Transcript Systemic Wilderness Adventure Therapy

Fraser Island, Qld. 2003
A fresh approach
to how we learn and grow. . .
Psychological First Aid
in Adventure Therapy
Dr. Simon Crisp
Clinical Child Adolescent & Family Psychologist
Melbourne, Australia
Key Learning Objectives
•
Ability to DETECT mental health /
behavioural / personal safety issues
•
Confidence in applying a RESPONSE
(Psychological first-aid)
•
Increased knowledge of resources,
options and REFERRAL processes
Jahari Window - knowledge
What you
know you
know
What you
don’t know
you know
What you
know you
don’t know
What you don’t
know you don’t
know
Medical First Aid Analogy
First Responder
Field staff, Outdoor Educator, etc.
Paramedic
Counsellor
Accident & Emergency Team
Program Coordinator, Child
Protection,
Surgeon / Physician
Psychologist, Mental Health Service
Ways Adolescents Cope
Non-Productive Coping:
• Worrying about the problem
• Using wishful thinking about the problem
• Not coping and becoming ill
• Letting off steam / tension reduction
• Avoidance of the problem
• Self Blaming
• Keeping to oneself / not talking to others
• Seeking spiritual support (ie. Praying to God to fix it)
• Depending on a professional and not trying to cope
Ways Adolescents Cope – cont.
Productive Coping:
• Seeking social support, talk to others (help seeking)
• Actions aimed at solving the problem
• Applying themselves to make changes
• Spending time with boy/girl friend
• Improve relationships with others
• Join others with similar concerns
• Focus on the positives of a situation
• Seek relaxing diversions or leisure activities
• Maintain fitness and health – physical recreation
Psychological First Aid
PREP
D anger
R eadiness – Resources
A ct
B rainstorm
C onsult
D ecide
Recap & Follow-up
Response > approach & engagement
P.R.E.P.
P rivacy – discretion: see how it might look
R eassuring manner and approach: de-role
E ngage adolescent: open up communication
P roblem – define it as a shared concern,
normalise it, seek collaboration
Response > approach & engagement
Small group discussion:
What are effective ways to ‘PREP’
adolescents before responding with
Psychological First Aid?
P.R.E.P.
PRIVACY
• Private place – how does this set the scene? What
messages does this communicate?
• Timing may compromise privacy
• How will a “private discussion” be perceived?
P.R.E.P.
REASSURING manner & approach
• De-role from your usual manner?
• Approach at their level
• Be aware of body language – actions speak louder
than words
• Appear calm and confident – instills trust
• Humor to reduce anxiety?
P.R.E.P.
ENGAGE - open communication
• Be patient
• Be an active and interested listener – be receptive
• Wait until the adolescent is relaxed and more open
with feelings and information
• If still reluctant: acknowledge it and validate /
normalise it
P.R.E.P.
PROBLEM: describe & normalise
•
•
•
•
•
Express your concerns simply and directly
Seek to learn how and if they see a problem
Be ready to acknowledge differing perspectives
Seek to find a shared concern
Outline implications of this concern – why it
deserves attention
• Find leverage for how the client might collaborate
on the problem
Psychological First Aid
PREP
D anger
R eadiness – Resources
A ct
B rainstorm
C onsult
D ecide
Recap & Follow-up
Demonstration of Response
 Presentation of all of
Response >
- 16 year old female student
- Teacher (Year Level Co-ordinator)
[25 minutes]
the stages of
Psychological First Aid
D anger
What are common dangers that need
to be assessed?
Psychological First Aid
D anger
- remove the student from danger or danger from
the student (& medical FA if necessary)
- secure the environment
- ensure supervision
- anticipate how the student might harm you,
others or self-harm (in that order)
- risks: medium & long –term
Psychological First Aid
D anger – questions to ask:
- Do you feel unsafe? Should I be concerned?
- How much control do you have over…?
- What could happen that might reduce your level
of control, or make you less safe?
- Can you easily talk to someone about feeling
unsafe?
- Do you have thoughts about hurting yourself or
anyone else?
Psychological First Aid
R eadiness - Resources
- What are common reasons why you
may be unready to respond?
- What are common resources you or
your student may be able to draw
on?
Psychological First Aid
R eadiness - Resources
 Readiness: am I the ‘best’ person? What is
my mental state? Am I adequately prepared?
When is the best time for me, when is the best
time for the student?
 Resources: who, or what else can I access:
what person or resources can the student access
for themselves (empowerment)
Psychological First Aid
R eadiness – Resources – questions:
- How do you feel with me talking to you about this?
