Treating Survivors in the Acute Aftermath of Traumatic
Events
Excerpted with permission, from a chapter written by Arieh Y.
Shalev, M.D., Department of Psychiatry, Hadassah University
Hospital, Jerusalem to appear in R. Yehuda (Ed.),
Treating Trauma Survivors with PTSD: Bridging the Gap Between
Intervention Research and Practice. Washington, DC: American
Psychiatric Press.
Summary
Treatment of survivors in the acute aftermath of traumatic
events is complex. Survivor's concrete needs may be very urgent,
secondary stressors may still be operating, expressions of distress
are volatile and highly reactive to external realities, and
symptoms expressed may not reflect psychopathology. Normal healing
processes are already operating, and significant assistance is
provided by natural supporters and healers (e.g., relatives,
community leaders) and should not be interfered with. Professional
helpers are often enduring significant stress themselves and do not
operate in their usual environment. A treatment model, which favors
knowledge of pathogenic processes over symptom recognition, is
described.
Introduction
Therapy' during the acute phase may be distinctive in the
following ways:
* A
conceptual re-framing is needed: at this phase one may still
be handling the trauma, rather than treating a post-traumatic
condition. Psychological rescue (or first aid) may be the proper
term for some interventions.
Along with symptoms, current sources of stress should be in
the forefront of the clinical evaluation. Relocation, separation,
or continuous threat (such as during political repression) are
powerful modulators of behavior. Help at this stage may consist
of mitigating the effect of concurrent stressors.
The mental and physical conditions that follow traumatic
events are extremely complex, unstable, and rapidly changing.
Perception of the event may vary from one individual to the
other, individuals may be suggestible and unusually reactive:
they may be very responsive to the emotional tone of helpers, but
also reactive to real or fantasized realities, such as
rumors.
Expressions of distress are often appropriate at this stage,
and one should be very careful not to classify them as
symptoms' in the sense of being indicative of a mental
disorder. The appropriateness and the productiveness' of
the early response are more important indicators of disorder than
the intensity of the response.
During rescue efforts, professionals and nonprofessionals may
have similar roles (e.g., soothing, comforting, orienting,
reassuring etc.). Nonprofessionals are available in larger
numbers and include the survivor's natural supporters (e.g.,
relatives, peers) and other community members (nurses,
volunteers, disaster area managers). These supporters may also be
overwhelmed and distressed, and mental health professionals'
roles may be to support and guide the supporters.
Professionals may be induced to share another person's grief
as part of the healing process. The degree to which they can do
this may have important effects on their efficacy as helpers and
on their own well being.
Who should be treated by mental health specialists?
This dilemma has been approached in two systematic ways: The
first was to provide specialized treatment to those identified as
being ill (e.g., soldiers who ceased to function during combat
because of stress responses). The second consisted of covering all
those exposed by providing some kind of professional intervention,
recently in the form of debriefing. This chapter proposes to help
making such decisions by pointing to the following ideas:
The dichotomous choice between treatment and no-treatment
should be replaced by the notion of depth of
treatment'.
The early and urgent needs of all should be addressed (yet,
not necessarily by psychological interventions).
Trauma survivors should be considered at risk for developing
traumatic stress disorders.
Specific risk factors should be evaluated, for each case on
the basis of the existing literature.
The survivors' progress towards recovery should be followed
and clinical decisions made on the basis of observations over
time (instead of symptoms at any particular point in time).
Treatment should be provided in a context of continuity of
care.
The nature of traumatic events
DSM IV definition sets an entry criterion for considering an
event to be traumatic in the context of making a diagnosis of
PTSD-that is, an event that is life-threatening and in which one
responds with a specific subjective response. However, it is not a
good-enough definition of a traumatic event in that it is
nonspecific and does not address the mechanisms of mental
traumatization.
Extreme events may traumatize people in many different ways.
Concrete elements of traumatic events that increase the risk for
PTSD include:
Threat to one's life or body integrity.
Severe physical harm or injury.
Intentional injury or harm.
Exposure to the grotesque.
Witnessing or learning of violence to loved ones.
Causing death or severe harm to another.
The severity of traumatic events is related to them being
intense, inescapable, uncontrollable, and unexpected.
Traumatic events can also be defined as those exceeding the
person's coping resources or breaking his or her protective
defenses.
Traumatizing elements of events can include:
Fear and threat.
