A  Mul&-­‐Systemic  Psychosocial  Support  Model  for  Responding  to  

Disasters  and  Mass  Violence  

Gilbert  Reyes,  PhD  Affiliate  Member  

Na&onal  Child  Trauma&c  Stress  Network  (NCTSN)  Disaster  Relief  Chair  

Trauma  Psychology  Division  (56)  of  APA    

The  previously  scheduled  program  has  been  interrupted  for  this  breaking  news  story:  

APA  Stunned  by  Revela&ons  in  the  Hoffman  Report.  On  Eve  of  Annual  Conven&on,  Crack  Team  of  Trauma  Psychologists  Deployed  to  Toronto  to  Heal  the  Survivors  

Learning  Objec&ves  

Par&cipants  will  be  able  to:  1).  Itera&vely  map  the  “dose  of  exposure”  terrain  in  the  aWermath  of  a  disaster.  2).  Dynamically  map  the  currently  and  readily  available  resources  for  responding  to  the  an&cipated  psychosocial  needs.  3).  Match  exis&ng  resources  to  the  an&cipated  and  manifest  psychosocial  support  needs  with  cultural  sensi&vity  and  responsiveness  to  change  across  &me.  

Presenter  Background  Early  Career:    •  Faculty  at  the  Disaster  Mental  Health  Ins&tute,  Univ.  of  S.  

Dakota  –  Major  Product:  Handbook  of  Interna&onal  Disaster  Psychology  (Edited  4  Vols.)  

–  Ac&vi&es:  Research  and  Training  Consulta&ons  with  World  Health  Organiza&on  (WHO),  Interna&onal  Society  of  Red  Cross  and  Red  Crescent  Socie&es  (IFRC),  etc.  

–  Rapid  Assessment  of  Refugee  Mental  Health  Needs  –  Development  of  Trainers  and  Training  Curriculum  for  Community-­‐Based  Psychological  Support  

–  Major  Experiences:  1999  –  Tornadoes  (Oklahoma);  1999  –  Hurricane  (N.  Carolina);  2000  –  Terrorism  (Kenya);  2000  –  Massive  Flood  (Venezuela);  2001  –  Na&onal  PFA  Conference  (Cuba);  2001  –  Terrorism  (New  York);  2002  –  Consulta&on  at  IFRC  (Switzerland);  2002  –  IFRC  Training  of  Easter  European  Delegates  (Hungary)  

Presenter  Background  Mid-­‐Career:    •  Faculty  Administrator  at  Fielding  Graduate  University  (now  

adjunct  faculty)  –  Main  Product:  Encyclopedia  of  Psychological  Trauma  (Lead  Editor,  with  Elhai  &  Ford)  

–  Ac&vi&es:  Member  of  the  NCTSN  •  Terrorism  and  Disaster  Center  

–  Hurricane  Katrina  Research  – Manual  for  Working  with  Displaced  Popula&ons  –  Disaster  Research  Training  Program  

•  UCLA  –  Na&onal  Center  for  Child  Trauma&c  Stress  –  Terrorism  and  Disaster  Network  –  Psychological  First  Aid  (Development  and  Training)  –  Skills  for  Psychological  Recovery  (Development  and  Training)  –  Task  Force  on  the  Core  Curriculum  on  Childhood  Trauma  

–  Research:  Wildfire  Research  Team  (UCSB  &  Univ.  of  Iowa)  

Personal  Lessons  Learned  •  Almost  nothing  in  graduate  school  (clinical  psychology)  prepared  me  for  

the  American  Red  Cross  model  of  Disaster  Mental  Health  (RC  –  DMH)  –  Paramilitary  aitudes  and  culture  (“swaggering  lifers”)  –  Reliance  on  heroics  rather  than  servant  leadership  and  robust  

adap&ve  personnel  systems  (just  like  in  the  movies)  –  S&gma&zed  iden&ty  of  DMH  mission  and  personnel  –  Small  army  of  licensed  mental  health  clinicians  (advance  to  the  

rear)  –  Minimal  workforce  training  and  prepara&on  (intro  to  RC  and  intro  

to  DMH)  –  Minimal  grasp  of  “community  psychology”  and  “public  health  

model”  –  No  clear  and  consistent  model  of  service  delivery  or  outcome  

objec&ves  –  Inadequate  feedback  loops  for  program  evalua&on  or  product  

improvement  –  Inadequate  efforts  to  mi&gate  occupa&onal  hazards  (i.e.,  

secondary  or  vicarious  trauma&c  stress,  and  compassion  fa&gue)  

