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Crisis Intervention in the acute Phase after Trauma, the client´s subjective needs Acute Interventions after sudden loss: the families´ subjective view.

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Presentation on theme: "Crisis Intervention in the acute Phase after Trauma, the client´s subjective needs Acute Interventions after sudden loss: the families´ subjective view."— Presentation transcript:

1 Crisis Intervention in the acute Phase after Trauma, the client´s subjective needs Acute Interventions after sudden loss: the families´ subjective view B. Juen, E. Mohr, Siller, H., Gmeiner, V. University of Innsbruck

2 Stage models assume a detmermined course of grief like: disbelief, intensive emotions, acceptance In working models of grief, the tasks that have to be accomplished are also conceptualized in phases like: realization, working through emotions and reuptake of emotional life Phase or stage models do not have an empirical basis Research example Maciejewski et al analysed a group of 233 grieving persons and found that disbelief was not the dominant response in the beginning, acceptance was most dominant in all phases and yearning was the most prominent negative grief indicator in the first months. Over time, disbelief and yearning decreased and acceptance increased Stage or phase models of grief

3 Today most reseachers prefer coping models of grief to phase or stage models Grieving persons have to cope with new and overwhelming emotions as well as with new life circumstances (Znoj, 2007) Research example, Berne study on parental grief: If this process is completed in a positive way, persons may be more able to cope with extreme negative emotions than others (Znoj, 2006) Coping models of grief

4 Loss is a life-event that has a specific, even biologically determined reaction course and takes time. According to Znoj (2004,2006) therapeutic help is not always needed and does not shorten the reaction. It may even hinder the natural healing process (“too much grief”) Psychotherapy only works when the bereavement has become complicated (e.g. Shear et al., 2001, Wagner et al. 2005) “Thus it must be stated...that there can be no justification for routine intervention for bereaved persons in terms of therapeutic modalities -- either psychotherapeutic or pharmacological -- because grief is not a disease.” (Raphael, Minkov & Dobson, 2001) Therapy means interventions that shall help to confront oneself with the difficult aspects of the loss. This may be useful in complicated grief but too confrontative if grief is normal. But what kind of support is effective in the acute phase if not therapy? Grief therapy

5 In lower Austria two support systems are active for families after the sudden death of a family member. 1. Crisis Intervention teams consisting of specially trained emergency personnel come to the site immediately after the event (if the family wants it) and support the family through the very first hours (this is paid by the red cross and other NGOs which provide the service) 2. In the more severe cases the Acute team consisting of psychologists and psychotherapists can come into the family up to five times after the event to give immediate psychological and psychosocial support (this service is paid by the government) Acute Psychosocial Interventions for grieving families

6 In a study using a mixed method approach the following questions were analysed Quantitative data analysis Which Risk factors can be identified in the families? Which resources can be identified? Which interventions are used by the team and how are they perceived by the affected families? Which risk factors can predict problematic acute reactions? Which interventions can predict satisfaction? The Study about the work of the Acute Team

7 In a study using a mixed method approach the following questions were analysed Qualitative data analysis Which resources are subjectively seen as important by the affected families? Which interventions are seen as important? Which indicators do the affected see for positive and negative change? The Study about the work of the Acute Team

8 426 cases of sudden death were analysed in a quantitative manner 376 cases were documented by narrative protocols and analysed by qualitative content analysis, 15 of which were analysed in a detailled manner. In these cases 1194 individual persons were supported. In these cases it is not possible to collect data about individuals because families/groups are in the focus of the interventions. The events were in most cases sudden death of a family member by suicide, Illness or accident The families/groups received a one to three time acute crisis intervention at their home by psychologists/ psychotherapists of the Acute Team in Lower Austria Acute Team Cases Analysed

9 Risk factors stem from the situation, the person, previous trauma or disorder Problematic acute reactions like severe dissociation, panic attacks, severe forms of helplessness etc. can be seen rather often in the familes supported Of the resources the most prominent are the social resources The team uses interventions according to the Hobfoll principles (safety, connectedness, calm, self/colelctive efficacy and hope) Most prominent are the interventions promoting self (colllective) efficacy and calming interventions Only the situational factors can predict problematic reactions in the acute phase (especially violent events and accidents with near death situations) Satisfaction can best be predicted by calming interventions Quantitative Results (see poster session)

10 Being able to talk to somebody from outside Connectedness with family and friends Social integration (to have a network of friends, school, broader social network) To be able to take responsibility for the family Personal resources (creativity and rituals) Qualitative results Subjectively perceived resources

11 To talk about the death can bring stress reduction It can also enhance the feeling of self efficacy and saftety if the person to whom you talk can be trusted and is able to give psychoeducation Safety can be enhanced if the person realises that the horrible event which cannot be fully put into words can be shared with another person who bears witness to it (especially in violent trauma this is an important factor) Being able to talk to someone from outside

12 To be able to talk about difficult emotions like guilt feelings and fears To have a person listening who is objective and comes from outside the family To talk to family and freiends is often only done in small pieces whereas here they feel they can take their time and talk about the whole story in detail They find it important that they are given time and space to think about the event and „summmarize“ the things that have happened They feel they can bring order into their thoughts and feel less lonely In the words of the affected persons

13 To feel connected to others espeically family and friends is one of the most important resources in these situations Also the feeling to be part of a broader social network is perceived as very important To be able to take responsibility for the family is an important factor in self and collective efficacy and helps the affected persons to be not only on the receiving end of social support. This includes not talking about certain aspects of the event with the family in order to protect them (especially after violence, see also Yehuda et al 1998) Connectedness and social support