Stress theory proposes that specific innate or acquired
mechanisms control human responses to threat. Learning theory
predicts that psychobiological responses to extreme threats will be
reexperienced because associations are learned between the
threatening event and cues present at the time of trauma. Further,
through conditioned learning, avoidance of trauma reminders
increases. The intensity of the threat, its perception by the
individual, and the immediate bio-psychological response are
important predictors of subsequent psychopathology. The degree of
perceived control over events and over one's reaction is an
important modulator of the effect of stress on the brain.
Physiological stress (e.g., bleeding or dehydration) may further
influence response to a stressor.
Actual or symbolic loss.
Real and symbolic damage in the form of injury, separation or
death of significant others, loss of property, destruction of
social networks etc., result in feelings of loss and damage to
esteem and identity. Loss and subsequent mental processing may be
central to the development of PTSD. Suffering a loss not
experienced by those around you can result in feelings of extreme
alienation from others. E.g., after finding a close friend mortally
wounded, an Israeli army officer described feeling "totally cut off
from others. I was completely alone, detached from my own soldiers
who suddenly became total strangers to me."
Exposure to grotesque and disfigured human bodies.
Emotional or physical pain of others, dehumanization,
degradation, humiliation. Exposure to the grotesque, extreme agony of others, human
cruelty, dehumanization, degradation, and humiliation can shatter
reassuring assumptions and damage defenses or coping
mechanisms.
Forced relocation.
Separation from and/or lack of information about loved
ones. The cutting of comforting social ties can result in loneliness
and social isolation.
Damaging appraisals of survivor's behavior or response.
A stable narrative of the traumatic events and of one's own
responses is formed and consolidated during the short period that
follows trauma and shapes how the event will be remembered.
Memories of a traumatic event can be influenced by social
appraisals of behaviors during or following the event (e.g.,
shameful, virtuous, dishonorable, heroic, cowardly, etc.). Extreme
social labels are often counter-productive because they make it
harder for survivors to process the complexities and ambiguity of
their own experience.
Phases of coping with traumatic stress
Responses in the days that follow trauma are characterized by
being under stress, use of extreme defenses, (such as over control
of emotions or dissociation), and a focus on physical and emotional
survival.
A later period of reappraisal and reevaluation has the main
psychological task of assimilation of events and their
consequences. This period is characterized by intrusive
recollections of the traumatic event.
Both periods can be physically and psychologically
demanding.
Coping styles vary from action prone to reflective and
analytical, from emotionally expressive to reticent. Clinically,
response style is not as ultimately important as the degree to
which coping efforts are successful as defined by the survivor's
ability to:
Continue task-oriented activity
Regulate emotion
Sustain positive self value
Maintain and enjoy rewarding interpersonal contacts
Symptoms expressed following trauma
Initial symptoms are varied, complex, and unstable. They can
include exhaustion, stupefaction, sadness, anxiety, agitation,
numbness, dissociation, disorientation, confusion, depression,
physical arousal, and blunted affect.
Some responses are normal' in the sense of affecting most
survivors, being socially acceptable, psychologically effective,
and self-limited.
Indicators of effective coping include: a low degree of distress
(though this should not be confused with numbing or blunted
affect); intrusive recollections that lead a survivor to recruit
sympathy and help; upon repetition, the trauma narrative becomes
richer, includes other elements, and takes on a reflective tone
(e.g., "When I think about it now, I could have done worse.");
nightmares change from mere repetition of the event to more remote
renditions.
Indicators of more pathological responses include: continuous
distress without periods of relative calm or rest; severe
dissociation symptoms that continue following a return to safety;
intense intrusive recollections that are fearfully avoided,
experienced as a torment, or seriously interfere with sleep;
extreme social withdrawal; the inability to think about rather than
just emotionally experience the trauma.
Assessment and evaluation
Need to clarify what elements were traumatizing for the
individual rather than imposing own assumptions or theory. Domains
to assess and evaluate include:
Exposure to traumatizing elements includes death of loved ones,
injury, relocation, loss of property, social network, previously
held beliefs, cognitive schemata, identity, honor, peace of mind,
sense of continuity with previous life (e.g., "I'm not the same
person any more.").
Individual prior risk factors for traumatization: Including prior psychological disorder, prior trauma
exposure
Presence of secondary physiological stressors: Includes effects of injuries, pain, internal bleeding,
dehydration, medical procedures
Presence of secondary psychological stressors: Includes police interrogation, media attention, prolonged
relocation, continued separation and estrangement from family and
friends, bewilderment, disorientation, uncertainty about safety of
self and significant others, missing family members, continued lack
of control over what is happening.
