Cuyahoga Community College Psychological First Aid Discussion You probably are familiar with medical first aid, the immediate but limited care provided to

Cuyahoga Community College Psychological First Aid Discussion You probably are familiar with medical first aid, the immediate but limited care provided to survivors suffering a medical emergency. Medical first aid usually is employed at the scene of disasters, crises, and traumas to help survivors who have been physically injured. For example, an army medic will try to stop the bleeding of a wounded soldier before removing him or her from the battlefield for further treatment. Psychological first aid is similar to medical first aid in that early intervention is provided at the scene, immediate needs are addressed first, and the likelihood of recovery improves as a result.

In the aftermath of a disaster, crisis, or trauma, the use of psychological first aid can lessen the negative psychological impact of the event on survivors. Crisis workers employing psychological first aid might start with making connections with survivors, enhancing their safety, and providing them with physical and emotional comfort. They might also offer practical assistance, such as helping survivors complete paperwork, providing information about community support resources, and explaining effective coping strategies. All of these actions can have a powerful influence on how well survivors cope during the aftermath of a disaster, crisis, or trauma.

To prepare for this Discussion:

Think about the purpose of psychological first aid and how it is used during the initial response to survivors of disasters, crises, and traumas.
Identify the core action assigned to you in the Week 4 Discussion: Core Action Assignments Announcement area. Reflect on the primary goal associated with the core action.SAFETY AND COMFORT
Also, consider response practices related to the core action, and think about how employing these practices might help support survivors of disasters, crises, and traumas.
Reflect on a disaster, crisis, or trauma with which you are familiar. Think about the physical and psychological needs of survivors in its aftermath. Consider how you might apply your assigned core action to best address the survivors’ needs.

With these thoughts in mind:

BY DAY 4

Post a description of the psychological first aid core action that you were assigned(SAFETY AND COMFORT). In your description, be sure to include the primary goal of the core action, response practices associated with the core action, and the significance of the core action in the psychological first aid model. Then, explain how you might apply the core action to a specific disaster, crisis, or trauma. Provide examples to illustrate your explanation. Be sure to protect the identity of any real persons used in the example, including yourself. This is not intended as a venue for self-disclosure of very personal issues. No identifying information should be used.

Be sure to support your postings and responses with specific references to the Learning Resources.