Current  ARC-­‐DMH  seems  improved  

Current  ARC-­‐DMH  seems  improved  

Current  ARC-­‐DMH  seems  improved    

Literature  Review  Brymer,  M.,  Jacobs,  A.,  Layne,  C.,  Pynoos,  R.,  Ruzek,  J.,  Steinberg,  A.,  Vernberg,  E.,  &  Watson,  P.,  (2006).  Psychological  First  Aid:  Field  Opera&ons  Guide  (2nd  Ed.).  Published  by  the  Na&onal  Child  Trauma&c  Stress  Network  and  Na&onal  Center  for  PTSD.    •  Expert  and  key  informant  based  consensus  and  evidence  informed  

descrip&on  of  principles  and  prac&ces  for  suppor&ng  resilient  recovery  from  poten&ally  trauma&c  experiences.    

•  Framework  s&pulates  eight  “core  ac&ons”:  contact  and  engagement,  safety  and  comfort,  stabiliza&on,  informa&on  gathering,  prac&cal  assistance,  connec&on  with  social  supports,  informa&on  on  coping  support,  and  linkage  with  collabora&ve  services.    

•  Includes  many  handouts,  and  comes  in  versions  addressing  the  par&cular  context  of  schools,  religious  professions,  and  in  a  number  of  transla&ons.    

•  Also:  6-­‐hour  interac&ve  PFA  online  course  and  a  PFA  Mobile  app.  

Literature  Review  Hobfoll,  S.  E.,  Watson,  P.,  Bell,  C.  C.,  Bryant,  R.  A.,  Brymer,  M.  J.,  Friedman,  M.  J.,  Friedman,  M.,  Gersons,  B.  P.  R.,  deJong,  J.  T.  V.,  Layne,  C.  M.,  Maguen,  S.,  Neria,  Y.,  Norwood,  A.  E.,  Pynoos,  R.  S.,  Reissman,  D.,  Ruzek,  J.  I.,  Shalev,  A.  Y.,  Solomon,  Z.,  Steinberg,  A.,  &  Ursano,  R.  J.  (2007).  Five  essen&al  elements  of  immediate  and  mid-­‐term  mass  trauma  interven&on:  Empirical  evidence.  Psychiatry:  Interpersonal  and  Biological  Processes,  70,  283-­‐315.    •  AWer  extensive  review  of  evidence  for  mass-­‐trauma  

interven&ons,  these  essen&al  elements  were  iden&fied:    –  1)  a  sense  of  safety  –  2)  calming  –  3)  a  sense  of  a)  self–efficacy  and  b)  community  efficacy  –  4)  connectedness  –  5)  hope.  

Literature  Review  McCabe,  O.  L.,  Everly,  G.S.,  Brown,  L.M.,  Wendelboe,  A.M.,  Hamid,  N.H.,  Tallchief,  V.L.,  Links,  J.  (2014).  Psychological  first  aid:  A  consensus-­‐derived,  empirically-­‐supported,  competency-­‐based  training  model.  American  Journal  of  Public  Health,  104(4),  621-­‐628.  •  Describes  a  competency-­‐based  model  for  PFA  training  developed  in  

conjunc&on  with  the  Centers  for  Disease  Control  and  Preven&on  and  the  Associa&on  of  Schools  of  Public  Health.    

•  Established  a  consensus  set  of  6  KSA  (knowledge,  skills,  aitudes)  core  competencies:    –  1.  ini&al  contact,  rapport  building,  and  stabiliza&on;  –  2.  brief  assessment  and  triage;  –  3.  interven&on;  –  4.  triage;  –  5.  referral,  liaison,  and  advocacy;    –  6.  self-­‐awareness  and  self-­‐care.  

•  Proposal  is  that  these  results  could  serve  as  a  curricular  basis  for  fulfilling  the  aims  of  the  Pandemic  and  All-­‐Hazards  Preparedness  Act  of  2006  (i.e.,  to  train  public  health  prac&&oners  to  promote  public  health  preparedness  and  response  by  teaching  these  competencies  to  lay-­‐providers).  

