Psychological First Aid Dr. de Klerk
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Transcript of 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
When to make a referral to EAPmore subtle signs
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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When to make a referral to EAPmore subtle signs
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