A case for Therapeutic Reparative Psychiatry:post-disaster intervention

1. A case for Therapeutic Reparative Psychiatry:post-disaster intervention Raquel E. Cohen MD, MPH www.raquelcohendisaster.com

2. What are some key issues in all disaster programs During the past 20 years, increased awareness, understanding, and recognition of the emotional and psychological toll of disasters has led to the emergence of the therapeutic reparative assistance to survivors.

3. DEFINITON:POST-DISASTER REPARATIVE PSYCHIATRY Post disaster therapeutic reparative psychiatry is defined as intervention procedures to assist the survivor to recuperate the capacity to function and to cope with the present painful reality

4. Planning specific intervention modalities according to the the different categories of survivors will assure higher probability of effectiveness and ameliorations of sequelae. Specific questions to obtain data in regard to whether the survivor was in the impact area and how much time has elapsed before they were offered assistance will guide your intervention strategies.Planning specific intervention modalities according to the the different categories of survivors will assure higher probability of effectiveness and ameliorations of sequelae. Specific questions to obtain data in regard to whether the survivor was in the impact area and how much time has elapsed before they were offered assistance will guide your intervention strategies.

5. Psychosocial Impact of Disasters It is important to realize that the largest number of reactions are �normal in an abnormal situation�. With the appropriate support and assisting techniques you will be able to assist a large number of survivors. A smaller number of reactions are going to be chronic and pathological and will need further professional help.It is important to realize that the largest number of reactions are �normal in an abnormal situation�. With the appropriate support and assisting techniques you will be able to assist a large number of survivors. A smaller number of reactions are going to be chronic and pathological and will need further professional help.

6. Key Issues Labeling Concepts Contributions of the Behavioral Sciences New roles for disaster responders (Emergency workers) Socio-cultural/spiritual component

7. Labeling Concepts It is imperative to remember: THE REACTION IS NORMAL FOR THE ABNORMAL SITUATION. This presents a challenge to reparative rescue workers in the post-disaster trauma work who need to communicate dysfunction (normative behavior post-disaster) without �labels� associated with clinical psychopathology.

8. Labeling Concepts Professionals in the mental health field are trained to organize observations along clinical categories, which serve as guidelines for intervention. In disasters the documenting of behavior needs to be interpreted as a combination of post-disaster efforts to return to function, coping, adaptation and symptoms of distress, mourning, anxiety and depression. The manifestation of these signs may vary for weeks or months.

9. Advances in Behavioral Sciences Q. What concepts are used as guidelines to recognize post-disaster reactions? A. All reactions result from bio-psychosocial-cultural/spiritual impact and reestablishing/reconstructive efforts.

10. Advances in Behavioral Sciences Knowledge of the relationship between psychic trauma and the different multilevel expressions of stress response is key to understanding a survivor�s behavior. Important brain changes follow the impact of trauma, which may be acute, chronic or recurrent according to multiple variables, including genetic and experience.

11. Advances in Behavioral Sciences What Key areas of Knowledge are useful: Stressor-stress response Crisis reactions Coping mechanisms Resiliency Support networks Loss and bereavement processes Adaptation Behavior

12. Advances in Behavioral Sciences The emergence of the bio-psycho-sociolcultural system perspective, which attempts to identify the mechanisms through which psychosocial stress affect behavior, has offered new guidelines to understand post-disaster behavior and the basis for many therapeutic modalities including: psychological first aid, crisis intervention, medication, counseling, education, and group work.

13. What are the New Roles for Emergency Disaster Workers? Need to expand their understanding of how multi-variant circumstances unleashed by the traumatic event impact the individual. Must devise a new interactive approach to develop therapeutic techniques that take all these new concepts into account. This function and role shift will influence his/her role as a member of the disaster team.

14. New Roles for Emergency Disaster Workers In acquiring this novel role the worker will incorporate a new body of knowledge. This knowledge includes an awareness of the shifting and changing reactions of individuals through time and relocation sites where they will congregate looking for safety, food and shelter.

15. The EmergencyDisaster Worker: Knowledge Attitude Skills

16. The Emergency Worker: Knowledge & Skills What does a worker need to know and be able to do in order to be capable of helping the survivors of a catastrophic disaster? Enter disaster area and be identified Observe and notice survivor�s behavior Understand crisis processes Choose appropriate intervention per phase Assist the survivor according to need Continually monitor self-care

17. The Emergency Disaster Worker:KNOWLEDGE Commonality with professional knowledge Different and new professional function Shifting rhythm and schedule of work Evolution in expectations and attitudes of non-mental disaster workers Professional boundaries and guidelines confusing Disaster- non-mental health workers-responsibilities different from those of mental health workers

18. ATTITUDE Operate in a way that minimizes the survivor�s dependence on the worker. Comfortable acceptance of the possibility of rejection or skepticism by the survivor. Willingness to accept that survivors may not consider themselves in need of mental health services and may not seek out such services as a result.

19. SKILLS Skills/Capacity to: set aside usual methods of classifying emotions and behaviors according to clinical categories or mental health labels. resist the impulse to promise to supply all the needs of survivors, which would necessitate more resources and for a longer duration than feasible through the recovery program.

20. Socio-Cultural/Spiritual Issues Workers bring knowledge, attitudes and skills obtained in their previous experiences, coupled with their own cultural/spiritual background. These characteristics strongly influence their: communication style approach to establish relationships perceptions of survivors� response.

21. DISASTER PHASES The disaster consequences changes across the passage of time Social consequences Economic problems Structural changes Psychological processes

22. Reactions and Behavior Changes Through Disaster �Phases� What happens to people and what behavior manifestations can reparative psychosocial workers detect after the initial impact when catastrophic disaster strikes? According to the passage of time and conceptual perspectives: biological psychological/emotional interpersonal socio-cultural/spiritual.