Literature  Review  Bisson,  J.  I.,  &  Lewis,  C.  (2009)  Systema&c  review  of  Psychological  First  Aid.  Geneva:  World  Health  Organiza&on.    •  Reviewed  published  studies  regarding  the  use  of  PFA,  finding  

none  had  any  data  and  that  there  were  no  empirical  studies  of  efficacy  or  effec&veness.    

•  Recommends  that  emergency  interven&ons  should  focus  on  well-­‐established  risk  factors:  a)  peri-­‐trauma&c  dissocia&on  and  b)  perceived  inadequacy  of  social  support.    

•  Cites  NATO,  TENTS  and  IASC  recommenda&ons  that  favor    –  “social”  and  “community”  focused  interven&ons  over  “individual”  and  

“psychological”  targets  (i.e.,  public  health  model  and  community  psychology),  –   but  with  capabili&es  for  detec&ng  clinical  needs  and  referral  to  more  

adequate  services.    

•  Supports  the  principles  underlying  PFA.  

Literature  Review  Dieltjens,  T.,  Moonens,  I.,  Van  Praet,  K.,  De  Buck,  E.,  &  Vandekerckhove,  P.  (2014).  A  systema&c  literature  search  on  psychological  first  aid:  Lack  of  evidence  to  develop  guidelines.  PLoS  ONE,  9(12),  e114714.  •  Belgian  Red  Cross  (Flanders)  tried  to  ensure  that  its  

volunteers  were  trained  in  the  best  way  possible.  •  Reviewed  5  bibliographic  databases  and  found  no  published  

evidence  regarding  the  effec&veness  of  PFA.  •  Conclusion:  No  empirical  evidence  to  develop  guidelines.  

Literature  Review  Forbes,  D.,  Lewis,  V.,  Varker,  T.,  Phelps,  A.,  O'Donnell,  M.,  Wade,  D.,  Ruzek,  J.,  Watson,  P.,  Bryant,  R.,  &  Creamer,  M.  (2011).  Psychological  first  aid  following  trauma:  Implementa&on  and  evalua&on  framework  for  high-­‐risk  organiza&ons.  Psychiatry,  74(3),  224–239.  •  Laments  lack  of  empirical  evidence  for  PFA  •  Acknowledges  the  difficul&es  of  conduc&ng  such  studies  in  

most  real-­‐world  situa&ons  •  Recommends  a  phasic  framework  for  establishing  and  

evalua&ng  PFA  within  high-­‐risk  organiza&ons.  –  Pre-­‐event:  

•  Phase  1:  PFA-­‐consistent  organiza&onal  policies  &  procedures  •  Phase  2:  PFA  promo&on  and  staff  training  

–  Post-­‐event:  •  Phase  3:  PFA  response  •  Phase  4:  Monitoring  and  follow-­‐up  of  staff  

Literature  Review  Lewis,  V.,  Varker,  T.,  Phelps,  A.,  Gavel,  E.,  &  Forbes,  D.  (2013).  Organiza&onal  implementa&on  of  psychological  first  aid  (PFA):  Training  for  managers  and  peers.  Psychological  Trauma:  Theory,  Research,  Prac&ce  and  Training,  6(6),  619–623.  •  Describes  a  pilot  evalua&on  of  training  provided  to  managers  

and  peer-­‐supporters  in  a  high-­‐risk  organiza&on  according  to  the  Phased  PFA  model  proposed  by  Forbes  et  al.  (2011).  

•  Trainees  demonstrated  small  but  significant  gains  in    –  PFA  and  PTE  content  knowledge  –  Self-­‐reported  increased  sense  of  confidence  in  being  prepared  to  

respond  to  incidents  

Literature  Review  Legerski,  J.  P.,  Vernberg,  E.  M,  &  Noland,  B.  J.  (2012).  A  qualita&ve  analysis  of  barriers,  challenges,  and  successes  in  mee&ng  the  needs  of  Hurricane  Katrina  evacuee  families.  Community  Mental  Health  Journal,  48,  729-­‐740.  DOI  10.1007/s10597-­‐011-­‐9446-­‐1  •  Used  qualita&ve  focus  groups  to  generate  an&cipated  mental  

health  needs,  displacement-­‐related  challenges,  and  secondary  adversi&es.    

•  Iden&fied  concerns  were  as  might  be  expected  (coping  with  exposures,  unemployment  and  financial  pressures,  housing  and  transporta&on  difficul&es,  material  losses,  exacerba&on  of  pre-­‐exis&ng  psychological  condi&ons).    