Questions to assess secondary psychological stressors include:
Is the survivor secure and out of danger? Does he or she have
enough control of what is happening? Are there major uncertainties
in the present? Are negative events (or news) still expected?
Does the survivor have clear enough information about self and
significant others? Has adequate human attention and warmth been
given to the survivor? Has trust been established between survivors
and helpers? Can the current conditions humiliate or dishonor the
survivors?
Evolution of symptoms over time: This includes the quality, intensity, and development of early
responses. Assess content and structure of trauma narrative as it
evolves (including concrete descriptions, subjective appraisals,
emotional responses) without pointing out inconsistencies or making
interpretations. Notice whether narrative becomes richer, includes
more elements, takes on a reflective tone.
Coping efficacy: degree to which symptoms are tolerated by
survivor or interfere with functioning: Can the survivor continue task-oriented activity? How well
organized, goal directed, and effective is such activity? Is the
survivor overwhelmed by strong emotions most of the time? Can
emotions be modulated when such modulation is required? Is the
survivor inappropriately blaming himself or herself? Does the
survivor generalize such accusations to his or her personality or
self? How isolated, alienated, or withdrawn is the survivor? Does
he seek the company of others or avoid it?
Availability of healing resources: Includes access to social support, nature of societal
response.
Interventions
General principles
Help providers must be tolerant of symptomatic behavior,
strong emotions.
Help providers must respect the survivor's ability to
self-regulate and monitor his or her environment.
Help providers must break the wall of mental isolation that
can follow trauma exposure and must maintain continuity of care
so that survivors do not begin to feel betrayed and
re-isolate.
Help providers must provide care that is tailored to the
needs, capacities, and desires of survivors.
The survivor must be able to properly utilize and enjoy what
is offered. Stress responses may reduce such capacity.
Generic goals of early interventions
To reduce psychobiological distress and the effects of
secondary stressors.
To treat specific symptoms when they interfere with normal
healing processes.
To assist the normal healing process by supporting the
survivor and helpers, by seeing that such helpers are available,
that families are evacuated together, etc.
To follow progress by continued assessment of global coping
efficacy.
Interventions in the different phases of the acute
response
Peri-traumatic period
Protect from further exposure to stress, contain the
immediate physiological and psychological responses, and increase
controllability of the event and of subsequent rescue
efforts.
Be aware of and responsive to survivor's comfort and dignity
(e.g., by covering his or her body, avoiding intrusive looks of
others and of the media).
Reorient survivor within the rescuing environment, identify
self and role.
Continuously inform survivors about steps to be taken (e.g.,
evacuation to a hospital), medication given (e.g., morphine), and
other information.
Provide genuine information (including admitting lack of
information) but avoid breaking bad news if possible.
Maintain human contact with survivors throughout rescue
efforts.
Bring in natural helpers (e.g., relatives, friends) and
support them with advice and information.
If survivors have difficulty expressing their experience
verbally, use other bodily and emotional channels are open for
communication. E.g., comforting touch (with respect for gender
and social boundaries), physical comforts (warmth, hot showers,
clean clothes), favorite music, foods, books, movies.
Whenever possible, reconnect or evacuate survivors with their
family and friends.
Addressing Early Responses
Early post-trauma interventions should aim to facilitate
psychological recovery and disable progressive sensitization.
Encourage survivors to verbalize and share their individual
story with others: While telling the story is stressful and rarely without strong
emotion, it also creates an emotional bond that reduces the
survivor's isolation.
Expect oscillation between periods of extreme anguish and
relative rest.
Encourage grieving for losses and re-adaptation (new learning
about self /others).
Encourage survivors to express painful emotions (verbally,
through art, music).
Attempt to interrupt continuous distress.
Encourage survivors to be with others.
Encourage increased thinking about the trauma (rather just
experiencing).
Allow for specific recovery styles to develop in individuals
and families (one may talk and another may be silent).
Assess the strengths and the weakness of the survivor's
immediate supporters.
Explain meaning of symptoms and recovery process to survivors
and their helpers.
Treating Emergent or Unremitting Symptoms Upon Return to
Normal Activities
Survivors may become more symptomatic as they prepare to
leave the hospital.
Phobic responses, major depression, and acute PTSD may become
evident because they start to interfere with normal tasks.
If there are new or unremitting symptoms 4 or more weeks
after return to a safe environment, survivor may require
professional care.
Specific techniques
Crisis interventions and stress management
These interventions attempt to stop the vicious circle of
catastrophic appraisal and extreme distress, address survivors'
perception that their reaction is abnormal or that they have
totally lost their inner strength, move subjects from a stage of
disarray to a stage of effective coping.
