Behavioral Health Interventions Following Mass Violence

PatriciaWatson, National Center for PTSD

The field of behavioral intervention following mass trauma has received high visibility since September 11, 2001. The interest in early intervention has expanded rapidly in the past few years in an attempt to prevent the distress, impaired functioning, and long-term difficulties that so often are associated with exposure to mass violence. While thoughtfully designed and carefully executed randomized controlled trials are critical in establishing best practices, there are few randomized controlled trials following mass violence. Therefore, methods such as case studies and consensus conferences have attempted to provide guidance in the absence of empirical support. A consensus conference on mental health interventions following mass violence assembled experts from around the world to arrive at guidance statements for professionals in this field (http://www.nimh.nih-gov/research/ massviolence.pdf). In August 2003, two expert panels on assessment/screening and outreach/intervention were conducted to expand on the consensus findings. A book currently is in progress (Ritchie E.C., Watson P., Friedman M., Mental Health Intervention Following Disasters or Mass Violence. Guilford Press).

Experts at the mass violence consensus conference agreed that a sensible working principle in the immediate postincident phase is to expect normal recovery. Therefore, the majority of interventions should promote normal recovery, resilience and personal growth. However, good practice in early intervention takes into account the special needs of those who previously have experienced enduring mental health problems, those who are disabled, and other high-risk groups who may be predisposed to less ability to cope with unfolding situations. The following key components of early intervention were recommended to promote individual and community-wide recovery following episodes of mass violence. These components overlap in time, are provided by diverse individuals, organizations and professionals, and create an overall framework within which recovery from mass violence can be maximized:

• Provision for Basic Needs. Essential for mental health are the meeting of basic needs for safety, security and survival, such as food and shelter; orientation to the disaster and recovery efforts; facilitating communication with family, friends and community; and reducing ongoing environmental threat.
• Psychological First Aid. Basic strategies to reduce psychological distress include orientation to disaster and recovery efforts, reduction of physiological arousal, mobilization of support for those who are most distressed, facilitation of reunion with loved ones and keeping families together, providing education about available resources and coping strategies, and using effective risk communication techniques.
• Needs Assessment. A systematic assessment of the current status of individuals, groups and the overall affected community is important. Included in the assessment should be an evaluation of whether survivors' needs are being adequately addressed, the characteristics of the recovery environment, and what additional interventions and resources are required.
• Monitoring of the Rescue and Recovery Environment. Those most affected by the incident are observed and monitored for potential behavioral and physical health sequelae. The environment is monitored for ongoing stressors or toxins, services that are being provided and media coverage and rumors.
• Outreach and Information Dissemination. Following disasters and incidents of mass violence, services are provided in the many environments where survivors can be found (sometimes referred to as "therapy by walking around"). Established community structures are utilized to provide information and support. Information is disseminated via distribution of fliers and referral to Web sites, which also can provide online support. Material is provided to the media (e.g., interviews, releases, and programs) to help increase knowledge about trauma and recovery.
• Technical Assistance, Consultation and Training. Organizations, leaders, responders, and caregivers are supported via the dissemination of knowledge, consultation, and training, so that they can improve their capacity to provide what is needed to reestablish community structure, foster family recovery/resilience and safeguard the community.
• Fostering Resilience/Recovery. Resources are provided to improve social interactions, coping skills, risk assessment and self-assessment and referral. This also includes group and family interventions, fostering natural social support, looking after the bereaved, and repairing community and organizational fabric.
• Triage. Mental health personnel assess survivors, identify vulnerable, high-risk individuals and groups, and provide referral and/or emergency hospitalization when indicated.
• Treatment. Mental health personnel seek to reduce symptoms and improve functioning via education, individual, family and group psychotherapy, pharmacotherapy, spiritual/existential support and short-term or long-term hospitalization.

Expanded Recommendations
The NIMH/SAMSHA expert panel, which met August 27-28, agreed that in the immediate phase postincident (up to seven days), universal interventions have a higher standard of doing no harm--they warrant a low level of interference and a high-level choice to balance out possible negative effects. Nothing more than education and caring should be applied universally. For instance, basic orienting information on trauma response and available resources should be offered, as well as education on parenting and friendship skills.

Selective behavioral health intervention involves screening for increased risk and/or decreased resiliency. A small proportion of those with high exposure to the incident or previous behavioral health issues, will need immediate triage and more formal psychiatric or psychological interventions. For those with less pressing presentations, psychological first aid components should be applied to those individuals experiencing higher levels of distress or having higher risk factors. Psychological first aid is based on a consensus model, and doesn't expect disclosure and expression of emotion.

The expert panelists reviewed the literature on debriefing and concluded that there is currently no well-controlled empirical evidence for the use of CISD in preventing long-term negative outcomes, and there have been studies of CISD that find a higher incidence of negative outcome effects. Panelists hypothesized that negative outcomes may be due to the psychological and physiological need for avoidant "down time," and debriefing can interrupt this process. It was agreed upon that the systematic ventilation of feelings is the most potentially harmful phase of debriefing. "Operational debriefing" in first responder settings is not a psychological intervention but a collection of shared information (minus the emotional processing phase), and may be helpful in allowing the construction of a more coherent, shared narrative of the incident.

There currently is no empirical evidence to support any intervention that utilizes the components of trauma remembrance and emotional processing in the early phases following mass violence. Because of the possible negative effects from this type of emotional processing, and the chaotic and stressful nature of the postrecovery environment, these interventions generally are not recommended in the first two to three weeks postincident. However, for those individuals who pay the full price with devastating psychiatric conditions, there is an obligation to treat them utilizing the best empirically supported treatments to prevent long-term conditions.

In the intermediate to longer-term phases postincident (two weeks to some months), more formal individual interventions for those most severely impacted are recommended. At this time, cognitive behavioral techniques (CBT) have the strongest empirical support for preventing long-lasting psychiatric conditions. It was noted that general supportive procedures cater primarily to a normal response to trauma. For those individuals who are exhibiting PTSD, anxiety disorders, and depressive disorder symptoms, screening and referral to more formal treatment is recommended.

As stated previously, it is recommended that processing of trauma occur at later stages (two weeks to some months later, depending on the extent of the incident, postincident stress and readiness of the individual to engage in this type of treatment). Cognitive behavioral interventions are not recommended prior to this time but are recommended as the most sound empirically supported treatments for PTSD, anxiety and depression once the individual is ready to tolerate a more intensive trauma-focused treatment. With children, school-based CBT group counseling can be applied after screening the student body for exposure level and distress. The timing of these interventions with both adults and children can best be determined by careful clinical judgment.

We still need to determine empirically which interventions are most appropriate for which individuals, and when to apply specific interventions in the early to intermediate phases postincident. At this time, there is little empirical data following disasters and terrorism. It is hoped that new programs in behavioral health preparedness offered through SAMSHA and NIMH, can assist in building the empirical literature in this area and in moving the field forward toward more effective recovery across a diverse set of individuals, communities and circumstances.