Crisis Intervention in the acute Phase after Trauma, the client´s subjective needs Acute Interventions after sudden loss: the families´ subjective view B. Juen, E. Mohr, Siller, H., Gmeiner, V. University of Innsbruck
Feb 24, 2016
Crisis Intervention in the acute Phase after Trauma, the client´s subjective needs
Acute Interventions after sudden loss: the families´ subjective viewB. Juen, E. Mohr, Siller, H., Gmeiner, V.University of Innsbruck
Stage models assume a detmermined course of grief like: disbelief, intensive emotions, acceptance
In working models of grief, the tasks that have to be accomplished are also conceptualized in phases like: realization, working through emotions and reuptake of emotional life
Phase or stage models do not have an empirical basis
Research example Maciejewski et al analysed a group of 233 grieving persons and found that disbelief was not the dominant response in the beginning, acceptance was most dominant in all phases and yearning was the most prominent negative grief indicator in the first months.Over time, disbelief and yearning decreased and acceptance increased
Stage or phase models of grief
Today most reseachers prefer coping models of grief to phase or stage models
Grieving persons have to cope with new and overwhelming emotions as well as with new life circumstances (Znoj, 2007)
Research example, Berne study on parental grief: If this process is completed in a positive way, persons may be more able to cope with extreme negative emotions than others (Znoj, 2006)
Coping models of grief
Loss is a life-event that has a specific, even biologically determined reaction course and takes time. According to Znoj (2004,2006) therapeutic help is not always needed and does not shorten the reaction. It may even hinder the natural healing process (“too much grief”)Psychotherapy only works when the bereavement has become complicated (e.g. Shear et al., 2001, Wagner et al. 2005)
“Thus it must be stated ...that there can be no justification for routine intervention for bereaved persons in terms of therapeutic modalities -- either psychotherapeutic or pharmacological -- because grief is not a disease.” (Raphael, Minkov & Dobson, 2001)
Therapy means interventions that shall help to confront oneself with the difficult aspects of the loss. This may be useful in complicated grief but too confrontative if grief is normal.But what kind of support is effective in the acute phase if not therapy?
Grief therapy
In lower Austria two support systems are active for families after the sudden death of a family member.
1. Crisis Intervention teams consisting of specially trained emergency personnel come to the site immediately after the event (if the family wants it) and support the family through the very first hours (this is paid by the red cross and other NGOs which provide the service)
2. In the more severe cases the Acute team consisting of psychologists and psychotherapists can come into the family up to five times after the event to give immediate psychological and psychosocial support (this service is paid by the government)
Acute Psychosocial Interventions for grieving families
In a study using a mixed method approach the following questions were analysed
Quantitative data analysisWhich Risk factors can be identified in the families?Which resources can be identified?Which interventions are used by the team and how are they perceived by the affected families?Which risk factors can predict problematic acute reactions?Which interventions can predict satisfaction?
The Study about the work of the Acute Team
In a study using a mixed method approach the following questions were analysed
Qualitative data analysisWhich resources are subjectively seen as important by the affected families? Which interventions are seen as important? Which indicators do the affected see for positive and negative change?
The Study about the work of the Acute Team
426 cases of sudden death were analysed in a quantitative manner
376 cases were documented by narrative protocols and analysed by qualitative content analysis, 15 of which were analysed in a detailled manner.
In these cases 1194 individual persons were supported. In these cases it is not possible to collect data about individuals because families/groups are in the focus of the interventions. The events were in most cases sudden death of a family member by suicide, Illness or accident
The families/groups received a one to three time acute crisis intervention at their home by psychologists/psychotherapists of the Acute Team in Lower Austria
Acute Team Cases Analysed
Risk factors stem from the situation, the person, previous trauma or disorder Problematic acute reactions like severe dissociation, panic attacks, severe forms of helplessness etc. can be seen rather often in the familes supportedOf the resources the most prominent are the social resourcesThe team uses interventions according to the Hobfoll principles (safety, connectedness, calm, self/colelctive efficacy and hope)
Most prominent are the interventions promoting self (colllective) efficacy and calming interventionsOnly the situational factors can predict problematic reactions in the acute phase (especially violent events and accidents with near death situations)Satisfaction can best be predicted by calming interventions
Quantitative Results (see poster session)
Being able to talk to somebody from outsideConnectedness with family and friendsSocial integration (to have a network of friends, school, broader social network)To be able to take responsibility for the familyPersonal resources (creativity and rituals)
Qualitative resultsSubjectively perceived resources
To talk about the death can bring stress reduction
It can also enhance the feeling of self efficacy and saftety if the person to whom you talk can be trusted and is able to give psychoeducation
Safety can be enhanced if the person realises that the horrible event which cannot be fully put into words can be shared with another person who bears witness to it (especially in violent trauma this is an important factor)
Being able to talk to someone from outside
To be able to talk about difficult emotions like guilt feelings and fears To have a person listening who is objective and comes from outside the familyTo talk to family and freiends is often only done in small pieces whereas here they feel they can take their time and talk about the whole story in detailThey find it important that they are given time and space to think about the event and „summmarize“ the things that have happened They feel they can bring order into their thoughts and feel less lonely
In the words of the affected persons
To feel connected to others espeically family and friends is one of the most important resources in these situations
Also the feeling to be part of a broader social network is perceived as very important
To be able to take responsibility for the family is an important factor in self and collective efficacy and helps the affected persons to be not only on the receiving end of social support. This includes not talking about certain aspects of the event with the family in order to protect them (especially after violence, see also Yehuda et al 1998)
Connectedness and social support
Creativity is seen as important by the affected persons. They write letters and poems, they draw pictures
They engage in a variety of individual and collective rituals that help to work through the feelings of loss and to keep contact to the deceased (see also Schwaiger, 2011, Duffek, 2012)
Personal resources
Rituals can help to fulfill needs that cannot be fulfilled by the social environment
to feel proximity to the deceased, to give the deceased person space in everyday life, to express ambivalent emorions, to create order and control….
