Our previous module tried to give you some guidelines for intervention, so let me just recap the key points. We mentioned that intervention largely consists of two forms of intervention. One is stabilization, the other is mitigation. Keeping in mind that we are going to try to do somewhere between eight and 15 interventions a day, meaning eight to 15 people a day, if necessary, in a large scale disaster, that may be what's required. And we're keeping in mind the importance of social support. But in the previous module we listed specific tactics under stabilization, and specific tactics under mitigation that you might employ. So under stabilization we talked about removing provocative cues and encouraging a task focus allowing people to ventilate, delaying what may be self defeating impulsive actions, and using distraction tasks. Under mitigation we talked about the value of education, both explanatory and anticipatory, normalization, reassurance, stress management techniques, and re-framing, planting a seed, to help people focus on not what they've lost, but what they had and how they can take that and move forward. Stabilization, mitigation, keeping in mind the importance of social support. In module six, we'll take a look at the concept that we call disposition. It's our final module in terms of psychological first aid in the field. Based upon evidence of the disposition to function effectively in the wake of adversity. Said another way, based upon the evidence that a person can function effectively in the wake of adversity, a decision is then made concerning the need to facilitate access to a higher level of care. And of course, ideally, some form of follow-up is attempted with the possibility of an attendant psychological intervention, and subsequent determination of a referral for a subsequent, or higher level of care based on your follow-up. So just to make sure this module stands as a major decision making process, you have tried to stabilize, you tried to mitigate and now the question is how successful have those interventions been? Can a person function without you, without further intervention or not? After your intervention, if the person seems more capable of taking care of themselves, and are capable of discharging their responsibilities, perhaps to others, then your intervention has ended. And as the previous slide said we will encourage you to follow up a day or two or three or four later. It's then recommended that part of your follow up be a little bit more of an assessment. How are you doing? How have the last several days been? Sometimes things will deteriorate rather dramatically. So you actually go all the way back to assessment and you start at that level again. No, you don't have to repeat the telling of the story in its entirety, but you say, well what has happened in the last several days and how are you reacting to that. Sometimes a second follow up may be useful. However, please keep in mind if a third follow up seems to be needed, it's probably time to facilitate access to the next level of care. Just keep that in mind. A rough rule of thumb is one follow up is absolutely mandatory if possible, two follow-ups can be helpful. Three follow-ups even can be helpful if, however, anything beyond the third seems indicated, then perhaps it's time to get another level of care involved. And some will decide that even at that third level, that third follow-up, it's probably better to be biased toward a referral. If it's determined that the person cannot function independently or requires significant support from others, and again, don't think just psychiatric or psychological, think medical, logistical, financial, spiritual. I have certainly in my career referred people to faith based, or religious leadership, because that seemed to be the origin of their dysfunction. So what do you do? What role do you play in that? You become a liaison, sometimes an advocate. Your job is to instill hope, and as indicated, provide follow up. So disposition is really a decision point. Has my stabilization and or mitigation effort been successful? If people are able to take care of what they need to take care of and the people they need to take care of, then you're moving on. You will check back with that person at the appropriate time to see how they're doing with an expectation that sometimes things worsen, so be prepared for that. It is not a condemnation of your mitigation. It could be that the situation has changed. If however, you believe that people will prosper from a higher or different level of care, again, psychological, medical, logistical, financial, spiritual, any of those, then your job becomes shepherding that person to that next resource. It is not simply giving them a phone number and saying gee, I think you might benefit from calling this person. It's making that contact as much a reality as you possibly can. Sometimes it may be accompanying someone. So the next level of care, friends, family. If you're dealing with a work environment it could be the Employee Assistance Program sometimes called the EAP. Could be a hospital emergency department. But also remember in the wake of a large scale disaster, sometimes hospital emergency departments are more than busy. Could be crisis hotlines, police, paramedics, disaster relief services on scene, faith based resources, and even financial resources. How do you get someone to take advantage of the resources that may be there. I cannot tell you how many times I have responded to disasters and people simply hesitated or outright refused to take advantage of the resources that were available. Sometimes it's a pride thing, it's cultural thing sometimes. Sometimes it's a distrust, a suspicion. Sometimes you must use encouragement. You must be sometimes an advocate for that person. And you must be a logistical liaison sometimes. That's our job. And moving the person along not only helps them but helps you because it frees you up to attend to other people who may be needing acute intervention. That then, is our RAPID psychological first aid model. It is a model that has been shown to have content validation. It is a model that in pilot investigations have shown clinical effectiveness. The most important thing you must consider, however, is this is not psychotherapy. If you are listening from the perspective of being a psychologist, psychiatrist, social worker, therapist, you may say this is remarkably rudimentary, and you would be right. This is crisis intervention, stabilization, mitigation, facilitation to the next level of care as indicated. It is not therapy, it is not a replacement for therapy. I've trained many psychiatrists and psychologists in the past. I've trained many paramedics, police officers, and firefighters. The biggest challenge I have with the mental health clinicians is encouraging them not to do diagnosis and treatment, but to do crisis intervention. I must encourage them not to delve too deeply into people's problems. Leave that for the role of the therapist. As for the police and firefighters and paramedics, the biggest challenge there is getting them to recognize when people really do need assistance, and instructing them on how to provide the most appropriate assistance, and point people in the right direction for further assistance. Rapid, R-A-P-I-D, Rapport, Reflective Listening, Assessment, Prioritization, Intervention and Disposition. That is the John Hopkins University Psychological First Aid Model of Crisis Intervention. In our final module, module seven, we'll examine the concept of self-care. Is it possible that doing crisis intervention can actually be distressing to the interventionist?