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

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

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

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

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

In a study using a mixed method approach the following questions were analysed

Quantitative data analysisWhich 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

In a study using a mixed method approach the following questions were analysed

Qualitative data analysisWhich 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

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

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)

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 resultsSubjectively perceived resources

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

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

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

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

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)

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

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

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

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

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

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

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

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

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