Compassion, Common Sense & Continuity: a partnership model in crisis response

1. Compassion, Common Sense & Continuity:a partnership model in crisis response Mandy RutterClinical Manager, FIRSTcall/CRISIScallICAS UK

2. PROGRAMME OF SESSION • Introductions & plan of workshop • Drivers for change • Organisational issues • Interventions • - Psychological First Aid, • - Trauma Focussed Interpersonal Psychotherapy • Activity • Future directions • Feedback & discussion

3. DEBRIEFING – OUR MODEL • Apparently sound clinical intervention • Modular approach - easily operationalised • Affiliates understood it - paid to be trained in it • Applied to both group and individual settings • Internationally available • Enhanced credibility and reputation of ICAS

4. INTERNAL CRITICISMS OF OUR MODEL • No empirical evidence demonstrating effectiveness • One outcome study was inconclusive • Clinical staff increasingly split on views of its effectiveness/appropriateness • Many “follow-up” onsite groups were not authorised by organisations.

5. EXTERNAL FACTORS • Many National, International Disasters • Further studies on criticisms of debriefing • Psychological First Aid • Concept of Resilience • “Treatment” modality inappropriate

6. INITIAL RESPONSE TO TRAUMA “Debriefing is inert at its best and possibly detrimental to some” (Rose, Bisson and Wessely, 2004)

7. “For individuals who have experienced a traumatic event, the systematic provision to that individual alone of brief, single session interventions (often referred to as debriefing) that focus on the traumatic incident, should not be routine practice when delivering services.” National Institute for Clinical Excellence, 2005

8. So what should we do?

9. “Efforts should be made to enhance the capacity of existing networks, both formal and informal, to support recovery and resilience.” (Bulletin of World Health Organisation, 2005)

10. “assistance should be offered to promote the objective of improving the quality of the recovery environment in support of the aim of helping survivors make phased adaptations and eventual adjustment to what has happened” (Orner, King et al, 2003)

11. Trauma is……….. “sudden uncontrollable disruption of affiliate bonds”

12. SURVEY OF HIGH RISK OCCUPATIONAL GROUPS (ORNER ET AL 2003): • 80% of employees wanted to talk to someone about the incident • 71% prefer to talk to colleague • 72% prefer to talk to someone close to them • 9% prefer to talk to independent professional • 85% prefer to talk in free and flexible manner

13. IS EARLY INTERVENTION STILL VIABLE? • Requested by Employers • Appreciated by Employees, customers, passengers. • Dealing with disequilibrium • Evidence of increased complexity of symptoms • over time • Research on Early Intervention • White paper criminal compensation

14. WORKPLACE INCIDENT – THE CONTEXT Employers want: • employees to know they care • to provide resources for affected staff • to understand the impact of the trauma on the staff • to regain workgroup cohesion • to return the workplace to effective performance and productivity • to prevent absenteeism • to reduce the potential for compensation claim

15. SHAREHOLDER VALUE REACTION TO DISASTERS RECOVERS-Initial loss 5% capitalisation. After 50 days, gained 5% over the pre-crisis value. NON-RECOVERS-Initial loss 11% capitalisation continued to fall over period of 12 months.

16. SHAREHOLDER VALUE REACTION TO DISASTERS 50 40 30 20 ValueReaction (%) 10 0 -10 -20 -30 Non-recoverers Recoverers Event Trading Days

17. WHAT REALLY MATTERS “In crises, the key determinant of whether a company’s reputation and share value will recover depends on the ability of the: • senior management to demonstrate strong leadership and communicate with honesty and transparency” • CEO to respond with sensitivity and compassion to victims families “Those companies which prepare and react appropriately at the right time have a higher chance of recovery than those which do not” “Companies that use an outside disaster management service provider performed 40% better than those that did not” (Knight, 2005)