23. PHASE: Impact Duration: Hours to a few days Impact period Plans activated Survival behaviors: Seeking Safety Search You will participate as part of the emergency effort to help survivors with basic needs as your first priority. The Impact Phase will be the most difficult to assist survivors who are traumatize and show signs of intense trauma. Description of this First Phase survival reactions will be presented in this Module. The effects of the destroyed environment will be presented in Module 3 plus the survivors stressors-stress responses. The manifested behavior that may appear abnormal could be labeled pathological if there had not occurred the tragedies of the disaster.You will participate as part of the emergency effort to help survivors with basic needs as your first priority. The Impact Phase will be the most difficult to assist survivors who are traumatize and show signs of intense trauma. Description of this First Phase survival reactions will be presented in this Module. The effects of the destroyed environment will be presented in Module 3 plus the survivors stressors-stress responses. The manifested behavior that may appear abnormal could be labeled pathological if there had not occurred the tragedies of the disaster.

24. PHASE: Impact Priority is on saving lives and rescuing buried bodies. Workers are focusing on action, but their stress level may begin to rise. The following slides will present the Impact Reactions lasting 3 or 4 days which are the days when you will start helping the survivors obtain shelter. Further psychosocial/mental health interventions and help will be necessary for many more months. In Module #3 these reactions will be presented which manifest themselves after the first week/months post-disaster during the �2nd Disaster�. This next Phases will necessitate different intervention modalities.Priority is on saving lives and rescuing buried bodies. Workers are focusing on action, but their stress level may begin to rise. The following slides will present the Impact Reactions lasting 3 or 4 days which are the days when you will start helping the survivors obtain shelter. Further psychosocial/mental health interventions and help will be necessary for many more months. In Module #3 these reactions will be presented which manifest themselves after the first week/months post-disaster during the �2nd Disaster�. This next Phases will necessitate different intervention modalities.

25. The first manifestation of traumatic human reactions appear - specially as survivors view the dead bodies, the destruction of their homes and neighborhoods and disappearance of their familiar surroundings. Everybody in the immediate areas are distressed, in pain and anxious but able to assist and care for loved ones.The first manifestation of traumatic human reactions appear - specially as survivors view the dead bodies, the destruction of their homes and neighborhoods and disappearance of their familiar surroundings. Everybody in the immediate areas are distressed, in pain and anxious but able to assist and care for loved ones.

26. Phases of reactive behavior in natural disasters As the phases post-disasters change so do the reactions observed in survivors. The descriptions presented per category of human behavior has been observed in many disasters and they seem to follow patters of crisis reaction and resolutions; bereavement and mourning. IMPORTANT-all interventions should be in consonance to the stage of the individual process of coping and adaptationAs the phases post-disasters change so do the reactions observed in survivors. The descriptions presented per category of human behavior has been observed in many disasters and they seem to follow patters of crisis reaction and resolutions; bereavement and mourning. IMPORTANT-all interventions should be in consonance to the stage of the individual process of coping and adaptation

27. Phases of reactive behavior in natural disasters As the phases post-disasters change so do the reactions observed in survivors. The descriptions presented per category of human behavior has been observed in many disasters and they seem to follow patters of crisis reaction and resolutions; bereavement and mourning. IMPORTANT-all interventions should be in consonance to the stage of the individual process of coping and adaptationAs the phases post-disasters change so do the reactions observed in survivors. The descriptions presented per category of human behavior has been observed in many disasters and they seem to follow patters of crisis reaction and resolutions; bereavement and mourning. IMPORTANT-all interventions should be in consonance to the stage of the individual process of coping and adaptation

28. Phases of reactive behavior in natural disasters This category of behaviors will present many problems to you as it may involve not only the individuals that you are trying to help but it will also affect the other individuals working in every agency of Relief and bureaucratic governmental programs. It may start to affect you so you should be constantly aware of your own reactions. Emotional pain and anxiety are �contagious� and will affect you.This category of behaviors will present many problems to you as it may involve not only the individuals that you are trying to help but it will also affect the other individuals working in every agency of Relief and bureaucratic governmental programs. It may start to affect you so you should be constantly aware of your own reactions. Emotional pain and anxiety are �contagious� and will affect you.

29. Phases of reactive behavior in natural disasters Different cultural groups will have their own mode of reactions so you should be sensitive and respectful to their belief systems. Some of this behavior may facilitate coping while other will interfere with healthy adjustment. If you do not understand the reactions of a survivor from a different culture or language ask for assistance to learn or translate.Different cultural groups will have their own mode of reactions so you should be sensitive and respectful to their belief systems. Some of this behavior may facilitate coping while other will interfere with healthy adjustment. If you do not understand the reactions of a survivor from a different culture or language ask for assistance to learn or translate.

30. Many studies indicate that the impact of the news, TV information, gruesome pictures etc. can have a effect on individual functioning even though the person is not directly impacted. There are many effects of indirect influence of the disaster on human lives. The level of trauma will differ but different expressions of distress and emotional pain will be manifested.Many studies indicate that the impact of the news, TV information, gruesome pictures etc. can have a effect on individual functioning even though the person is not directly impacted. There are many effects of indirect influence of the disaster on human lives. The level of trauma will differ but different expressions of distress and emotional pain will be manifested.

31. A number of survivors will return to higher level of function and emerge as leaders of the community. Most communities and their citizens will recover within a few years with exception of poverty areas or with the loss of large number of jobs.A number of survivors will return to higher level of function and emerge as leaders of the community. Most communities and their citizens will recover within a few years with exception of poverty areas or with the loss of large number of jobs.

32. QUESTION: What Areas of Knowledge are Available to Conceptualize Reactions of Survivors During the Disaster Phases? The knowledge that will be presented in summary form are key to start your understanding of reactions and behavior of survivors post-disaster. Remember this course is to set guidelines so you have a sense of direction but it will not supply all the details of your daily work. Hopefully you will have colleagues to share experiences and develop answers to questions and problems.The knowledge that will be presented in summary form are key to start your understanding of reactions and behavior of survivors post-disaster. Remember this course is to set guidelines so you have a sense of direction but it will not supply all the details of your daily work. Hopefully you will have colleagues to share experiences and develop answers to questions and problems.