•  A  major  concern  was  that  providers  lacked  cultural  competence  to  work  with  a  displaced  popula&on  from  a  very  different  cultural  background  and  milieu  (encountering  the  “other”).    

•  There  were  also  expressions  of  apprehension  regarding  the  challenges  of  working  with  survivors  who  typically  engaged  in  illegal  or  unethical  behaviors  (nega&ve  stereotype  of  these  evacuees).  

Literature  Review  Reifels,  L.,  Naccarella,  L.,  Blashki,  G.,  &  Pirkis,  J.  (2014).  Examining  disaster  mental  health  workforce  capacity.  Psychiatry:  Interpersonal  and  biological  processes,  77(2),  199-­‐205.  •  Examined  the  capacity  of  a  disaster  mental  health  workforce  

to  provide  three  evidence-­‐supported  interven&on  types:  –  psychological  first  aid  –  skills  for  psychological  recovery  –  intensive  mental  health  treatments  

•  From  32  to  42%  of  this  workforce  self-­‐reported  a  composite  of  perceived  skills,  experiences,  and  confidence  in  being  able  to  deliver  these  interven&ons.    

•  Recommenda&on  is  for  increased  aren&on  to  workforce  capacity-­‐building.  

Literature  Review  Akoury-­‐Dirani,  L.,  Sahakian,  T.  S.,  Hassan,  F.  Y.,  Hajjar,  R.  V.,  &  Asmar,  K.  E.  (2015).  Psychological  First  Aid  training  for  Lebanese  field  workers  in  the  emergency  context  of  the  Syrian  refugees  in  Lebanon.  Psychological  Trauma:  Theory,  Research,  Prac&ce,  and  Policy.  Advance  online  publica&on.    •  Best  published  evalua&on  of  the  training  effect,  but  no  data  

on  the  interven&on  effect.    •  Examined  efficacy  of  2.5-­‐day  na&onal  PFA  training  program  in  

preparing  mental  health  field  workers  to  work  with  Syrian  refugees.    

•  Content  knowledge  and  skills  measured  at  pre,  immediate  post-­‐training,  and  aWer  one  month  suggested  a  durable  training  effect.  

Literature  Review  Conclusions  Numerous  areas  of  improvement  are  needed:  •  Overall  workforce  preparedness  for  providing  psychosocial  

support  remains  inadequate  •  Emergency  phase  psychosocial  support  interven&ons  are  well  

defined,  but  their  effec&veness  remains  in  ques&on  •  Despite  excep&ons  like  the  Red  Cross,  the  models  of  service  

delivery  are  not  well  defined  •  Models  of  service  delivery  are  not  well  researched  •  Cultural  varia&on  in  the  accessibility,  acceptability,  credibility,  

sustainability,  and  effec&veness  of  disaster  interven&ons  are  not  well  researched  (i.e.,  what  is  cultural  competence?)  

•  Differen&al  effec&veness  of  approaches  to  training  are  not  well  researched  

•  Quality  assurance  of  provider  competence  is  unexamined  

Case  Example:  Santa  Barbara  Response  Network  Grassroots  organiza&on  (501c3)  founded  in  2009  in  response  to  community-­‐level  poten&ally  trauma  events  that  fell  through  the  cracks  (not  covered  by  Red  Cross,  Vic&m’s  Assistance,  Hospice)  •  Suicides  •  Community  violence  •  Violent  accidents  Interven&on:  •  Psychological  First  Aid  Training  and  Prepara&on:  •  Volunteers  are  taught  incident  command  system  (ICS)  and  

PFA  in  accordance  with  the  NCTSN/NCPTSD  materials  •  Role  plays  and  incident  simula&ons  •  Excep&onal  performance  leads  to  leadership  roles    

Case  Example:  Santa  Barbara  Response  Network  Model  of  Service  Delivery:  •  Trained  PFA  teams  of  commensurate  size  deploy  by  invita&on  

to  loca&ons  where  psychosocial  support  is  considered  appropriate  and  accessible  

•  Where  appropriate  a  proximal  base  of  opera&ons  is  established  as  a  “Compassion  Center”  and  staffed  with  trained  volunteers  

•  To  accomplish  informa&on  gathering  and  other  outreach  goals  pairs  and  trios  of  volunteers  (no  solos)  are  deployed  as  “Compassion  Patrols”  