18. JOHNSON AND JOHNSON: TYLENOL TAMPERING • managed the current situation • planned for the future Refer to the ‘Credo’ • stopped the production • stopped advertising • recalled all capsules (31 million) • continuous relationship with other authorities • reward for information • Gave 2500 press interviews (125,000 news clippings)

19. AIR FRANCE CONCORDE AIR DISASTER “Germany and France are united in their horror over the accident, in mourning for the victims and in sympathy for their families”

20. “Disasters focus the glare of attention on top management, if the company communicates well and shareholders and investors view the event as well-managed, the impact on stock values is generally positive” (Knight & Petty 1997 “the impact of catastrophes on shareholder value”)

21. “One of the great shortcomings in most managers is that they appear cold, arrogant, unfeeling, and corporately driven when bad things happen and there are victims. These behaviours are the source of employee anger and frustration; litigation; angry neighbours; and bad, embarrassing media coverage. Say you are sorry. Help the victims no matter what. Treat everyone as thought they were a member of your family” Lukaszewski (1999)

22. Opportunities for educating staff on trauma response • •Directors • • Managers • • Employees • Seminars, training, education • Coaching, briefings, communication

23. INTENSE STRESS REACTION (FIGHT OR FLIGHT RESPONSE) Parts of brain active/inactive(event feels disjointed some parts clear others lost) Only parts of brain needed for survival active(think and behave logically and rationally) Increased flow of blood to brain, quickens speed of brain activity(incident in slow motion) Brain goes into overdrive - absorbs detailed information(vivid visual impressions) Pupils dilate allowing extra peripheral vision(means of escape) Breathing becomes shallow and fast(hyperventilation) Increased heart rate(palpitations /heart attack) Muscles of jaw, mouth and forehead tense(headaches) Shut down of feelings(auto pilot/emotional numbness) Digestion stops(dry mouth) Excessive amounts of adrenaline unless able to burn off through intense activity(shaking) Unusual blood flow patterns(hot or cold) Muscles tense - shoulders, arms, back and legs(muscular pain) Colon starved of blood(constipation)or Bowels suddenly emptied to lighten body(defecation) Freeze/immobile body appears limp/motionless(not feel pain/analgesia)

24. IMMEDIATE EFFECTS PHYSICAL symptoms of shock FEELINGS fear denial anxiety BEHAVIOURAL crying hysterical automatic pilot wandering around COGNITIVE Why me? I must tell … What if ….

25. ICAS “BEST PRACTICE APPROACH” Stabilisation Psychological first aid ‘watchful waiting’, assessment tools Assessment Trauma focused IPT Trauma focused CBT Treatment onsite / individual

26. SKILLS & ATTRIBUTES REQUIRED FOR IMMEDIATE RESPONSE • Offer a reassuring and confident approach • Ability to stay calm under pressure • Ability to give “space” • Ability to judge when to enter that “space” • Be able to listen • Show empathy without sympathy • Think practically and take action • Be able to respond to difficult questions • Be able to handle the “not knowing”

27. PSYCHOLOGICAL FIRST AID Attend to Basic needs, with Compassion Psychological First Aid – use of pragmatic-orientated interventions delivered during the immediate – impact phase of a trauma to people who are at risk of being unable to regain sufficient functional equilibrium by themselves

28. THE ESSENTIAL PRINCIPLES OF PSYCHOLOGICAL FIRST AID 1. To console distress and offer comfort 2. To offer practical help 3. To recognise the abnormality of the experience of the trauma 4. To recognise and respect the normality of the post trauma reaction, whatever that might be 5. Not to medicalise of pathologise the reaction 6. Not to overwhelm with information 7. To speak in a language and with a familiarity that the individual will recognise 8. To use other professional support networks

29. TRAUMA FOCUSSED INTERPERSONAL THERAPY Aims to fill the gap between immediate post-trauma and any requirement for Intervention and formal psychological /psychiatric treatment for PTSD or other disorders

30. Evidence: Brewin and Lennard (1999) demonstrated that risk factors operating during trauma, such as trauma severity, lack of social support, additional life stress have somewhat stronger effects that pre-trauma factors.

