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Editor’s note: ISTSS participated in the development of the Vicarious Trauma Toolkit, a repository of tools and resources that law enforcement, emergency medical, fire and victim services organizations can use to address vicarious trauma in staff and volunteers

Soldiers, police officers, firefighters, paramedics and other professionals in high-risk occupations regularly face high stress and life-threatening situations. These situations can lead to acute stress reactions (ASRs) immediately after exposure to a potentially traumatic event (PTE). Since every decision during a crisis counts, ASRs can endanger professionals and their teams through impaired decision-making and reckless behaviors (Farchi et al., 2018; Svetlitzky et al., 2019). Managing ASRs quickly and effectively on-site is therefore essential for individuals to regain adequate levels of functioning. This piece will build on two recent peer-reviewed articles on rapid interventions aimed at reducing ASRs (Farchi et al., 2018; Svetlitzky et al., 2019).

Following exposure to a PTE, individuals can exhibit several symptoms and reactions. To date, the most studied psychopathologies linked to PTEs are acute stress disorder (ASD—which can only be diagnosed three days after exposure) and posttraumatic stress disorder (PTSD—which can only be diagnosed 30 days after exposure; American Psychiatric Association [APA], 2013). ASRs, however, can appear immediately following exposure; this means there is an important lack of information on symptom management for the first 72 hours following exposure (Farchi et al., 2018). While ASRs are not listed in DSM-5 (APA, 2013), they are included in the International Classification of Diseases-11 (World Health Organization [WHO], 2018) as polymorphic and unstable anxiety symptoms (e.g., autonomic signs of anxiety such as tachycardia, sweating or flushing, being in a daze, confusion, sadness, anxiety, anger, despair, overactivity, inactivity, social withdrawal, or stupor). 

Rapid intervention becomes necessary when individuals who are responsible for carrying out perilous missions (e.g., soldiers, firefighters) start exhibiting signs of acute stress. Indeed, certain reactions such as confusion, anger, stupor and hyperactivity can jeopardize individuals’ abilities to follow protocols under stress and ensure their own safety and that of their teams (Svetlitzky et al., 2019). In a military context, ASRs are referred to as Combat Stress Reaction (CSR) or Combat and Operational Stress Reaction (Svetlitzky et al., 2019). These reactions are generally considered non-pathological and transient. However, ASRs may impact the adjustment trajectory of affected individuals and increase the risk for subsequent mental health disorders such as ASD and PTSD (Farchi et al., 2018; Svetlitzky et al., 2019). The first 72 hours after exposure to a PTE can therefore be viewed as a crucial window of opportunity for the improvement posttraumatic outcomes (Svetlitzky et al., 2019).

Psychological First Aid (PFA) programs may come as a natural first choice for some clinicians, as this type of intervention aims to improve short- and long-term adaptive functioning and coping following exposure to a PTE (Brymer et al., 2006). In their studies, however, Farchi and Svetlitzky identified several key limitations in the context of ongoing high stress and life-threatening situations (Farchi et al., 2018; Svetlitzky et al., 2019). For example, PFA is usually offered once a disaster response system is in place (i.e., an established safe space away from danger), which precludes professionals who are still involved in risky operations (e.g., during combat). Consequently, Farchi and colleagues (2018) developed the “Six Cs Model.” They describe this intervention as an Immediate Cognitive-Functional Psychological First Aid (ICF-PFA) program. The “Six Cs Model” was designed to reduce signs of ASRs on-site among professionals involved in high stress and life-threatening situations (Farchi et al., 2018). It draws inspiration from important theoretical and empirically tested concepts such as hardiness, coherence, self-efficacy and the neuropsychology of the stress response (specifically, interactions between the amygdala and the prefrontal cortex during stressful events). The Six Cs Model has five core objectives (Farchi et al., 2018):

  1. Cognitive Communication: Increase prefrontal cortex activity and lower the amygdala’s response by asking short cognitive questions that are related to the event (e.g., “How long have you been here?”).
  2. Challenge: Reduce the sense of helplessness and passiveness by challenging individuals to complete simple, cognitive-based behavioral tasks (e.g., “Please collect all your things into your bag and make sure that nothing is missing.”).
  3. Control: Reduce the sense of helplessness and passiveness by offering individuals options to choose from (e.g., “In which area do you prefer the blood perfusion?”).
  4. Commitment: Reduce the sense of loneliness by providing individuals with a verbal commitment to their safety (e.g., “We are here with you, we are not going anywhere until you are safe again.”).
  5. Continuity: Reduce confusion in the narrative of the event by explaining to individuals the chronology of the event and emphasizing the ending point (e.g., “Three minutes ago, you were involved in a car accident […], in the next 2–3 minutes, we will walk to the ambulance and you will be taken to the hospital for further checkups. The accident has ended”).