33. Theories of: Stressor/stress response Coping and adaptation Loss and mourning Social support systems Crisis response and resolution You should have some knowledge of these systems and processes to understand, evaluate and choose modalities of intervention. These theories capture the knowledge needed to conceptualize the type of behavior observed post-disaster but currently we have no �bridge theories� to clarify their interaction and influencing factors that may modify severity and cronicity.You should have some knowledge of these systems and processes to understand, evaluate and choose modalities of intervention. These theories capture the knowledge needed to conceptualize the type of behavior observed post-disaster but currently we have no �bridge theories� to clarify their interaction and influencing factors that may modify severity and cronicity.

34. Reactions to stressful events depend on characteristics of: the social environment the events individual resources the task required These variables are some of the issues that will influence the perception of danger following a disaster. These are modifiers that interact with the survivors capacity to regain their previous sense of safety and hope. You should keep this in mind as you are planning your intervention and assisting plans.These variables are some of the issues that will influence the perception of danger following a disaster. These are modifiers that interact with the survivors capacity to regain their previous sense of safety and hope. You should keep this in mind as you are planning your intervention and assisting plans.

35. The categories are presented for clarity but in real life they are integrated and interrelated in the individual�s life. As they respond and change the feed-back effect will in turn influence the capacity to modulate the coping and adaptive responses.The categories are presented for clarity but in real life they are integrated and interrelated in the individual�s life. As they respond and change the feed-back effect will in turn influence the capacity to modulate the coping and adaptive responses.

36. Multiple losses: Home and shelter Basic necessities Vehicles Personal items Community and social support There is a correlation between the number and extent of losses and the extension of psychological trauma. Each of these losses will have to be evaluated as far as priority and support for basic needs of the survivor. There is a correlation between the number and extent of losses and the extension of psychological trauma. Each of these losses will have to be evaluated as far as priority and support for basic needs of the survivor.

37. The mantra of disaster psychology can be summed up in one sentence: Realizing that the traumatizing impact of the disaster has mobilized emotions and behavior which are part of the coping repertory will clarify for you that the behavior you are observing is expected in post Trauma. Also the universality of response attest to the normal reaction to a catastrophe. Noticing how these coping behaviors change as the situation becomes less painful will also give you testimony that these reactions are appropriate. Some individuals will manifest pathological, chronic responses that do not change even though the situation is better.Realizing that the traumatizing impact of the disaster has mobilized emotions and behavior which are part of the coping repertory will clarify for you that the behavior you are observing is expected in post Trauma. Also the universality of response attest to the normal reaction to a catastrophe. Noticing how these coping behaviors change as the situation becomes less painful will also give you testimony that these reactions are appropriate. Some individuals will manifest pathological, chronic responses that do not change even though the situation is better.

38. Intense/Protracted Stress The wear and tear that the body experiences due to repeated cycles of stress as well as the inefficient turning-on or shutting off of these responses. Includes many aspects of an individual's life that affect the regulation and level of the mediators of the nervous system. Individuals that are subjected to random traumatic events in a short time may develop difficulties in functioning. Disaster impacts severely on individuals that have vulnerable systems of responding to stressors. Emotional pain, depression and anxiety can have long lasting debilitating effects on the lives of survivors.Individuals that are subjected to random traumatic events in a short time may develop difficulties in functioning. Disaster impacts severely on individuals that have vulnerable systems of responding to stressors. Emotional pain, depression and anxiety can have long lasting debilitating effects on the lives of survivors.

39. Chronic stress reactions Analogy� Fire alarm that keeps ringing even after the fire has been put out This metaphor clarifies the observation that some survivors continue to show signs of stress even though their environment does not appear dangerous or threatening any more. Even though the conditions of stress have disappeared for many months some survivors will not be able to recover.This metaphor clarifies the observation that some survivors continue to show signs of stress even though their environment does not appear dangerous or threatening any more. Even though the conditions of stress have disappeared for many months some survivors will not be able to recover.

40. Statistical association outcome studies are reporting findings that there seems to be some correlation between stress and these illness. The best lines of study are the illness associated with the immunologic system.Statistical association outcome studies are reporting findings that there seems to be some correlation between stress and these illness. The best lines of study are the illness associated with the immunologic system.

41. SOCIAL SUPPORT Available social support after a disaster is a a major intervention necessary for recuperation of social and psychological capacity. It should be prompt, pervasive, continues and appropriate

42. Social Supports Concepts It is hypothesized that individuals with a strong array of social resources are less likely to have a given noxious circumstance override his/her defenses. Extending support to assist in problem solving is a continuous activity of the worker to help survivors. In his article �Psychosocial modifiers of Response to Stress- C, David Jenkins: - 1979- offers models to relate stress response outcome, in relation to quality of support systems so as to measure adaptive capacity of the individual. All these processes are examined at the biological, psychological, interpersonal and sociocultural levels simultaneously and successivelyIn his article �Psychosocial modifiers of Response to Stress- C, David Jenkins: - 1979- offers models to relate stress response outcome, in relation to quality of support systems so as to measure adaptive capacity of the individual. All these processes are examined at the biological, psychological, interpersonal and sociocultural levels simultaneously and successively

43. Social Supports Concepts It is hypothesized that individuals with a strong array of social resources are less likely to have a given noxious circumstance override his/her defenses. Extending support to assist in problem solving is a continuous activity of the worker to help survivors. In his article �Psychosocial modifiers of Response to Stress- C, David Jenkins: - 1979- offers models to relate stress response outcome, in relation to quality of support systems so as to measure adaptive capacity of the individual. All these processes are examined at the biological, psychological, interpersonal and sociocultural levels simultaneously and successivelyIn his article �Psychosocial modifiers of Response to Stress- C, David Jenkins: - 1979- offers models to relate stress response outcome, in relation to quality of support systems so as to measure adaptive capacity of the individual. All these processes are examined at the biological, psychological, interpersonal and sociocultural levels simultaneously and successively

44. Coping & Adaptation Appraisal Shapes The Coping Process Our perception and interpretation of the understanding of what has happened will set into motion the type of response needed for survival, Past experiences and memories of traumatic events sets the stage for appraisal.Our perception and interpretation of the understanding of what has happened will set into motion the type of response needed for survival, Past experiences and memories of traumatic events sets the stage for appraisal.

