Nebraska Psychlgical First Aid Curriculum Rbin Zagurski, L.C.S.W. Denise Bulling, M.A. Rbin Chang, M.A. 2005 1
Nebraska Psychlgical First Aid Training Prgram University f Nebraska Public Plicy Center Brief Overview This training prgram is an adaptatin f Cmmunity-Based Psychlgical Supprt develped by the Internatinal Federatin f Red Crss and Red Crescent Scieties. The purpse f the Nebraska psychlgical first aid prgram is t equip natural helpers t prvide psychlgical supprt t survivrs f critical events (e.g. disasters, cnflicts, accidents, etc.). This training prgram is 8 hurs lng and designed t fit int the busy schedule f natural helpers and cmmunity respnders. It is segmented int seven mdules, each addressing critical skills that can make an immediate and lasting impact n a persn s psychlgical health fllwing a crisis. The Mdules (1) Psychlgical supprt 1 hur Defines psychlgical supprt and prvides natural helpers with skills t prvide supprt t individuals fllwing critical events. The mdule fcuses n prviding psychlgical supprt in disasters, but the apprach is applicable and relevant t ther cntexts as well. (2) Stress and cping 1 hur This mdule fcuses n hw natural helpers can help peple manage stress. Basic infrmatin abut stress and cping is prvided alng with simple interventin techniques. (3) Supprtive cmmunicatin 1.5 hur Natural helpers may find themselves in challenging situatins, where feeling cnfident abut hw t cmmunicate well with ther peple is vitally imprtant. This mdule prvides practical cmmunicatin tls that can be used in many situatins. (4) Prmting cmmunity self-help 1 hur Mdule 4 explres hw t engage individuals and cmmunities in their wn recvery prcess. Engaging peple in their wn recvery can reduce feelings f pwerlessness, which in turn may reduce the risk f develping mre serius psychlgical prblems later. (5) Ppulatins with special needs 1 hur Mdule 5 describes ppulatins wh are vulnerable t the psychlgical effects f a disaster r traumatic event. It explres the psychlgical needs f these grups, while recgnizing the vital rle they play in scial and cmmunity structures. (6) Helping the helper.5 hur Timely and adequate supprt fr helpers is a prerequisite fr prviding quality care and relief t thers. Helpers may be affected bth psitively and negatively by the experiences they have caring fr thers. This mdule prvides infrmatin n hw helpers can care fr their wn mental health needs. (7) De-escalatin 2 hur This mdule fcuses n wrking with agitated r angry individuals and the strategies that can be emplyed t assist them. Natural helpers are intrduced t active listening, interviewing and empathy skills that are useful in helping thers manage fear and anxiety. Internatinal Federatin f Red Crss and Red Crescent Scieties. (2003). Cmmunity-based psychlgical supprt Training manual. Zagurski, R., Bulling, D., Chang, R. (2004). Nebraska Psychlgical First Aid Curriculum. Lincln, NE: University f Nebraska Public Plicy Center. This participant guide is designed t reinfrce the majr pints f this curriculum. Much f the material is reinfrced by activities and discussin during the training sessin. Adults learn in different ways sme learn by ding, thers by hearing the material, and sme by seeing it written dwn. This training is designed t be delivered in all three ways. The participant guide is ne f the tls relied upn t give the adult learner in this curse a meaningful experience. 2
Mdule 1 Psychlgical Supprt Ntes Learning Objectives: Describe the purpse f psychlgical supprt Describe the rle f cmmunity respnders in the prvisin f psychlgical supprt Describe the basic principles invlved in the implementatin f a psychlgical supprt prgram in a disaster situatin Disasters are critical events characterized by lss amng multiple aspects f life: lved nes, ecnmically, cmmunity and dignity. Disaster mental health fcuses n (1) respnses t an abnrmal situatin. The cmmunity respnder may take n a number f activities t fulfill their rle f prviding (2) first aid. They are expected t: Prvide scial supprt Educate abut nrmal and abnrmal stress reactins Teach stress management techniques Mbilize cmmunity resurces The three gals f prviding Psychlgical Supprt are: 1. Relieve bth emtinal and physical (3) 2. Imprve peple s shrt term functining 3. (4) the individual s curse f recvery The basic principles that prvide a framewrk fr implementing psychlgical supprt in disasters include the fllwing: D n (5) Use a cmmunity-based apprach Recgnize and uses indigenus healing netwrks and practices Use trained persnnel Empwer affected peple Encurage cmmunity participatin Exercise care with terminlgy Encurage active invlvement Value early interventin Use viable interventins 3
