Psychological First Aid Dr. de Klerk

8/12/2019 Psychological First Aid Dr. de Klerk

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Psychological First Aid

October 2007Mental Health Awareness week

Dr Daniel de KlerkAir NZ Medical Unit

Auckland International Airport

http://www.psychiatry.co.nz

A Working Definition

Psychological first aid (PFA) refersto a set of skills identified to limit thedistress and negative behaviorsthat can increase fear and arousal.

(National Academy of Sciences, 2003)

Fear

StressDistress

Arou sal

Indicators of Distress

References to suicide

Isolating self from others

Decrease in energy and motivational level

Change in behavior

Erratic attendance or performance

Sudden unwillingness to communicate

Drop in performance

Alcohol and/or other substance abuse

Body image and/or eating concerns

Indicators of Distress

Self-criticism and guilt

Sense of worthlessness, hopelessness orhelplessness

Headaches or nausea Change in appetite or sleeping habits

Anxiety, depression, stress and "burnout"

Relationships: break-ups, divorce or death

Threatening bodily injury or harm to others

Violent behavior

Being overly suspicious and fearful

Psychological First Aid is.

Psychological first aid (PFA) is as natural,necessary and accessible as medical first aid.

Psychological first aid means nothing morecomplicated than assisting people withemotional distress resulting from an accident,injury or sudden shocking event.

Like medical first aid skills, you don't need to bea doctor, nurse or highly trained professional toprovide immediate care to those in need.


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Psychological First Aid isNot

Debriefing

Counseling

Psychotherapy

Mental healthtreatment

The PFA Skill Set

Supportive Communication Verbal De-escalation

Screening and referral tohigher level of care

Factors Adversely Influencing

Response to Traumatic Events

Multiple traumatic exposures

History of mental illness

Low Social Economic Status (SES)

Intensity and Duration ofExposure

Gender

Age

Pre-trauma Factors

On-going support.

Opportunity to share their story.

Sense of closure.

Media exposure.

Substance Abuse.

Re-exposure or re-victimization.

Post-trauma Factors

Factors Favourably Influencing

Response to Traumatic Events

Communicating inPsychological First Aid

Guiding Principles in Providing

PFA

Protect: From further exposure

Direct: Be kind, gentle, clear

Connect: With loved ones andinformation and support


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Personal Safety

Observe safe practices by showing concern foryour own safety

Remain calm and appear relaxed, confidentand non-threatening

Three rules for personal safety:

Never sacrifice safety for rapport;

Leaving one minute too soon, always better thanone minute too late;

If you have to run, dont run from danger, run towardsafety!

Someone Is Telling You About

Their Problem..

What can you do to help? Should you give opinions or offer

solutions?

Is it helpful to be sympathetic, orshould you be firm and positive?

Should you report the problem tosomeone else?

Guiding Principles inProviding Psychological

Support Do not give false assurances

Recognize the importance of taking action

Reunite with family members

Provide and ensure emotional support

Focus on strengths and resilience

Encourage self-reliance

Respect feelings and cultures of others

Supportive Communication

Supportive communication conveys:

Empathy (one's ability to recognize, perceive and feeldirectly the emotion of another vs sympathy: strongconcern for the other person, but does not share thatperson's feelings )

Concern Respect Confidence

Do not underestimate the importance of

Compassionate Presence

Interpersonal Communication

Skills

Non-verbal communication

Listening and responding

Giving feedback

Facilitate building rapport(unconscious human interaction)

Increasing Trust andConfidence

General behaviours (depending onculture) to increase trust andconfidence:

Face the speaker

Display an open posture

Keep an appropriate distance

Frequent and soft eye contact

Appear calm and relaxed


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Communicating Warmth

SOLER S it squarely

O pen Posture

L ean Forward

E ye Contact

R elax

Warmth

Soft tone

Smile Interested facial expression

Open/welcoming gestures

Allow the person you are talking with todictate the spatial distance between you(This can vary according to cultural orpersonal differences)

Also dictate the rate of speech

Communication and Empathy(and Safety!)

L-Shaped Stance:

Demonstrates respect

Decreases confrontation

Rapport

Body Language

Mirroring

Pacing

Flinching

Eye Contact

Excellent rapport Slowing It Down

Apply the STOPapproach:

S it

T hink

O bserve

P lan


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Listening and Responding

Seek to understand first, then to be

understood one mouth two ears Concentrate on what is being said

Be an active listener(nod, affirm)

Be aware of your own biases/values

Listen and look for feelings

Do not rehearse your answers

Listening and Responding (cont)

Pause to think before answering Do not judge

Use clarifying questions and statements

Avoid expressions of approval ordisapproval

Do not insist on the last word

Ask for additional details

Put your own feelings in your pocket

Benefits of Active Listening

Shows empathy

Builds rapport

Builds relationships

Helps people acknowledge their emotionsand to talk about them instead ofnegatively acting on them

Clears up misunderstandings between

people

Guidelines for Responding

Validate feelings

Give subtle signals that you are listening

Ask questions sparingly

Never appear to interview / interrogate theperson

Address the content (especially feelings)of what you hear without judging

Focus on responding to what the person is

really saying or asking

AcceptablePsychological FirstAid Statements

1. These are normal reactions to a disaster.

2. It is understandable and expectable that you

feel this way.3. You are not going crazy, intense emotions may

come and go like waves.