45. Coping & Adaptation What stimulates the antecedent of the appraisal? We have a built-in neurological mechanism that responds to dangerous situations. It is genetic and experientially developed. Danger is mediated by complicated systems of the brain which eventually converge into the locus cerulean, a major modulator in the brain of anxiety which in turn has links to the stress response components: emotions, motor activity and physiologic responses.Danger is mediated by complicated systems of the brain which eventually converge into the locus cerulean, a major modulator in the brain of anxiety which in turn has links to the stress response components: emotions, motor activity and physiologic responses.

46. Assistance to Disaster Survivors Description: Introduces post-disaster intervention programs & applied operational guidelines. Purpose: To review scope and application of assistance guidelines. Intervention activities to assist the multiple needs of survivors are categorized along the spectrum of psychosocial support and mental health assistance. Currently there is a need to identify what type of intervention is appropriate for the phase post-disaster in which you are working. You may have to decide which procedure is effective based on the key guidelines in this course.Intervention activities to assist the multiple needs of survivors are categorized along the spectrum of psychosocial support and mental health assistance. Currently there is a need to identify what type of intervention is appropriate for the phase post-disaster in which you are working. You may have to decide which procedure is effective based on the key guidelines in this course.

47. What Post-Disaster Intervention Procedures & Techniques are Available for Psychosocial Workers to Assist Survivors? Assistance to Disaster Survivors What are the guidelines that give support to assist the survivors? What techniques are available? These are questions you will have to answer based on your knowledge of distress signs, cultural and religious traditions and the resources at your disposal Can you consult with a supervisor or discuss with a colleague? Do you have access to the WEBB or a training manual?What are the guidelines that give support to assist the survivors? What techniques are available? These are questions you will have to answer based on your knowledge of distress signs, cultural and religious traditions and the resources at your disposal Can you consult with a supervisor or discuss with a colleague? Do you have access to the WEBB or a training manual?

48. Assistance to Disaster Survivors Content: First Aid & Outreach Crisis Counseling Consultation Education Each of these interventions are basic throughout the sequential phases post-disaster. The objectives of the intervention changes due to the adapting development achieved by survivors. You need to match your techniques to the survivors needs. You may need to decide when the survivor should be referred to a mental health professional due to severe symptoms, substance abuse or out of control violence.Each of these interventions are basic throughout the sequential phases post-disaster. The objectives of the intervention changes due to the adapting development achieved by survivors. You need to match your techniques to the survivors needs. You may need to decide when the survivor should be referred to a mental health professional due to severe symptoms, substance abuse or out of control violence.

49. Guidelines Expect normal recovery Promote normal recovery Assume survivors are competent Recognize survivor strengths Promote resiliency Support survivors to master the disaster experience You can notice that the underlying theme in these guidelines is supporting hope, respect and awareness of the strength in survivors. This is powerful motivation both for you and the survivor. You will notice that survivors appear to regain coping capacity as you assist the during the first weeks -your �presence and attitude� are powerful ingredients in disaster assistance.You can notice that the underlying theme in these guidelines is supporting hope, respect and awareness of the strength in survivors. This is powerful motivation both for you and the survivor. You will notice that survivors appear to regain coping capacity as you assist the during the first weeks -your �presence and attitude� are powerful ingredients in disaster assistance.

50. Guidelines Injured Contaminated Bereaved Intensely exposed Displaced from home or work Loss of property Children Elderly History of: Previous trauma Mental illness Substance abuse Chronic illness These groups and variables present more challenges than the general population with fewer conditions of trauma and loss. The added vulnerabilities of these individuals may necessitate further professional assistanceThese groups and variables present more challenges than the general population with fewer conditions of trauma and loss. The added vulnerabilities of these individuals may necessitate further professional assistance

51. Guidelines Match intervention to: Disaster phase Setting Survivor characteristics Individual, community, cultural needs To achieve these guidelines you will have to acquire data that will help you conceptualize the characteristics of the survivor and the context of his life. The inter-relation between these variables makes it difficult to generalize in chaotic situations as the uniqueness of each situation varied.To achieve these guidelines you will have to acquire data that will help you conceptualize the characteristics of the survivor and the context of his life. The inter-relation between these variables makes it difficult to generalize in chaotic situations as the uniqueness of each situation varied.

52. Assistance to Disaster Survivors Care should be taken not to interfere with psychological defenses. The survivor needs these defenses during the initial period post-disaster. Denial defenses are primary in all catastrophic situation. You have to be sensitive to the fact that most survivors need to defend themselves FOR A TIME from the reality of their situation. Carefully support them into accepting reality and help them process the sense of loss and mourning they will phase. Denial defenses are primary in all catastrophic situation. You have to be sensitive to the fact that most survivors need to defend themselves FOR A TIME from the reality of their situation. Carefully support them into accepting reality and help them process the sense of loss and mourning they will phase.

53. Assistance to Disaster Survivors Psychological Defenses Resistance Denial is: A primary defense during the initial period following the awareness of the impact produced by the disaster. Expectable, and should be handled as a healthy capacity of the organism to become overwhelmed by the terrible situations in which they find themselves. Many survivors will be thankful to be alive initially but later as they become aware of the catastrophic changes in their lives emotional reactions will surface. This progression is an example of different psychological assistance through the passage of time.Many survivors will be thankful to be alive initially but later as they become aware of the catastrophic changes in their lives emotional reactions will surface. This progression is an example of different psychological assistance through the passage of time.