Mdule 2 Stress and Cping Ntes Learning Objectives Use the terminlgy f stress and cping. Describe hw peple react t and cpe with stress. Describe cmmn reactins t lss and grief. Emply guidelines fr the prvisin f psychlgical supprt. Stress Mst peple react t a perceived threat r challenge in the envirnment with (6): a state f physical and/r psychlgical arusal. Stress reactins are experienced at the physical, cgnitive (hw we perceive and "think" abut events), emtinal, behaviral and spiritual levels. Stress Reactin Phases 1. Acute phase (minutes t hurs r days) 2. Reactin phase (1-6 weeks) 3. Repair phase (1-6 mnths) 4. Rerientatin phase (apprximately 6 mnths) Cping with Stress Cping is a way t prevent, delay, avid, r manage (7) Cping mechanisms can be placed int three brad categries: 1. Changing the surce f stress 2. Changing the view f the situatin 3. Tlerating the stressr until it passes r becmes less trublesme Lss and Grief Lss is a cmmn theme in mst disaster settings. It is nrmal t experience (8) in respnse t lss. Cmmn reactins t lss Denial, numbness r shck Bargaining Depressin Anger Acceptance Rerientatin 4
Immediately fllwing a disaster r critical event, sme peple may appear dazed r in shck. This usually subsides quickly, but if it des nt, the persn may be experiencing a mre serius reactin. An ppsite respnse is als pssible. The persn may becme extremely emtinal and appears unable t regain cntrl f his r her emtins. Either f these extremes, emtinal (9) r extreme agitatin demands immediate attentin and cping assistance. The fllwing are general principles f psychlgical supprt that specifically apply t the immediate situatin, and are smetimes referred t as psychlgical first aid: First (10) frm danger Fcus n physical and material care Be direct, active and remain calm Fcus n the here and nw situatin Prvide accurate infrmatin abut the situatin Assist with mbilizatin f resurces D nt give false assurances Recgnize the imprtance f taking actin Reunite with family members Prvide and ensure emtinal supprt Fcus n strengths and resilience Encurage self-reliance Respect feelings and cultures f thers Crisis Interventin While psychlgical supprt is nt intended as a slutin fr such situatins, it is still imprtant t have an understanding f hw apprpriately respnd. Abve all, remember t maintain yur wn safety. The fllwing seven steps are a well-accepted way fr reslving a crisis: 1. Assess the situatin 2. Establish (11) 3. Identify the main prblem(s) 4. Deal with feelings and emtins 5. Generate and explre alternative cping strategies 6. Frmulate an actin plan 7. Fllw up 5
Mdule 3 Supprtive Cmmunicatin Ntes Learning Objectives Recgnize the values that characterize the supprtive cmmunicatin style Cmmunicate effectively in challenging situatins Describe cmmunicatin elements that supprt resilience and self-help. Wrk with grups f peple in a cmmunity setting Understand when and hw t refer peple t ther prfessinals r rganizatins Cmmunicatin Values The fllwing set f values is imprtant fr effective cmmunicatin (12) Cmpetence Empathy Respect Genuineness Psitive regard Nn-judgmental Empwering Practical Cnfidentiality Ethical cnduct Interpersnal Cmmunicatin Skills Being aware f the fllwing three cmmunicatin cmpnents may help t imprve yur ability t understand and supprt affected peple: 1. (13) cmmunicatin 2. Listening and respnding 3. Giving feedback 6
Increasing Trust and Cnfidence General behavirs (depending n culture) t increase trust and cnfidence: Face the speaker Display an pen psture Keep an apprpriate distance Frequent and sft eye cntact Appear calm and relaxed Listening and Respnding Seek t understand first, then t be understd Cncentrate n what is being said Be a(n) (14) listener (nd, affirm) Be aware f yur wn biases/values Listen and lk fr feelings D nt rehearse yur answers Pause t think befre answering Use clarifying questins and statements Ask mstly pen-ended questins Ask fr additinal details Ways f Respnding Ask mstly (15) questins Address thughts r feelings Paraphrase Avid giving utright advice 7
Assisted Cping Remember that the gal is nt fr yu t cpe fr peple, but t prvide the necessary assistance t help them cpe themselves. The RIBEYE Mdel gives bth the helper and the persn being assisted an easy way t remember the imprtant aspects f prblem slving. R = (16) I = Identify the prblem B = Brainstrm pssible slutins E = Evaluate each pssible slutin Y = Yes t ne f the chices E = Encurage and cngratulate yurself fr making a decisin Wrking with Grups Define a grup with an issue which will mtivate active participatin Psychlgical well-being cmes frm cmmunity participatin and cperative effrt Sense f membership and wrth can be derived frm belnging t an effective grup Making a Referral Referral means recmmending that a persn speak t a prfessinal wh is trained t handle the difficulties and cmplexities f his/her needs. Refer in cnsultatin with yur supervisr. 8
