological First Aid: Field Opera&ons Guide (2nd Ed.). Published by the Na&onal Child Trauma&c Stress Network and Na&onal Center for PTSD. • Expert and key informant based consensus and evidence informed
descrip&on of principles and prac&ces for suppor&ng resilient recovery from poten&ally trauma&c experiences.
• Framework s&pulates eight “core ac&ons”: contact and engagement, safety and comfort, stabiliza&on, informa&on gathering, prac&cal assistance, connec&on with social supports, informa&on on coping support, and linkage with collabora&ve services.
• Includes many handouts, and comes in versions addressing the par&cular context of schools, religious professions, and in a number of transla&ons.
• Also: 6-‐hour interac&ve PFA online course and a PFA Mobile app.
Literature Review Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., Friedman, M., Gersons, B. P. R., deJong, J. T. V., Layne, C. M., Maguen, S., Neria, Y., Norwood, A. E., Pynoos, R. S., Reissman, D., Ruzek, J. I., Shalev, A. Y., Solomon, Z., Steinberg, A., & Ursano, R. J. (2007). Five essen&al elements of immediate and mid-‐term mass trauma interven&on: Empirical evidence. Psychiatry: Interpersonal and Biological Processes, 70, 283-‐315. • AWer extensive review of evidence for mass-‐trauma
interven&ons, these essen&al elements were iden&fied: – 1) a sense of safety – 2) calming – 3) a sense of a) self–efficacy and b) community efficacy – 4) connectedness – 5) hope.
Literature Review McCabe, O. L., Everly, G.S., Brown, L.M., Wendelboe, A.M., Hamid, N.H., Tallchief, V.L., Links, J. (2014). Psychological first aid: A consensus-‐derived, empirically-‐supported, competency-‐based training model. American Journal of Public Health, 104(4), 621-‐628. • Describes a competency-‐based model for PFA training developed in
conjunc&on with the Centers for Disease Control and Preven&on and the Associa&on of Schools of Public Health.
• Established a consensus set of 6 KSA (knowledge, skills, aitudes) core competencies: – 1. ini&al contact, rapport building, and stabiliza&on; – 2. brief assessment and triage; – 3. interven&on; – 4. triage; – 5. referral, liaison, and advocacy; – 6. self-‐awareness and self-‐care.
• Proposal is that these results could serve as a curricular basis for fulfilling the aims of the Pandemic and All-‐Hazards Preparedness Act of 2006 (i.e., to train public health prac&&oners to promote public health preparedness and response by teaching these competencies to lay-‐providers).
Literature Review Bisson, J. I., & Lewis, C. (2009) Systema&c review of Psychological First Aid. Geneva: World Health Organiza&on. • Reviewed published studies regarding the use of PFA, finding
none had any data and that there were no empirical studies of efficacy or effec&veness.
• Recommends that emergency interven&ons should focus on well-‐established risk factors: a) peri-‐trauma&c dissocia&on and b) perceived inadequacy of social support.
• Cites NATO, TENTS and IASC recommenda&ons that favor – “social” and “community” focused interven&ons over “individual” and
“psychological” targets (i.e., public health model and community psychology), – but with capabili&es for detec&ng clinical needs and referral to more
adequate services.
• Supports the principles underlying PFA.
Literature Review Dieltjens, T., Moonens, I., Van Praet, K., De Buck, E., & Vandekerckhove, P. (2014). A systema&c literature search on psychological first aid: Lack of evidence to develop guidelines. PLoS ONE, 9(12), e114714. • Belgian Red Cross (Flanders) tried to ensure that its
volunteers were trained in the best way possible. • Reviewed 5 bibliographic databases and found no published
evidence regarding the effec&veness of PFA. • Conclusion: No empirical evidence to develop guidelines.
Literature Review Forbes, D., Lewis, V., Varker, T., Phelps, A., O'Donnell, M., Wade, D., Ruzek, J., Watson, P., Bryant, R., & Creamer, M. (2011). Psychological first aid following trauma: Implementa&on and evalua&on framework for high-‐risk organiza&ons. Psychiatry, 74(3), 224–239. • Laments lack of empirical evidence for PFA • Acknowledges the difficul&es of conduc&ng such studies in
most real-‐world situa&ons • Recommends a phasic framework for establishing and
evalua&ng PFA within high-‐risk organiza&ons. – Pre-‐event:
• Phase 1: PFA-‐consistent organiza&onal policies & procedures • Phase 2: PFA promo&on and staff training
– Post-‐event: • Phase 3: PFA response • Phase 4: Monitoring and follow-‐up of staff
Literature Review Lewis, V., Varker, T., Phelps, A., Gavel, E., & Forbes, D. (2013). Organiza&onal implementa&on of psychological first aid (PFA): Training for managers and peers. Psychological Trauma: Theory, Research, Prac&ce and Training, 6(6), 619–623. • Describes a pilot evalua&on of training provided to managers
and peer-‐supporters in a high-‐risk organiza&on according to the Phased PFA model proposed by Forbes et al. (2011).