31. Evidence: Schnyder and Moergeli (2003) report that recent life events, stress attributable to daily life and hassles correlate significantly with PTSD

32. Evidence: Pilgrim (1999) if steps are taken to mitigate the development of beliefs about being “vulnerable and flawed” or “out of control”, a positive influence may be exerted on trauma related reactions.

33. Evidence: Trauma focussed IPT is a series of individually tailored, practical, collaborative suggestions designed to supplement, enhance and operationalise the potential support available from within existing social support networks and thereby optimise successful adaptation.

34. TRAUMA FOCUSSED IPT INTERVENTION Session 1: Assessment Description of symptoms Description of event What has caused need for treatment History of distress Session 2: Psycho-education Normalisation of responses

35. Session 3 Session 4 Who, how often, what activities shared, expectations changes Session 5 Session 6 Role transition Grief Strategies

36. “If invited to give assistance, providers will do well to approach the challenge of delivering quality services with and open minded flexibility that recognises the need to draw upon a broad repertoire of skills to be delivered in a phased manner over time” (Bonanno, 2004)

37. “When specific interventions are undertaken they must occur without supplanting or replacing natural contacts and supports which promote autonomy and resilience, with artificial structures that reinforce vulnerability or encourage reliance on inappropriate ineffective, or ill-times strategies of coping and resolution” (Oxford Handbook on Disaster and Terrorism Psychology, 2005)

38. PROGRESS SUMMARY • Reviewed evidence • Considered clinical opinion • Identified appropriate intervention • Obtained feedback • Finalised model

39. FUTURE DIRECTIONS • Research and establish standards • Briefing & training internally and externally • To reorientate and develop best practice • Educate client organisations • Enhance credibility and reputation of our • organisation

40. Thank you What are your views?

41. mrutter@icasgroup.com

42. REFERENCES • Bonanno, G (2004) Loss, Trauma & Human Resilience Columbia: American Psychological Ass Inc • Delongis, A, Lazarus, R.S and Folkman, S. (1988). The impact of daily stress on health and mood: psychological and social resources as mediators. Journal of Personality and Social Psychology 54 (3): 486-496. • Knight & Petty (1996). The impact of castrophes on share holder value” A research report sponsored by Sedgwick group, from the Oxford Executive Research Briefings series from Oxford University • Mayo R.A, Ehlers A, Hobbs M (2000), Psychological debriefing for road traffic accident victims. Three yearfollow-up of a randomised controlled trial. British Journal of Psychiatry 176:589-93 • Mitchell, J. (1983) Guidelines for Psychological debriefing, emergency management course manual. Emmitsburg, MD: Federal Emergency Management Agency, Emergency Management Institute. • Orner R.J, King S, Avery A, Bretherton R, Stolz P, Ormerod J. (2003) Coping and Adjustment Strategies used by Emergency Services Staff after Traumatic Incidents. New Zealand: Massey University.

43. REFERENCES • • Rose S, Bisson J, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). In: The Cochrane Library, Issue 1, 2004. Chicester, UK: John Wiley & Sons Ltd. • • Schnyder U, Moergeli H et al (2002) “Who develops acute stress disorder after accidental injuries” Psychotherapy and Psychosomatrics 71 Pages 214 - 221 • • Shaler AY (2002) “Acute Stress reactions in adults” Biol Psych 51 532 - 543 • Watson P (2004) Behavioural health interventions following mass violence.Traumatic Stress Points, 18, 8-9 • (2005) Bulletin of World Health Organisation Switzerland: World Health Organisation • (2005) N.I.C.E Guidelines UK: National Institute for Health & Clinical Excellence • Oxford Handbook on Disaster & Terrorism Psychology, (2005)