When t Refer When the persn hints r talks penly abut (17) If there is a pssibility f child abuse r any criminal activity The prblem is beynd yur training r capabilities The persn seems t be scially islated The persn has imaginary ideas r feelings f persecutin Yu have difficulty maintaining real cntact with the persn Yu becme aware f dependency n alchl r drugs When the persn is engaging in risky r threatening behavir When yu yurself: Becme restless and cnfused Have negative recurring thughts Dream abut the case Feel that yu are the ONLY ne wh can help Hw t Refer Infrm the persn cncerned abut yur intentins. Let him/her knw that yu care and then explain the reasns fr the referral Present different ptins. Discuss matters such as fees, lcatin, accessibility, etc Assure them that yu will cntinue yur supprt until the referral is cmplete Arrange fr a fllw up call r visit 9
Mdule 4 Prmting Cmmunity Self-help Ntes Learning Objectives Describe the factrs that make a cmmunity supprtive and healthy fr its members Give details f hw cmmunities can be helped t use their wn resurces fr slving prblems Develp ideas and methds t engage peple and achieve participatin Cmmunity Participatin Cmmunity participatin helps establish wnership f supprt r relief initiatives and may lead t mre sustainable recvery. Cmmunity participatin, here meaning self-help, assumes: 1. Recvery prjects are based n ideas develped by the cncerned peple themselves 2. A planned prcess exists that encurages cmmunity participatin Prmting Self Help Cmmunity respnders are in a gd psitin t prmte the prcess f cmmunity self-help. In many instances, they are part f the affected cmmunity - they share the same language and ften cultural backgrund, and may be better able t prvide supprt t affected peple than smene cming in frm utside the cmmunity. The fllwing are essential elements in the prcess f prmting cmmunity self-help: Identify and invlve cmmunity leaders r influential persns Establish a sense f wnership by the cmmunity Identify cmmunity resurces Prmte psychlgical well-being Mbilize resurces Encurage (18) decisin making and cnsensus 10
We knw that there are certain prtective factrs in life that prvide peple with a psychlgical cver and therefre reduce the likelihd f severe psychlgical effects when encuntering hardship r suffering. Sme prtective factrs are: (19) t a caring family r cmmunity Maintaining traditins and cultures Having a strng religius belief r plitical idelgy Prtective factrs fr children als include: Stable emtinal relatinship with adults Scial supprt bth within and frm utside the family Cmmunity respnders can help strengthen these prtective factrs by empwering peple and giving them a sense f cntrl and predictability ver their lives. This can be dne by acknwledging that peple are nt helpless and by setting up structures that allw peple t participate in cmmunity activities. In ther wrds, it can be dne by building n r strengthening resurces in the cmmunities. Once the resurces have been identified in the cmmunity, the next step is t (20) the resurces and strengthen the cmmunity's wn capacities. Steps in Actin Planning 1. Identify the visin r gal 2. (21) pssible actins 3. Weigh the advantages and disadvantages f each actin 4. Determine resurces needed fr each ptin 5. Chse an acceptable plan f actin 6. Decide wh will d what, when, where and hw 7. Establish a time frame and criteria t evaluate success 11
Mdule 5 Ppulatins with Special Needs Ntes Learning Objectives Identify and describe the characteristic reactins f vulnerable grups affected by disaster Describe effective interventins t assist vulnerable grups Grups with Special Needs The characteristics f a vulnerable grup influence their respnses and needs. Children Older persns Persns with disabilities (physical/mental illness/substance abuse/develpmental) Peple with past traumatic experiences Ethnic and cultural grups Parents with dependent children Bereaved spuses r partners Ecnmically disadvantaged grups Scially disadvantaged grups First respnders/disaster respnse persnnel Children Listen t what children say bth in wrds and thrugh their behavir. Observe what children d as yu talk t them r as they play. Children s Typical Respnses Fear and anxiety Childish r regressive behavir Difficulty sleeping Physical reactins Trigger respnses Difficulty cncentrating r thinking 12