• Trainees demonstrated small but significant gains in – PFA and PTE content knowledge – Self-‐reported increased sense of confidence in being prepared to
respond to incidents
Literature Review Legerski, J. P., Vernberg, E. M, & Noland, B. J. (2012). A qualita&ve analysis of barriers, challenges, and successes in mee&ng the needs of Hurricane Katrina evacuee families. Community Mental Health Journal, 48, 729-‐740. DOI 10.1007/s10597-‐011-‐9446-‐1 • Used qualita&ve focus groups to generate an&cipated mental
health needs, displacement-‐related challenges, and secondary adversi&es.
• Iden&fied concerns were as might be expected (coping with exposures, unemployment and financial pressures, housing and transporta&on difficul&es, material losses, exacerba&on of pre-‐exis&ng psychological condi&ons).
• A major concern was that providers lacked cultural competence to work with a displaced popula&on from a very different cultural background and milieu (encountering the “other”).
• There were also expressions of apprehension regarding the challenges of working with survivors who typically engaged in illegal or unethical behaviors (nega&ve stereotype of these evacuees).
Literature Review Reifels, L., Naccarella, L., Blashki, G., & Pirkis, J. (2014). Examining disaster mental health workforce capacity. Psychiatry: Interpersonal and biological processes, 77(2), 199-‐205. • Examined the capacity of a disaster mental health workforce
to provide three evidence-‐supported interven&on types: – psychological first aid – skills for psychological recovery – intensive mental health treatments
• From 32 to 42% of this workforce self-‐reported a composite of perceived skills, experiences, and confidence in being able to deliver these interven&ons.
• Recommenda&on is for increased aren&on to workforce capacity-‐building.
Literature Review Akoury-‐Dirani, L., Sahakian, T. S., Hassan, F. Y., Hajjar, R. V., & Asmar, K. E. (2015). Psychological First Aid training for Lebanese field workers in the emergency context of the Syrian refugees in Lebanon. Psychological Trauma: Theory, Research, Prac&ce, and Policy. Advance online publica&on. • Best published evalua&on of the training effect, but no data
on the interven&on effect. • Examined efficacy of 2.5-‐day na&onal PFA training program in
preparing mental health field workers to work with Syrian refugees.
• Content knowledge and skills measured at pre, immediate post-‐training, and aWer one month suggested a durable training effect.
Literature Review Conclusions Numerous areas of improvement are needed: • Overall workforce preparedness for providing psychosocial
support remains inadequate • Emergency phase psychosocial support interven&ons are well
defined, but their effec&veness remains in ques&on • Despite excep&ons like the Red Cross, the models of service
delivery are not well defined • Models of service delivery are not well researched • Cultural varia&on in the accessibility, acceptability, credibility,
sustainability, and effec&veness of disaster interven&ons are not well researched (i.e., what is cultural competence?)
• Differen&al effec&veness of approaches to training are not well researched
• Quality assurance of provider competence is unexamined
Case Example: Santa Barbara Response Network Grassroots organiza&on (501c3) founded in 2009 in response to community-‐level poten&ally trauma events that fell through the cracks (not covered by Red Cross, Vic&m’s Assistance, Hospice) • Suicides • Community violence • Violent accidents Interven&on: • Psychological First Aid Training and Prepara&on: • Volunteers are taught incident command system (ICS) and
PFA in accordance with the NCTSN/NCPTSD materials • Role plays and incident simula&ons • Excep&onal performance leads to leadership roles
Case Example: Santa Barbara Response Network Model of Service Delivery: • Trained PFA teams of commensurate size deploy by invita&on
to loca&ons where psychosocial support is considered appropriate and accessible
• Where appropriate a proximal base of opera&ons is established as a “Compassion Center” and staffed with trained volunteers
• To accomplish informa&on gathering and other outreach goals pairs and trios of volunteers (no solos) are deployed as “Compassion Patrols”
• Execu&ve consulta&ons are provided to leaders of affected systems and responsive systems
• Public health approaches are employed for dissemina&ng informa&on on coping and resilience behaviors
Case Example: Santa Barbara Response Network Dose of Exposure and Needs Assessment: • Mee&ng is held of key informants from affected and
responsive systems • An&cipated doses of exposure are mapped in accordance with
the es&mated severity of event impact • Concentric circles and spa&al loca&ons are used to represent
higher and lower an&cipated doses of exposure (e.g., inner and outer rela&onal circles)
• Dis&nct systems and individuals are iden&fied to take responsibility for inves&ga&ng actual impacts and needs within each circle (accountability)
• Assump&ons are revised based on rapid feedback to allow tailoring of the response
• Needs maps are dynamic and revised at least daily
Case Example: Santa Barbara Response Network Resource Mapping: • First itera&on is based on generic assump&ons and familiar
resources • Second itera&on is responsive to key informant feedback on
more specific characteris&cs of the cri&cal event • Subsequent itera&ons are responsive to changing needs