Note: Identify the core action you discussed in the first line of your post. You will be asked to respond to a colleague who discussed a core action that you did not. Psychiatry 70(4) Winter 2007
283
Essential
Hobfoll
et Elements
al.
of Mass Trauma Intervention
Five Essential Elements of Immediate
and Mid–Term Mass Trauma Intervention:
Empirical Evidence
Stevan E. Hobfoll, Patricia Watson, Carl C. Bell, Richard A. Bryant, Melissa J.
Brymer, Matthew J. Friedman, Merle Friedman, Berthold P.R. Gersons, Joop
T.V.M de Jong, Christopher M. Layne, Shira Maguen, Yuval Neria, Ann E.
Norwood, Robert S. Pynoos, Dori Reissman, Josef I. Ruzek, Arieh Y. Shalev,
Zahava Solomon, Alan M. Steinberg, and Robert J. Ursano
Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date,
no evidence–based consensus has been reached supporting a clear set of recom-
Stevan E. Hobfoll, PhD, is affiliated with Kent State University and Summa Health System. Patricia
Watson, PhD, is with the National Center for PTSD. Carl C. Bell, MD, is affiliated with the Community
Mental Health Council and the Department of Psychiatry—School of Medicine and School of Public
Health at the University of Illinois at Chicago. Richard A. Bryant, PhD, is Scientia Professor, School of
Psychology, at the University of New South Wales in Sydney, Australia. Melissa J. Brymer, PsyD, is affiliated with the UCLA/Duke University National Center for Child Traumatic Stress, Department of Psychiatry and Biobehavioral Sciences, at the University of California, Los Angeles. Matthew J. Friedman MD,
PhD, is with the National Center for PTSD, U.S. Department of Veterans Affairs, and is Professor of Psychiatry and Pharmacology at Dartmouth Medical School. Merle Friedman, PhD, is at the South African
Institute of Traumatic Stress in Johannesburg, South Africa. Berthold P.R. Gersons, MD, PhD, Department of Psychiatry, Academic Medical Center, University of Amsterdam. Joop T.V.M. de Jong, MD, PhD,
Professor of Mental Health and Culture at Vrije Universiteit Amsterdam. Christopher M. Layne, PhD, is
affiliated with Brigham Young University and the UCLA National Center for Child Traumatic Stress.
Shira Maguen, PhD, is affiliated with the San Francisco VA Medical Center and University of California at
San Francisco. Yuval Neria, PhD, is with the Department of Psychiatry, College of Physicians and Surgeons, Columbia University. Ann E. Norwood, MD, is with the Office of Public Health Emergency Preparedness Department of Health and Human Services in Washington, DC. Robert S. Pynoos, MD, MPH,
is affiliated with the UCLA/Duke University National Center for Child Traumatic Stress, Department of
Psychiatry and Biobehavioral Sciences, at the University of California, Los Angeles. Dori Reissman,
MD,MPH (CDR, U.S. Public Health Service) is with the Division of Violence Prevention, National Center
for Injury Prevention and Control, Centers for Disease Control and Prevention, U.S. Department of Health
and Human Services. Josef I. Ruzek, PhD, is affiliated with the National Center for PTSD. Arieh Y Shalev,
MD, is with the Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel. Zahava Solomon, PhD, is affiliated with the School of Social Work, Tel Aviv University, Ramat Aviv, Israel. Alan M.
Steinberg, PhD, is with the UCLA/Duke University National Center for Child Traumatic Stress, Department of Psychiatry and Biobehavioral Sciences, at the University of California, Los Angeles. Robert J.
Ursano, MD, Department of Psychiatry at the Uniform Services University School of Medicine.
Address correspondence to Stevan E. Hobfoll Ph.D., Director, Summa-Kent State University, Center for the Treatment and Study of Traumatic Stress, 444 North Main Street, Akron, OH 44310; e-mail:
shobfoll@kent.edu.
This work was made possible in part by the support of the NIMH Traumatic Stress Research Program and by SAMSHA/HHS who supported a meeting wherein the central ideas of this paper were generated and discussed.
Essential Elements of Mass Trauma Intervention
284
mendations for intervention during the immediate and the mid–term post mass
trauma phases. Because it is unlikely that there will be evidence in the near or
mid–term future from clinical trials that cover the diversity of disaster and mass
violence circumstances, we assembled a worldwide panel of experts on the study
and treatment of those exposed to disaster and mass violence to extrapolate from
related fields of research, and to gain consensus on intervention principles. We
identified five empirically supported intervention principles that should be used
to guide and inform intervention and prevention efforts at the early to mid–term
stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self– and
community efficacy, 4) connectedness, and 5) hope.
Restoring social and behavioral functioning after disasters and situations of mass
casualty has been extensively explored over
the last few decades. No evidence–based consensus has been reached to date with regard to
