Psychological First Aid Steven Marks, DNP, RN, APN, COHN-S, FAAOHN

Objectives Overview of common mental health conditions and describe how they can present in the workplace Describe and demonstrate techniques for interviewing patient interviewing with a focus on de-escalation of situations. Describe and demonstrate stress management techniques Describe Mental health evaluations in a mass casualty situation

Definition Psychological First Aid is an evidence-informed1 modular approach to help children, adolescents, adults, and families in the immediate aftermath of disaster and terrorism. Medical Reserve Corps Field Operations Guide http://www.nctsn.org/sites/default/files/assets/pdfs/MRC_PFA_04_02_08.pdf

Goals Psychological First Aid is designed to reduce the initial distress caused by traumatic events and to foster short- and long-term adaptive functioning and coping. Medical Reserve Corps Field Operations Guide http://www.nctsn.org/sites/default/files/assets/pdfs/MRC_PFA_04_02_08.pdf

Four Standards of PFA Consistent with research evidence on risk and resilience following trauma Applicable and practical in field settings Appropriate to development levels across the lifespan Culturally informed and adaptable https://www.counseling.org/resources/library/VISTAS/2009-V-Print/Article%2024%20Uhernik%20Husson.pdf

Applicability of PFA It can be used in any location where trauma survivors may be found It is ideal for immediate response and for the practical administration in field settings PFA supports the concept of resiliency, in individuals and in communities, which encourages self efficacy and decreases victimization and dependency https://www.counseling.org/resources/library/VISTAS/2009-V-Print/Article%2024%20Uhernik%20Husson.pdf

Why PFA? People do better over the long term if they… Feel safe, connected to others, calm & hopeful Have access to social, physical & emotional support Regain a sense of control by being able to help themselves http://www.who.int/mental_health/world-mental-health-day/ppt.pdf

PFA: Who, When, Where? Who can benefit from PFA? Boys, girls, women and men who have recently experienced a crisis event and are distressed Some people need more than PFA alone such as people with life-threatening injuries or unable to care for themselves or their children When should PFA be provided? When encountering a person in distress, usually immediately following a crisis event Where should PFA be provided? Anywhere that is safe for the helper and affected person, ideally with some privacy as appropriate to the situation

How to Help Responsibly Adapt what you do to take account of the person’s culture Respect safety, dignity and rights Safety: don’t expose people to further harm, ensure (as best you can) they are safe and protected from further physical or psychological harm Dignity: treat people with respect and according to their cultural and social norms Rights: act only in people’s best interest, ensure access to impartial assistance without discrimination, assist people to claim their rights and access available support Be aware of other emergency response measures Care for caregivers: practice self-care and team-care

Helping Responsibly: Ethical Guidelines Do’s Be honest and trustworthy. Respect a person’s right to make their own decisions. Be aware of and set aside your own biases and prejudices. Make it clear to people that even if they refuse help now, they can still access help in the future. Respect privacy and keep the person’s story confidential, as appropriate. Behave appropriately according to the person’s culture, age and gender.

Helping Responsibly: Ethical Guidelines Don'ts Don’t exploit your relationship as a helper. Don’t ask the person for any money or favor for helping them. Don’t make false promises or give false information. Don’t exaggerate your skills. Don’t force help on people, and don’t be intrusive or pushy. Don’t pressure people to tell you their story. Don’t share the person’s story with others. Don’t judge the person for their actions or feelings.

Components of PFA Contact and Engagement Safety and Comfort Stabilization Information Gathering Practical Assistance Connection with Social Support Coping Information Linkage with Collaborative Services PFA Components Psychological First Aid (PFA) is a structured intervention that has been developed over the past few years to replace the various forms of “psychological debriefings.” Reference to the development of PFA can be found in the Field Operations Guide for Psychological First Aid published by the National Center for Child Traumatic Stress Network and National Center for PTSD (2006). Psychological First Aid includes a set of eight interventions that can be used to support survivors after a disaster or traumatizing event. These eight core actions and focus goals include: 1. Contact and Engagement. The goal is to respond to survivors and to engage in a non-intrusive and supportive manner. 2. Safety and Comfort. The goal is to help meet immediate safety needs and to provide emotional comfort. 3. Stabilization. The goal is to reduce stress caused by a traumatic event. Psychological First Aid: An Evidence Informed Approach for Acute Disaster Behavioral Health Response 275 4. Information Gathering. The goal is to assess the immediate needs of the survivors. 5. Practical Assistance. The goal is to create an environment where the survivor can begin to problem solve. 6. Connection with Social Supports. The goal is to assist survivors to connect or re-connect with primary support systems. 7. Coping Information. The goal is to offer verbal and written information on coping skills and the concept of resilience in the face of disaster. 8. Linkage with Collaborative Services. The goal is to inform survivors of services that are available to them https://www.counseling.org/resources/library/VISTAS/2009-V-Print/Article%2024%20Uhernik%20Husson.pdf

