Assessment.

 Assessment. 

Identifying Benign from more Severe Psychological and Behavioral Reactions.

 That's our task we've used the term assessment as a broad umbrella to capture that essence. Now you'll remember from the previous module, we talked about gaining rapport techniques we use to gain rapport or the things we called Reflective Listening or Active Listening techniques. We will now build on those skills and apply them directly. The rapid model progresses from rapport and reflective listening, to the assessment of basic physical and psychological needs. This rudimentary assessment is derived from what is really a guided conversation. It's based on the survivor's own narrative. It's punctuated with specific questions that you will offer regarding the details of the event. And specific reactions that the survivor has encountered to the event. Now sometimes we think of this assessment in clinical terms and I, I don't want you to think that way. This program is designed largely for non-clinicians. So the assessment we're goingto be doing is an assessment that should make sense on a common sense level, perhaps. Now, assessment is important because it allows the survivor to basically tell you what happened and what reactions they've encountered because of what happened. Remember the intervention is largely predicated on the unique needs of the person in distress. Let me say that again. The intervention itself, is largely predicated upon the unique needs of the person in distress. In order to formulate your intervention, therefore, you must listen very carefully to the survivor's story. The story consists of the person's reactions to the event and the event itself. So the story is not complete. Your quest to understand and even the most rudimentary manner what happened and how to basically inform your intervention. That process is not complete unless you have some sense of what happened and what reactions that person has encountered. So the story consists of the persons reactions to the event, refined by some rudimentary disclosure of the event itself. So what I'd like you to do is think about how you would elicit the survivor's current physical and psychological status? In other words, how you would identify how the person is doing? And in order to refine your understanding,put the survivor's status in a context, it's an event-based context. You will be identifying what happened, and that's the story. 

Now remember to ask specific questions when necessary in order to clarify ambiguous aspects ofthe personal reactions, or aspects of the event that just don't seem to make sense to you. Also, don't be afraid to ask a question when someone uses a term that you're not that familiar with. Now, the next question that comes to mind is what are you going to see in the field? What will you be listening for

as the personal narrative unfolds? Well, from the 30,000 foot view, as we'll sometimes say, from the macro perspective. Think that there will be three groups of survivors. 

The Eustress group. 

The first group we will call the Eustress group. 

This is a group that is basically, all things considered, doing well. What do I mean by doing well? They are able to discharge their daily demands on things they must accomplish. We'll sometimes call that activities of daily living. What is it you need to do today? Can you do it? That's the question we often will pose. The Eustress group is not happy about the adversity or the disaster. But they are moving on in that context. 

Our prescription is very simple. Take no action, and just be available and continue to observe. 

The Dysfunction group.

At the other end of the spectrum, however, is a group that we will call the Dysfunction group.

 This is a group that has severe impairment, an incapacitating impairment. Interfering with the things

they need to get done, that concept of activities of daily living again. Our prescription is very simple for them. If there are things they need to do, and they can't do it, 

Your job is to assist them as directly or indirectly as appropriate.

The Dysfunction group.

 Now, the third group is a bit of an enigma.(a person or thing that is mysterious or difficult to understand.)  We'll call that groupthe Dysfunction group.

These are people that may not look particularly good but they are doing what they need to get done. We will call that the Distress group. The distress is benign. It is mild. 

Our prescriptions for them? Continue to monitor them. The vast majority of that group, that middle group, will move on without any direct aid whatsoever, other than perhaps physical aid, shelter, food, clothing, etc.

Decompensate

 However, some in that group will,we will use the term Decompensate. They will lose and regress in their ability to function, to achieve the activities of daily living. And they will move into

the dysfunction group. So that's why we monitor the distress group. 

So the question I would be asking if I were you is what percent of people fall

into each of the categories? Well it really depends on the event and the context of the event but roughly speaking we think that 60 to ninety percent 90% of those directly affected experience acute distress and

that's where our prescription is to identify and continue to observe or monitor. Most of those survivors

will show resilience. And while having some adjustment difficulty they will sustain or quickly regain functional capacities without assistance from relief personnel.

