1. The European Network for Traumatic Stress Training & Practice www.tentsproject.eu

2. Early intervention Curriculum for early intervention strategies after trauma Dag Ø. Nordanger Venke A. Johansen Brigitte Lueger-Schuster Jonathan Bisson

3. What is early intervention? Here: General concept for psychosocial and mental health responses to mass trauma Includes both broad multiagency responses And more specific/formalised interventions: –Psychological first aid (PFA) –Supportive counselling (SC) –Trauma risk management (TRM) –Critical incident stress debriefing (CISD) –Trauma-focused Cogn. Behav. Therapy (TB-CBT)

4. What is trauma? Event which outplays natural coping resources Involves actual or threatened death or injury, or threat to physical integrity of oneself or others. Subjective response marked by intense fear, helplessness, or horror..

5. Traumatizing elements Severity, duration and intensity Unexpected, uncontrollable or inescapable Interpersonal, and with intention Perceived life threat Combination of physical injury and perceived life threat Serious offence

6. Subjective experience Sense of unreality and fear Images of sights, sounds, smells Basic assumptions challenged Feeling vulnerable, helpless and hopeless. Grief Survivor guilt

7. Trauma-related diagnosis Posttraumatic stress disorder (PTSD) Acute stress disorder Depression Various anxiety disorders Substance misuse Adjustment disorders Complicated grief Hard to limit effects to certain diagnosis!

8. Increased vulnerability Changed picture of oneself and others Emotional problems Reduced concentrations, memory- problems Triggers increase Relational problems, Closeness and intimacy may be difficult QUALITYOFLIFEQUALITYOFLIFE Posttraumatic reactions and quality of life

9. Posttraumatic growth Trauma does not just tear down Crisis common source of positive change Identity, philosophy, and goals Relationship and social network Empathy Vulnerability and receptiveness of help

10. Natural recovery PTSD after 9/11 terror attack

11. Protective factors Safety, predictability Social support Sense of belonging Sense of coherence Sense of mastery Purpose and role

12. Risk factors Protective systems missing or eroded Isolation/lack of social support Previous traumatic exposure History of complex/relational trauma History of psychopathology Sleeping problems Life situation still insecure or stressing

13. Early intervention: Evidence Best multiagency early intervention? No definitive evidence Best immediate psychosocial response? Limited evidence, but PFA “evidence informed” Best preventive interventions? Evidence for multiple session individual TF-CBT for symptomatic people Best screening instrument? Evidence for short q’naires CISD: No supportive evidence Supportive counseling: No supportive evidence “Wait and target” recommended

14. Individual Psych. Debrief. Rose et al, 2007

15. Wait and Target Roberts et al, 2009

16. Wait and target ASD, PTSD Roberts et al, 2009

17. The TENTS guidelines ”The Five Step Model” translated into its practical implications Also: ”Wait and target” operationalized Primarily based on consensus reached through Delphi Method

18. The five step model 1.Sense of Safety 2.Calming 3.Sense of self- and community efficacy 4.Connectedness 5.Hope

19. The six sections of the TENTS guidelines 1.Planning, preparation and management 2.General components of the response 3.Responses within first week 4.Responses within first month 5.Responses one to three months 6.Long term responses

20. Planning, preparation and management Planning group Guidelines Interagency coordination Mapping of services Testing and exercises Involvement of officials

21. General components Promote the five steps Consider human rights Facilitate indigenous healing practices Social, physical and psychological support Family support Education on reactions and coping No formal interventions or screening of all

22. General components (cont.) Prioritize those directly affected Access to specialist assessment/management Promote self-help interventions Involve culturally informed people Inform GPs about people at risk Identify supportive resources Access to financial, legal and other services Planning of memorial services/ceremonies

23. Within the first week Practical and pragmatic support Information about the situation Education about trauma reactions Normalise psychological reactions Detailed accounts on own choice only! Infrastructure (assistance centre, telephone helpline, website and database) Work closely with the media

24. Attitudes and appearance Clearly defined roles Confidentiality Informed about the setting Compassionate Visible and available, but non-intrusive Soft, calm and concrete talk

25. Within the first month Formal assessment for further input TB-CBT for high risk individuals Evidence based treatments for other mental health problems Proactive contact with distressed people Option of further pro-active contact to all

26. One to three months Formal assessment by a trained professional TF-CBT for acute post traumatic stress disorder Evidence based treatments for chronic PTSD second option Evidence based interventions for other mental health difficulties Proactive contact with distressed people Option of further pro-active contact to all

27. Beyond three months Assessment by trained professionals Evidence based interventions for people with mental health difficulties Providing work/rehabilitation Planning/funding of long term follow up

28. Treatment: Evidence Evidence from controlled studies for: TC-CBT EMDR Stress management Group therapy Some pharmacological treatment

29. Chronic PTSD – clinician ratings (vs wait list or placebo) SMD & 95% CIs Effect Size

30. TFCBT vs WL/Usual Care Bisson, Andrew & Lewis, in prep’n

31. EMDR vs WL/Usual Care Bisson, Andrew & Lewis, in prep’n

32. Summary People are basically resilient No reason for specialised services for all But build up under protective factors, and monitor how people cope Then target people who struggle, with evidence based treatments TENTS guidelines represent this