Components of PFA Contact and Engagement To respond to contacts initiated by survivors, or to initiate contacts in a non intrusive, compassionate and helpful manner https://itz-mylife.com/2017/03/05/understanding-others/

Components of PFA Safety and Comfort To enhance immediate and ongoing safety, and provide physical and emotional comfort Photo By Dermot Tatlow Courtesy Of The Red Cross https://www.newtimesslo.com/sanluisobispo/disaster-responders-red-cross-volunteers-give-their-time-to-help-others-caught-up-in-the-worst-crisis-of-their-lives/Content?oid=4090347

Components of PFA Stabilization To calm and orient emotionally overwhelmed or disoriented survivors https://www.mindful.org/wp-content/uploads/Calm.jpg

Components of PFA Information Gathering To identify immediate needs and concerns, gather additional information, and tailor Psychological First Aid interventions https://www.ciyoudixonlaw.com/general-practice/discovery-general-practice/gathering-information-how-to-reach-third-parties/

Components of PFA Practical Assistance To offer practical help to survivors in addressing immediate needs and concerns http://www.helpinghandsgtx.org/

Components of PFA Connection with Social Support To help establish brief or ongoing contacts with primary support persons and other sources of support, including family members, friends, and community helping resources http://healthandsicklecelldisease.blogspot.com/2016/04/social-support-and-stress.html

Components of PFA Coping Information To provide information about stress reactions and coping to reduce distress and promote adaptive functioning https://www.diabeteseducator.org/living-with-diabetes/aade7-self-care-behaviors/healthy-coping

Components of PFA Linkage with Collaborative Services To link survivors with available services needed at the time or in the future Vector Design by <a href="https://vecteezy.com">Vecteezy.com</a>

When Terrible Things Happen Domain Negative Response Positive Response Cognitive Confusion, disorientation, worry, Intrusive thoughts and images, self blame Determination and resolve, sharper perception, courage optimism, faith Emotional Shock, sorrow, grief, sadness, fear, anger, numbness, irritability, guilt and shame Feeling involved, challenged, mobilized Social Extreme withdrawal, interpersonal conflict Social connectedness, altruistic helping behaviors Physiological Fatigue, headache, muscle tension, stomachache, increased heart rate, exaggerated startle response, difficulties sleeping Alertness, readiness to respond, increased energy Medical Reserve Corps Field Operations Guide http://www.nctsn.org/sites/default/files/assets/pdfs/MRC_PFA_04_02_08.pdf

When Terrible Things Happen Common Negative Reactions Intrusive reactions Avoidance and withdrawal reactions Physical arousal reactions (fight or flight) Reactions to trauma or loss reminders Medical Reserve Corps Field Operations Guide http://www.nctsn.org/sites/default/files/assets/pdfs/MRC_PFA_04_02_08.pdf https://web.stanford.edu/group/poeticthinking/cgi-bin/wordpress/?p=1459

When Terrible Things Happen Positive Reactions Enhanced appreciation for family and friends Meeting the challenge of addressing difficulties Shifting expectations and focusing on positive progress Shifting priorities to include quality time with friends and family Increased commitment to self, family, friends and faith Medical Reserve Corps Field Operations Guide http://www.nctsn.org/sites/default/files/assets/pdfs/MRC_PFA_04_02_08.pdf http://thinkpositive30.com/blog/wp-content/uploads/2012/03/focus.jpg

When Terrible Things Happen So… What do we do? Talk to others Engage in positive distracting activities Adequate rest and nutrition Take a break Focus on practical things that can be accomplished Relaxation methods Support group Exercise in moderation Keep a journal Seek counseling Medical Reserve Corps Field Operations Guide http://www.nctsn.org/sites/default/files/assets/pdfs/MRC_PFA_04_02_08.pdf

When Terrible Things Happen AND… What do we AVOID? Alcohol or drug use as an escape Extreme avoidance Violence or conflict Overeating or under eating Blaming others Working too much Withdrawal from friends and family Not taking care of yourself Doing risky things Withdrawal from pleasant activities Medical Reserve Corps Field Operations Guide http://www.nctsn.org/sites/default/files/assets/pdfs/MRC_PFA_04_02_08.pdf