54. Assistance to Disaster Survivors Guidelines for Intervention *?Increase understanding of stress reactions so as to mitigate its effects *?Minimize the impact of trauma by increasing coping strategies *?Obtain and identify concrete types of help Develop and improve communication to aid in problem-solving skills and identify concrete types of help These objectives are examples of the different interventions available to you. It clarifies the focus of the needed attitudes and skills. Although many will be categorized as psychosocial support they will have a beneficial effect on restoring coping capacity and return to function.These objectives are examples of the different interventions available to you. It clarifies the focus of the needed attitudes and skills. Although many will be categorized as psychosocial support they will have a beneficial effect on restoring coping capacity and return to function.

55. Assistance to Disaster Survivors Guidelines for Intervention Restore social coping and functioning within rapidly changing systems and disorganized social structures. Support relationships with other survivors and staff of agencies providing health care, housing, and economic assistance. Link survivors to their families and loved ones as rapidly as possible. These are examples of the early aftermath phase intervention, It aims at restoring the individual bonds to the human supportive systems as one of the essential needs of survivors to regain the sense of being part of a community. Continually inform the survivor of changes in the community or emergency programs--diminishing uncertainty and increasing knowledge will reinforce coping capacity.These are examples of the early aftermath phase intervention, It aims at restoring the individual bonds to the human supportive systems as one of the essential needs of survivors to regain the sense of being part of a community. Continually inform the survivor of changes in the community or emergency programs--diminishing uncertainty and increasing knowledge will reinforce coping capacity.

56. Assistance to Disaster Survivors Guidelines for Intervention The worker needs to be aware that the survivor is going to face different experiences as the community is reorganizing and as individuals continue to return to function. Keeping a clear direction and objective of all the activities to assist a survivor is a difficult task due to the myriad possibilities and shifting situations in which both you and the survivor find yourselves. Discuss all the options available and allow the survivor to choose the ones that is more in consonance with his life style. Support, guide, inform, prevent negative choices as you assist the survivor.Keeping a clear direction and objective of all the activities to assist a survivor is a difficult task due to the myriad possibilities and shifting situations in which both you and the survivor find yourselves. Discuss all the options available and allow the survivor to choose the ones that is more in consonance with his life style. Support, guide, inform, prevent negative choices as you assist the survivor.

57. Crisis Theory The situation can be: An overwhelming concrete disaster OR A subtle symbolic event linked to emotionally laden meaning that amplifies and distorts responses to reality events. We may also go into crisis over an anticipated event. Research studies are showing that the brain has the capacity to react to concrete events, symbolic events and anticipated expectations. It is not clear what are the systems that carry the internal messages to all the affected systems but it is known that behavior, function and coping is affected.Research studies are showing that the brain has the capacity to react to concrete events, symbolic events and anticipated expectations. It is not clear what are the systems that carry the internal messages to all the affected systems but it is known that behavior, function and coping is affected.

58. Crisis Theory Past Present AND Future Anxiety and distress are manifestations of a crisis situation. This reactions are individual specific based on innate predisposition experiences and the circumstances lived by the survivor.Anxiety and distress are manifestations of a crisis situation. This reactions are individual specific based on innate predisposition experiences and the circumstances lived by the survivor.

59. Techniques in Crisis Intervention: Guidance� is task-oriented focuses on the �here and now� communicates: hope concern confidence The approach to assisting survivors is focused on the present and the reality of the catastrophic situation. Although many times concrete resources are absent the capacity of the workers attitude to convey �I am here and will help you to the best of my ability� is a powerful resource to support and enhance coping.The approach to assisting survivors is focused on the present and the reality of the catastrophic situation. Although many times concrete resources are absent the capacity of the workers attitude to convey �I am here and will help you to the best of my ability� is a powerful resource to support and enhance coping.

60. Techniques in Crisis Intervention: Guidance� All support system resources should be mobilized, and responsibilities of daily living should be apportioned among members of family. The choices to act and mobilize assistance and resources to a survivor will present you with difficult decisions. There is so much to do, for so many and generally with insufficient resources. You are the only one who can choose what to do as you are present in the �scene� and can weight the priorities and choices.The choices to act and mobilize assistance and resources to a survivor will present you with difficult decisions. There is so much to do, for so many and generally with insufficient resources. You are the only one who can choose what to do as you are present in the �scene� and can weight the priorities and choices.

61. Techniques in Crisis Intervention: A balance between rest and work should be encouraged Use linking to networks as a strategy Facilitate the expression and understanding of painful emotions that are part of all phases. The above priorities have been found helpful and may give you a general approach of helping the survivor at the start of assistance efforts. Be careful not to confuse �facilitate� with �stimulate� the expression of painful emotions as the timing and place to share pain may not be appropriate at the beguiling of the relation.The above priorities have been found helpful and may give you a general approach of helping the survivor at the start of assistance efforts. Be careful not to confuse �facilitate� with �stimulate� the expression of painful emotions as the timing and place to share pain may not be appropriate at the beguiling of the relation.

62. Phase-Oriented Interventions Assistance procedures and techniques vary according to the reactions manifested by the survivor. To understand the reactions of the survivor you need to listen with sensitivity, respect and have some knowledge of the circumstances surrounding the setting of the survivor. Knowledge of coping processes, changes of behavior according to phases, specific needs of the survivor and access to resources will help you.To understand the reactions of the survivor you need to listen with sensitivity, respect and have some knowledge of the circumstances surrounding the setting of the survivor. Knowledge of coping processes, changes of behavior according to phases, specific needs of the survivor and access to resources will help you.