Personal rituals are not done when others are present but only in privateRituals can be realized by actions but soem are done only by imaginationRituals can but do not have to contain spiritual elements
Functions of rituals (Schwaiger 2011)
To have an external person who one can trustTo have the possibility to express emotions and enhance understanding by talking about the event To be coached through next steps To have continuity and a certain length of supportSomebody who is really present, interested and attentiveTo have enough time (more than one contact)Support in activating resourcesListeningGetting information about where to get further help and how to cope with symptoms
Qualitative results: Subjectively important Interventions
To be able to talk about guilt feelings and be unconditionally acceptedGetting information about what to do next and how to get further helpTo be able to ask questions about any aspects of the event that is important like, how has he died, did he suffer etc.The affected persons feel that they become more active by getting information and advice about how to cope with the new life circumstancesThey appreciate psychoeducation because they learn about their symptoms and how to cope, they fell more secure They say that it was especially helpful to again talk about everything after some weeks and to have a continuity in support from the accident until four weeks afterwards. They would wish even more contacts.To be present, interested and attentive: The feeling that somebody cares
In the words of the affected
Uncontrollable thoughts about the deceased/the event have decreasedActive and contolled working through becomes possible: death is a reality now and acceptance is enhanced, rituals are done to understand and mark the next stepMood and climate within the family are better now, tension has been reducedMood of the person has become better, he/she feels stronger, is more calmTo talk about loss and guilt feelings becomes possibleFear is diminishedNormal everyday life can be started again „Old“ rituals like how to celebrate christmas or birthdays are rearranged
Qualitative results: Indicators of positive change
These stem mostly from the grieving process but also from the necessity of role change in the family after a loss as well as from difficult reactions in the social environment (negative social support) or from previous family conflicts
New conflicts in the familyMisunderstandings and lack of understanding from the outside worldOld conflicts from the past intervene with the acute traumaMood decreases and grief gets worse (often as a normal phase in the grieving process)
Qualitative results: Indicators of negative change
There is not such a big tension any moreGrandma can now talk about her loss and guilt feelingsI am feeling stronger and better nowOld conflicts between our family and the family of our uncle become mixed up with our present storyWe start to go on with our lives (we meet friends again, we go out again…)
In the words of the affected
Grief is becoming worse when you realize that he is never coming backYou have to let him goEspecially christmas is a very difficult time
In the words of the affected
1. Listen to the grieving person and support the natural grieving process• For the grieving family to be able to talk to an outsider who is present interested and attentive is
very important especially when dealing with difficult emotions
2. Give information and psychodeducation• To get information and psychoeducation is very important in order to be active and feel
competent and able to cope with the extreme negative emotions
3. Accompany and support understanding in a nonintrusive manner• To be able to repeatedly talk about event and deceased person in order to come to a better
understanding is seen as the most important aspect of talk
4. Promote connectedness• To be connected to family and friends but also to a broader social network is seen as crucial
5. Encourage personal resources and rituals• But also personal resources like creativity and rituals are seen as helpful in the grieving process
and can support the coping process
Conclusions: Supporting the normal process of coping by the following interventions
Positive changes are described by the affected persons as a change from the uncontrollable rumination towards a more controlled thinking about the deceased and the event. This process is very similar to what Tedeschi and Callhoun describe as the pathway to Posstraumatic Growth
Conclusions
Duffek, P. (2012) Kollektive Rituale zur Traumebewältigung nach Katastrophen (unveröffentlichte Diplomarbeit, Institut für Psychologie, Universität Innsbruck)Neimeyer,R.A. & Currier M. (2009): Grief Therapy. Evidence of Efficacy and Emerging Directions. In: Current Directions in Psychological Science 18 (6), S. 352–356Raphael B, Minkov C, Dobson M (2001) Psychotherapeutic and pharmacological intervention for bereaved persons. Death Studies 24: 603–610 Schwaiger, E. (2011) Die Funktion von Ritualen nach traumatischen Ereignissen (unveröffentlichte Diplomarbeit, Institut für Psychologie, Universität Innsbruck)Tedeschi, R.S., & Calhoun, L.G. (2006). The foundations of Posttraumatic Growth: an expanded framework. In: Calhoun, L.G. & Tedeschi, R.G. (eds) Handbook of Posttraumatic Growth: Research and Practice, New Jersey: Lawrence ErlbaumWagner, B., Knaevelsrudb, Ch, Maercker, A. (2006) Internet-Based Cognitive-Behavioral Therapy for Complicated Grief: A Randomized Controlled Trial, Death Studies, 30 (5) Pages 429 – 453Shear, M.K., Frank, E., Foa, E., Cherry, C, Reynolds, C.F.., Vander Bilt, J. & and Masters, S. (2001) Traumatic Grief Treatment: A Pilot Study, Am J Psychiatry 158:1506-1508Yehuda, R., McFarlane, A.C., Shalev, A.Y. (1998). Predicting the Development of Posttraumatic Stress Disorder from the Acute Response to a Traumatic Event. Society of Biological Psychiatry, Vol. 44, pp. 1305–1313.Znoj, H.J. & Maercker, A. (2004). Trauerarbeit und Therapie der komplizierten Trauer. In M. Linden & M. Hautzinger (Hrsg.). Verhaltenstherapiemanual (5. Aufl.). Berlin: Springer
References