- What response do you expect from me?
- Have you spoken to anyone about this before?
- Who else can help you with this?
- Who has tried to help you with this in the past?
Was it helpful?
Psychological First Aid
A ct – within your limits / role / boundaries
- Is it ethical / legal /good
practice for me to intervene?
- How far do I go?
- What is the best role for me to take on?
- What does my student expect of me?
- Could I compromise my relationship & role with
my student?
Psychological First Aid
A ct – within your limits – questions:
- What are you expecting I would do in this
situation?
- Often there are things that are best talked about
with a counsellor, is this one of those times?
- I wonder if you may feel it is more private and
easier to talk to someone less involved with you
everyday / in the way I am?
A ct - How Receptive are you?
(Johnson ,2000)
Receptivity:
…continuum of psychological ‘closeness’ to clients
Continuum of Receptivity
Absent Objective Distant Empathetic Sympathetic Identified Fused
Destructive
‘at risk’
OK
Ideal
OK
‘at risk’
Destructive
A ct - Boundaries & Self Disclosure
• Self disclosure has the potential to confuse &/or interfere
with boundaries
• Immediacy = appropriate self-disclosure
• The helping relationship will lead to feelings of
‘imbalance’ for staff - this important asymmetry in
relationship defines roles of helper and recipient of help
• These feelings must be ‘held’, and the tendency to equalise
the relationship must be resisted
• Seek alternative responses to self-disclosure
A ct - Keeping Boundaries
Avoid:
• Acknowledging or discussing own mental
health issues, family issues, drug use, school
experiences - including telling client of own
similar issue or problem and how you
overcame it
• Expressing personal rather than professional
feelings about the client
• Telling personal issues: partner / spouse,
sexual or relationship history, family, political
or religious views
A ct - Keeping Boundaries
1. Whose needs am I meeting by disclosing?
2. Do they really want to know about me,
or if I can understand their situation?
3. Is their question really about themselves?
4. Does a personal question about me, result in
avoidance of own issues?
5. If I disclose, will the adolescent begin to worry
about me (role reversal)?
6. Could I keep my own personal feelings about my
issues contained and boundaried within myself?
7. Is a adolescent pushing disclosure about wanting
to equalise or gain more power?
When asked a personal question, ALWAYS:
• Keep answer general, or ‘in principle’
• Describe the concept or reasoning behind your
answer
• Broaden a question to a discussion about values
and guidelines for behaviour or relationships
Remember it is always good to say “That is
personal and I want to keep that private”
Psychological First Aid
B rainstorm strategies
- What can my student do?
- What can I do?
- Take a collaborative problem solving approach
Psychological First Aid
B rainstorm strategies – questions:
- What has worked in the past?
- What haven’t you tired that might help?
- What do you think needs to happen to take this in
a more positive direction? – what do other people
think?
- If you had more information, would that make it
easier to deal with?
Psychological First Aid
C onsult
- with peers / senior / parent / expert
- share responsibility with your superior
- utilize the resources of the parents or an expert
to your student’s benefit
Psychological First Aid
C onsult – questions (to yourself):
- Do I have all the pertinent info?
- How much do I know about this type of issue?
Have I dealt with this type of problem before?
- Is there something unique to this situation that
suggests I should consult?
- Do my reactions / confidence suggest that I should
get support?
- Is specialised assessment indicated?
Psychological First Aid
C onsult
Who could you consult to:
peer / senior / expert?
Psychological First Aid
D ecide
- Monitor OR Manage myself OR Refer?
- Re-assess Danger (repeat DRABCD if necessary)
Psychological First Aid
D ecide – questions (to yourself):
- What might hinder this student accepting referral?
- What can I do to ensure the student follows
through?
- How can I ensure that the referee get all the info?
- What are my obligations to parents about the
referral?
- What is the best way to review this? – make a plan
Response >
termination
Re-cap & Follow-up:
Re-cap
• Key points of information
• Strategies to use
• Plan of action
Follow-up
• Who / what / when
Morning Tea? Something to eat?
Specific Problems: Anxiety Disorders
•
Generalised Anxiety Disorder
•
Panic Disorder
•
Phobias: Social Phobia / Agoraphobia
•
Obsessive- Compulsive Disorder (OCD)
•
Post-Traumatic Disorder (PTSD)
Anxiety Process
1. Visual stimulus cues the person to appraise
the situation as either “safe” OR “threat”
2. Physiological symptoms: Perspiration;
increased respiration, blood pressure, etc.