Excessive distress is thought to impair effective problem
solving, and coping.
Steps of crisis interventions include 1. Appraising with the
individual what specific elements in a given situation create
intolerable distress. 2. Recognizing, legitimizing, and
challenging the perceived totality of the situation. 3.
Addressing efforts already made to solve the salient problem. 4.
Assessing other ways of problem-solving, other resources,
alternative plans of action (such as effective help-seeking,
postponing efforts to find a solution, and focusing on
alternative goals).
Treatment of combat stress reaction (CSR) within the
military
CSR has had dual goals of treating combat soldiers and
reducing manpower loss due to psychological reactions.
PIE model (proximity, immediacy, and expectations) focused on
treating CSR casualties as near as possible to the frontline, as
soon as possible, and with an expectation of recovery and return
to duty.
Effectiveness of PIE approach has not been confirmed by
studies of CSR, and there is some evidence that it is not
effective in preventing PTSD.
Best approach may be to allow a natural selection process by
which those who recover within the time allocated to staying in a
frontline facility may go back to their previous role, while
those with persistent reactions are evacuated to the rear.
Brief cognitive interventions
4 and 5 session Cognitive Behavioral Therapy (CBT) interventions
administered weeks after trauma have been found to reduce rates of
PTSD in samples of sexual assault, nonsexual assault, and accident
victims.
Debriefing
Semi-structured individual and group interventions are
designed to alleviate initial distress and prevent the
development of mental disorders following exposure to traumatic
events through reviewing the facts, sharing emotions, validating
individual experiences, learning coping skills, evaluating
current symptoms, and preparing for future experience.
Controlled studies of debriefing interventions have shown
that most survivors perceived debriefing sessions as beneficial
and satisfying and that the interventions significantly reduced
concurrent distress and enhanced group cohesion.
But in controlled studies of 4 different types of trauma
survivors, one-session interventions were not effective in
preventing PTSD and, in 2 of 4 studies, had negative long-term
effects.
The effects of debriefings in the context of continuous care
have not been studied.
Pharmacological interventions
Short-term administration of anxiolytics (i.e.,
benzodiazepines for 5 nights) to recent (between one and three
weeks) trauma survivors was found to improve sleep and PTSD
symptoms, but prolonged treatment by high potency benzodiazepines
in recent trauma survivors (2 to 18 days following trauma) was
associated with higher incidence of PTSD at six months.
Pharmacological agents that interfere with learning (e.g.,
benzodiazepines) may prevent post-trauma adaptation. This argues
against administering such drugs continuously to trauma
survivors.
Therefore, the use of sedatives in recent trauma survivors
should have specific target (e.g., sleep, control of panic
attacks) and should be time-limited.
No studies have been conducted on effects of antidepressants
in acute trauma victims.
Other classes of drugs may prove useful, but no studies have
yet been completed.
Effects on helpers
Rescuers and helpers are also at risk for developing stress
responses.
Warning signs of burnout include excessive exposure,
inability to disengage from work, irritability, inability to
relax, difficulties communicating with others.
Effects on rescuers can be reduced by: monitoring exposure to
trauma, ordering and enforcing breaks and resting periods,
providing relief replacement workers.
Professional and lay helpers who help by listening to trauma
survivors' distress and trauma stories need adequate preparation,
support, and opportunities to ventilate and share their
emotions.
Conclusions
There are multiple reasons why early interventions can be
ineffective:
PTSD has a complex etiology.
The relative contribution of early and short interventions is
necessarily small.
Early responses to trauma are changeable and a mixture of
normal and abnormal behavior.
It is difficult to identify which persons are at risk for
continued problems.
It is difficult to conduct interventions in early aftermath
of disastrous events.
What have been found to be effective are multiple sessions of
CBT provided weeks (not days) following the trauma. However, in
many cases, if the client cannot tolerate CBT, supportive
counseling is in order until the client can tolerate the intensity
of some aspects of brief CBT.
Effective treatment should be administered during the early
posttraumatic period to symptomatic survivors.
Immediate contact can provide the survivor with an open door (or
address) for continuous or later treatment and the ability to
identify oneself as being in need of treatment.
Stages of early responses to traumatic events should follow this
general framework:
1. Provide concrete help, food, warmth, and shelter.
2. Once out of concrete danger, soothe and reduce states of
extreme emotion and increase controllability.
3. Assist survivors in the painful and repetitive re-appraisal
of the trauma.
4. Treat specific syndromes such as acute stress disorder,
depression, and other anxiety disorders.