4. It wasnt your fault, you did the best you could.

5. Things may never be the same but they will getbetter and you will feel better.

1. It could have been worse.

2. You can always get another

pet/house/car.3. He is better off now, at least he went

quickly.

4. I know just how you feel.

5. You need to relax, grieve, calm down.

UnacceptablePsychological FirstAid Statements


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Verbal De-escalation

Intense Emotions

Are often appropriate reactionsfollowing a disaster or crisis

Can often be managed by PFAresponders

Resolving Cultural Conflicts

1. Be aware that culture may be a factor.

2. Be willing to work on the cultural issues.

3. Be willing to talk about how the otherperson's culture would address this problem.

4. Develop a solution together.

5. If there is confusion or amisunderstandingtalk about it and learnfrom each other.

Seek Assistance

Loss of Control, Becoming VerballyThreatening

If the person becomes threatening orintimidating and does not respond to yourattempts to calm them, seek immediateassistance

Workplace Violence

Violence and aggression common at work

Fatalities relatively rare 709 U.S. 1998

About 6% of total U.S. homicides

About 15% committed by coworkers Most due to crime such as robbery

Cab drivers and liquor store clerks most common

Nonfatal Very common

No weapons

Client, customer, or patient

Healthcare workers, e.g., nurses

Managers should

Know who to refer to

Know when to refer on

Make time

Value and recognize

Be available

Walk and talk the job

Open door policy

Document!!


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Referring people on

Medical Centre Dr David Powell andteam EAP

GP

Psychologist

Drug assessment and counselling

Psychiatrist

CATT (crisis psychiatrist)

When to make a referral to EAP

Acute event at work

Following an acute event away from work Gradual onset

When to Refer

A person hints or talks openly of suicideor homicide

There is any indication of a medicalemergency

There is a possibility of abuse or anycriminal activity

The problem is beyond your training

The problem is beyond your capability

When to Refer

The person seems to be sociallyisolated

The person has imaginary ideas orfeelings of persecution

You have difficulty maintaining realcontact with the person

You become aware of dependency

on alcohol or drugs

When to make a referral to EAPmore subtle signs

Work Indicators:

Inconsistent work quality

Disruptive behaviors

Signs of fatigue/poor concentration

Unexplained changes is behavior

Increase in mistakes/carelessness

An unexplained pattern of tardiness

Unexplained and unscheduled absences


Att itude & Physical Indi cators:

Overreaction to criticism

Fights with coworkers

Blaming others Morale decline

Avoidance or isolation from coworkers

Crying spells/loss of emotional control

Unprovoked hostility/physical attacks

Sluggish movements and unresponsiveness


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More Attitude & Physical Indicators:

Apathetic Rebellious

Difficulty with authority

Appears anxious

Manipulation of coworkers

Decline in personal hygiene

Overstressed and anxious

Difficulty managing anger

Recognising signs of mentalillness:

Alcohol and substance use

Depression Mania

Psychosis

Cognitive problems

Medical problems

Suicide

Risk factors

How to spot it

Risk factors for suicide

S - Sex

A - Age

D- Depression

P - Psychiatric care

E - Excessive drug use

R - Rational thinking absent

S - Single

O - Organised attempt

N - No supports (isolated) S - States future intent

How to Refer

Inform the person about yourintentions

Present different options

Assure them that you will continueyour support until the referral iscomplete

Arrange for follow up

In short:

If you observe, or an employee reports thathe/she feels depressed, overwhelmed,

stressed or anxious, angry, out-of-control, orunable to cope; or you are unable to cope

with the employee

If either the employee or you are out of yourdepth


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Alcohol - The NZ contextThe NZ context

Alcohol harm costs NZ between $14BILLION yearly!

Crime & related costs $240 million

Social welfare $200 million

Public health sector $655 million

Despite the public perception alcoholcauses the greatest harm of all drugsof abuse

Drinkcheck Training Manual

60%

Social Drinkers

(Drinking within upper limits)

20%

Problem

Drinkers

15%

Abst inen t

5%

Dependent

LOW

RISK

HAZARDOUS

HARMFUL

Brief Intervention

Referral to specialist

Alcohol & your practiceAlcohol & your practice

In an average general practice of say 2000patients (AirNZ = 10000)

There will be 100 alcohol dependent persons (AirNZ = 500)

400 (AirNZ = 2000) patients will drink hazardously - theirconsumption will exceed the WHO recommendations of 14standard drinks/week for women and 21 standard drinks formen.