Relaxation Techniques Deep Breathing Guided imagery Muscle tension/relaxation Yoga Thai Chi Medical Reserve Corps Field Operations Guide http://www.nctsn.org/sites/default/files/assets/pdfs/MRC_PFA_04_02_08.pdf http://www.unstressyourself.com/relaxation-techniques-stress-relief/

Relaxation Techniques For children Blowing bubbles with a bubble wand and dish soap Blow bubbles with chewing gum Blow paper wads or cotton balls around a table Tell a story where the child helps you imitate a character who is taking deep breaths Medical Reserve Corps Field Operations Guide http://www.nctsn.org/sites/default/files/assets/pdfs/MRC_PFA_04_02_08.pdf

Mental Health Overview

Personal Health Crisis - Causes Death of a Spouse or Family Member Marital Separation or Divorce Loss of a job Incarceration Personal Injury Natural Disasters Depression Substance Abuse Physical Abuse Mental Health Diagnosis (ie: Bipolar)

Anxiety Disorders Panic Disorders Phobia’s Emotional symptoms: Feelings of apprehension or dread Feeling tense and jumpy Restlessness or irritability Anticipating the worst and being watchful for signs of danger Physical symptoms: Pounding or racing heart and shortness of breath Upset stomach Sweating, tremors and twitches Headaches, fatigue and insomnia Upset stomach, frequent urination or diarrhea Panic Disorders Phobia’s Generalized Anxiety Disorder Social Anxiety Disorders Panic Disorder Characterized by panic attacks—sudden feelings of terror—sometimes striking repeatedly and without warning. Often mistaken for a heart attack, a panic attack causes powerful, physical symptoms including chest pain, heart palpitations, dizziness, shortness of breath and stomach upset. Many people will go to desperate measures to avoid having an attack, including social isolation or avoiding going to specific places. Phobias Everyone tries to avoid certain things or situations that make them uncomfortable or even fearful. However, for someone with a phobia, certain places, events or objects create powerful reactions of strong, irrational fear. Most people with specific phobias have several triggers. To avoid panicking, someone with specific phobias will work hard to avoid their triggers. Depending on the type and number of triggers, this fear and the attempt to control it can seem to take over a person’s life. Generalized Anxiety Disorder (GAD) GAD produces chronic, exaggerated worrying about everyday life. This can consume hours each day, making it hard to concentrate or finish routine daily tasks. A person with GAD may become exhausted by worry and experience headaches, tension or nausea. Social Anxiety Disorder Unlike shyness, this disorder causes intense fear, often driven by irrational worries about social humiliation–“saying something stupid,” or “not knowing what to say.” Someone with social anxiety disorder may not take part in conversations, contribute to class discussions, or offer their ideas, and may become isolated. Panic attack symptoms are a common reaction. Other anxiety disorders include: agoraphobia, separation anxiety disorder and substance/medication-induced anxiety disorder involving intoxication or withdrawal or medication treatment.