across &me and discovery of emergent resources • Cultural factors are ac&vely iden&fied through culture-‐
brokers, allowing improvement of the cultural acceptability and credibility of resources and services
• Resource maps are dynamic and revised frequently
Incident Example: Killing Spree in Isla Vista, 2014 • Six UCSB students killed and over a dozen other community
members injured – Crime scene of almost a square mile – Grisly details included mul&ple stab wounds to 3 vic&ms – Intense news media coverage of killer and his hateful internet
manifesto – Poli&cal barle erupts over gun violence and gun rights
• University of California campus and broader system profoundly affected
• Ci&zens and government of the county profoundly affected • Unusual characteris&cs of Isla Vista require careful planning
– No official governance or leadership – Not all students – Underserved La&no community
Response Example: Killing Spree in Isla Vista • Mee&ng of response planning representa&ves within hours • First itera&on of exposure dosage and needs map is
constructed • Systems and individuals are assigned as agents to ini&ate
contacts, gather informa&on, and inform the response • First itera&on of resource map is constructed • Systems and individuals are assigned to gather informa&on
about addi&onal resources • A PFA team is formed and deployed for the first of the
memorial vigils • Loca&ons for the Compassion Center are iden&fied • Law enforcement and other partners are enlisted to support
the deployment of PFA Compassion Patrols in the affected neighborhoods
Response Example: Killing Spree in Isla Vista • Volunteers are recruited and trained in PFA and the incident
management system • Bilingual/bicultural teams are formed for La&no neighbors • Experienced volunteers are paired with newbies • Coordina&on is managed with UCSB catchment system to
avoid duplica&on and ensure concerted coopera&on • Daily feedback is incorporated into opera&ons and
disseminated in daily briefings • Beyond the immediate aWermath, Compassion Center
ac&vi&es are geared toward community psychology and advocacy for non-‐violent and compassionate approaches to conflict-‐resolu&on
• Compassion Center re-‐opens at original loca&on for a week of anniversary remembrance and social support
Subsequent Incident Responses A father murders his mother and father, his two young sons, and kills the family dog. • Response model used for Isla Vista is employed and tweaked
to berer serve the affected schools and neighborhoods A high school student is killed in a fiery car crash • A compassion center is established the next day and staffed
by school personnel aWer a brief orienta&on training • An execu&ve consulta&on is held with school officials to
prepare for dealing with parents, students, staff, news media, and subsequent public events and memorials
A student at the same high school commits suicide • The school staff reac&vate their compassion center with
minimal need of external support • Compassion center in a box
Skills for Psychological Recovery (SPR) Psychological 2nd Aid
Berkowitz, S., Bryant, R., Brymer, M., Hamblen, J., Jacobs, A., Layne, C., Macy, R., Osofsky, H., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P. (2010). The Na&onal Center for PTSD & the Na&onal Child Trauma&c Stress Network, Skills for Psychological Recovery: Field Opera&ons Guide.
Skills for Psychological Recovery (SPR)
Basic Goals and Objec&ves: 1. Protect the mental health of disaster survivors 2. Enhance survivors’ abili&es to address their needs and concerns 3. Teach skills to promote the recovery of children, adolescents, adults, and families 4. Prevent maladap&ve behaviors while iden&fying and suppor&ng adap&ve behaviors
Skills for Psychological Recovery (SPR)
Core Skills: – Building Problem-‐Solving Skills – Promo&ng Posi&ve Ac&vi&es – Managing Reac&ons – Promo&ng Helpful Thinking – Rebuilding Healthy Social Connec&ons
Occupa&onal Hazards of Trauma Exposure
Secondary Trauma&c Stress: “emo&onal duress that results when an individual hears about the firsthand trauma experiences of another. Its symptoms mimic those of PTSD”
Vicarious Trauma: “transforma&on in the self of a trauma worker or helper that results from empathic engagement with trauma&zed clients and their reports of trauma&c experiences. Its hallmark is disrupted spirituality, or a disrup&on in the trauma workers' perceived meaning and hope”
Compassion Fa&gue: “gradual lessening of compassion over &me”
Frame of Reference Hazards
Trauma-‐Drama:
Heroes – Vic&ms – Villains
Frame of Reference Hazards
Conclusion 1. Providing community-‐based psychosocial support requires a dis&nct skill
set from those of counseling and psychotherapy. 2. Community psychology is an accessible and acceptable approach to
providing non-‐s&gma&zing and empowering support in PTEs 3. PFA is a readily learned and accessible interven&on by MHPs and at the
lay-‐level 4. PFA is a scalable method of providing all-‐hazards psychosocial support 5. Local capacity building for responding to PTEs is possible and sustainable,
but challenging 6. Mapping exposure dosage, needs, and resources supports a deliberate
and strategic response and helps to detect, monitor, and respond to what might otherwise be overlooked
7. We s&ll need to develop non-‐RCT methods for evalua&ng the compara&ve effec&veness of early interven&ons
8. Clinicians are advised to carefully take stock of their psychological and emo&onal vulnerabili&es and mindfully self-‐monitor their reac&ons
Ques&ons and Comments?