3. Cognitive: anticipating a catastrophe
“something bad is about to happen”; loss of
confidence or self-efficacy; memory
disturbance; attentional disruption (over-focus
on threat); hypervigilance, etc.
4. Behavioural: agitation; restlessness;
AVOIDANCE OF THREATENING SITUATION
Gereralised Anxiety Disorder
1. Reassure the student things are OK and under
2.
3.
4.
5.
control
Be firm, supportive and directive – take
control for the student
Encourage the student to ‘reality check’ their
fears, bring things in to perspective – use
visual cues
Allow the student to talk through their fears if
possible
Gentle distraction and humor can be useful if
done supportively
Panic Disorder
•
Acute experiences of heightened anxiety:
Difficulty breathing; feelings of chocking or
hyperventilation; trembling or shaking; racing
heart beat; dizziness; abdominal pain; fear of
loosing control, etc.
•
Person may feel they are going to die
•
Hyperventilation may appear
as asthma
•
Usually transitory and will
abate after a few minutes
Panic Disorder
1.
2.
3.
4.
If unsure if a medical condition, treat as one
Move to quiet and safe location if necessary
Encourage slow, relaxed breathing
Reassure and explain what is happening to
student – get them to focus on reassuring
using visual cues
5. Explain that attack will soon pass and they will
fully recover
6. Assure them you will stay until it has passed
7. Don’t restrict them from moving
Psychological First Aid Role Play
Managing acute anxiety:
•
In groups of 3, role play the scenario
described, especially focusing on
management of anxiety symptoms
•
In a large group, discuss how to ensure
you stay within the limits of your
expertise
Extreme Anxiety: Dissociation
•
•
•
•
Usually an adaptive response developed to
cope with abuse, trauma or extreme anxiety,
triggered by trauma related stimulus
Person psychologically ‘disconnects’ from
their physical body to avoid uncomfortable
sensations of fear, anxiety or pain
Can experience feelings of ‘derealisation’ and
‘depersonalisation’
May have very high pain threshold – danger of
accidental / deliberate self-harm or suicide
Dissociation
•
•
•
•
May be difficult to tell if it is happening – can
looks as if person is ‘floating’ and indifferent
May report being OK or “fine” and have no
awareness of their state
May refuse to move away from danger – stay
‘stuck’ or trance-like with fear
Usually occurs for seconds / minutes and
usually resolves itself
Dissociation
1.
2.
3.
4.
Assess if person is orientated:
time/place/person
Ask how they feel – may report nothing, or that
they are fearful but not show congruent signs
Gently take charge: simple, gentle, firm
directions, but avoid appearing coercive
Have them maintain eye contact with you or fix
on a reassuring visual point
Dissociation
5.
6.
7.
8.
9.
Encourage them to talk about their fears
– not ‘tune out’ to what I happening
Move to safer / less stressful location
Encourage relaxation strategies: breathing,
etc.
Normalise their experience & affirm their
ability to ‘put up’ with the fear
Specific problems: Depression
•
Equally common in both sexes
•
Often first noticed:
- fatigue, drop in general performance
- hopeless and nihilistic themes in
verbal comments
- social withdrawal, failure to engage with
peers
- friend reports that the student appears sad
Depression
•
Clinical assessment usually required
•
May be in denial that they have a problem,
highly secretive, avoid interactions, may be
expressed as irritability or anger
•
Hopelessness may make it difficult to motivate
them towards solving the problem
Depression
Do:
•
•
•
•
Take seriously
Persist in talking to adolescent about their
mood
Assume the presence of suicidal thoughts
Attempt to find out about recent stressors,
family/peer situation
Depression
Don’t:
•
•
•
•
Take their response that everything is fine on
face value
Take sarcasm or anger towards you personally
Give glib advice: “snap out of it” or list
reasons why they don’t have cause to feel sad
Raise concerns or comment in the presence of
others
Depression
Responds best to:
•
Directness, patience, measured concern
•
Closed questions about their mood
•
Confidence about how you approach the
situation
•
Empathy
Depression
When high priority:
•
Any signs of suicidality, self-harm, high risk
behaviour
•
If no professional involved (that you know of)
•
Prior history of depression/suicidality/self-harm
•
Recent stressor (especially loss)
•
Adolescent rejects help or denies a problem in
the face of contradictory evidence
Suicide and Self-harm
Continuum of self-harming behaviour
Deliberate
Self-harm
Suicide Attempt
Tension release,
| Call for help or failed
expression of anger |
serious attempt
etc.