Helping a Child Help by helping the parents Keep familiar (22) Talk abut what happened (as apprpriate) Find pprtunities fr children t participate in decisin-making When a Specialist is needed If yu have any dubts at all abut whether the child may need mre assistance, seek further infrmatin talk t yur supervisr, clleagues r smene in the cmmunity that knws the child. Seek prfessinal help if a child is experiencing any f the fllwing reactins fr lnger than ne mnth fllwing a critical event: (23) r hmicidal ideatin/behavir Hpelessness/helplessness Unable t stp thinking abut the event Physical prblems Alchl r drug use Hyperactivity (des nt include previusly identified ADHD) Older Persns Older Peple s Typical Reactins Wish t cnnect with past friends Increased dependence n family, refusing assistance frm authrities Fear f mrtality Negative view f the future Regressin Use f denial as a nrmal defensive reactin Immediate fear respnse, fllwed by anger and frustratin Cncentratin and cmmunicatin difficulties Physilgical respnses 13
Helping Older Peple Ensure (24) Give factual infrmatin Reassure by prviding infrmatin abut nrmal reactins Be supprtive and build cnfidence Identify secure attachments and relatinships Talk abut the event Be aware f cultural backgrunds Facilitate access t aid and supprt services Ensure that they are nt islated Establish rutine Prvide pprtunities fr cntinuity, culture and histry Help them t maintain their sense f cmmunity and preserve chesin Persns with Disabilities (Physical/Mental Illness/Substance Abuse/Develpmental) Peple wh have a disability are "peple first". Their needs and reactins are ging t be the same needs and reactins as thers. Hwever, while their reactins may be typical, smetimes their disabilities and the prblems assciated with their disability can create special challenges fr bth the persn and thse wh wrk with them. After a disaster, peple with disabilities: 1. May need assistance in negtiating the secnd disaster, applying fr assistance frm aid agencies 2. May need sme accmmdatins within shelters 3. May need assistance in replacing lst prescriptins Remember when yu seek advice t: Always link with existing services fr their disabilities Seek advice if these are evident r suspected: Suicidal ideatin Hmicidal ideatin (25) lasting lnger than tw weeks Active hallucinatins r delusins Rage Aggressin Inability t care fr self r carry ut activities f daily living 14
Mdule 6 Helping the Helpers Ntes Learning Objectives Describe hw reactins t stress may affect helpers Give details f warning signs f stress r burnut amng helpers Describe hw t prvide psychlgical supprt t helpers Give details f self-care methds fr helpers Stress is inherent in disaster situatins. Apart frm the usual jb stress, the fllwing situatins cnstitute additinal challenges fr helpers: Being part f the cllective crisis 15 Repeated expsure t grim experiences Carrying ut physically difficult, exhausting r dangerus tasks Lacking sleep and feeling fatigued Facing the perceived inability t ever d enugh Feeling guilt ver privileged access t fd, shelter, etc Facing mral and (26) dilemmas Being expsed t anger and lack f gratitude Being detached frm persnal supprt systems Feeling frustrated by plicies and decisins f supervisrs Burnut r High Stress Levels Burnut may ccur after a prlnged perid f time n a jb r even a shrt time in a very intense situatin. It implies that the stress factrs have taken ver, and that the helpers are n lnger able t distance themselves frm the situatin. Warning signs f burnut include: Cynicism r Wunded ideals Feeling unappreciated r betrayed by rganizatin Lss f enthusiasm Grandise beliefs abut wn imprtance Heric but reckless behavir Neglecting persnal safety and physical needs Mistrusting clleagues and supervisr Antiscial behavir Excessive tiredness Inability t (27) Symptms f illness r disease Sleep difficulties Inefficiency Excessive use f alchl, tbacc r drugs
Caring fr the psychlgical needs f the helpers The needs f helpers are very similar t thse directly affected. A supprtive envirnment is ne f the many crucial factrs in minimizing stress. This can be achieved in the fllwing ways: Guidance and supprt frm managers and peers shuld be accessible n a daily basis r sn after the event Open and sharing rganizatinal culture Regular and frequent staff meetings which bring all staff tgether and fster the feeling f belnging t a team Respect fr cnfidentiality s that peple can feel safe in admitting t feeling stressed and requesting help Creatin f peer supprt system Have (28) tgether Self-Help Techniques Knw the nrmal reactins t stressful events Be aware f yur tensin and cnsciusly try t relax Use the (29) system Talk t smene yu trust and with whm feel at ease Listen t what peple clse t yu say and think abut the event Wrk n rutine tasks if it is t difficult t cncentrate n demanding duties If yu cannt sleep r feel t anxius, discuss this with smene yu can trust Express yur feelings in ways ther than talking D nt self-medicate G easy n yurself Avid inflated r perfectinistic expectatins Seek prfessinal advice if reactins cntinue Rle f Supervisrs Supervisrs can prvide helpers with smene they can call n fr additinal guidance r infrmatin t slve the prblems f thers, r mre persnally with prblems they may be facing. Supprt emtinal and develpmental needs f helpers Identify limitatins n hw far helpers shuld be pushed r stretched Act as surce f advice and help with prblems 16
