[MUSIC] Welcome, to Psychological First Aid. The Johns Hopkins RAPID PFA. Hello I'm Doctor George Everly. We're here at the Johns Hopkins Public Health Preparedness Programs, at the Johns Hopkins Bloomberg School of Public Health. I want to welcome you to this program on Psychological First Aid. Perhaps we should start with the definition of just what psychological first aid is. Sometimes referred to as PFA. Psychological first aid may be defined as a compassionate and supportive presence designed to mitigate acute distress and asses the need for continued mental health care. Now please note, the absence, rather conspicuous absence perhaps, of the words, diagnosis and treatment. What that means is psychological first aid is not a process of diagnostic formulation nor is it a process of therapeutic formulation and intervention. It is not therapy. This program is designed specifically for Public Health Personnel, Educators, Emergency Responders, as well as Disaster Workers with little or no formal mental health training. While we certainly welcome clinicians from the mental health perspectives, this program was specifically designed with no pre-requisites in mind. We are specifically interested in training people outside of the mental health disciplines to provide acute, compassionate, and supportive care in the wake of adversity. Perhaps it would be good to set some expectations. Let's look at a checklist perhaps. Participants will increase their abilities to do the following. Understand the key concepts related to psychological first aid. We'll talk about Listening, but listening in particularly effective way. We call it Reflective Listening, or sometimes Active Listening. We'll differentiate the benign, non-incapacitating, psychological and behavioral reactions. For more severe, potentially incapacitating crisis reactions. We'll teach you a little bit about triage. Prior to 1999, there was virtually no literature experience on psychological triaging in the wake of adversity, and the disasters, specifically. So we'll talk about Prioritization. How do you prioritize psychological and behavioral reactions? Which ones do you know to respond to first? Which ones are more likely to resolve by themselves? Our fifth objective, mitigate acute distress and dysfunction as appropriate. We'll discuss specific interventions that you might use that can provide some short lived relief. Paletive perhaps sometimes more longer lasting. The sixth objective, recognize when to facilitate access to further mental health support and care and perhaps not only mental health care but other forms of care. When is it most appropriate to refer someone, or facilitate access to other healthcare and care providers? Our final objective, Practice Self Care. It's been said that the process of helping others may take a toll on ourselves. How can we ensure that we have the stamina, the psychological and physical stability to help others. In what may be the most disconcerting, distressing, day of their life. So lets get started with Terms and Concepts. It's really hard to teach anything unless we can agree on what terms and concepts are the platform for the discussion. You don't necessarily have to agree with everything I'm going to say. But we at least have to agree on the terminology. So the first thing we should probably agree on is there is a need. There's a need for psychological services, but more specifically, psychological first aid services. It would seem that disasters are on the rise, according to the United Nations' International Strategy for Disaster Reduction. The frequency of disasters caused by natural hazards has been increasing. Current global destabilization and armed conflicts will likely cause the number of disasters to dramatically increase in addition to these natural hazards. And this is likely to occur dra, rather dramatically in the second decade of this millennium. Now from a public health stand point, one of the terms that we're most interested in is that of Surge. Now Surge is simply a phrase that we use or a term that we use to describe demand. In the wake of disaster there will be a surge of demand for psychological or mental health or sometimes called behavioral health services. When considering the mental health aspects of public health emergencies and disasters, we are very focused on this phenomenon of surge. Now this is a rather new phenomenon I should say to you. Not the surge per say but our concern about it. It may be argued that the field of disaster mental health. Although in its nascency right now was actually formulated only around 1991 or 1992. That is not to say that there was not a mental health need in the wake of disasters and conflict. It's just that we weren't particularly focused on it. Experience in the United States and other countries has shown repeatedly at following disasters. Particularly those occasioned by violence, there is a surge of demand for health services, but most importantly mental health services. In an analysis of over 160 empirical studies conducted by Fran Norris and her colleagues. 