victims counselling kieran mundy
PSYCHOLOGICAL INTERVENTION
& TREATMENT
Kieran G. Mundy
OVERVIEW
Topic 1
Exposure to a traumatic event is common
Topic 2
Post Traumatic Stress Disorder (PTSD)
Topic 3
Acute Stress Disorder (ASD)
Topic 4
Awareness of Presence of ASD/PTSD
Topic 5
Treating Psychological Disorders
Acute stress reaction
Exposure to
Psychological
Trauma
Exposure to a traumatic event is
common
International community surveys reveal that the majority of people report at
least one traumatic event in their lives.
Most people have some kind of psychological
reaction to trauma—feelings of fear, sadness,
guilt and anger are common. But there is
also pain, a sense of loss, a loss of trust and
security, and often a total loss of community
as in the East Japan Great Earthquake.
During the life course, 60-80% of any human
population experience bio-psycho-social trauma
which may include victimization (i.e. exposure
to or witnessing community violence), severe
physical injuries, unexpected or untimely loss,
and life threatening catastrophic events.
THE SURVIVORS
( ≅ 60-80%)
POPULATION
Resilient
Total Impact
= SURVIVORS
Resilient
+ SURVIVORS
Non-
The majority (about 80%) recover over
time with the help of family , friends, and
community. Only a small proportion (about
20% to 3-4%) develop ASD or PTSD and
need professional help.
Resilient Survivors
Most (≅ 80%) people exposed to intense stressors,
especially children, have no apparent disruption in close
relationships, at work, or in their daily lives. They
maintain relatively healthy levels of psychological
functioning.
Non-resilient Survivors
A minority (< 20%) have moderate to severe initial
elevations in bio-psycho-psychological symptoms that
significantly disrupt normal functioning and that decline
gradually over weeks, months, or years before returning
to pre-trauma levels.
SURVIVORS (RESILIENT)
The overwhelming majority who, most
probably, want to be left alone once basic
needs are met.
Able to identify the risk early enough.
Are aware that environmental assaults (like
tsunamis) are deadly.
Have the options available to avoid death or
injury.
TARGET THE HIDDEN VICTIMS (HIGAI
SHA)
A small minority of high-risk (vulnerable)
people.
Women, children or the elderly, but not
necessarily so.
Those unable to identify the threat.
Those people unaware of its victimizing force.
Those who not have the personal and other
resources to cope.
co
Post Traumatic Stress Disorder
Despite the low risk, some people
develop Posttraumatic Stress Disorder
(PTSD) & Acute Stress Disorder (ASD).
The psychological reactions in the
aftermath of a SEA, MVA, or terrorist
attack, are TRAUMA-IDENTIFIED (cf.
Trauma-specific):i.e., the victim
identifies with the critical event cf. the
type of trauma is not specific to the
event).
The reactions include any threat, real
or perceived, to the life or physical
safety of a person, their loved ones or
those around them and lead to
feelings of intense fear, helplessness
or horror.
More than a quarter of a million
Australians experience PTSD in any
one year, and about 5% have had
PTSD at some point in their lives.
Prevalence rises to about 18% in
adults who have been physically
abused in childhood.
Diagnosing PTSD
Posttraumatic Stress
Disorder
Before a diagnosis of PTSD can be made, a number of symptoms
in each of three categories (re-experiencing, avoidance &
emotional numbing, and hyperarousal) must be present for at
least a month and lead to significant distress or impairment in
important areas of functioning.
While symptoms often develop in the days and weeks following
exposure to trauma, the onset of PTSD can be delayed for years
for a significant number of people.
Figure adapted from Dussich, J., Hall, B., Nobukazu, N., Rauch, S., Tuerk, P., & Yodder, M. The Psychological Effects of Trauma and Posttraumatic Stress
Disorder (PTSD). TIVI Crisis Response Team Work Group, Mito, Ibaraki. April 18-19, 2011.
Diagnosing ASD
Acute Stress Disorder (ASD)
ASD is diagnosed between two days and one month following a
traumatic event.
There is significant overlap in the diagnostic criteria of ASD and PTSD.
The diagnosis of ASD requires the experience of several dissociative
symptoms not included in PTSD (e.g., detachment, reduced
awareness of surroundings, depersonalization, and dissociative
amnesia).
PTSD places greater emphasis on avoidance symptoms.
The main difference between PTSD and ASD is the duration of
symptoms required for a diagnosis to be made.
Awareness of Presence of
Psychological Trauma
Awareness of PTSD/Acute
stress reaction/ASD
Most people experience some
level of stress after a traumatic
event and recover using their
own resources.