effective interventions for use in the immediate and the mid–term post mass trauma
phases (Gersons & Olff, 2005). Recent findings indicating that commonly utilized interventions, such as psychological debriefing, do
not prevent PTSD may not be effective in preventing long–term distress and dysfunction,
and they may even be harmful to direct survivors of disasters (for recent reviews, see
Carlier, Lamberts, van Uchelen, & Gersons,
1998; Litz & Gray, 2002; McNally, Bryant,
& Ehlers, 2003; Rose, Bisson, & Wessely,
2003). This has left the field without an evidence–based framework for post–disaster
psychosocial intervention. This gap in the
field has led to a search for an evidence–informed framework f or post–disaster
psychosocial intervention. One solution to the
lack of direct research evidence for such interventions has been to both extrapolate from related fields of research to create evidence–informed practices and to attempt to gain
consensus from researchers and practitioners
in the fields of trauma and disaster recovery.
Of greatest interest is the identification of core
intervention–related foci that are best supported by the literature as promoting
stress–resistant and resilient outcomes
following exposure to extreme stress (Layne,
Warren, Shalev, & Watson, in press).
Given the devastation caused both by
disasters and mass violence, it is critical that
intervention policy be based on the most updated research findings (Foa et al., 2005;
Pynoos, Schreiber, Steinberg, & Pfefferbaum,
2005). Recent increases worldwide in terrorist
attacks and disasters make this all the more
necessary. It is always a difficult task to extract findings from the empirical literature on
research and intervention in a format that can
inform intervention policy. Not all areas of research receive the same attention, and controversies and questions will always remain
open, with new questions to be investigated.
Nevertheless, in this paper, we summarize our
view of the distilled version of best intervention practices following major disaster and
terrorist attacks for the short–term and
mid–term period, a period that we define as
ranging from the immediate hours to several
months after disaster or attack.
This is not to say that we intend to recommend specific intervention models, as the
literature does not currently support this. The
heterogeneity of traumatic events and their aftermath defies any specific guidelines, and
there is a need for flexibility of interventions
and adaptations to specific circumstances.
We, therefore, address this issue by asserting
several general principles for successful intervention or policies, attempting to formulate
these principles in a way that will allow their
smooth translation to specific circumstances.
Thus, we believe that there are central elements or principles of interventions, ranging
from prevention, to support, to therapeutic
intervention that are supported by the empirical literature and can be termed “evidence–informed.” It is highly unlikely that we will have
an adequate representation of randomized
controlled trials of interventions for major disaster events or terrorist attack in the near to
mid–term future, if ever. Therefore a major
Hobfoll et al.
step in promoting the development of effective, efficient, and sustainable interventions is
to ensure that, to the extent possible, they are
informed by empirical evidence and meet
standards of reasonable support from
published studies of relevance to disaster
environments.
There are several ways in which stressful events may reach traumatic proportions
for individuals and communities. First, the
sheer physical, social, and psychological demands of situations involving mass casualty
may be overwhelming—either directly (by the
extent of pain, injury, destruction or devastation) or because of their grotesque and incongruous elements (e.g., bodily disfigurement,
school children being starved or massacred,
people jumping from the burning Twin Towers, bodies floating in a New Orleans street) or
by their symbolic implications (beheading of
prisoners) or personal relevance (e.g., assuming that an act of terror could reach one’s own
neighborhood) (Reissman, Klomp, Kent, &
Pfefferbaum, 2004). Second, the devastation
of resources can impoverish the capacity of individuals and communities’ to cope with a
traumatic situation and recover from its consequences, especially where individuals or
communities already have depleted
psychosocial and economic resources due to
prior trauma, a history of psychiatric disorder, or socioeconomic disenfranchisement
(Hobfoll, 1998). The loss, or threatened loss,
of attachment bonds that occurs in disasters
and instances of mass casualty comes close in
its intensity and effect to the previous elements
of witnessing horrors and direct personal
threat. Many traumatic events involve powerful reactivation of attachment systems and ensuing agony and distress (such as looking for