63. Disaster Phases & Intervention Each post-disaster time phase will be marked by different characteristics and manifestations of crisis. In the acute phase, survivors will be dependent on the workers, with few support systems available. Remember that each individual according to age, culture, social status and the impact of the disaster affecting the circumstances of their lives will express their distress and anxiety differently.Remember that each individual according to age, culture, social status and the impact of the disaster affecting the circumstances of their lives will express their distress and anxiety differently.

64. Assistance to Disaster Survivors Phase-Oriented Interventions TIME PHASES will present differences in: Intensity Acuteness Emergency Rapid assessment determines those survivors in most acute distress and in need of psychological attention. How to apportion resources and choose types of intervention is called�triage�. This is a very difficult operation in the chaotic environment of the first days pos-disaster. The program models world-wide vary in this situation. This will influence what you can do, when and where.Rapid assessment determines those survivors in most acute distress and in need of psychological attention. How to apportion resources and choose types of intervention is called�triage�. This is a very difficult operation in the chaotic environment of the first days pos-disaster. The program models world-wide vary in this situation. This will influence what you can do, when and where.

65. Assistance to Disaster Survivors Phase-Oriented Interventions Procedures & Techniques: OUTREACH The goal of psychological outreach is to alleviate a survivor�s emotional distress and/or cognitive disorganization and to suggest corrective action and offer appropriate information. New techniques that are evolving are categorized as �Psychological First Aid� to be used in the first few days to mitigate the distressing reactions to the event. They promote safety, comfort and function (increase coping and foster resiliency)The goal of psychological outreach is to alleviate a survivor�s emotional distress and/or cognitive disorganization and to suggest corrective action and offer appropriate information. New techniques that are evolving are categorized as �Psychological First Aid� to be used in the first few days to mitigate the distressing reactions to the event. They promote safety, comfort and function (increase coping and foster resiliency)

66. Assistance to Disaster Survivors Impact Phase-Oriented Interventions Procedures & Techniques: OUTREACH (stage 1) Approval Support Tell their story Instilling hope Initial outreach activities will assist in triage decisions by rapid observation and initial signs of distress. You will have to relate to the survivor with an attitude of respect and sensitivity to their plight. You may go from house to house, approach individuals in shelters or go visiting in tenets.Initial outreach activities will assist in triage decisions by rapid observation and initial signs of distress. You will have to relate to the survivor with an attitude of respect and sensitivity to their plight. You may go from house to house, approach individuals in shelters or go visiting in tenets.

67. Assistance to Disaster Survivors Phase-Oriented Interventions Procedures & Techniques: OUTREACH The balance between a positive, hopeful approach and a realistic appraisal of the painful situation in which survivors find themselves is a difficult attitude to sustain day after day. Expect that at times you will need support and guidance.The balance between a positive, hopeful approach and a realistic appraisal of the painful situation in which survivors find themselves is a difficult attitude to sustain day after day. Expect that at times you will need support and guidance.

68. Techniques in Early Intervention: GUIDELINES: The above groups will present more difficult challenges and may need special resources. Specialized procedures will be presented in future curriculums for �populations at risk�. Each on has different scenarios, needs and supportive procedures.The above groups will present more difficult challenges and may need special resources. Specialized procedures will be presented in future curriculums for �populations at risk�. Each on has different scenarios, needs and supportive procedures.

69. Techniques in Early Intervention: GUIDELINES: Secure Basic Needs These are needs that you may provide or be sure that someone obtains for the survivor. These items are symbolic expressions of safety and caring for the well being of the survivor.These are needs that you may provide or be sure that someone obtains for the survivor. These items are symbolic expressions of safety and caring for the well being of the survivor.

70. Assistance to Disaster Survivors Impact Phase-Oriented Interventions Procedures & Techniques: PSYCHOSOCIAL FIRST AID (stage 2) EACH OF THESE INTERVENTION HAVE DIFFERING OBJECTIVES, METHODS, TECHNIQUES AND PROCEDURES. Survivors will initially experience physiological manifestations of fear, distress, disorientation and helplessness. These reactions will change with time. RESPONSES MODES AND INTERVENTION INTENTIONS (ATTITUDES) EACH OF THESE INTERVENTION HAVE DIFFERING OBJECTIVES, METHODS, TECHNIQUES AND PROCEDURES. Survivors will initially experience physiological manifestations of fear, distress, disorientation and helplessness. These reactions will change with time. RESPONSES MODES AND INTERVENTION INTENTIONS (ATTITUDES)

71. Techniques in Intervention: GUIDELINES: Match Intervention To: To meet the above objectives you need to sort out your own capabilities and resources. Some of the objectives may necessitate a different agency or Procedures. Remember some of the content of the previous slides to guide your assistance.To meet the above objectives you need to sort out your own capabilities and resources. Some of the objectives may necessitate a different agency or Procedures. Remember some of the content of the previous slides to guide your assistance.

72. Several models are being published identifying the methods to achieve the above objectives-they all agree on the need to achieve a return to coping and functionality. They present different modes of intertwining to achieve the objective of achieving safety, comfort and capacity to deal with their painful reality.Several models are being published identifying the methods to achieve the above objectives-they all agree on the need to achieve a return to coping and functionality. They present different modes of intertwining to achieve the objective of achieving safety, comfort and capacity to deal with their painful reality.

73. Psychological First Aid Acute phase: Foci of intervention Arousal: decrease excitement Behavior: assist survivors to function effectively in disaster Cognition: provide reality testing and clear information Further details can be found in Dr. Beverly Raphael publications. She presents one of the models of First Aid.Further details can be found in Dr. Beverly Raphael publications. She presents one of the models of First Aid.

74. ABCs of Psychological First Aid Comfort and console Provide a sense of safety Reunite families Keep families together Identify distressed survivors for early attention and support Provide basic needs The above techniques are helpful in the immediate aftermath. Some of these functions may be assisted by you, others may need help from other resources which you may access.The above techniques are helpful in the immediate aftermath. Some of these functions may be assisted by you, others may need help from other resources which you may access.