Mdule 7 De-escalatin Ntes Learning Objectives Demnstrate cmmunicatin skills that can be used t calm anxius r agitated individuals Understand cmmn signs f escalating anxiety Identify effective methds f de-escalating anxius r agitated behavir Anxiety Anxiety is a state f intense apprehensin, uncertainty, and fear resulting frm the anticipatin f a threatening event r situatin Anxiety is cmpletely nrmal and apprpriate in an extreme situatin Anxiety can smetimes escalate t anger r agitatin Cmmunicatin and Empathy Skills L-Shape Stance - This stance is imprtant t use when wrking with peple wh may be upset. Demnstrates respect Decreases cnfrntatin Warmth - Helping smene stay calm is ften easier if yu appear warm and apprachable. N ne wants t talk t smene wh is staring at them cldly, r wh seems indifferent. SOLER S = Sit squarely O = Open psture L = Lean frward E = Eye cntact R = (30) Sft tne Smile Interested facial expressin Open/welcming gestures Allw the persn yu are talking with t dictate the spatial distance between yu 17
Dr Openers There are a variety f ways t help peple feel cmfrtable enugh t talk with yu. Then what happened? Then what did yu d? That is really interesting. Pairing dr-peners with apprpriate nn-verbal cmmunicatin helps thers t talk abut their feelings. Nn-Verbal Cmmunicatin - Here are sme examples f nn-verbal cmmunicatin that encurages peple t talk: SOLER Head ndding Clse prximity with the L-shaped stance Aviding impersnal r "cld" stares Fcusing n the speaker, nt n the paperwrk Apprpriate facial expressins Para-verbal Cmmunicatin Para-verbal cmmunicatin is (31) we say smething, nt what we say The three cmpnents f para-verbal cmmunicatin are: Vice Tne Vice Vlume Rate f Speech Cngruence Cngruence means that ur wrds and actins cmmunicate the same thing and frm a clear message. Cngruency will help: 18 Dente trustwrthiness Shw thers that we care Shw we are in cntrl Active Listening In active listening we listen and respnd t anther persn in a way that: Emphasizes that we are attending Imprves cmmunicatin Shws empathy Reflects what the ther persn is saying Des NOT ffer (32) Active listening is a skill that can be learned. There is a set structure t active listening that must be practiced t avid sunding wden and unnatural.
1. Attend t the speaker cmpletely 2. Repeat in yur wn wrds (paraphrase) what yu heard the speaker say a. This des NOT mean yu agree with what they said 3. Speaker then gives feedback t the listener as t whether what they heard was accurate Paraphrase/Reflectin Rephrasing r reflecting what the speaker says t help clarify r insure yu hear what the speaker is trying t say Active listening becmes mre difficult, and even mre necessary, when the tw parties are frm different cultures. T reslve a cultural cnflict: De-escalatin Skills 1. Be aware that culture may be a factr 2. Be willing t wrk n the cultural issues 3. Be willing t talk abut hw the ther persn's culture wuld address this prblem 4. Develp a slutin (33) 5. If there is cnfusin r a misunderstanding talk abut it and learn frm each ther Smetimes, despite ur best attempts at active listening, peple becme agitated This is their reactin t an extremely abnrmal situatin, and it has nthing t d with yu Elements f Escalatin Challenging authrity r questining Refusal t fllw directins Lss f (34), becming verbally agitated Becming threatening 19
Elements f De-escalatin Establish a relatinship Use cncrete questins t help the persn fcus Cme t an agreement n smething Speak t the persn with respect Dn't make glbal statements abut the persn's character Use I statements Use f lavish praise is nt believable The mst imprtant thing t remember when wrking with smene wh is agitated is that yu must lk and act (35) even if yu are nt. 20
Psychlgical First Aid Ntes Answers (1) Nrmal (2) Psychlgical (3) Suffering (4) Accelerate (5) Harm (6) Stress (7) Stress (8) Grief (9) Numbness (10) Prtect (11) Rapprt (12) Cultural (13) Nn-verbal (14) Active (15) Open ended (16) Relax (17) Suicide (18) Jint (19) Belnging (20) Mbilize (21) Brainstrm (22) Rutines (23) Suicidal (24) Safety (25) Depressin (26) Ethical (27) Cncentrate (28) Fun (29) Buddy (30) Relax (31) Hw (32) Advice (33) Tgether (34) Cntrl (35) Calm 21
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