By Associate Professor David Forbes MAPS, Clinical Director and Professor Mark Creamer FAPS, Director
Australian Centre for Posttraumatic Mental Health and Department of Psychiatry, University of Melbourne

<< Return to InPsych April 2009

The recent Victorian bushfires were a highly distressing and potentially traumatic experience for those involved. The extent of devastation was such that, for many, it will be a long time before their lives return to normal. For those who lost loved ones, the experience of traumatic grief will have an additional major impact on their lives. The loss of homes and communities, and the security that they provide, will make the recovery process longer and more difficult. How organisations and health services support those affected by the fires may have a lasting impact on individuals' ability to cope.

Initial support

Although most people involved will have experienced distress following the fires, the majority will recover using existing coping strategies and social supports. As such, formal intervention in the first couple of weeks is not generally recommended (Australian Centre for Posttraumatic Mental Health (ACPMH), 2007). Instead, psychological first aid (PFA), an evidence-informed approach to assisting people in the immediate aftermath of disaster (Brymer et al., 2006), is now internationally recognised as the recommended intervention. PFA is based on five empirically supported principles to guide post-disaster interventions: (a) promoting sense of safety; (b) promoting calming; (c) promoting sense of self- and community-efficacy; (d) promoting connectedness; and (e) instilling hope. Interventions included as part of PFA are provided in a step-wise manner tailored to individual needs.

PFA comprises eight components (see boxed information) and is designed to reduce initial distress and foster short- and long-term adaptive functioning. It is typically delivered by generalist health and disaster response workers, with support from mental health professionals. PFA is also recommended for use by emergency service organisations to support their own members. As part of PFA, individuals should also be reminded that there are many things they can do to aid their own recovery and that of their loved ones. Examples include returning to normal routines as soon as possible, spending time with loved ones, getting plenty of rest and exercise, and avoiding making major life decisions. A detailed manual to guide PFA is available from the US National Centre for PTSD website (www.ncptsd.org).

Importantly, the routine use of structured interventions that focus on recounting the traumatic event and ventilation of feelings following disaster, such as psychological debriefing, are not recommended (Forbes et al., 2007). Obviously many survivors will wish to discuss their experiences and they should be supported in doing so. Psychologists, however, should be mindful of the survivor's capacity to tolerate distress and the potential adverse effects of excessive ventilation in those who are very distressed or have dissociative symptoms.

Where distress does not settle in the days following the disaster, an intermediate phase of intervention is recommended. This more formal phase has a strong focus on skills development and is provided by health practitioners or general counsellors. Still based on a resilience-building rather than pathology model, this brief counselling phase is referred to as skills in psychological recovery (SPR). As this is a relatively new model, detailed manuals are currently under development by the US National Center for PTSD (National Center for PTSD & National Child Traumatic Stress Network, 2009) and not yet publicly available. SPR focuses on utilising an evidence-based set of interventions tailored to needs, including assessment, problem-solving, activities scheduling, helpful thinking, social support facilitation, and distress management. Practitioners at this point are also well placed to assist survivors to begin addressing issues of loss. These interventions should be provided over a period of one to five sessions in a flexible manner tailored to need.

In the context of disasters that affect whole communities, key interventions in the early stages should also focus on the community as a whole (see article by Dr Rob Gordon this edition).

The eight components of psychological first aid (PFA)
  1. Initiating contact and engaging with an affected person in a non-intrusive, compassionate and helpful manner
  2. Providing immediate and ongoing safety and both physical and emotional comfort
  3. If necessary, stabilising survivors who are overwhelmed and distraught
  4. Gathering information to determine immediate needs and concerns and to tailor PFA interventions
  5. Providing practical assistance in helping the survivor address immediate needs and concerns
  6. Connecting the survivor with social supports by helping to structure opportunities for brief or ongoing contacts with primary support persons and/or community helping services
  7. Providing information on coping, including education about stress reactions and coping (often in a written format)
  8. Linking the survivor with collaborative services and providing information about those that may be needed in the future

 

Psychological interventions for mid- and long-term problems

For most survivors, distress will begin to subside over the first few weeks, although ongoing fires and high fire danger days in some areas will maintain a sense of continued threat. For those whose distress continues despite receiving PFA and SPR support, more formal assessment and interventions should be considered. Common mental health problems following trauma include depression, anxiety disorders such as posttraumatic stress disorder (PTSD), generalised anxiety disorder (GAD), panic disorder (PD), and simple phobias, complicated grief, and substance misuse. Associated problems such as guilt, anger, somatisation and sleep problems can also exist alongside the above problems or independently.