14 Creativity is seen as important by the affected persons. They write letters and poems, they draw pictures They engage in a variety of individual and collective rituals that help to work through the feelings of loss and to keep contact to the deceased (see also Schwaiger, 2011, Duffek, 2012) Personal resources

15 Rituals can help to fulfill needs that cannot be fulfilled by the social environment to feel proximity to the deceased, to give the deceased person space in everyday life, to express ambivalent emorions, to create order and control…. Personal rituals are not done when others are present but only in private Rituals can be realized by actions but soem are done only by imagination Rituals can but do not have to contain spiritual elements Functions of rituals (Schwaiger 2011)

16 To have an external person who one can trust To have the possibility to express emotions and enhance understanding by talking about the event To be coached through next steps To have continuity and a certain length of support Somebody who is really present, interested and attentive To have enough time (more than one contact) Support in activating resources Listening Getting information about where to get further help and how to cope with symptoms Qualitative results: Subjectively important Interventions

17 To be able to talk about guilt feelings and be unconditionally accepted Getting information about what to do next and how to get further help To be able to ask questions about any aspects of the event that is important like, how has he died, did he suffer etc. The affected persons feel that they become more active by getting information and advice about how to cope with the new life circumstances They appreciate psychoeducation because they learn about their symptoms and how to cope, they fell more secure They say that it was especially helpful to again talk about everything after some weeks and to have a continuity in support from the accident until four weeks afterwards. They would wish even more contacts. To be present, interested and attentive: The feeling that somebody cares In the words of the affected

18 Uncontrollable thoughts about the deceased/the event have decreased Active and contolled working through becomes possible: death is a reality now and acceptance is enhanced, rituals are done to understand and mark the next step Mood and climate within the family are better now, tension has been reduced Mood of the person has become better, he/she feels stronger, is more calm To talk about loss and guilt feelings becomes possible Fear is diminished Normal everyday life can be started again „Old“ rituals like how to celebrate christmas or birthdays are rearranged Qualitative results: Indicators of positive change

19 These stem mostly from the grieving process but also from the necessity of role change in the family after a loss as well as from difficult reactions in the social environment (negative social support) or from previous family conflicts New conflicts in the family Misunderstandings and lack of understanding from the outside world Old conflicts from the past intervene with the acute trauma Mood decreases and grief gets worse (often as a normal phase in the grieving process) Qualitative results: Indicators of negative change

20 There is not such a big tension any more Grandma can now talk about her loss and guilt feelings I am feeling stronger and better now Old conflicts between our family and the family of our uncle become mixed up with our present story We start to go on with our lives (we meet friends again, we go out again…) In the words of the affected

21 Grief is becoming worse when you realize that he is never coming back You have to let him go Especially christmas is a very difficult time In the words of the affected

22 1. Listen to the grieving person and support the natural grieving process For the grieving family to be able to talk to an outsider who is present interested and attentive is very important especially when dealing with difficult emotions 2. Give information and psychodeducation To get information and psychoeducation is very important in order to be active and feel competent and able to cope with the extreme negative emotions 3. Accompany and support understanding in a nonintrusive manner To be able to repeatedly talk about event and deceased person in order to come to a better understanding is seen as the most important aspect of talk 4. Promote connectedness To be connected to family and friends but also to a broader social network is seen as crucial 5. Encourage personal resources and rituals But also personal resources like creativity and rituals are seen as helpful in the grieving process and can support the coping process Conclusions: Supporting the normal process of coping by the following interventions

23 Positive changes are described by the affected persons as a change from the uncontrollable rumination towards a more controlled thinking about the deceased and the event. This process is very similar to what Tedeschi and Callhoun describe as the pathway to Posstraumatic Growth Conclusions

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25 Duffek, P. (2012) Kollektive Rituale zur Traumebewältigung nach Katastrophen (unveröffentlichte Diplomarbeit, Institut für Psychologie, Universität Innsbruck) Neimeyer,R.A. & Currier M. (2009): Grief Therapy. Evidence of Efficacy and Emerging Directions. In: Current Directions in Psychological Science 18 (6), S. 352–356 Raphael B, Minkov C, Dobson M (2001) Psychotherapeutic and pharmacological intervention for bereaved persons. Death Studies 24: 603–610 Schwaiger, E. (2011) Die Funktion von Ritualen nach traumatischen Ereignissen (unveröffentlichte Diplomarbeit, Institut für Psychologie, Universität Innsbruck) Tedeschi, R.S., & Calhoun, L.G. (2006). The foundations of Posttraumatic Growth: an expanded framework. In: Calhoun, L.G. & Tedeschi, R.G. (eds) Handbook of Posttraumatic Growth: Research and Practice, New Jersey: Lawrence Erlbaum Wagner, B., Knaevelsrudb, Ch, Maercker, A. (2006) Internet-Based Cognitive-Behavioral Therapy for Complicated Grief: A Randomized Controlled Trial, Death Studies, 30 (5) Pages 429 – 453 Shear, M.K., Frank, E., Foa, E., Cherry, C, Reynolds, C.F.., Vander Bilt, J. & and Masters, S. (2001) Traumatic Grief Treatment: A Pilot Study, Am J Psychiatry 158:1506-1508 Yehuda, R., McFarlane, A.C., Shalev, A.Y. (1998). Predicting the Development of Posttraumatic Stress Disorder from the Acute Response to a Traumatic Event. Society of Biological Psychiatry, Vol. 44, pp. 1305–1313. Znoj, H.J. & Maercker, A. (2004). Trauerarbeit und Therapie der komplizierten Trauer. In M. Linden & M. Hautzinger (Hrsg.). Verhaltenstherapiemanual (5. Aufl.). Berlin: Springer References


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