relatives in the rubble of an earthquake or
searching casualty lists). Third, and linked to
the former, is the loss of territory, or safety
within a territory—either via relocation—or
indirectly, as people’s previously secure base is
infiltrated by threat and horror. In many instances of disaster and mass casualty, the ongoing violence, aftershocks, massive failure to
provide aid, and the secondary losses that follow the initial phase mean that there may be
285
no clearly demarcated period that can be
termed post–trauma. Finally, the potentially
damaging effects of traumatic events on people’s sense of meaning, justice, and order often
have extremely stressful effects. Many trauma
survivors struggle with challenges to sense of
meaning and justice in the face of shattered assumptions about prevailing justice in the
world due to the way in which they were either
exposed to traumatic events (e.g., being sent
to a war they perceive as senseless, being an innocent victim) or treated during the
post–traumatic aftermath (e.g., via
discriminatory distribution of resources). It is
on the basis of these principles that we came to
seek, identify, and describe the basic, practical
recommendations that follow.
It is important to recognize from the
outset that people’s reactions should not necessarily be regarded as pathological responses
or even as precursors of subsequent disorder.
Nevertheless, some may be experienced with
great distress and require community or at
times clinical intervention (Galea et al., 2003).
This pattern underscores the conclusion that
many people will have transient stress reactions in the aftermath of mass violence and
that such reactions may occur, occasionally,
even years later. As such, most people are
more likely to need support and provision of
resources to ease the transition to normalcy,
rather than traditional diagnosis and clinical
treatment. Thus, in this paper, we consider intervention in its broad sense, ranging from
provision of wide–ranging community support and public health messaging to clinical
assessment and intensive intervention.
We have identified five intervention
principles that have empirical support to
guide evolving intervention practices and programs following disaster and mass violence.
We recommend that these practices and techniques, or their elements, should be contained
within intervention and prevention efforts at
the early to mid–term stages. These guidelines
will be particularly important to those responsible for broader public health and emergency
management. These principles are:
1. Promote sense of safety.
Essential Elements of Mass Trauma Intervention
286
2. Promote calming.
3. Promote sense of self– and collective efficacy.
4. Promote connectedness.
5. Promote hope.
PROMOTION OF SENSE OF SAFETY
The principle of promotion of sense of
safety comes from several avenues of investigation relating to both objective reality and
perceived reality. It is the nature of disasters
and mass violence that people are forced to respond to events that threaten their lives, their
loved ones, or the things they most deeply
value (Basoglu, Salcioglu, Livanou, Kalender,
& Acar, 2005; Briere & Elliot, 2000; de Jong,
2002a, 2002b; Hobfoll et al. 1991; Ursano,
McCaughey, & Fullerton, 1994; van der Kolk
& McFarlane, 1996). Young children, parents, and caretakers are especially challenged
by a mutual sense of disruption of a “protective shield” that underlies much of early child
development and family life (Pynoos,
Steinberg & Wraith, 1995). As such, it is not
surprising that negative post–trauma reactions are common in large percentages of populations, across the full spectrum of age
ranges that are exposed to disasters or mass
violence. Hence, it is not unexpected that disaster-affected populations have been found
to have high prevalence rates of mental health
problems, including acute stress disorder,
posttraumatic stress disorder (PTSD), depression, anxiety, separation anxiety, incident–specific fears, phobias, somatization,
traumatic grief, and sleep disturbances
(Balaban et al., 2005). These negative
post–trauma reactions tend to persist under
conditions of ongoing threat or danger, as
studies in a variety of cultures have shown (de
Jong et al., 2001; de Jong, Mulhern, Ford, van
der Kam, & Kleber, 2000; Neria, Solomon, &
Dekel, 2000; Porter & Haslam, 2005;
Yzermans & Gersons, 2002). To the extent,
however, that safety is introduced, these reactions show a gradual reduction over time
(Ozer, Best, Lipsey, & Weiss, 2003; Silver,
Holman, McIntosh, Poulin, & Gil–Rivas,
2002). Moreover, even where threat continues, those that can maintain or re–establish a
relative sense of safety have considerably
lower risk of developing PTSD in the months
following exposure than those who do not
(Bleich, Gelkopf, & Solomon, 2003; Grieger,
Fullerton, & Ursano, 2003).
When people are confronted with ongoing threats of this magnitude they will naturally respond with deeply embedded
