By Associate Professor David Forbes MAPS, Deputy Director and Professor Mark Creamer FAPS, Director, Australian Centre for Posttraumatic Mental Health

The floods across the Eastern States, particularly in areas such as Toowoomba and the Lockyer Valley in Queensland - with their heavy toll on life and property - will leave thousands deeply affected. The extent of devastation has been such that, for many, it will be a long time before lives return to normal. Lessons from the Black Saturday Victorian bushfires and the 1974 floods indicate that re-establishing a sense of normality and rebuilding after such events can continue for years afterward. 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 floods may have a lasting impact on individuals' ability to cope. While much attention in the early stages will focus on broad community interventions designed to enhance cohesion and support, there is also an important place for individual assistance.

Initial support

Although most people affected by the floods are likely to experience distress, the majority will recover using their existing coping strategies and social supports. As such, more formal interventions are not generally recommended in the first couple of weeks after the event (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 in PFA are provided in a stepwise 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 (Allen et al., 2010). PFA is also recommended for use by emergency service organisations to support their own members. A detailed manual to guide PFA is available from the US National Center for PTSD website (www.ncptsd.org).  

Importantly, there is international expert consensus that 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., 2010). 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.

Clinical and research data following disasters, however, indicate that a significant number will continue to experience distress despite their best attempts to cope and receipt of PFA-type support. These people may experience mild to moderate distress and report worry, sadness, insomnia, anger, social withdrawal, decreased ability to function at work, school or home, or other psychological issues. These problems are often exacerbated by practical issues arising from bereavement, destruction of property and other possessions, relocation and rebuilding. For these intermediate difficulties, a formal intervention called Skills for Psychological Recovery (SPR; Berkowitz et al., 2010) is gaining considerable international attention.

SPR has a strong focus on skills development and is provided by health practitioners or general counsellors. It was developed by the US National Center for PTSD and National Child Traumatic Stress Network in the aftermath of Hurricane Katrina, and first trialled in Australia in the aftermath of the Black Saturday bushfires. SPR utilises an evidence-based set of interventions, including assessment, problem solving, activity 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 are provided over a period of one to five sessions in a flexible manner tailored to need. Data from the implementation of SPR following the Victorian bushfires indicated that health providers from various disciplines and paradigms perceived it as a useful intervention for disaster survivors with moderate levels of mental health difficulties (Forbes et al., 2010).

Psychological interventions for mid- and long-term problems

Although most people will experience reduced distress and a return to normal functioning over the initial days and weeks, a significant minority will continue to experience more serious problems requiring formal assessment and intervention. Common mental health problems following disaster include depression, anxiety disorders such as posttraumatic stress disorder (PTSD), generalised anxiety disorder (GAD), panic disorder (PD) and simple phobias, and complicated grief and substance misuse. These disorders may be newly developed in the aftermath of this disaster or may represent exacerbations of existing or remitted mental health disorders. Guilt, anger, somatisation, sleep and related problems may exist alongside, or independently of, these diagnosed conditions.

There is no ‘one size fits all' approach for these conditions and careful assessment of specific presenting problems is important in order to tailor interventions. In terms of PTSD treatment, 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 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. In routine clinical practice, trauma-focused psychological treatments are embedded in a treatment plan that includes initial stabilisation and engagement, psychoeducation, arousal reduction and other symptom management strategies, and encouraging the resumption of key relationships and roles as soon as possible.

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.

THE EIGHT COMPONENTS OF PSYCHOLOGICAL FIRST AID (PFA) 

  • Initiating contact and engaging with an affected person in a non-intrusive, compassionate and helpful manner
  • Providing immediate and ongoing safety and both physical and emotional comfort
  • If necessary, stabilising survivors who are overwhelmed and distraught
  • Gathering information to determine immediate needs and concerns and to tailor PFA interventions
  • Providing practical assistance in helping the survivor address immediate needs and concerns
  • 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
  • Providing information on coping, including education about stress reactions and coping (often in a written format)
  • Linking the survivor with collaborative services and providing information about those that may be needed in the future 

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 is able 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 evidence-based treatment at an appropriate ‘stepped care' level. 

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

References

Allen, B., Brymer, M.J., Steinberg, A.M., Vernberg, E.M., Jacobs, A., Speier, A.H. & Pynoos, R.S. (2010). Perceptions of Psychological First Aid Among Providers Responding to Hurricanes Gustav and Ike. Journal of Traumatic Stress, 23(4), 509-513.

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

Berkowitz, S., Bryant, R., Brymer, M., Hamblen, J., Jacobs, A., Layne, C., Macy, R., Osofsky, H., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P. (2010). Skills for Psychological Recovery: Field Operations Guide. The National Center for PTSD and the National Child Traumatic Stress Network.

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., Bisson, J., Cohen, J., Crowe, B., Foa, E., Friedman, M., Keane, T., Kudler, H., & Ursano, R. (2010). A guide to guidelines for the treatment of PTSD and related conditions. Journal of Traumatic Stress, 23(5), 537-552.

Forbes, D., Fletcher, S., Wolfgang, B., Varker, T, Creamer, M., Brymer, M., Ruzek, J., Watson, P., & Bryant, R.A. (2010). Practitioner perceptions of Skills for Psychological Recovery: A training program for health practitioners in the aftermath of the Victorian bushfires. Australian and New Zealand Journal of Psychiatry, 44, 1105-1111.

InPsych February 2011