 The group that we are most concerned, the dysfunction group. It will range from 5% to 49%

of those directly affected. And those we identify we assess, and we do offer assistance or intervention. Assessment of dysfunction may be the sine qua non of the disaster mental health process. What I mean by that is, we want to make sure that the people most in need of help get that help. And, at the same time, we want to make sure that those who are seeming to recover under their own impetus, those people who have shown some resilience, we want to make sure we do not interfere with their natural resilience. And although our intentions are good,it is actually possible to interfere with the natural trajectory of a survivor's resilient recovery by not understanding them or the context. And since we don't have time nor the skill necessary to analyze someone as you might do clinically, we are left to observe. 

The next series of slides will hopefully assist you in distinguishing Distress from Dysfunction. I've broken them down into domains. How signs and symptoms will emerge. And we'll say that there is a Cognitive domain, an Emotional domain, a Behavioral domain, a Spiritual domain and a Physiologic domain. And each slide will show you a column that shows distress. Those are the people that we identify and monitor. And at the same time in the same domain show you a column with dysfunction. And those are the things that we are concerned about, and need to respond to. 

So for example,on the cognitive reactions slide, you'll see a column that says distress. Temporary confusion. Inability to concentrate. Reduced problem solving capacity. Feeling overwhelmed. Obsessional thoughts, thoughts that people just can't get off of their mind. Reliving the event. And perhaps Nightmares. These are things that we would expect. This is not to say they are comfortable. It is not to say they're not distressing, they are. But this is what we would expect in the natural trajectory, the natural course of things. When we move from distress to dysfunction, however, we are far more concerned. Incapacitating confusion,diminished cognitive capacity. 

What that says is that, people are unable to make the decisions that normally they can make,or could have made. And what that also means,is that their resilience and recovery are going to be inhibited. And sometimes, people will actually do self defeating things because of a diminished cognitive capacity. Hopelessness. Suicidal or homicidal thoughts. Hallucinations in extremely rare conditions. People who have no history of mental illness may actually experience hallucinations. Hearing things, seeing things,

that are not there. However, as we noted from numerous recent disasters. One of the biggest demands on the mental health core was responding to the needs of those who already were on Psychiatric

Medications or Psychotropic Medications. They already had a history of mental illness. And without their medications or even with their medications, the symptoms returned and seemed augmented. And that's to be expected because of the extreme stress associated with extreme adversity or

disaster. Sometimes people experience Paranoid Delusions. That's a suspicious belief that seems

unfounded by the facts of the situation. So again, cognition refers to the way people think. Emotions. What does emotional distress look like? A partial list would consist of fear, sadness, irritability, anger, frustration, bereavement, which is loss, anxiety. All of these things are very common. And with time,

usually resolve without direct assistance. However, when are we concerned about emotional reactions? Look at the column that says dysfunction. Panic attacks. Panic attacks are extreme anxiety attacks. Often times people will say things like, I thought I was going to die. I couldn't breathe. And people act often times irrationally under such conditions. The other reason we are concerned with panic attacks is rarely a panic is not a panic attack. It could be a form of brain seizure. So some sub-cortical seizures actually present as if they are panic attacks. So we are concerned and would want to get medical

consultation to rule out the seizure. 

Immobilizing depression, people are so numb and depressed that they just cannot help themselves or

help those who rely upon them. And of course, you're probably familiar with the term Post-Traumatic Stress and Post-Traumatic Stress Disorder. The disorder is what we're most concerned with. Symptoms such as reliving the event to the point that you find it hard to concentrate on anything else. Nightmares that interfere with your sleep, though you cannot really get much rest. Anxiety, Post Traumatic Stress Disorder, is often typified by hyper-vigilance, and exaggerated startle response. And this whole cluster, this constellation of symptoms, seems to come as a package in dramatically interfering with your ability to recover from adversity. 

Third category of reactions in the wake of adversity would be Behavioral Reactions. And again, we've divided the slide into distress versus dysfunction. Under distress, you'll see Temporary phobic avoidance. Phobia is an irrational fear. Avoidance is avoiding doing things,avoiding people or places based on this irrational fear.