41% of studies revealed evidence of severe to very severe impairment. Now, what we mean by severe impairment is interference with one's ability to function as one needs to, and this was significant among disaster survivors. Let's translate that. Because right now it sounds very statistical, and may not have much meaning. Translating those statistics to actual demand. It may be said the increased demand for mental health services may range from 15 to 25% of the directly affected population. So, for example, if we are looking at a catch area of roughly ten million people that is affected by some wide spread adversity. Could be a hurricane, could be a bombing, a terrorist attack. Public health planners should estimate that somewhere between 1.5 million and 2.5 million people will require direct mental health services of some form. Now what we have traditionally done is to see the provision of those services in more traditional ways. We provide those services from emergency departments as we provide those services from psychiatric clinics and hospitals, satellite clinics perhaps. But it becomes very clear to us, that has limitations. Perhaps the first textbook to really recognize the limitations, and the need, was written by Beverley Raphael, in her book, When Disaster Strikes. She notes, and I'm quoting. In the hours after a disaster, at least 25% of the population may be stunned dazed, apathetic, and wandering, suffering from the disaster syndrome, especially if impact has been sudden and totally devastating. At this point, she recommends psychological first aid and triage are necessary. So there appears to be a need to enhance surge capacity. So, what is Surge Capacity? Surge Capacity is the ability to respond to a surge. Now remember what surge is, surge is an increase demand for services. The surge capacity is the ability to provide those services when needed. So, our point is very simple, the need to enhance surge capacity would seem self-evident. The only question then, is how? One answer to that question, resides in looking back at history, and looking forward at current research. Recent evidence suggests that psychological crisis intervention, can increase the perceptions of personal resilience and preparedness, as well as enhance community resilience. At this point it is important to stop and differentiate psychological crisis intervention, which is a form of psychological first aid or said another way, psychological first aid may be considered a subset of psychological crisis intervention. And it may be good to compare that to Psychotherapy, as we traditionally think of it, sometimes called Counselling or Psychotherapy. The goals of psychological crisis intervention, including psychological first aid, are primarily to stabilize and mitigate acute distress. The goal of counselling and therapy will be to not only Help people in their moment of distress. But help them learn to grow beyond that stress and preferably develop skills that assist them in becoming resistant to further perturbation of their psychological status. So Psychological Crisis Intervention is, a wholly different skill set, and Psychological First Aid may be thought as a subset of psychological crisis intervention, again, a different skill set. Another point is important to keep in mind, the crisis intervention has been shown to be superior to multi-session psychotherapy, post disaster, for reducing acute distress. And that may come as a surprise to you. There was actually a study done after the terrorist attacks of 9/11 in New York City. And the researchers compared acute phase crisis intervention with multi-session psychotherapy sessions. And what they found was that crisis intervention, the psychological first aid if you will, was actually superior to multi-session psychotherapy. And an even more surprising finding, they noted that psychotherapy post-disaster might actually delay or complicate the psychological and behavioral recovery of his recipients. Now that may seem as a conundrum, or certainly contradicting what some may intuit, or may have learned. Why might that be the case? Let's go back to our definition. The goal of psychological first aid crisis intervention is to stabilize and to mitigate acute distress. It is not long term psycho-therapeutic growth. The goal of psychological crisis intervention, psychological first aid, is stabilization and mitigation of acute distress. It is not long term psycho-therapeutic growth. So the strategies that one uses in psychotherapy to promote long term therapeutic growth may actually be slightly disruptive. It may actually be destabilizing in the acute phase. So again I'm trying to emphasize the point that psychological crisis intervention and psychological first aid as I'm now using the terms interchangeably represent a solely different skill set. Separated from psychotherapy and counseling. Is there an overlap? Of course there is. But where the natural corollary leads is that training in psychotherapy does not necessarily prepare one to be competent in psychological first aid. The good news, however, is that it does not necessarily take the same amount of time to train a competent psychological first aid responder as it does a competent psychotherapist. And this is the view that we have taken here at Johns Hopkins, that the best way to build community surge capacity is from the inside out. So when we come back, we'll take a little closer look at the historical platforms for what we do today.
