Compassion, Common Sense & Continuity:

a partnership model in crisis response

Mandy RutterClinical Manager, FIRSTcall/CRISIScall ICAS UK

PROGRAMME OF SESSION

• Introductions & plan of workshop• Drivers for change• Organisational issues• Interventions

- Psychological First Aid, - Trauma Focussed Interpersonal Psychotherapy

• Activity• Future directions• Feedback & discussion

DEBRIEFING – OUR MODEL

• Apparently sound clinical intervention

• Modular approach - easily operationalised

• Affiliates understood it - paid to be trained in it

• Applied to both group and individual settings

• Internationally available

• Enhanced credibility and reputation of ICAS

INTERNAL CRITICISMS OF OUR MODEL

• No empirical evidence demonstrating effectiveness

• One outcome study was inconclusive

• Clinical staff increasingly split on views of its effectiveness/appropriateness

• Many “follow-up” onsite groups were not authorised by organisations.

EXTERNAL FACTORS

• Many National, International Disasters

• Further studies on criticisms of debriefing

• Psychological First Aid

• Concept of Resilience

•“Treatment” modality inappropriate

“Debriefing is inert at its best and

possibly detrimental to some”

(Rose, Bisson and Wessely, 2004)

INITIAL RESPONSE TO TRAUMA

“For individuals who have experienced a traumatic event, the systematic provision to that individual alone of brief, single session interventions (often referred to as debriefing) that focus on the traumatic incident, should

not be routine practice when delivering services.”

National Institute for Clinical Excellence, 2005

So what should we do?

“Efforts should be made to enhance the capacity of existing

networks, both formal and informal, to support recovery

and resilience.”

(Bulletin of World Health Organisation, 2005)

“assistance should be offered to promote the objective of improving

the quality of the recovery environment in support of the aim of

helping survivors make phased adaptations and eventual adjustment

to what has happened”

(Orner, King et al, 2003)

Trauma is………..

“sudden uncontrollable disruption of affiliate

bonds”

SURVEY OF HIGH RISK OCCUPATIONAL GROUPS (ORNER ET AL 2003):

• 80% of employees wanted to talk to someone about the

incident

• 71% prefer to talk to colleague

• 72% prefer to talk to someone close to them

• 9% prefer to talk to independent professional

• 85% prefer to talk in free and flexible manner

IS EARLY INTERVENTION STILL VIABLE?

• Requested by Employers

• Appreciated by Employees, customers, passengers.

• Dealing with disequilibrium

• Evidence of increased complexity of symptoms

over time

• Research on Early Intervention

• White paper criminal compensation

WORKPLACE INCIDENT – THE CONTEXT

Employers want:

• employees to know they care

• to provide resources for affected staff

• to understand the impact of the trauma on the staff

• to regain workgroup cohesion

• to return the workplace to effective performance and productivity

• to prevent absenteeism

• to reduce the potential for compensation claim

RECOVERS - Initial loss 5% capitalisation.

After 50 days, gained 5% over

the pre-crisis value.

NON-RECOVERS - Initial loss 11% capitalisation

continued to fall over period

of 12 months.

SHAREHOLDER VALUE REACTION TO DISASTERS

SHAREHOLDER VALUE REACTION TO DISASTERS

50

40

30

20

10

0

-10

-20

-30

Event Trading DaysRecoverers Non-recoverers

Val

ueR

eact

ion

(%)

“In crises, the key determinant of whether a company’s reputation and share value will recover depends on the ability of the:

“Those companies which prepare and react appropriately at the right time have a higher chance of recovery than those which do not”

“Companies that use an outside disaster management service provider performed 40% better than those that did not”

(Knight, 2005)

• CEO to respond with sensitivity and compassion to victims families

• senior management to demonstrate strong leadership and communicate with honesty and transparency”

WHAT REALLY MATTERS

• managed the current situation

• planned for the future

• Gave 2500 press interviews (125,000 news clippings)