•  Execu&ve  consulta&ons  are  provided  to  leaders  of  affected  systems  and  responsive  systems  

•  Public  health  approaches  are  employed  for  dissemina&ng  informa&on  on  coping  and  resilience  behaviors  

   

Case  Example:  Santa  Barbara  Response  Network  Dose  of  Exposure  and  Needs  Assessment:  •  Mee&ng  is  held  of  key  informants  from  affected  and  

responsive  systems  •  An&cipated  doses  of  exposure  are  mapped  in  accordance  with  

the  es&mated  severity  of  event  impact  •  Concentric  circles  and  spa&al  loca&ons  are  used  to  represent  

higher  and  lower  an&cipated  doses  of  exposure  (e.g.,  inner  and  outer  rela&onal  circles)  

•  Dis&nct  systems  and  individuals  are  iden&fied  to  take  responsibility  for  inves&ga&ng  actual  impacts  and  needs  within  each  circle  (accountability)  

•  Assump&ons  are  revised  based  on  rapid  feedback  to  allow  tailoring  of  the  response  

•  Needs  maps  are  dynamic  and  revised  at  least  daily  

Case  Example:  Santa  Barbara  Response  Network  Resource  Mapping:  •  First  itera&on  is  based  on  generic  assump&ons  and  familiar  

resources  •  Second  itera&on  is  responsive  to  key  informant  feedback  on  

more  specific  characteris&cs  of  the  cri&cal  event  •  Subsequent  itera&ons  are  responsive  to  changing  needs  

across  &me  and  discovery  of  emergent  resources  •  Cultural  factors  are  ac&vely  iden&fied  through  culture-­‐

brokers,  allowing  improvement  of  the  cultural  acceptability  and  credibility  of  resources  and  services  

•  Resource  maps  are  dynamic  and  revised  frequently  

Incident  Example:  Killing  Spree  in  Isla  Vista,  2014  •  Six  UCSB  students  killed  and  over  a  dozen  other  community  

members  injured  –  Crime  scene  of  almost  a  square  mile  –  Grisly  details  included  mul&ple  stab  wounds  to  3  vic&ms  –  Intense  news  media  coverage  of  killer  and  his  hateful  internet  

manifesto  –  Poli&cal  barle  erupts  over  gun  violence  and  gun  rights  

•  University  of  California  campus  and  broader  system  profoundly  affected  

•  Ci&zens  and  government  of  the  county  profoundly  affected  •  Unusual  characteris&cs  of  Isla  Vista  require  careful  planning  

–  No  official  governance  or  leadership  –  Not  all  students  –  Underserved  La&no  community  

Response  Example:  Killing  Spree  in  Isla  Vista  •  Mee&ng  of  response  planning  representa&ves  within  hours  •  First  itera&on  of  exposure  dosage  and  needs  map  is  

constructed  •  Systems  and  individuals  are  assigned  as  agents  to  ini&ate  

contacts,  gather  informa&on,  and  inform  the  response  •  First  itera&on  of  resource  map  is  constructed  •  Systems  and  individuals  are  assigned  to  gather  informa&on  

about  addi&onal  resources  •  A  PFA  team  is  formed  and  deployed  for  the  first  of  the  

memorial  vigils  •  Loca&ons  for  the  Compassion  Center  are  iden&fied  •  Law  enforcement  and  other  partners  are  enlisted  to  support  

the  deployment  of  PFA  Compassion  Patrols  in  the  affected  neighborhoods  

Response  Example:  Killing  Spree  in  Isla  Vista  •  Volunteers  are  recruited  and  trained  in  PFA  and  the  incident  

management  system  •  Bilingual/bicultural  teams  are  formed  for  La&no  neighbors  •  Experienced  volunteers  are  paired  with  newbies  •  Coordina&on  is  managed  with  UCSB  catchment  system  to  

avoid  duplica&on  and  ensure  concerted  coopera&on  •  Daily  feedback  is  incorporated  into  opera&ons  and  

disseminated  in  daily  briefings  •  Beyond  the  immediate  aWermath,  Compassion  Center  

ac&vi&es  are  geared  toward  community  psychology  and  advocacy  for  non-­‐violent  and  compassionate  approaches  to  conflict-­‐resolu&on  

•  Compassion  Center  re-­‐opens  at  original  loca&on  for  a  week  of  anniversary  remembrance  and  social  support  

