Reconstruction of early intervention after trauma was the main feature of the program sponsored by the new Disaster and Trauma Section of the Canadian Psychological Association at its convention in 2004. What emerged is an assertion of new values that should underpin this aspect of applied psychology.
Of particular concern is the principle that there be a sound knowledge base, which, with relevant theory, informs service innovation. Early intervention practice has often failed to honor this principle. Instead, the reputation earned by early intervention is of rigid orthodoxy and doctrinaire prescriptions (e.g., Groopman, 2004).
No one doubts that provision for care of those distressed by recent trauma is imperative. Following satisfaction of primary needs such as safety, shelter, comfort and nourishment, it makes sense to consider reconnection with existing wider support networks provided by family and friends. From nonintervention studies (e.g., Ørner, 2003) we learn that survivors typically draw on personal resources and their own social support networks to modulate the effects of critical incidents. Thus formalized assistance is not an invariable requirement or a necessity in the early aftermath of many types of trauma. Likely exceptions are the survivors of recent sexual assault trauma or the ongoing care provision put in place where mass violence leads to the destruction of social infrastructure or when whole communities are displaced.
Within this emergent perspective on early intervention it is easier to understand why the carefully controlled studies that are included in the most recent Cochrane Review (Rose, Bisson, & Wessely, 2003) failed to confirm a consistent beneficial gain from single, protocol driven, prescriptive interventions for trauma survivors. Such interventions are, at best, ill advised and unnecessary; at worst they may interfere with immediate coping processes so as to compromise future adjustment (Watson, 2004).
The risk of doing harm arises through a number of either direct or indirect processes. To impose help when survivors prefer to rely on personal or more intimate support networks will be experienced as unwelcome intrusions. Articulating a personal trauma narrative or being made to listen to those of other trauma survivors can engender and reinforce higher levels of arousal in those who may already be hyperaroused. Active intervention can intensify an already pervasive subjective sense of being out of control. Not only is this unhelpful in itself but its insidious effect may be to disempower survivors. Unintentionally, they may be cast in roles of passive recipients of care when actually they are actively engaged in accommodating and assimilating recent critical experiences.
Rather than conceptualizing evoked reactions as symptoms of a diagnosable disorder, the elimination of which becomes a rationale for early intervention, it makes sense to recognize recent trauma survivors as being both distressed and frightened. If we respond sensitively to distress and fear as adaptive signals from others who may need help, change can be fostered through dialogue and consultation.
Sometimes the most pressing needs are obvious and easily provided for. If less clear, we do well to confer with survivors about what help and support they may welcome. The objective is to provide and facilitate that which is not already in place to promote the overarching aim of early intervention: to improve the quality of the recovery environment. Protocol prescriptions will not accommodate all expressed needs and wishes. Instead, practical actions taken in the early aftermath of trauma should accord with agreements reached between service users and providers.
Our conference discussions engendered a recognition that the earliest expressed psychological needs following trauma are typically for affiliation, attachment and the comforts of being cared for by others. Therefore, the focus for early intervention should be directed on individual survivors in the interpersonal context within which they live and work.
We call for a new set of values for reconstructed early intervention. These values derive from respect and recognition of survivors being actively engaged in a process of adjustment in which expressed distress and fear are signals, not symptoms. With humility we may offer discreet assistance for individuals and communities actively engaged in adapting, accommodating and assimilating recent trauma. Our concerns therefore should not be with the elimination of symptoms but to foster affiliations and helpful attachments.
Traumatic events often occur to individuals functioning as part of an organization. Management of organizations plays an important role in determining the extent to which the emotional effects are positive or negative (e.g., Huddleston et al., 2003). Leadership that facilitates a positive recovery environment thus must be seen as a crucial factor in the psychosocial preparation for and response to traumatic stress. Similarly, for communities following disasters, the restoration of civic cohesion is crucial for the re-establishment of healthy functioning (Kaniasty and Norris, 1993).
Systematic evaluations are needed to formally establish the veracity of the new values for early intervention that we believe will foster flexibly delivered, evidence-based early intervention. Only then can we start addressing survivors’ phased, changing and developing needs. In so doing we will strengthen the aspirations of psychology to be a science that informs relevant, professional, evidence-based practice.
References
Groopman, J. (2004) The grief industry: How much does crisis counseling help—or hurt? The New Yorker, January 22.
Huddleston, L., Paton, D. and Stephens, C. (2003) The impact of traumatic stressors on New Zealand police recruits: A longitudinal investigation of psychological health and posttraumatic growth outcomes. Presented at the International Conference for Traumatic Stress Studies, University of Tasmania, Australia.
Kaniasty, K.Z. and Norris, F.H. (1993) A test of the social support deterioration model in the context of natural disaster. Journal of Personality and Social Psychology , 64, 395-408.
Ørner, R. (2004) A new evidence base for making early intervention in emergency services complementary to officers’ preferred adjustment and coping strategies. Chapter 12 in R. Ørner and U. Schnyder (Eds) Reconstructing early intervention after trauma: Innovations in the care of survivors. Oxford: Oxford University Press., Pp 143-153.
Rose, S., Bisson, J. and Wessely, S. (2004) Psychological debriefing for preventing posttraumatic stress disorder. (Cochrane Review) In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd. Web access: www.update-software.com
Watson, P. (2004) Behavioral health interventions following mass violence. Traumatic Stress Points, 18, 8-9.
David S. Hart is honorary visiting professor, ECPS, Faculty of Education, at the University of British Columbia in Vancouver, BC, Canada. Roderick Ørner is consultant clinical psychologist and visiting professor in clinical psychology at Lincoln University, Lincolnshire Partnership NHS Trust, England. For references used in this article, see StressPoints online.
For more information about early intervention, visit the ISTSS Early Intervention SIG on the SIG section of the Web site.