• stopped the production

Refer to the ‘Credo’

• stopped advertising

• recalled all capsules (31 million)

• continuous relationship with other authorities

• reward for information

JOHNSON AND JOHNSON: TYLENOL TAMPERING

“Germany and France are united in their horror over the accident, in mourning for

the victims and in sympathy for their families”

AIR FRANCE CONCORDE AIR DISASTER

“Disasters focus the glare of attention on top management, if the company communicates well and shareholders and investors view the event as well-managed, the

impact on stock values is generally positive”

(Knight & Petty 1997 “the impact of catastrophes on shareholder value”)

“One of the great shortcomings in most managers is that they appear cold, arrogant, unfeeling, and corporately driven when bad things happen and

there are victims. These behaviours are the source of employee anger and frustration; litigation; angry

neighbours; and bad, embarrassing media coverage.

Say you are sorry. Help the victims no matter what. Treat everyone as thought they were a member of

your family”

Lukaszewski (1999)

Opportunities for educating staff on trauma response

• Directors

• Managers

• Employees

Seminars, training, education

Coaching, briefings, communication

INTENSE STRESS REACTION (FIGHT OR FLIGHT RESPONSE)

Brain goes into overdrive - absorbs detailed information (vivid visual impressions)

Increased flow of blood to brain, quickens speed of brain activity (incident in slow motion)

Breathing becomes shallow and fast (hyperventilation)

Muscles of jaw, mouth and forehead tense (headaches)

Shut down of feelings (auto pilot/emotional numbness)

Unusual blood flow patterns (hot or cold)

Colon starved of blood (constipation)or Bowels suddenly emptied to lighten body (defecation)

Only parts of brain needed for survival active (think and behave logically and rationally)

Parts of brain active/inactive (event feels disjointed some parts clear others lost)

Pupils dilate allowing extra peripheral vision (means of escape)

Increased heart rate (palpitations /heart attack)

Digestion stops (dry mouth)

Excessive amounts of adrenaline unless able to burn off through intense activity (shaking)

Muscles tense - shoulders, arms, back and legs (muscular pain)Freeze/immobile body appears

limp/motionless (not feel pain/analgesia)

IMMEDIATE EFFECTS

PHYSICALsymptoms of shock

FEELINGS

feardenialanxiety BEHAVIOURAL

cryinghysterical

automatic pilotwandering around

COGNITIVE

Why me?I must tell …What if ….

ICAS “BEST PRACTICE APPROACH”

Stabilisation

Assessment

Treatment

Psychological first aid

‘watchful waiting’, assessment tools

Trauma focused IPT

Trauma focused CBT

onsite / individual

SKILLS & ATTRIBUTES REQUIRED FOR IMMEDIATE RESPONSE

• Offer a reassuring and confident approach

• Ability to stay calm under pressure

• Ability to give “space”

• Ability to judge when to enter that “space”

• Be able to listen

• Show empathy without sympathy

• Think practically and take action

• Be able to respond to difficult questions

• Be able to handle the “not knowing”

PSYCHOLOGICAL FIRST AID

A ttend to

B asic needs, with

C ompassion

Psychological First Aid – use of pragmatic-orientated interventions delivered during the immediate – impact phase of

a trauma to people who are at risk of being unable to regain sufficient functional equilibrium by themselves

THE ESSENTIAL PRINCIPLES OF PSYCHOLOGICAL FIRST AID

1. To console distress and offer comfort

2. To offer practical help

3. To recognise the abnormality of the experience of the trauma

4. To recognise and respect the normality of the post trauma reaction, whatever that might be

5. Not to medicalise of pathologise the reaction

6. Not to overwhelm with information

7. To speak in a language and with a familiarity that the individual will recognise

8. To use other professional support networks

Aims to fill the gap between immediate post-trauma and any requirement for Intervention and formal psychological /psychiatric treatment for PTSD or other disorders

TRAUMA FOCUSSED INTERPERSONAL THERAPY

Evidence:

Brewin and Lennard (1999) demonstrated that risk factors operating during trauma, such as

trauma severity, lack of social support, additional life stress have somewhat stronger

effects that pre-trauma factors.

