Jimmy Buffett once penned a song entitled Trying to Reason with Hurricane Season in which he laments the trials and tribulations of living in a coastal state during the time of year when hurricanes are most active. And what a hurricane season this has been. Hurricane Katrina is now recognized as being one of the top 10 natural disasters to ever hit the United States. Hurricane Rita added insult to injury when it struck southeast Texas and southwest Louisiana.
Millions of our fellow citizens have been significantly affected. Thousands of volunteers have given uncountable hours to help those in need. As things start to slowly wind down, concern has been expressed about the mental health of both victims and rescuers. Numerous guidelines have been issued, and EMS providers should be familiar with these.
First and foremost, EMS managers should do their homework before involving their personnel in Critical Incident Stress Management (CISM), particularly the defusing and Critical Incident Stress Debriefing (CISD) elements. CISM, while initially popular in EMS, has been repeatedly proven to be ineffective and, in selected cases, harmful.1-3 Numerous organizations have recommended that CISM/CISD not be utilized. The National Institute for Mental Health (NIMH), in conjunction with the Departments of Justice, Defense, Health and Human Services, Veterans Affairs and the American Red Cross, held a consensus conference on the mental health response to victims and survivors of mass violence. The researchers did not recommend CISM/CISD.4
Further, the World Health Organization (WHO) issued a consensus paper on the mental and social aspects of survivors of extreme stressors and concluded, Because of the negative effects, it is not wise to organize forms of single-session psychological debriefing 5 After the tsunami devastated parts of the Pacific rim earlier this year, the WHO issued a warning reminding responders that psychological debriefing should not be used. They repeated the warning after Hurricane Katrina.6 Also, following the recent bombings in London, ambulance and mental health personnel were reminded not to use CISM/CISD or other forms of psychological debriefing.7
So now that CISM/CISD has been determined to be ineffective and possibly harmful, what should be done for victims and rescuers? The model that has emerged and is now widely accepted is referred to as the resiliency-based model and uses a practice referred to as psychological first aid.
It s recognized that traumatic stress can t be adequately treated after it has occurred. Instead, it is best prevented. Thus, with the resiliency-based model the emphasis is on developing stress-management and coping strategies before the crisis has occurred. The literature has clearly demonstrated that having pre-existing stress management strategies and a personal support system were the most effective measures to prevent problems after exposure to a critical incident.
Psychological first aid is an evidence-informed modular approach for assisting those affected by traumatic stress. It s designed to reduce the initial stress caused by traumatic events and foster short- and long-term adaptive functioning. Further, psychological first aid meets four basic standards that were not all met by CISM/CISD.
First, it s consistent with the prevailing research. Second, it s applicable and practical in the austere field setting. Third, it s appropriate for all developmental levels. Finally, it s culturally informed and adaptable to the situation at hand.
The objectives and principles of psychological first aid are as follows:
- Establish a human connection in a non-intrusive, compassionate manner.
- Enhance immediate and ongoing safety, and provide physical and emotional comfort.
- Calm and orient emotionally overwhelmed or distraught survivors.
- Help survivors to articulate immediate needs and concerns, and gather additional information as appropriate.
- Offer practical assistance and information to help survivors address their immediate needs and concerns.
- Connect survivors as soon as possible to social support networks, including family members, friends, neighbors and community resources.
- Support positive coping, acknowledge coping efforts and strengths, and empower survivors; encourage adults, children and families to take an active role in their recovery.
- Provide information that may help survivors to cope effectively with the psychological impact of disasters.
- Facilitate continuity in disaster response efforts by clarifying how long the Psychological First Aid provider will be available, and (when appropriate) linking the survivor to another member of a disaster response team or to indigenous recovery systems, mental health services, public-sector services and organizations. An excellent set of guidelines and recommendations has been published by the National Center for Child Traumatic Stress and the National Center for PTSD.8
As mentioned above, research and experience have demonstrated that a person s response to an extremely stressful situation is based on their personal pre-existing stress management strategies and personal support system. Such post-incident stress management strategies as CISM/CISD have been proved ineffective and possibly harmful. Post-traumatic stress disorder (PTSD) is a rare outcome of exposure to a stressor and usually occurs in conjunction with other mental disorders. In fact, following the World Trade Center attack in 2001, the incidence of PTSD in Manhattan below 110th street rose to 7.5% (higher for people closer to ground zero). But overall, the rate returned to normal (1.7%) within a few months without treatment. This trend illustrates that humans are naturally adaptable and resilient to stress.9 The vast majority of people exposed to a major disaster do absolutely fine. The few who may develop PTSD will usually do so within a few months of the exposure. These people can be identified and referred to competent mental health personnel who can use various cognitive-behavioral therapies to treat the illness.
Thus, how should we help those in this hurricane season? First, no debriefings should be offered, and CISM teams should not be used. Simply, do what good neighbors do: Help and protect those exposed to the disaster. If they want to talk, let them talk. If they don t want to talk, don t try to make them talk. Keep them warm. Take care of their physical needs. Engage their personal support system. If necessary, provide access to a bona fide mental health professional who can help screen them in the upcoming months for maladaptive symptoms and, if necessary, refer them to a competent mental health practitioner experienced in treating acute stress disorder and PTSD with proven therapies.
Our most fundamental tenet in medicine is Primum non nocere (first, do no harm). This dictum holds true for all interventions, including crisis management and mental health. So, make the switch to psychological first aid. It s what good neighbors do.
- McNally RJ, Bryant RA, Ehlers A: Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest. 4(2):45 79, 2003. Available online at http://www.psychologicalscience.org/pdf/pspi/pspi421.pdf.
- Bledsoe BE: Critical incident stress management: benefit or risk for emergency services? Prehospital Emergency Care. 7:272 279, 2003.
- van Emmerik AAP, Kamphuis JH, Hulsbosch AM, et al: Single-session debriefing after psychological trauma: A meta-analysis. Lancet. 360:766 771, 2002.
- National Institute of Mental Health: Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence. A Workshop to Reach Consensus on Best Practices. NIH Publication No. 02-5138, Washington, D.C.: U.S. Government Printing Office, 2002.
- World Health Organization: Mental Health in Emergencies. Mental and Social Aspects of Health of Populations Exposed to Extreme Stressors. Geneva: World health Organization, 2003. Available online at http://www.who.int/mental_health/media/en/640.pdf.
- World Health Organization: Single-Session Psychological Debriefing: Not Recommended. Geneva: World Health Organization. Sept. 18, 2005. Available online at http://www.who.int/mental_health/media/en/note_on_debriefing.pdf.
- Wesley S: Victimhood and resiliency. New England Journal of Medicine. 353(6):548 550, 2005. Available online at http://content.nejm.org/cgi/content/full/353/6/548.
- The National Center for Child Traumatic Stress and the National Center for PTSD: Psychological First Aid: Field Operations Guide. September 2005. Available online at http://www.nctsnet.org/nctsn_assets/pdfs/pfa/PFA9-6-05Final.pdf.
- Galea S, et al: Trends of probable post-traumatic stress disorder in New York City following the September 11, 2001 terrorist attacks. American Journal of Epidemiology. 158(6):514_ 524, 2003.