Bipolar Disorder Manic symptoms: “special powers” Risky Behaviors Impulsive Reckless Unaware of negative consequences Depression symptoms: Hopeless Unable to perform normal tasks Difficulty with falling and staying asleep Minor decisions are overwhelming Obsessed with feelings of loss, hopelessness, Suicidal ideation Mixed symptoms: Experience symptoms of both or in rapid sequence a chronic mental illness that causes dramatic shifts in a person’s mood, energy and ability to think clearly. People with bipolar have high and low moods, known as mania and depression Panic Disorder Characterized by panic attacks—sudden feelings of terror—sometimes striking repeatedly and without warning. Often mistaken for a heart attack, a panic attack causes powerful, physical symptoms including chest pain, heart palpitations, dizziness, shortness of breath and stomach upset. Many people will go to desperate measures to avoid having an attack, including social isolation or avoiding going to specific places. Phobias Everyone tries to avoid certain things or situations that make them uncomfortable or even fearful. However, for someone with a phobia, certain places, events or objects create powerful reactions of strong, irrational fear. Most people with specific phobias have several triggers. To avoid panicking, someone with specific phobias will work hard to avoid their triggers. Depending on the type and number of triggers, this fear and the attempt to control it can seem to take over a person’s life. Generalized Anxiety Disorder (GAD) GAD produces chronic, exaggerated worrying about everyday life. This can consume hours each day, making it hard to concentrate or finish routine daily tasks. A person with GAD may become exhausted by worry and experience headaches, tension or nausea. Social Anxiety Disorder Unlike shyness, this disorder causes intense fear, often driven by irrational worries about social humiliation–“saying something stupid,” or “not knowing what to say.” Someone with social anxiety disorder may not take part in conversations, contribute to class discussions, or offer their ideas, and may become isolated. Panic attack symptoms are a common reaction. Other anxiety disorders include: agoraphobia, separation anxiety disorder and substance/medication-induced anxiety disorder involving intoxication or withdrawal or medication treatment. Causes Scientists have not discovered a single cause of bipolar disorder. They believe several factors may contribute: Genetics. The chances of developing bipolar disorder are increased if a child’s parents or siblings have the disorder. But the role of genetics is not absolute. A child from a family with a history of bipolar disorder may never develop the disorder. And studies of identical twins have found that even if one twin develops the disorder the other may not. Stress. A stressful event such as a death in the family, an illness, a difficult relationship or financial problems can trigger the first bipolar episode. Thus, an individual’s style of handling stress may also play a role in the development of the illness. In some cases, drug abuse can trigger bipolar disorder. Brain structure. Brain scans cannot diagnose bipolar disorder in an individual. Yet, researchers have identified subtle differences in the average size or activation of some brain structures in people with bipolar disorder. While brain structure alone may not cause it, there are some conditions in which damaged brain tissue can predispose a person. In some cases, concussions and traumatic head injuries can increase the risk of developing bipolar disorder.

Family Issues Illness Disability Addiction Job Loss School problems Marital Issues

Depression Causes Symptoms Trauma Genetics Life Circumstances Brain Structure Other Medical Conditions (ie: chronic pain) Substance Abuse Symptoms Changes in sleep Changes in appetite Lack of Concentration Loss of Energy Lack of Interest Low Self Esteem Hopelessness Physical Aches and Pain Changes in movement (ie: agitated) Irrational thinking

Substance Abuse People abuse substances such as drugs, alcohol, and tobacco for varied and complicated reasons CAUSES: Factors within a family that influence a child's early development have been shown to be related to increased risk of drug abuse. Chaotic home environment Genetic risks (drug or alcohol abuse sometimes can run in families) Lack of nurturing and parental attachment Factors related to a child’s socialization outside the family may also increase risk of drug abuse. Inappropriately aggressive or shy behavior in the classroom Poor social coping skills Poor school performance Association with a deviant peer group Perception of approval of drug use behavior The National Institute on Drug Abuse estimated the number of users of illicit drugs in 2014 in the United States ages 12 and over to be about 7 million. In addition, the survey estimated that 6.4% of Americans (roughly 17 million adults) abuse or are dependent on alcohol.

Signs and Symptoms of Substance Abuse Cigarettes A distinctive smell on the breath and clothing Cigarettes and lighter in his or her possession Cigarette butts outside a bedroom window or in other odd places around the home Alcohol Alcohol or mouthwash (used to cover up alcohol) breath or hangover symptoms (nausea, vomiting, or headache), if recently used Marijuana Sweet smell on clothing or bloodshot eyes, if recently used, and frequent use of eye drops to reduce the redness Drug paraphernalia (pipes) in his or her possession Carelessness in grooming, increased fatigue, and changes in eating and sleeping patterns, if using regularly Inhalants Chemical breath, red eyes, or stains on clothing or face, if recently used Soaked rags or empty aerosol containers in the trash Club drugs Skin rash similar to acne Small bottles with liquid or powder in his or her possession Stimulants Persistent runny nose and nosebleeds, injection marks on arms or other parts of the body, or long periods of time without sleep Possession of drug paraphernalia, such as syringes, spoons with smoke stains, small pieces of glass, and razor blades LSD or other hallucinogens Trance-like appearance with dilated pupils, if recently used Small squares of blotter paper (sometimes stamped with cartoon characters) or other forms of the drug in his or her possession

Signs and Symptoms of Substance Abuse (cont.) Heroin Very small pupils and a drowsy or relaxed look, if recently used Possession of injecting supplies, called an outfit or rig, that may consist of a spoon or bottle cap, syringe, tourniquet, cotton, and matches Anabolic steroids An unpleasant breath odor Mood changes, including increased aggression Changes in physical appearance that can't be attributed to expected patterns of growth and development Possession of medicines or syringes Other general signs Changes in sleeping patterns Changes in appetite or weight loss Changes in dress Loss of interest and motivation Hoarseness, wheezing, or persistent cough