psychophysiological and neurobiological reactions that underscore the brain’s cortical
and subcortical responses as well as peripheral
fight, flight, or freeze reactions (Ursano et al.,
1994; van der Kolk & McFarlane, 1996). Biological adaptation to extreme stress is necessary for survival in a Darwinian sense
(Hobfoll, 1998; van der Kolk & McFarlane,
1996), and hence, it is not surprising that
these reactions are deeply embedded in the
brain (Charney, Friedman, & Deutch, 1995;
Panksepp, 1998; Yehuda, 1998; Yehuda,
McFarlane, & Shalev, 1998). There is also a
developmental neurobiology to their
ontogenesis (Pynoos, Steinberg, Ornitz, &
Goenjian, 1997). Translational research highlights that promoting a sense of safety is essential in both animals and humans to reduce
these biological responses that accompany
ongoing fear and anxiety (Bryant, 2006). The
implication of this pattern is that promoting
safety can reduce biological aspects of
posttraumatic stress reactions (Bryant, 2006).
Parallel to these physiological reactions, cognitive processes that inhibit recovery
also occur and are exacerbated by ongoing
threat. Foa (1997) has suggested that spontaneous or natural recovery following exposure
to a trauma is associated with maintenance of
a balanced view about the dangerousness of
the world. A belief that “the world is completely dangerous” is held to be a primary dysfunctional cognition that mediates development of PTSD (Foa & Rothbaum, 1998).
Because trauma memories are often encoded
in the context of overwhelming emotion and
confusion, Ehlers and Clark (2000) posit that
such memories are easily and involuntarily
triggered by a wide range of reminders and often subjectively feel as if they are happening
Hobfoll et al.
“right now,” even if safety is restored. This
model holds that corrective information is
needed in the aftermath of trauma to ensure
that individuals can appraise future threat in a
realistic manner. Consistent with this view,
convergent evidence indicates that people
who are likely to develop subsequent disorders are more likely to exaggerate future risk
(Ehlers, Mayou, & Bryant, 1998; Smith &
Bryant, 2000; Warda & Bryant, 1998). If actual safety is not restored, reminders will be
omnipresent and contribute to an ongoing
sense of exaggerated threat, preventing a
return to a psychological sense of safety
(Ehlers & Clark, 2000; Nortje, Roberts, &
Moller, 2004).
There are several intervention strategies
that will promote a psychological sense of
safety. These can be instituted on individual,
group, organization, and community levels.
On an individual level, studies of exposure therapy have found that a key to therapeutic success is to interrupt the post–traumatic stimulus generalization that links
harmless images, people, and things to dangerous stimuli associated with the original
traumatic threat (Bryant, Harvey, Dang,
Sackville, & Basten, 1998; Foa & Rothbaum,
1998; Gersons, Carlier, Lamberts, & van der
Kolk, 2000; Resick, Nishith, Weaver, Astin,
& Feuer, 2002). This is done through both
imagined exposure and real–world, in–vivo
exposure in ways that re–link those images,
people, and events with safety (“The bridge
that collapsed was threatening, but all bridges
are not” “That night was unsafe, but all nights
are not unsafe.”). Interventions have also utilized reality reminders, teaching contextual
discrimination in the face of trauma and loss
triggers, assisting in developing more adaptive
cognitions and coping skills, and grounding
techniques to enhance people’s sense of safety
(Hien, Cohen, Miele, Litt, & Capstick, 2004;
Najavits, 2002; Najavits, Weiss, Shaw, &
Muenz, 1998; Resick & Schnicke, 1992).
Such interventions have been used for individuals and small groups and can be applied after
screening in post-disaster and mass violence
situations. When working with children, in
addition to utilizing these components, the re-
287
versal of regression in their ability to discriminate among indications of danger is another
core therapeutic objective (Goenjian et al.,
1997; Goenjian et al., 2005; Layne et al.,
2001; Pynoos et al., 1995).
Evidence from frontline treatment of
trauma in combat situations also supports the
centrality of promoting safety and has implications for individual and more organizational and large group intervention. Hence,
safety must be approached as a relative state,
and even in disaster or combat zones where
total safety cannot be achieved, the extent that
safety is enhanced will aid people’s coping. In
studies of combatants in Israel, one of the key
principles of immediate treatment of combatants who were experiencing acute stress reactions was bringing them to relative safety, out
of the line of fire (Solomon & Benbenishty,
1986; Solomon, Shklar, & Mikulincer, 2005).
This breaks the automaticity of the
threat–survival physiology and associated
cognitions (Solomon et al., 2005).
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