Professional help is only
necessary when a person’s
distress is persistent or severe
enough to cause significant
impairment.
A thorough clinical assessment
includes physical,
psychological, and social
functioning.
Some people may still face
ongoing threat & be at risk of
further exposure to trauma
[e.g., emergency personnel/
victims of domestic violence
may have to return to unsafe
environments]
Look for signs in specific
trauma populations
Some sub-populations are more at risk of victimization
than others.
For example, IDPs (the overwhelming majority),
refugees and asylum seekers, military and emergency
personnel, survivors of motor vehicle accidents, crime,
sexual assault,
natural disasters, and terrorism.
Refer to PHC for a thorough
clinical
assessment if you suspect
PTSD/ASD.
Family members
should be included
in the assessment
process, education
and treatment
planning
The needs for care
of family members
should also be met.
Everything should
be done with the
person’s consent.
Treatment of
Psychological
Trauma
Transforming the suffering of
PTSD: Is Recovery Possible?
Effective treatments for PTSD include psychological and medical
interventions.
The cornerstone of treatment involves confronting the traumatic
memory and addressing thoughts and beliefs associated with the
experience.
Trauma-focused psychological interventions can reduce PTSD
symptoms, lessen anxiety and depression, and improve quality of
life. They are also effective with people who have experienced
prolonged or repeated traumatic events.
It is important to develop trust and a good therapeutic
relationship to obtain a positive outcome.
Awareness of Comorbid
Conditions
For people with comorbid
conditions, the sequencing of
treatment needs to be
carefully considered.
Summary
Summary
1
Initial Screening
For person presenting
with non-specific health
problems:
1.Ask if person has
experienced a traumatic
event
2.Ask that person to
describe some examples
of the traumatic event.
2
Comprehensiven
ess of
Assessment
A detailed assessment
of:
1.Of PTSD & related
diagnoses.
2.Quality of life &
psychosocial functioning
3.Trauma history
4.General psychiatric
status (including
comorbidity).
5.Physical health
6.Substance use
7.Marital & Family
situation
8.Vocational & social
status
3
Assessment &
Intervention
Should be considered in
context of time elapsed
since the traumatic
event:
1.Most people show
distress in initial weeks
after trauma exposure.
2.Most symptoms remit
within three months.
3.In assessing PTSD,
comorbidity & quality of
Life, use self-report &
structured clinical
interviews.
Summary
4
Assessment &
Monitoring
Should be undertaken
throughout treatment.
When progress is slow:
1.revisit case
formulation
2.re-assess potential
treatment obstacles
3.implement
appropriate strategies.
5
[continued]
Service
Planning
Screen individuals at
high risk after major
disasters and critical
events.
1.Culturally &
linguistically appropriate
screening for refugees
and asylum seekers at
high risk of developing
PTSD.
2.There should be
adequate services in the
context of the service
delivery system for all
those who require care.
6
Psychological
intervention
with adults with
PTSD
Trauma-focused
interventions:
1.Cognitive behavioral
therapy or eye movement
desensitization &
reprocessing.
2.Most gains with EMDR are
due to engagement with
traumatic memory,
cognitive processing, &
rehearsal of coping and
mastery responses.
3.Supportive counseling &
relaxation SHOULD NOT be
provided to adults cf.
Trauma-focused
interventions.
Summary
6
Psychological
intervention
with adults with
PTSD
[Continued]
7
[continued]
Psychological
intervention
with adults with
PTSD
[Continued]
Where symptoms have
not responded:
Other issues for
consideration:
1.Use non-traumafocused intervention
(e.g., stress
management, or
psychopharmacology.
1.Imaginal imaging
sessions require at least
90 minutes to ensure
adequate therapy.
2.For people with
problems due to
multiple traumatic
events, traumatic
bereavement, or if PTSD
is chronic and
associated with
disability and
comorbidity, specific
sessions should be used
8
Psychological
intervention
with adults with
PTSD
[Continued]
4. If adults have
developed PTSD
following exposure to
prolonged/repeated
traumatic events,
take time to
establish trust, pay
attention to teaching
emotional regulation
skills, and adopt a
gradual approach to
exposure therapy.
Summary
9
Psychosocial
Rehabilitation
There should be focus
on vocational, family,
and social rehabilitation
interventions from the
outset:
1.Where symptoms of
PTSD have been present
for three months or
longer, psychosocial
intervention should be
considered to prevent or
reduce disability
associated with the
disorder..