Evidence:

Schnyder and Moergeli (2003) report that recent life events, stress attributable to daily life and hassles correlate significantly with

PTSD

Evidence:

Pilgrim (1999) if steps are taken to mitigate the development of beliefs about being

“vulnerable and flawed” or “out of control”, a positive influence may be exerted on

trauma related reactions.

Evidence:

Trauma focussed IPT is a series of individually tailored, practical, collaborative

suggestions designed to supplement, enhance and operationalise the potential

support available from within existing social support networks and thereby optimise

successful adaptation.

Session 1: Assessment

Description of symptoms

Description of event

What has caused need for treatment

History of distress

Session 2: Psycho-education

Normalisation of responses

TRAUMA FOCUSSED IPT INTERVENTION

Session 3

Session 4

Who, how often, what activities shared, expectations changes

Session 5

Session 6

Role transition

Grief Strategies

“If invited to give assistance, providers will do well to approach the challenge of delivering quality services with and open

minded flexibility that recognises the need to draw upon a broad repertoire of skills to be delivered in a phased manner over

time”

(Bonanno, 2004)

“When specific interventions are undertaken they must occur without

supplanting or replacing natural contacts and supports which promote autonomy and resilience, with artificial structures

that reinforce vulnerability or encourage reliance on inappropriate ineffective, or

ill-times strategies of coping and resolution”

(Oxford Handbook on Disaster and Terrorism Psychology, 2005)

PROGRESS SUMMARY

• Reviewed evidence

• Considered clinical opinion

• Identified appropriate intervention

• Obtained feedback

• Finalised model

• Research and establish standards

• Briefing & training internally and externally

• To reorientate and develop best practice

• Educate client organisations

• Enhance credibility and reputation of our

organisation

FUTURE DIRECTIONS

Thank you

What are your views?

mrutter@icasgroup.com

REFERENCES• Bonanno, G (2004) Loss, Trauma & Human Resilience Columbia:

American Psychological Ass Inc

• Delongis, A, Lazarus, R.S and Folkman, S. (1988). The impact of daily stress on health and mood: psychological and social resources as mediators. Journal of Personality and Social Psychology 54 (3): 486-496.

• Knight & Petty (1996). The impact of castrophes on share holder value” A research report sponsored by Sedgwick group, from the Oxford Executive Research Briefings series from Oxford University

• Mayo R.A, Ehlers A, Hobbs M (2000), Psychological debriefing for road traffic accident victims. Three year follow-up of a randomised controlled trial. British Journal of Psychiatry 176:589-93

• Mitchell, J. (1983) Guidelines for Psychological debriefing, emergency management course manual. Emmitsburg, MD: Federal Emergency Management Agency, Emergency Management Institute.

• Orner R.J, King S, Avery A, Bretherton R, Stolz P, Ormerod J. (2003) Coping and Adjustment Strategies used by Emergency Services Staff after Traumatic Incidents. New Zealand: Massey University.

REFERENCES• Rose S, Bisson J, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). In: The Cochrane Library, Issue 1, 2004. Chicester, UK: John Wiley & Sons Ltd.

• Schnyder U, Moergeli H et al (2002) “Who develops acute stress disorder after accidental injuries” Psychotherapy and Psychosomatrics 71 Pages 214 - 221

• Shaler AY (2002) “Acute Stress reactions in adults” Biol Psych 51 532 - 543

• Watson P (2004) Behavioural health interventions following mass violence.Traumatic Stress Points, 18, 8-9

• (2005) Bulletin of World Health Organisation Switzerland: World Health Organisation

• (2005) N.I.C.E Guidelines UK: National Institute for Health & Clinical Excellence

• Oxford Handbook on Disaster & Terrorism Psychology, (2005)