Subsequent  Incident  Responses  A  father  murders  his  mother  and  father,  his  two  young  sons,  and  kills  the  family  dog.  •  Response  model  used  for  Isla  Vista  is  employed  and  tweaked  

to  berer  serve  the  affected  schools  and  neighborhoods  A  high  school  student  is  killed  in  a  fiery  car  crash  •  A  compassion  center  is  established  the  next  day  and  staffed  

by  school  personnel  aWer  a  brief  orienta&on  training  •  An  execu&ve  consulta&on  is  held  with  school  officials  to  

prepare  for  dealing  with  parents,  students,  staff,  news  media,  and  subsequent  public  events  and  memorials  

A  student  at  the  same  high  school  commits  suicide  •  The  school  staff  reac&vate  their  compassion  center  with  

minimal  need  of  external  support  •  Compassion  center  in  a  box  

Skills  for  Psychological  Recovery  (SPR)  Psychological  2nd  Aid  

Berkowitz,  S.,  Bryant,  R.,  Brymer,  M.,  Hamblen,  J.,  Jacobs,  A.,  Layne,  C.,  Macy,  R.,  Osofsky,  H.,  Pynoos,  R.,  Ruzek,  J.,  Steinberg,  A.,  Vernberg,  E.,  &  Watson,  P.  (2010).  The  Na&onal  Center  for  PTSD  &  the  Na&onal  Child  Trauma&c  Stress  Network,  Skills  for  Psychological  Recovery:  Field  Opera&ons  Guide.  

Skills  for  Psychological  Recovery  (SPR)  

Basic  Goals  and  Objec&ves:    1.  Protect  the  mental  health  of  disaster  survivors    2.  Enhance  survivors’  abili&es  to  address  their  needs  and  concerns    3.  Teach  skills  to  promote  the  recovery  of  children,  adolescents,  adults,  and  families    4.  Prevent  maladap&ve  behaviors  while  iden&fying  and  suppor&ng  adap&ve  behaviors  

Skills  for  Psychological  Recovery  (SPR)  

Core  Skills:  – Building  Problem-­‐Solving  Skills  – Promo&ng  Posi&ve  Ac&vi&es  – Managing  Reac&ons  – Promo&ng  Helpful  Thinking  – Rebuilding  Healthy  Social  Connec&ons  

Occupa&onal  Hazards  of  Trauma  Exposure  

Secondary  Trauma&c  Stress:  “emo&onal  duress  that  results  when  an  individual  hears  about  the  firsthand  trauma  experiences  of  another.  Its  symptoms  mimic  those  of  PTSD”  

Vicarious  Trauma:  “transforma&on  in  the  self  of  a  trauma  worker  or  helper  that  results  from  empathic  engagement  with  trauma&zed  clients  and  their  reports  of  trauma&c  experiences.  Its  hallmark  is  disrupted  spirituality,  or  a  disrup&on  in  the  trauma  workers'  perceived  meaning  and  hope”  

Compassion  Fa&gue:  “gradual  lessening  of  compassion  over  &me”  

Frame  of  Reference  Hazards  

Trauma-­‐Drama:    

Heroes  –  Vic&ms  –  Villains    

Frame  of  Reference  Hazards  

Conclusion  1.  Providing  community-­‐based  psychosocial  support  requires  a  dis&nct  skill  

set  from  those  of  counseling  and  psychotherapy.  2.  Community  psychology  is  an  accessible  and  acceptable  approach  to  

providing  non-­‐s&gma&zing  and  empowering  support  in  PTEs  3.  PFA  is  a  readily  learned  and  accessible  interven&on  by  MHPs  and  at  the  

lay-­‐level  4.  PFA  is  a  scalable  method  of  providing  all-­‐hazards  psychosocial  support  5.  Local  capacity  building  for  responding  to  PTEs  is  possible  and  sustainable,  

but  challenging  6.  Mapping  exposure  dosage,  needs,  and  resources  supports  a  deliberate  

and  strategic  response  and  helps  to  detect,  monitor,  and  respond  to  what  might  otherwise  be  overlooked  

7.  We  s&ll  need  to  develop  non-­‐RCT  methods  for  evalua&ng  the  compara&ve  effec&veness  of  early  interven&ons  

8.  Clinicians  are  advised  to  carefully  take  stock  of  their  psychological  and  emo&onal  vulnerabili&es  and  mindfully  self-­‐monitor  their  reac&ons  

 Ques&ons  and  Comments?