Suicide
| Deliberate wish to
| die or accidental
death
Suicide and Self-harm
Signs:
•
•
•
•
•
Depressed, anxious, angry, agitated, mood
swings, concentration or memory problems
Often high risk-taking behaviour
Poor coping, may have eating disorder,
personality problems
May be aggressive towards others
Sometimes have difficulty being assertive
Suicide and Self-harm
Do:
•
Always take seriously, regardless of frequency
•
Gently persist in talking to adolescent about
self-harming behaviour / suicidal thoughts
•
Assume even fleeting thoughts can be deadly
•
Affirm telling someone is best thing to do
Suicide and Self-harm
Don’t:
•
Avoid or put off investigating the issue, or
hope it will subside with time
•
Convey anger, disgust, or a punitive attitude
•
Believe you can tell the student’s real
motivation, ie. “just trying to get attention”
Suicide and Self-harm
1.
Remain non-judgmental
2.
Encourage verbalisation of feelings
3.
Affirm your role is to keep student safe from
harm
Set clear limits about not tolerating self harm
in your presence (if necessary)
4.
Suicide and Self-harm
5.
6.
7.
8.
Don’t reinforce/reward the behaviour
accidentally – give a neutral response
Don’t attempt to physically restrain if actively
self-harming – move away, avoid watching,
but remain in close proximity
Ensure student is directly supervised at all
times if suicidal
Seek expert consultation as soon as possible
Psychological First Aid Role Play
Managing suicide / self-harm risk:
•
In groups of 3, role play the scenario
described, especially focusing on engagement,
building rapport and direct questions about
mood and suicidal thoughts
•
In a large group, discuss how to ensure you
stay within the limits of your expertise
Psychological First Aid Role Play
Key points:
•
Develop sufficient rapport to allow student to open-up
•
Normalise the adolescent’s experience
•
Ask direct, closed questions to determine risk factors
•
Ensure you have a clear plan + student adherence to it
•
Plan for follow-up or monitoring
Acute Stress & PTSD
Definition of Psychological Trauma:
An adverse psychological reaction to a stressful and
extraordinary event
Eg.s
•
•
•
•
•
Accident, near accident, injury, death
Assault, threat of harm, extreme behaviour
Self harm, threats of self harm, suicide gestures,
completed suicide
Natural disasters and extreme environmental conditions
Observing or in any way being a witness to any of the
above
“Comfort Zones” & Trauma
Trauma
Typical (normal) Stress Response Symptoms:
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•
•
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•
•
•
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Shock, disbelief
Heightened arousal, fear
Hopelessness, abandonment
Flight or escape behaviour
Protective postures
Holding others
Family oriented behaviours
Heroic behaviour
Time distortion: brief, suspended
Emotional ‘shutting down’
Panic is rare
Acute Stress Disorder & PTSD
Acute Stress Disorder:
•
Occurs within 2 days to 4 weeks post incident
•
<20% of people are likely to experience it
•
75% of ASD continue onto PTSD
Acute Stress Disorder & PTSD
Acute Stress Disorder - Features:
•
•
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•
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Persistent dissociation
Re-experiencing of the event (e.g. ‘flashbacks’)
Avoidance of being reminded of the traumatic
event
‘Regressed’ behaviour
Increased arousal: startle response, hypervigilence
Derealisation, depersonalisation, dissociative
amnesia
Acute Stress Disorder & PTSD
Post Traumatic Stress Disorder:
•
•
•
•
•
Post Acute Stress Disorder > 4 weeks
< 15% of all survivors develop PTSD
Symptoms may worsen with time
Likely to seriously effect functioning: school,
family, peers, adult relationships
Can be foundation to: depression, substance
abuse, self-harm, suicide
Managing Critical Incidents
1.
2.
3.
4.
5.
6.
7.
Ensure physical safety
Take personal inventory
Take charge
Seek and give personal support
Develop a routine
Balance activity and restore normalcy
Establish links to social supports ASAP
Trauma Reactions of Adolescents
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Withdrawal
Depression
Less responsible, more demanding - regress
Rebellious, competitive
Frustrated & angry
Physical complaints
Traumatic Events
Needs of Adolescents:
•
•
•
•
Education about the crisis: what happened and
why
Talk about their feelings / frustrations
Encouragement to re-engage in activities and
socialise
Encouragement to become actively involved in
getting things ‘back to normal’
Traumatic Event Hypothetical
Managing a traumatic incident:
•
In groups of 3, discuss how to manage the
scenario described. Plan your response in
points and chronological order.
•
In a large group, discuss what action you
planned, what order you would apply them
and why?
Round Up
How’s your Jahari Window?
•
Outstanding questions?
•
Most helpful thing?
•
Where to now?