1
0
[continued]
Psychosocial
Rehabilitation
[Continued]
2. If person does not
respond to evidence
based treatment,
psychosocial
intervention may
reduce disability,
improve functioning
and community
tenure.
3. Aerobic exercise may
help in managing
PTSD symptoms as
part of general selfcare practices.
PSYCHOLOGICAL
INTERVENTION &
TREATMENT
And……finally
Are PTSD, ASD, Major Depression Disorder (MDD), and Substance Use
Disorder (SUD) separate entities, or comorbid, and a universal cross
culturally valid psychopathological response to traumatic stress?
Can these victimizations be cured or ameliorated with Western oriented
clinical and psychosocial therapeutic interventions?
A relativist approach would suggest that psychological and/or physical
trauma is embedded in the social and cultural framework of any society.
Transcultural psychiatry is making tentative steps to address “social
suffering”. a concept that combines Western and traditional healing
strategies.
Differential
victimization in
When the coping threshold of a person is exceeded, outcomes range
from dying to long-term severe physical and/or psychological injury.
aftermath
of SEA
V lh (learned helplessness) is when the
victim learns to behave helplessly even
when the opportunity is restored for that
person to help him/herself by avoiding an
unpleasant or harmful circumstance to
which they have been exposed.
V guilt is the degree to which a person
believes his/her victimization has violated
a moral standard and he/she bears
significant responsibility for that
violation.
Differential victimization in
V
is heightened
victimizing habitus and
aftermath
of in
SEA
fear
can lead to aberrant changes in behavior when
the cause of the victimization is unknown (e.g.,
in a nuclear accident, climate change, or when
an assailant is unidentified), and is less when
the cause is known (e.g., in a crime in which
the perpetrator is identified, CO2 emissions are
responsible, and so on).
V hope is the level of anxiety associated with an
anticipated loss of hope. Hope is important to
both well-being and educational performance;
people low in hope are more likely to be
anxious and depressed.
Differential
victimization
in
Two maxims can be derived from this analysis:
aftermath of SEA
1.
The magnitude of an acute
environmental event (e.g., a 9.1
magnitude earthquake) is
independent of its victimizing force
(V ).
2.
The impact of the victimizing force is
dependent on awareness of the
victimizing potential of the SEA (e.g.,
a tsunami).
& TREATMENT
Kieran G. Mundy
OVERVIEW
Topic 1
Exposure to a traumatic event is common
Topic 2
Post Traumatic Stress Disorder (PTSD)
Topic 3
Acute Stress Disorder (ASD)
Topic 4
Awareness of Presence of ASD/PTSD
Topic 5
Treating Psychological Disorders
Acute stress reaction
Exposure to
Psychological
Trauma
Exposure to a traumatic event is
common
International community surveys reveal that the majority of people report at
least one traumatic event in their lives.
Most people have some kind of psychological
reaction to trauma—feelings of fear, sadness,
guilt and anger are common. But there is
also pain, a sense of loss, a loss of trust and
security, and often a total loss of community
as in the East Japan Great Earthquake.
During the life course, 60-80% of any human
population experience bio-psycho-social trauma
which may include victimization (i.e. exposure
to or witnessing community violence), severe
physical injuries, unexpected or untimely loss,
and life threatening catastrophic events.
THE SURVIVORS
( ≅ 60-80%)
POPULATION
Resilient
Total Impact
= SURVIVORS
Resilient
+ SURVIVORS
Non-
The majority (about 80%) recover over
time with the help of family , friends, and
community. Only a small proportion (about
20% to 3-4%) develop ASD or PTSD and
need professional help.
Resilient Survivors
Most (≅ 80%) people exposed to intense stressors,
especially children, have no apparent disruption in close
relationships, at work, or in their daily lives. They
maintain relatively healthy levels of psychological
functioning.
Non-resilient Survivors
A minority (< 20%) have moderate to severe initial
elevations in bio-psycho-psychological symptoms that
significantly disrupt normal functioning and that decline
gradually over weeks, months, or years before returning
to pre-trauma levels.
SURVIVORS (RESILIENT)
The overwhelming majority who, most
probably, want to be left alone once basic
needs are met.
Able to identify the risk early enough.
Are aware that environmental assaults (like
tsunamis) are deadly.
Have the options available to avoid death or
injury.
TARGET THE HIDDEN VICTIMS (HIGAI
SHA)
A small minority of high-risk (vulnerable)
people.
Women, children or the elderly, but not
necessarily so.
Those unable to identify the threat.