Physical & Emotional/Verbal Abuse Physical abuse intentional act causing injury or trauma to another person by way of bodily contact. domestic violence work aggression Emotional and Verbal Abuse “checking in” Excessive testing Humiliation Intimidation Isolation Stalking

Counseling tips and techniques

Conversation openers Have a plan in mind Encourage exploration Initial quarter Increase understanding Middle half Facilitate action Final quarter

Relationship building Help your patient feel Valued and respected Understood They should feel safe enough to Tell their story Express emotions and fears

Interviewing Techniques Body Language Non verbal communication Active listening Reflective feeling Summarizing and restating Open ended questions

Non Verbal Communication Body language Head nodding Attention Being present

Active Listening Giving full attention Avoid internal conversations “Uh huh” & “Right” Reflect thoughts feelings and observations Develop an emotional language

Emotional Language Mad Bad Sad Glad Afraid Others Annoyed Belligerent Broken Cheerful Anxious Bold Cross Cruel Crushed Elated Hesitant Curious Enraged Devious Flat Enthusiastic Insecure In-tune Furious Envious Gloomy Excited Panicky Loving Losing it Jealous Heart broken Festive Scared Proud Out of control Rebellious Suffering Jubilant Shaky Sensual Sullen Sulky Tortured Merry Terrified Tender From : Counseling for Dummies (2013), G. Evans, P. 138

Building Rapport Don’t put words in a patient’s mouth Better to voice what a patient MAY be feeling and normalize it

Landmines Silence Look at the speaker, especially their eyes Looking up Thinking about or picturing something 1,000 yard stare Having an inner conversation Looking down Engulfed in his/her feelings

Landmines

Depression screening Beck Depression Index PHQ-9

Add all circled answers Add all circled answers.  For every answer circled: Not at all = 0 Several Days = 1 More than half the days = 2 Nearly every day = 3

Crisis Intervention Psychological First Aid Protocol Contact and engage the patient Is patient safe? Stabilization Identify needs and concerns Assist with needs and concerns Connect patient with support Educate about stress reactions and promote coping techniques Connect patient with local collaborative services Source: http://www.fpnotebook.com/psych/Exam/PsychlgclFrstAd.htm http://www.nctsn.org/content/psychological-first-aid

https://www. slideshare https://www.slideshare.net/drsunilsuthar/crisis-intervention-in-psychiatry

https://www. slideshare https://www.slideshare.net/drsunilsuthar/crisis-intervention-in-psychiatry

https://www. slideshare https://www.slideshare.net/drsunilsuthar/crisis-intervention-in-psychiatry

https://www. slideshare https://www.slideshare.net/drsunilsuthar/crisis-intervention-in-psychiatry

https://www. slideshare https://www.slideshare.net/drsunilsuthar/crisis-intervention-in-psychiatry

Case Studies Stress PTSD MTBI Military Service

PTSD Screening Tool Introduction In your life, have you ever had any experience that was so frightening, horrible, or upsetting that In the PAST MONTH, you (1 point for each positive) Have had Nightmares about it or thought about it when you did not want to? Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings? Interpretation Suggestive of PTSD if score of 3 or 4 References Prins (2003) Primary Care Psychiatry 9: 9-14 [PubMed] http://www.fpnotebook.com/psych/Exam/PrmryCrPtsdScrn.htm

Case Studies Depression/Anxiety Marital issues Divorce Abuse Sexual dysfunction

Case Studies Death of a child SIDS Child killed in Pedestrian MVC Child abuse allegations (UNFOUNDED) DYFS took children away during investigation Child killed in Pedestrian MVC Mom withdraws from husband and living children

Case Studies Immigration Stress Fear Vs

Substance Abuse Abusing adult child placing family at risk Alcoholic living in woods Blames staff for termination Anger mgmt case THC positive (lifestyle) Lost custody due to termination

Case Studies End of life issues Elder care issues Employee Spouse Parent of employee Elder care issues Parent in home difficult to manage Parent out of state/country Logistical nightmare

Case Studies Fatality CISD Needs of employees Self preservation

Resources Location of psychiatric emergency services http://www.therapistaid.com http://www.fpnotebook.com/psych/ http://www.nctsn.org/content/psychological-first-aid https://www.slideshare.net/drsunilsuthar/crisis-intervention-in-psychiatry https://www.nctsn.org/resources/psychological-first-aid-pfa-field-medical-reserve-corps-field-operations-guide

Questions? Thank you