Given the array of mental health conditions that can manifest posttrauma, careful assessment of specific presenting problems is important in order to tailor interventions accordingly. There is no ‘one size fits all' approach in the aftermath of trauma. In terms of treatment for PTSD, the Australian guidelines (ACPMH, 2007) recommend the use of trauma-focused psychological treatment such as trauma-focused cognitive-behaviour therapy (TFCBT) or Eye Movement Desensitisation and Reprocessing (EMDR) in addition to in vivo exposure. The three key elements of these interventions comprise:

  • Confronting the traumatic memory in a controlled and safe manner (imaginal exposure)
  • Identifying and addressing maladaptive thoughts and beliefs about the event that may be interfering with recovery (e.g., cognitive therapy to address issues such as safety, control, trust, and self esteem)
  • Confronting avoided situations, people, places or activities in a graded and systematic manner (in vivo exposure).

Importantly, these same elements are often appropriate interventions, either singly or in combination, for other posttraumatic mental health problems. These include, for example, cognitive therapy for trauma-related depression and GAD, in vivo exposure for simple phobias, and all three combined with grief counselling for complicated grief. Obviously, these would be combined with other evidence-based interventions to address these problems as appropriate.

In routine clinical practice, trauma-focused psychological treatments are embedded in a treatment plan that commences with stabilisation and engagement; the confronting nature of trauma-focused interventions highlights the importance of developing a robust therapeutic alliance. Psychoeducation is also part of the early stages - providing a clear explanation of, and rationale for, treatment and promoting realistic and hopeful outcome expectancies. Symptom management approaches such as anxiety management and arousal reduction strategies, anger management, sleep hygiene and strategies to control substance abuse are useful. Encouraging the resumption of key relationships and roles as soon as possible is also recommended.

Pharmacological treatments for traumatic stress disorders are not normally recommended as a first-line treatment in preference to trauma-focused therapy unless psychological treatment is unavailable or the distress cannot be managed by psychological means alone. Where medication is considered for PTSD, depression and other anxiety disorders, SSRI antidepressants are usually the first choice. Other new generation antidepressants and older tricyclic antidepressants are considered as a second line pharmacological option.

Dealing with comorbidity

Posttraumatic mental health problems rarely exist in isolation, especially as conditions become more chronic. The co-occurrence of PTSD, depression and substance abuse present treatment sequencing dilemmas for practitioners. Generally, where PTSD is comorbid with mild or moderate depression, the PTSD should be treated first as depression often improves as PTSD symptoms reduce. Severe depression, however, should be treated first to minimise suicide risk and improve the person's ability to tolerate trauma-focused therapy. When PTSD and substance abuse co-occur, they should be treated simultaneously due to the likelihood of mutual maintenance. The trauma-focused component of PTSD treatment, however, should not commence until the person has demonstrated their ability to manage distress without turning to alcohol or drugs, and to attend treatment sessions without being under the influence. Re-assessing the severity of the depression following remittance of substance abuse, however, is important as the drug may have affected the nature and severity of the depressive features.

Conclusion

Psychologists have a great deal to offer in assisting individuals, groups and communities to recover from disaster and trauma. Our first responsibility should not be to intervene but, rather, to support the normal recovery process and naturally occurring networks. For those who do not show a normal recovery, however, it is incumbent upon us to provide the best available treatment. Evidence-based interventions for common posttraumatic mental health conditions have a demonstrable track record of efficacy for the majority of those affected.

The principal author can be contacted at dforbes@unimelb.edu.au.

References

Australian Centre for Posttraumatic Mental Health. (2007). Australian Guidelines for the treatment of adults with Acute Stress Disorder and Posttraumatic Stress Disorder. Melbourne: ACPMH.

Brymer, M. J., Jacobs, A. K., Layne, C. M., Pynoos, R. S., Ruzek, J. I.,
Steinberg, A. M., Vernberg, E. M., & Watson, P. J. (2006). Psychological first aid: Field operations guide, 2nd edition. Retrieved February 2009 from www.nctsn.org and www.ncptsd.va.gov.

Forbes, D., Creamer, M. C., Phelps, A. J., Couineau, A.-L., Cooper, J. A., Bryant, R. A., McFarlane, A. C., Devilly, G. J., Matthews, L. R., & Raphael, B. (2007). Treating adults with acute stress disorder and post-traumatic stress disorder in general practice: A clinical update. Medical Journal of Australia, 187, 120-123.

National Center for PTSD and National Child Traumatic Stress Network. (2009).
Skills for Psychological Recovery: Field Operations Guide. Unpublished draft edition.