To date, the Six Cs model has been adopted by several Israeli governmental agencies, such as the Ministry of Education, Health and Internal Security, the Israel traffic police and the Israel Defense Forces (Farchi et al., 2018). Unfortunately, despite its strong theoretical and empirical basis, the Six Cs Model is difficult to test ethically and methodologically. Additional research is needed to recommend this type of intervention despite preliminary evidence of program efficacy (Farchi  et al., 2018).

On this note, at least two interventions have been adapted from the Six Cs model for intervening with ASRs during a mission-related event for military personnel: YaHaLOM (Svetlitzky et al., 2019) for the Israel Defense Forces and iCOVER for U.S. soldiers (Adler et al., 2020). The YaHaLOM intervention presents the five core elements of the Six Cs Model as a set of sequential steps designed for delivery within a 30- to 60-second timeframe. The program is intended as a tool to help units maintain functioning even under extremely difficult situations (see this YaHaLOM intervention video for an example [Hebet Unit, 2017]). Svetlitzky and colleagues (2019) encourage other researchers and decision-makers to adapt YaHaLOM to help professionals in other high-risk occupations (e.g., policemen, firefighters) as “they share a team-based orientation and have to operate in dangerous conditions” (Svetlitzky et al., 2019, p.9).

In conclusion, these studies offer promising leads to reduce ASRs in at-risk professionals during high-stress situations (Farchi et al., 2018; Svetlitzky et al., 2019). The interventions aim to help professionals quickly return to their previous levels of functioning and to hopefully decrease the risk for posttraumatic stress. More studies are needed to confirm the short- and long-term benefits of these types of interventions (Farchi et al., 2018; Svetlitzky et al., 2019).

About the Authors

Josianne Lamothe, MSW, is a doctoral student in criminology at Université de Montréal. She works as a clinician in mental health. Her research focuses on the experiences of youth protection workers with client violence. 

Marine Tessier, PhD.c., MPs, is pursuing her doctorate in clinical psychology at the Université de Montréal. She holds a master’s degree in clinical psychology from France and has significant clinical experience with various populations including victims of crime and detainees. Her doctoral research project deals with posttraumatic stress injuries among paramedics and emergency dispatchers. 

References

Adler, A. B., Start, A. R., Milham, L., Allard, Y. S., Riddle, D., Townsend, L., & Svetlitzky, V. (2020). Rapid response to acute stress reaction: Pilot test of iCOVER training for military units. Psychological Trauma: Theory, Research, Practice, and Policy, 12(4), 431–435. https://doi.org/10.1037/tra0000487
 
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
 
Brymer, M. Jacobs, A. Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg. E. & Watson, P. (2006). Psychological First Aid: Field Operations Guide: 2nd Edition. National Child Traumatic Stress Network. https://doi.org/10.1037/e536202011-001
 
Farchi, M., Levy, T. B., Gershon, B. B., Hirsch-Gornemann, M. B., Whiteson, A., & Gidron, Y. (2018). The SIX Cs model for immediate cognitive psychological first aid: From helplessness to active efficient coping. International Journal of Emergency Mental Health, 20, 1–12. http://dx.doi.org/10.4172/1522-4821.1000395
 
Hebet Unit. (2017, 19 mars). Magen for Soldier (psychological first aid on the battlefield) [vidéo]. YouTube. https://www.youtube.com/watch?v=t-QZgZd-PJ4

Svetlitzky, V., Farchi, M., Yehuda A.B. & Adler A.B. (2019). YaHaLOM: A Rapid Intervention for Acute Stress Reactions in High-Risk Occupations, Military Behavioral Health, 8(2), 232-242.  
http://dx.doi.org/10.1080/21635781.2019.1664356
 
World Health Organization. (2018). International classification of diseases for mortality and morbidity statistics (11th Revision). Retrieved from https://icd.who.int/browse11/l-m/en