Those people unaware of its victimizing force.
Those who not have the personal and other
resources to cope.
co
Post Traumatic Stress Disorder
Despite the low risk, some people
develop Posttraumatic Stress Disorder
(PTSD) & Acute Stress Disorder (ASD).
The psychological reactions in the
aftermath of a SEA, MVA, or terrorist
attack, are TRAUMA-IDENTIFIED (cf.
Trauma-specific):i.e., the victim
identifies with the critical event cf. the
type of trauma is not specific to the
event).
The reactions include any threat, real
or perceived, to the life or physical
safety of a person, their loved ones or
those around them and lead to
feelings of intense fear, helplessness
or horror.
More than a quarter of a million
Australians experience PTSD in any
one year, and about 5% have had
PTSD at some point in their lives.
Prevalence rises to about 18% in
adults who have been physically
abused in childhood.
Diagnosing PTSD
Posttraumatic Stress
Disorder
Before a diagnosis of PTSD can be made, a number of symptoms
in each of three categories (re-experiencing, avoidance &
emotional numbing, and hyperarousal) must be present for at
least a month and lead to significant distress or impairment in
important areas of functioning.
While symptoms often develop in the days and weeks following
exposure to trauma, the onset of PTSD can be delayed for years
for a significant number of people.
Figure adapted from Dussich, J., Hall, B., Nobukazu, N., Rauch, S., Tuerk, P., & Yodder, M. The Psychological Effects of Trauma and Posttraumatic Stress
Disorder (PTSD). TIVI Crisis Response Team Work Group, Mito, Ibaraki. April 18-19, 2011.
Diagnosing ASD
Acute Stress Disorder (ASD)
ASD is diagnosed between two days and one month following a
traumatic event.
There is significant overlap in the diagnostic criteria of ASD and PTSD.
The diagnosis of ASD requires the experience of several dissociative
symptoms not included in PTSD (e.g., detachment, reduced
awareness of surroundings, depersonalization, and dissociative
amnesia).
PTSD places greater emphasis on avoidance symptoms.
The main difference between PTSD and ASD is the duration of
symptoms required for a diagnosis to be made.
Awareness of Presence of
Psychological Trauma
Awareness of PTSD/Acute
stress reaction/ASD
Most people experience some
level of stress after a traumatic
event and recover using their
own resources.
Professional help is only
necessary when a person’s
distress is persistent or severe
enough to cause significant
impairment.
A thorough clinical assessment
includes physical,
psychological, and social
functioning.
Some people may still face
ongoing threat & be at risk of
further exposure to trauma
[e.g., emergency personnel/
victims of domestic violence
may have to return to unsafe
environments]
Look for signs in specific
trauma populations
Some sub-populations are more at risk of victimization
than others.
For example, IDPs (the overwhelming majority),
refugees and asylum seekers, military and emergency
personnel, survivors of motor vehicle accidents, crime,
sexual assault,
natural disasters, and terrorism.
Refer to PHC for a thorough
clinical
assessment if you suspect
PTSD/ASD.
Family members
should be included
in the assessment
process, education
and treatment
planning
The needs for care
of family members
should also be met.
Everything should
be done with the
person’s consent.
Treatment of
Psychological
Trauma
Transforming the suffering of
PTSD: Is Recovery Possible?
Effective treatments for PTSD include psychological and medical
interventions.
The cornerstone of treatment involves confronting the traumatic
memory and addressing thoughts and beliefs associated with the
experience.
Trauma-focused psychological interventions can reduce PTSD
symptoms, lessen anxiety and depression, and improve quality of
life. They are also effective with people who have experienced
prolonged or repeated traumatic events.
It is important to develop trust and a good therapeutic
relationship to obtain a positive outcome.
Awareness of Comorbid
Conditions
For people with comorbid
conditions, the sequencing of
treatment needs to be
carefully considered.
Summary
Summary
1
Initial Screening
For person presenting
with non-specific health
problems:
1.Ask if person has
experienced a traumatic
event
2.Ask that person to
describe some examples
of the traumatic event.
2
Comprehensiven
ess of
Assessment
A detailed assessment
of:
1.Of PTSD & related
diagnoses.
2.Quality of life &
psychosocial functioning
3.Trauma history
4.General psychiatric
status (including
comorbidity).
5.Physical health
6.Substance use
7.Marital & Family
situation
8.Vocational & social
status
3
Assessment &
Intervention
Should be considered in
context of time elapsed
since the traumatic
event:
1.Most people show
distress in initial weeks
after trauma exposure.