Binge drinking will be acceptable for the majority of youradult patients

Dangerous drinking

Standard drinks:

Men : 21

Women : 14

Binge:More than 3 / day

Symptoms of excessive alcoholuse

CAGE questionnaire

Have you tried to cut down?

Have you been annoyed by othersnagging?

Been guilty about your drinking?

Needed an eye-opener?

Red Flags for excessive alcoholuse

DUI

Blackouts

Tolerance Monday sickies

Changed personality when drunk

Great guy when hes sober


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Dosand DontsofPsychological First Aid

Dos & Donts

Promote Safety Help people meet basic needs for food,

shelter, and obtain emergency medicalattention.

Provide repeated, simple and accurateinformation on how to obtain these.

Dos & Donts

Promote Calm

Listen to people who wish to share theirstories and emotions and remember thereis no wrong or right way to feel.

Be friendly and compassionate even ifpeople are being difficult.

Offer accurate information about thedisaster or crisis event, and theassistance available to help victims

understand their situation.

Dos & Donts

Promote Connectedness

Help people quickly connect with friendsor loved ones.

Keep families together. Keep children andparents or other close relatives togetherwhen ever possible.

Dos & Donts

Promote Self-Efficacy

Give practical suggestions that steerpeople towards helping themselves.

Engage people in meeting their ownneeds.

Promote Hope

Find out the types of help available topeople and direct people to those services.

Remind people (if you know) that morehelp and services are on the way whenthey express fear or worry.

Dos & Donts


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Force people to share their stories withyou, especially very personal details (thismay decrease calmness in people who arenot ready to share their experiences).

Give simple reassurances like everythingwill be OK or at least you survived(statements like this diminish calmness).

Dos & Donts

Tell people what you think they should bethinking or feeling or how they should haveacted (this decreases self-efficacy).

Tell people why you think they havesuffered by alluding to personal behaviorsor beliefs of the victims (this alsodecreases self-efficacy).

Dos & Donts

Make promises that may not be kept.

Criticize existing relief efforts or existingservices in front of people in need of theseservices (this undermines hope andcalmness.

Dos & Donts Thank you

http://www.psychiatry.co.nz

Medications

Antidepressants

Anti-mania

Antipsychotics Uppers

Downers


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CBT

Feeling

Behaviour

Thinking

CBT

Negative view:

world

Negative view:

Future

Negative view:

self

Cognitive distortions

All-o r-not hing t hink ing - Thinking of things in absolute terms, like "always", "every" or"never".

Overgeneralization Mental filter- Focusing exclusively on certain, usually negative or upsetting, aspects of

something while ignoring the rest, like a tiny imperfection in a piece of clothing. Disqualifying the positive - Continually "shooting down" positive experiences for arbitrary, ad

hoc reasons. Jumping to conclusions - Assuming something negative where there is no evidence to

support it. Two specific subtypes are also identified: Mind reading - Assuming the intentions of others. Fortune telling - Predicting how things will turn before they happen.

Magnification and Minimization - Inappropriately understating or exaggerating the waypeople or situations truly are. Often the positive characteristics of other people areexaggerated and negative characteristics are understated. There is one subtype ofmagnification:

Catastrophizing - Focusing on the worst possible outcome, however unlikely, or thinking that a situationis unbearable or impossible when it is really just uncomfortable.

Emotional reasoning - Making decisions and arguments based on how you feel rather thanobjective reality.

Making should statements - Concentrating on what you think "should" or ought to be ratherthan the actual situation you are faced with, or having rigid rules which you think shouldalways apply no matter what the circumstances are.

Labeling - Related to overgeneralization, explaining by naming. Rather than describing the

specific behaviour, you assign a label to someone or yourself that puts them in absolute andunalterable terms. Personalization - Assuming you or others directly caused things when that may not have

been the case. When applied to others this i s an example of blame.

The Law in NZ

Under the Health and Safety inEmployment Amendment Act 2002employers have a duty to ensure, as far as

reasonably practical, that employees arenot exposed to hazards that cause stressor mental fatigue, where the employerknew or ought reasonably to have knownabout the problem.

Work-Family Conflict, WFC

Incompatible demands between work and family

Gallup poll found 34% of Americans experience WFC

Causes Work hours

Inflexible work schedules

Negative affectivity

Effects Absence and Lateness

Depression

Health Symptoms

Job dissatisfaction

Interventions Flexible work schedules

On-site child care


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Burnout

Distressed psychological state in response tooccupational stressors

Emotional exhaustion

Depersonalization

Reduced personal accomplishment

Effects Absence

Fatigue

Low motivation

Poor performance

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Psychological First Aid Dr. de Klerk

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