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A Working Definition

Psychological First Aid

October 2007 Mental Health Awareness week Dr Daniel de Klerk Air NZ Medical Unit Auckland International Airport http://www.psychiatry.co.nz

Psychological first aid (PFA) refers to a set of skills identified to limit the distress and negative behaviors that can increase fear and arousal.
(National Academy of Sciences, 2003)

Indicators of Distress
Arousal Fear



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 or helplessness 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 more complicated than assisting people with emotional distress resulting from an accident, injury or sudden shocking event. Like medical first aid skills, you don't need to be a doctor, nurse or highly trained professional to provide immediate care to those in need.

Psychological First Aid is Not

Debriefing Counseling Psychotherapy Mental health treatment

The PFA Skill Set

Supportive Communication Verbal De-escalation Screening and referral to higher level of care

Factors Adversely Influencing Response to Traumatic Events

Pre-trauma Factors
Multiple traumatic exposures History of mental illness Low Social Economic Status (SES) Intensity and Duration of Exposure Gender Age

Factors Favourably Influencing Response to Traumatic Events

Post-trauma Factors
On-going support. Opportunity to share their story. Sense of closure. Media exposure. Substance Abuse. Re-exposure or re-victimization.

Communicating in Psychological First Aid

Guiding Principles in Providing PFA

Protect: From further exposure Direct: Be kind, gentle, clear Connect: With loved ones and information and support

Personal Safety
Observe safe practices by showing concern for your own safety Remain calm and appear relaxed, confident and non-threatening Three rules for personal safety:
Never sacrifice safety for rapport; Leaving one minute too soon, always better than one minute too late; If you have to run, dont run from danger, run toward safety!

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, or should you be firm and positive? Should you report the problem to someone else?

Guiding Principles in Providing 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 feel directly the emotion of another vs sympathy: strong concern for the other person, but does not share that person'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 and Confidence

General behaviours (depending on culture) to increase trust and confidence:
Face the speaker Display an open posture Keep an appropriate distance Frequent and soft eye contact Appear calm and relaxed

Communicating Warmth
S it squarely O pen Posture L ean Forward E ye Contact R elax

Soft tone Smile Interested facial expression Open/welcoming gestures Allow the person you are talking with to dictate the spatial distance between you (This can vary according to cultural or personal differences) Also dictate the rate of speech

Communication and Empathy (and Safety!)

L-Shaped Stance:
Demonstrates respect Decreases confrontation

Body Language Mirroring Pacing Flinching Eye Contact

Excellent rapport

Slowing It Down
Apply the STOP approach:

S it T hink O bserve P lan

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


Pause to think before answering Do not judge Use clarifying questions and statements Avoid expressions of approval or disapproval 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 emotions and to talk about them instead of negatively 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 the person Address the content (especially feelings) of what you hear without judging Focus on responding to what the person is really saying or asking

Acceptable Psychological First

Aid 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 get better and you will feel better.

Unacceptable Psychological First

Aid Statements
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.

Intense Emotions Verbal De-escalation

Are often appropriate reactions following a disaster or crisis Can often be managed by PFA responders

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 other person's culture would address this problem. 4. Develop a solution together. 5. If there is confusion or a misunderstandingtalk about it and learn from each other.

Seek Assistance
Loss of Control, Becoming Verbally Threatening If the person becomes threatening or intimidating and does not respond to your attempts to calm them, seek immediate assistance

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

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!!

Cab drivers and liquor store clerks most common Very common No weapons Client, customer, or patient Healthcare workers, e.g., nurses


Referring people on
Medical Centre Dr David Powell and team
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 suicide or homicide There is any indication of a medical emergency There is a possibility of abuse or any criminal activity The problem is beyond your training The problem is beyond your capability

When to Refer
The person seems to be socially isolated The person has imaginary ideas or feelings of persecution You have difficulty maintaining real contact with the person You become aware of dependency on alcohol or drugs

When to make a referral to EAP more 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 EAP more subtle signs

Attitude & Physical Indicators: 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

When to make a referral to EAP more 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 mental illness:

Alcohol and substance use Depression Mania Psychosis Cognitive problems Medical problems

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 your intentions Present different options Assure them that you will continue your support until the referral is complete Arrange for follow up