2.Most symptoms remit
within three months.
3.In assessing PTSD,
comorbidity & quality of
Life, use self-report &
structured clinical
interviews.
Summary
4
Assessment &
Monitoring
Should be undertaken
throughout treatment.
When progress is slow:
1.revisit case
formulation
2.re-assess potential
treatment obstacles
3.implement
appropriate strategies.
5
[continued]
Service
Planning
Screen individuals at
high risk after major
disasters and critical
events.
1.Culturally &
linguistically appropriate
screening for refugees
and asylum seekers at
high risk of developing
PTSD.
2.There should be
adequate services in the
context of the service
delivery system for all
those who require care.
6
Psychological
intervention
with adults with
PTSD
Trauma-focused
interventions:
1.Cognitive behavioral
therapy or eye movement
desensitization &
reprocessing.
2.Most gains with EMDR are
due to engagement with
traumatic memory,
cognitive processing, &
rehearsal of coping and
mastery responses.
3.Supportive counseling &
relaxation SHOULD NOT be
provided to adults cf.
Trauma-focused
interventions.
Summary
6
Psychological
intervention
with adults with
PTSD
[Continued]
7
[continued]
Psychological
intervention
with adults with
PTSD
[Continued]
Where symptoms have
not responded:
Other issues for
consideration:
1.Use non-traumafocused intervention
(e.g., stress
management, or
psychopharmacology.
1.Imaginal imaging
sessions require at least
90 minutes to ensure
adequate therapy.
2.For people with
problems due to
multiple traumatic
events, traumatic
bereavement, or if PTSD
is chronic and
associated with
disability and
comorbidity, specific
sessions should be used
8
Psychological
intervention
with adults with
PTSD
[Continued]
4. If adults have
developed PTSD
following exposure to
prolonged/repeated
traumatic events,
take time to
establish trust, pay
attention to teaching
emotional regulation
skills, and adopt a
gradual approach to
exposure therapy.
Summary
9
Psychosocial
Rehabilitation
There should be focus
on vocational, family,
and social rehabilitation
interventions from the
outset:
1.Where symptoms of
PTSD have been present
for three months or
longer, psychosocial
intervention should be
considered to prevent or
reduce disability
associated with the
disorder..
1
0
[continued]
Psychosocial
Rehabilitation
[Continued]
2. If person does not
respond to evidence
based treatment,
psychosocial
intervention may
reduce disability,
improve functioning
and community
tenure.
3. Aerobic exercise may
help in managing
PTSD symptoms as
part of general selfcare practices.
PSYCHOLOGICAL
INTERVENTION &
TREATMENT
And……finally
Are PTSD, ASD, Major Depression Disorder (MDD), and Substance Use
Disorder (SUD) separate entities, or comorbid, and a universal cross
culturally valid psychopathological response to traumatic stress?
Can these victimizations be cured or ameliorated with Western oriented
clinical and psychosocial therapeutic interventions?
A relativist approach would suggest that psychological and/or physical
trauma is embedded in the social and cultural framework of any society.
Transcultural psychiatry is making tentative steps to address “social
suffering”. a concept that combines Western and traditional healing
strategies.
Differential
victimization in
When the coping threshold of a person is exceeded, outcomes range
from dying to long-term severe physical and/or psychological injury.
aftermath
of SEA
V lh (learned helplessness) is when the
victim learns to behave helplessly even
when the opportunity is restored for that
person to help him/herself by avoiding an
unpleasant or harmful circumstance to
which they have been exposed.
V guilt is the degree to which a person
believes his/her victimization has violated
a moral standard and he/she bears
significant responsibility for that
violation.
Differential victimization in
V
is heightened
victimizing habitus and
aftermath
of in
SEA
fear
can lead to aberrant changes in behavior when
the cause of the victimization is unknown (e.g.,
in a nuclear accident, climate change, or when
an assailant is unidentified), and is less when
the cause is known (e.g., in a crime in which
the perpetrator is identified, CO2 emissions are
responsible, and so on).
V hope is the level of anxiety associated with an
anticipated loss of hope. Hope is important to
both well-being and educational performance;
people low in hope are more likely to be
anxious and depressed.
Differential
victimization
in
Two maxims can be derived from this analysis:
aftermath of SEA
1.
The magnitude of an acute
environmental event (e.g., a 9.1
magnitude earthquake) is
independent of its victimizing force
(V ).
2.
The impact of the victimizing force is
dependent on awareness of the
victimizing potential of the SEA (e.g.,
a tsunami).