75. ABCs of Psychological First Aid Protect from harm due to high-risk behaviors Link to support systems Redirect to constructive, helping behaviors Provide opportunities to gain mastery Reutilize activities Educate survivors on adaptive behaviors These are activities that will allow the survivor to exert some increasing independence. Depending on your repertoire of skills you may intervene according to your priorities. Again, you may need help from other sources.These are activities that will allow the survivor to exert some increasing independence. Depending on your repertoire of skills you may intervene according to your priorities. Again, you may need help from other sources.

76. ABCs of Psychological First Aid Communicate effectively Orient to the situation Clarify what happened Provide disaster updates Provide information for action Ground the survivor in reality Identify risks & resources As your interact with the survivor your guidance and support become more Focused. You may choose some of the above objectives immediately, while postponing some of them for later.As your interact with the survivor your guidance and support become more Focused. You may choose some of the above objectives immediately, while postponing some of them for later.

77. Long Term Phases & Counseling Mitigating the long-term debilitating effects of post-traumatic reactions through: Crisis counseling Consultation AND Education The term �Long Term Phase� is used to differentiate the intervention needed in the fist days and the subsequent time-related post-disaster. The length of the long term can be in months or years depending on the extent of the catastrophe, its effects and the resources to assist survivors.The term �Long Term Phase� is used to differentiate the intervention needed in the fist days and the subsequent time-related post-disaster. The length of the long term can be in months or years depending on the extent of the catastrophe, its effects and the resources to assist survivors.

78. Techniques in Crisis Intervention: Assisting survivors in organizing and getting to those disasters related services, resources and opportunities that will help them achieve pre-disaster levels of functioning and equilibrium. Although you may not be able to achieve all the concrete resources the survivor needs your assistance in figuring out how to obtain them may be of great assistance to the capacity of the individual.Although you may not be able to achieve all the concrete resources the survivor needs your assistance in figuring out how to obtain them may be of great assistance to the capacity of the individual.

79. Assistance to Disaster Survivors Long--Aftermath Phase-Oriented Interventions Procedures & Techniques: CRISIS COUNSELING EACH OF THESE INTERVENTION HAVE DIFFERING OBJECTIVES, METHODS, TECHNIQUES PROCEDURES RESPONSES MODES AND INTERVENTION INTENTIONS (ATTITUDES). According to your previous activities you may be familiar with some Techniques for achieving the help you choose for the survivor. EACH OF THESE INTERVENTION HAVE DIFFERING OBJECTIVES, METHODS, TECHNIQUES PROCEDURES RESPONSES MODES AND INTERVENTION INTENTIONS (ATTITUDES). According to your previous activities you may be familiar with some Techniques for achieving the help you choose for the survivor.

80. Disaster Phases & Crisis Counseling As time goes by, more resources will become available to assist in crisis intervention and assistance. Coping capacity will increase & Stress signs will diminish. Again time phases are presented to remind the workers how techniques will change with the passage of time. Other important events will be unleashed in the weeks/months after a disaster--loss of home, jobs, transportation. Some families will need to relocate severing important familiar bonds of the their neighborhood necessitating further adjustments.Again time phases are presented to remind the workers how techniques will change with the passage of time. Other important events will be unleashed in the weeks/months after a disaster--loss of home, jobs, transportation. Some families will need to relocate severing important familiar bonds of the their neighborhood necessitating further adjustments.

81. Disaster Phases & Crisis Counseling When assumptions regarding certain predictable events become disorganized, a complex series of responses are selected, depending on the individual�s: Remember the that the survivor is �navigating� in a new environment which may become a new severe stressor. This, in turn, will continue to affect the bio-psychological systems. These changes may affect his perceptions and behavior resulting in further social problems. Your guidance and support can mitigate these sequences post-disaster.Remember the that the survivor is �navigating� in a new environment which may become a new severe stressor. This, in turn, will continue to affect the bio-psychological systems. These changes may affect his perceptions and behavior resulting in further social problems. Your guidance and support can mitigate these sequences post-disaster.

82. Disaster Phases &Crisis Counseling TECHNIQUES IN CRISIS INTERVENTION: Counseling: Objectives & Procedures This procedure can be used after the first few days when you may have a clearer idea of the needs and also more time to spend with the survivor.This procedure can be used after the first few days when you may have a clearer idea of the needs and also more time to spend with the survivor.

83. Techniques in Crisis Intervention: Identifying the problems generated by stressors and difficulties presented by demand for change Listening of action alternatives, strategies Building a decision model and steps to accomplish Operationalizing alternatives Application of steps & feedback of results The objectives demand that you have more data and a developing relation to the survivor so that you can identify individual needs and understand the issues that are important presently. Also by now you have a better knowledge of the resources at your disposal and the plans of the community to assist in the reorganization of the region.The objectives demand that you have more data and a developing relation to the survivor so that you can identify individual needs and understand the issues that are important presently. Also by now you have a better knowledge of the resources at your disposal and the plans of the community to assist in the reorganization of the region.

84. Techniques in Crisis Intervention: Obtain information on experience post-disaster Establish competence and credibility Keep survivor updated on any subsequent steps As time goes by more resources are available and more agencies begin to offer assistance. This increase of available assistance helps the survivor begin to regain the capacity to participate with you in adapting to the new circumstances.As time goes by more resources are available and more agencies begin to offer assistance. This increase of available assistance helps the survivor begin to regain the capacity to participate with you in adapting to the new circumstances.

85. Techniques in Crisis Intervention: Provide realistic information Alleviate emotional distress Diminish cognitive confusion and disorganization Discourage dependence Continuous updating of the changing situations to inform the survivor of what is going on is a helpful technique to diminish distress. There is a tendency to develop an emotional dependence on you due to your efforts to help a survivor but you need to be tactful and sensitive not to encourage this.Continuous updating of the changing situations to inform the survivor of what is going on is a helpful technique to diminish distress. There is a tendency to develop an emotional dependence on you due to your efforts to help a survivor but you need to be tactful and sensitive not to encourage this.

