November 1st, 2016

Treating responders: a shift in technique

PHOTO BY TOM CROKE
Terence M. Keane, Ph.D., offered clinical assistance following the 9/11 and Boston Marathon attacks. He holds positions at the VA Boston Healthcare System and is director of the Behavioral Health Division at the National Center for Posttraumatic Stress Disorder.

The devastation that occurred on 9/11 shook the entire world. But since that time, numerous other traumatic events – the massacre at Sandy Hook Elementary School, the San Bernardino shooting, the Orlando nightclub attack, to name a few – have reinforced the importance of addressing psychological damage resulting from these incidents.

In response to the growing need, clinicians have shifted their thinking when it comes to treating first responders.

Joan M. Cook, Ph.D., associate professor of psychiatry at Yale, and current president of the American Psychological Association’s Division 56, Trauma Psychology, noted that events such as the Vietnam War, “put PTSD on the map, but 9/11 kicked it out of the ballpark.”

The latter disaster led to hundreds of research studies, yielding a tremendous amount of useful information and the creation of the World Trade Center Registry, which contains data related to early and delayed PTSD and intervention options.

One study evaluated nearly 11,000 World Trade Center first responders for eight years and found “the pathways of PTSD symptoms varied” and could change over time, according to Cook.

She explained that pathways involve unique factors before, during and after a trauma. External influences, the length of exposure, medical repercussions as a result of the trauma exposure and previous psychiatric issues contribute to the development of PTSD, she added.

In the past, critical incident stress management (CISM) or critical incident stress debriefing (CISD) was the treatment of choice following a traumatic event.

“But we found it was not good for people. It did nothing for some and was harmful for others. The general consensus is that we don’t do it now. We do have brief interventions based on cognitive behavioral therapy to affect management,” Cook said.

Psychological first aid, an evidence-informed strategy for assisting those who have been affected by disaster, is more widely used these days and promotes education regarding trauma, according to Cook.

This approach focuses on support, practical assistance and providing information and connection to appropriate services. “This is not like CISD. It promotes resiliency in the early post-trauma period and connects people with resources. You assess and assist with practical needs, such as finding missing animals, medications, etc., basic stuff,” Cook said.

Cook is a member of the APA Guideline Development Panel for Posttraumatic Stress Disorder, which recently released recommendations for public comment. Based on trials conducted between May 2012 and June 2016, the panel recommended CBT, cognitive processing therapy, cognitive therapy and exposure therapy for adults who have been diagnosed with PTSD.

The panel offered suggestions for other interventions, including brief eclectic psychotherapy, eye movement desensitization and reprocessing, and narrative exposure therapy.

When Hurricane Irene swept through Vermont, Craig W. Knapp, Ph.D., private practitioner in North Clarendon, Vermont and member of the state’s Disaster Mental Health Team, responded to the situation.

His team utilized psychological first aid, which focuses on identifying cognitive, emotional, behavioral, physiological and spiritual symptoms.

“There are only two ways strategically to deal with stress: defend against psychological effects or address the underlying factors/events that are producing the stress,” he said. “[Psychological first aid] helps you know what to look for and to provide relief. We do a lot of information gathering, talking with people, both responders and survivors.”

Knapp emphasized that events in themselves do not constitute trauma, but individual vulnerabilities and response determine the impact. “A person needs to know his reactions are normal to an abnormal situation and understand that help and support is a necessary part of the healing process,” he said.

In the days following the Boston Marathon bombing, the APA Disaster Response Network (which was renamed Disaster Resource Network in January 2016) in Maine was called upon for assistance.

Maine Coordinator Frederick A. White, Ph.D., and his team members, following the psychological first aid model, assessed first responders for safety, confirmed the presence of acute stress symptoms and referred the responder to a local clinician. “This went on for days and weeks. The acute phase went on for five days,” he said.

White pointed out that there are many variables to consider in traumatic situations. A responder’s personal and professional history as well as the type of disaster – natural, human-created or human perpetrated with malice – affects the person’s response and the appropriate intervention, he said.

Clinicians who provide psychological first aid to first responders should also practice some self-care, White said.

“You need a heavy dose of self-assessment and care before, during and after a disaster,” he said. During a crisis situation, clinicians check in and offer ‘virtual remote support’ for members in the field. “We phone, text and email teammates to offer support, either moral or practical,” said White.

Terence M. Keane, Ph.D., associate chief of staff, Research & Development, VA Boston Healthcare System, and director, Behavioral Health Division, National Center for Posttraumatic Stress Disorder, participated in offering clinical assistance following both the 9/11 attacks and the Boston Marathon bombing.

He explained that there currently is no “standard of care” for first responders.

CSID and CSIM, which were developed in the mid-1980s, were state-of-the-art 15 years ago, Keane noted. “More recently, we are looking for other models. Psychological first aid has not been evaluated, but looks good at first sight. We’re now looking for the best possible approach for treating first responders involved in large scale disasters, which are becoming increasingly common,” he said.

“We have so many options and must examine what’s best. The goal is to try to mitigate the impact of the experience on the responders and the people who have been victims.”

Keane pointed out that first responders at Ground Zero displayed amazing resiliency following the tragic situation. “The responders had remarkable esprit de corps. The vast majority did fine, despite the catastrophic events. This was a real lesson for us in the trauma field,” he said. “The level of community support was astounding and really helped in recovery.”

Following the Boston marathon bombing, Keane worked with emergency room staff and found a similar level of community support. He attributes this response as a “direct function of not reaching out to returning Vietnam War veterans.”

He said, “We learned an important lesson about how a community needs to help those exposed to massive trauma. This level of support is a way of ensuring that never happens again. We need to provide the right care to the right people at the right time. That’s the challenge in front of us.”

By Phyllis Hanlon

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