 A Compulsion is repetitively doing something over and over and over again, to the point that

it could interfere with your natural inclinations in terms of how you might recover. Hoarding, hoarding money, hoarding food, hoarding water. Those things could actually be quite adaptive depending on the situation. However when the hoarding interferes with ones ability to otherwise move on then

it becomes a problem. Sleep disturbance, Eating disturbance, again Easily startled. These are things that we expect. These are things that we expect to fade with time. The dysfunction however, again we are concerned with. Persistence Avoidance. Immobilizing compulsions. Aggression, violent behavior. We will sometimes see people who are able to work effectively, but then are more inclined to issues such as domestic violence, road rage, airline rage. Some people become hermits, they become reclusive. They build a brick house as one patient once described to me. Build a brick house,wall themselves up, and while they are not able to experience the outside world they still feel safe. Impulsiveness, risk taking and of course, self-medication with alcohol. Sometimes, people would abuse prescription drugs. And you'll note the last one, energy drinks. One way of getting more energy when there's so much to do is to avail yourself of energy drinks.

 However, not all energy drinks are necessarily created equal and some can be quite detrimental. And there is some evidence that some could even be life threatening. Our fourth category, Spiritual Reactions. Now, this does not mean that you have to have a spiritual orientation or religion, a belief of something greater than yourself. It is simply that some that you encounter may. Deep religious underpinnings or spiritual beliefs. And it is important that you are at least receptive to hearing them. Under our distress column, people will question their faith. They will question their God's actions. They will often say, how could my God allow such an evil thing to transpire? There's a fancy term for that, it's actually called a Theodalitic Challenge. The question of theodicy but you will hear that a lot especially in the wake of large scale disasters. 

Dysfunction, we would see cessation of faith related practices. Or, interestingly enough, the other side of the coin, which is projecting their faith onto others. Arguing that the only way to recover is to accept this faith, and the reason that adversity occurred was that you didn't have this faith. So we can see extreme examples in either direction.

Physiologic Reactions

 Our fifth and final category of what you are likely to see in the field comes out of the heading Physiologic Reactions. Changes in appetite. Changes in sex drive. Psychogenic headaches meaning headaches that arise and you didn't get hit on the head. Psychogenic muscle aches and spasms. And that would be muscle aches and spasms not associated with physical exertion. Decreased immunity. Studies going all the way back to the 90's have indicated that in the wake of extreme chronic adversity or disasters much of the population will suffer Immune Suppression. Which then makes them vulnerable to infectious diseases and disorders, such as viruses and bacteriologic infections. Any prolonged physical or physiologic change, or any symptoms of concern, should be evaluated by a medical professional. Under the heading Dysfunction. Changes in cardiac function. Gastroenterologic function. Appearance of occult blood. Unconsciousness. Chest pain. Dizziness. Numbness or Paralysis, especially of the arm, leg, face. The inability to speak or the inability to understand speech. And again please note that any of these in that column of dysfunction should receive an immediate referral for medical care. Our list has not been comprehensive. Our job within this module was to simply sensitize you to some of the things that we commonly see and should not be too concerned about, versus the things that we see less commonly, and should be very much concerned about. And I'm speaking of Distress versus Dysfunction, signs, and symptom. So that ends our discussion on Assessment. And the importance of distinguishing between distress, the things we commonly see, and know that in most people the natural trajectory is to fade with time. The distinguished distress from dysfunction, things that interfere with one's ability to do the things one needs to do. To help oneself or perhaps others. Now you may look at these slides and say, wow that's an overwhelming list. And yeah, I've already told you that it's not a comprehensive one, it's not an exhaustive one. So, a couple of comments. One, it's I think it's perfectly acceptable to take lists such as these out into the field, and just keep them as pocket reminders, or little cheat sheets. That's perfectly okay. With time, your reliance upon them will diminish. I think there's one other thing worth mentioning, and that is, that as you hear, as you see these signs and symptoms emerge, it is absolutely critical that you are able to see them and hear them without judgement. This is not your disaster. This is not your adversity. It is important that you remain as neutral as possible. Listening for opportunities to assist. Not to condemn. Not to evaluate. Not to over analyze. But rather to assist people regaining the lives or as close to the life that they once had inthe wake of what may be the worst day or days they've ever encountered. So, we will end on that note. And in our next module we'll examine the Art of Psychological Triage.