86. Assistance to Disaster Survivors Disaster Phases & Long Term Counseling A group of individuals will develop long term syndromes post-disaster and they may need assistance to refer them to mental health professionals. You will need to develop a protocol to define the boundary between the type of distress/coping that can be helped by you and when you will need assistance from other services. It also will depend on resources as in some areas you will not have the possibility of referral and you will have to offer the best assistance you can manage.A group of individuals will develop long term syndromes post-disaster and they may need assistance to refer them to mental health professionals. You will need to develop a protocol to define the boundary between the type of distress/coping that can be helped by you and when you will need assistance from other services. It also will depend on resources as in some areas you will not have the possibility of referral and you will have to offer the best assistance you can manage.

87. Long Term Phases Counseling TECHNIQUES IN INTERVENTION: Assisting in Reorganization and Return to Functioning Depending on resources available to the survivor you assisting through out the weeks/months post-disaster will vary. There are situations where you will be assisted by long-distance consultation or through technology communications.Depending on resources available to the survivor you assisting through out the weeks/months post-disaster will vary. There are situations where you will be assisted by long-distance consultation or through technology communications.

88. Long-Term Disaster Phases Counseling Assisting survivors in organizing themselves and accessing those� Disaster-related services Resources AND Opportunities � that will help them achieve pre-disaster levels of functioning and equilibrium. The level of functioning and adaptation will be influenced with the severity of the post-disaster reconstruction and its impact on the survivor. It may help or hinder adaptation and function. In areas where reconstruction is slow and the survivor is continuously reminded of the destruction/disorganization of his community, emotional healing may be slow or impaired.The level of functioning and adaptation will be influenced with the severity of the post-disaster reconstruction and its impact on the survivor. It may help or hinder adaptation and function. In areas where reconstruction is slow and the survivor is continuously reminded of the destruction/disorganization of his community, emotional healing may be slow or impaired.

89. Techniques in Intervention: Correct misconceptions in order to change the cognitive process and enable the survivor to determine reality. 2. Analyze dysfunctional self-statements and projections of future misfortunes� Train in problem-solving Rehearse options for decision-making These guidelines establishes the worker as a supportive, guiding, empathetic individual who listens carefully and clarifies options for the survivor. It will need more face to face meetings and available time sessions.These guidelines establishes the worker as a supportive, guiding, empathetic individual who listens carefully and clarifies options for the survivor. It will need more face to face meetings and available time sessions.

90. Techniques in Intervention: Train in methods of self-control Develop techniques for �stress inoculation as prevention� Connect type thinking (past-present) to emotions/congruity of perceptions/reality Same as previous slide these guidelines establishes the worker as a supportive, guiding, empathetic individual who listens carefully and clarifies options for the survivor.Same as previous slide these guidelines establishes the worker as a supportive, guiding, empathetic individual who listens carefully and clarifies options for the survivor.

91. Techniques in Intervention: Develop behavioral techniques to modify behavior Clarify role conflicts in the context of the present reality Identify interpersonal problems and problems of self-concept within social functions These guidelines establishes some of the approaches that have been found to be helpful.These guidelines establishes some of the approaches that have been found to be helpful.

92. Disaster Phases &Long Term Assistance Post-Disaster Consultation & Education Consultation and Education are two types of post-disaster assistance that can be very helpful to assist survivors to return to function. Generally they are available to Emergency Programs and need trained individuals to direct them.Consultation and Education are two types of post-disaster assistance that can be very helpful to assist survivors to return to function. Generally they are available to Emergency Programs and need trained individuals to direct them.

93. Techniques in Crisis Intervention: The definition of consultation establishes the interaction between the psychosocial worker and workers in other agencies asking for assistance in solving problems of survivors.The definition of consultation establishes the interaction between the psychosocial worker and workers in other agencies asking for assistance in solving problems of survivors.

94. Techniques in Crisis Intervention: The capacity of the agency will increase by understanding the issues affecting the survivor and receiving advise of how to deal with the situation from a psychological perspective.The capacity of the agency will increase by understanding the issues affecting the survivor and receiving advise of how to deal with the situation from a psychological perspective.

95. Agencies Problems These are expectable problems in many disasters. Be prepared to handle them. As you become more experienced you can anticipate them and ameliorate their effect on your work.These are expectable problems in many disasters. Be prepared to handle them. As you become more experienced you can anticipate them and ameliorate their effect on your work.

96. Assisting the community The opportunity to inform, educate, expect and prevent misinformation is an important function of post-disaster workers. After every disaster most communities are eager for news and information of the catastrophic aftermath and its effect on individuals.The opportunity to inform, educate, expect and prevent misinformation is an important function of post-disaster workers. After every disaster most communities are eager for news and information of the catastrophic aftermath and its effect on individuals.

97. Assisting the Community You can participate in these activities or help the individual who is assigned to do it.You can participate in these activities or help the individual who is assigned to do it.

98. Techniques in Crisis Intervention: GUIDELINES: These groups will need different methods of assistance and the content will be presented in modules produced for this purpose in the future.These groups will need different methods of assistance and the content will be presented in modules produced for this purpose in the future.

99. Assistance to Disaster Survivors Long term Phase-Oriented Interventions Procedures & Techniques: MENTAL HEALTH THERAPY EACH OF THESE INTERVENTION HAVE DIFFERING OBJECTIVES, METHODS, TECHNIQUES AND PROCEDURES. Survivors who are showing dysfunction many weeks post-disaster should be referred to mental health specialist. RESPONSES MODES AND INTERVENTION INTENTIONS (ATTITUDES) EACH OF THESE INTERVENTION HAVE DIFFERING OBJECTIVES, METHODS, TECHNIQUES AND PROCEDURES. Survivors who are showing dysfunction many weeks post-disaster should be referred to mental health specialist. RESPONSES MODES AND INTERVENTION INTENTIONS (ATTITUDES)