In short:
If you observe, or an employee reports that he/she feels depressed, overwhelmed, stressed or anxious, angry, out-of-control, or unable to cope; or you are unable to cope with the employee If either the employee or you are out of your depth



Alcohol - The NZ context

Alcohol harm costs NZ between $14 BILLION yearly! Crime & related costs $240 million Social welfare $200 million Public health sector $655 million Despite the public perception alcohol causes the greatest harm of all drugs of abuse

5% Dependent 20% Problem Drinkers

Referral to specialist


Brief Intervention

60% Social Drinkers (Drinking within upper limits)


15% Abstinent
Drinkcheck Training Manual

Alcohol & your practice

In an average general practice of say 2000 patients (AirNZ = 10000)
There will be 100 alcohol dependent persons (AirNZ = 500) 400 (AirNZ = 2000) patients will drink hazardously - their consumption will exceed the WHO recommendations of 14 standard drinks/week for women and 21 standard drinks for men. Binge drinking will be acceptable for the majority of your adult patients


Dangerous drinking
Standard drinks:
Men : 21 Women : 14 Binge: More than 3 / day

Symptoms of excessive alcohol use

CAGE questionnaire Have you tried to cut down? Have you been annoyed by others nagging? Been guilty about your drinking? Needed an eye-opener?

Red Flags for excessive alcohol use

DUI Blackouts Tolerance Monday sickies Changed personality when drunk
Great guy when hes sober

Dos & Donts

Psychological First Aid

Dos and Donts of

Promote Safety
Help people meet basic needs for food, shelter, and obtain emergency medical attention. Provide repeated, simple and accurate information on how to obtain these.

Dos & Donts

Promote Calm
Listen to people who wish to share their stories and emotions and remember there is no wrong or right way to feel. Be friendly and compassionate even if people are being difficult. Offer accurate information about the disaster or crisis event, and the assistance available to help victims understand their situation.

Dos & Donts

Promote Connectedness
Help people quickly connect with friends or loved ones. Keep families together. Keep children and parents or other close relatives together when ever possible.

Dos & Donts

Promote Self-Efficacy
Give practical suggestions that steer people towards helping themselves. Engage people in meeting their own needs.

Dos & Donts

Promote Hope
Find out the types of help available to people and direct people to those services. Remind people (if you know) that more help and services are on the way when they express fear or worry.


Dos & Donts

Force people to share their stories with you, especially very personal details (this may decrease calmness in people who are not ready to share their experiences). Give simple reassurances like everything will be OK or at least you survived (statements like this diminish calmness).

Dos & Donts

Tell people what you think they should be thinking or feeling or how they should have acted (this decreases self-efficacy). Tell people why you think they have suffered by alluding to personal behaviors or beliefs of the victims (this also decreases self-efficacy).

Dos & Donts

Make promises that may not be kept. Criticize existing relief efforts or existing services in front of people in need of these services (this undermines hope and calmness.

Thank you http://www.psychiatry.co.nz

Antidepressants Anti-mania Antipsychotics Uppers Downers






Negative view: self

Negative view: world


Negative view: Future

Cognitive distortions

All-or-nothing thinking - 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 way people or situations truly are. Often the positive characteristics of other people are exaggerated and negative characteristics are understated. There is one subtype of magnification:
Catastrophizing - Focusing on the worst possible outcome, however unlikely, or thinking that a situation is unbearable or impossible when it is really just uncomfortable.

Emotional reasoning - Making decisions and arguments based on how you feel rather than objective reality. Making should statements - Concentrating on what you think "should" or ought to be rather than the actual situation you are faced with, or having rigid rules which you think should always 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 and unalterable terms. Personalization - Assuming you or others directly caused things when that may not have been the case. When applied to others this is an example of blame.

The Law in NZ
Under the Health and Safety in Employment Amendment Act 2002 employers have a duty to ensure, as far as reasonably practical, that employees are not exposed to hazards that cause stress or mental fatigue, where the employer knew or ought reasonably to have known about 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

Absence and Lateness Depression Health Symptoms Job dissatisfaction

Flexible work schedules On-site child care


Distressed psychological state in response to occupational stressors
Emotional exhaustion Depersonalization Reduced personal accomplishment

Absence Fatigue Low motivation Poor performance