prioritisation

 psycholoical triage

It means to pick, select or create a hierarchy, and 

that's what we must do based on the knowledge we have gained in assessment.

Maslow's  prioritastionof physical needs

I :(a).physical or medical needs first (b) need for interpersonal relations to have  a feeling of sfety

II : (

1)evidence based .-EVIDENCE OF DYSFUNCTION (diminished cognitive capacity in survivors, compromised in the ability to exercise prudent insight, memory and problem solving ,can not understand the cosequences of ones own actions ) -take a direct and active role with intervention 

     (2)risk based - 3 Ds- fear of :death ,dislocation, disabling impact.

In our last module,

we examined assessment. In this module,

we'll look at prioritization, or what I call the art of

psychological triage. Now, just by definition, you'll remember

the word triage is of French derivation. It means to pick, select or

create a hierarchy, and that's what we must do based on the

knowledge we have gained in assessment. You've heard a story,

you've heard an event described. You've heard personal

reactions to that event. Now, we must decide for

whom immediate care is most warranted. We must create a hierarchy of needs and

respond to those needs. Prioritization is really an extension of assessment which represents the

application of basic triage principles. Attention is focused upon those people and

those needs which require emergent care. Emphasis is placed upon assisting

basic functional capacity. That is can the person in crisis

actually do what they need to do? Now what you may find surprising

is prior to 1999 there was virtually nothing written on psychological

triaging In the wake of disaster. I guess that's good news and bad news. The good news is, it's a field ripe for

inquiry and advancement. Bad news is, we're probably making

a lot of mistakes along the way. We're learning as we go. But let's start with some basic principles

that I think are pretty bedrock. We go to the work of a guy by

the name of Abraham Maslow. Dr. Maslow was a clinical psychologist

writing his seminal papers in the 1940s. And according to Maslow,

he said people have needs. There's a hierarchy of needs. Meet basic medical and

physical needs first. When in doubt, assume that a complaint

is medical and have it assessed. You will see on one of the slides

in this section, a pyramid. And you'll see that it represents

Maslow's hierarchy, and starting at the bottom are physical needs. Basic medical, physical needs. Meet them first. Then it says move to safety. Now here is the conundrum. Maslow's work didn't really take into

consideration disasters or wars for that matter. And what we have seen is a need to

adjust Maslow's hierarchy just a bit. because what we find is that once

physical needs have been satisfied, to a rudimentary level at least, people

will often leapfrog to the third level, which is affection Affiliation,

acceptance and support. And what that really means is, seeking

interpersonal support from friends, families, coworkers and community aid services in order

to achieve the second level. Now, according to Maslow's early writings, you must ascend the hierarchical

ladder step by step. There is no such thing as skipping steps. But the field of disaster

mental health has taught us that clearly that is not only possible but

an inclination that people have. Stop and think about it a minute. When you're afraid, what do you do? You seek out the support of others. So when you're feeling unsafe you go

from physical needs to the support, interpersonal support needs

in order to feel safe. Why do kids in high

crime areas join gangs? It's not because they have

a desire to commit crimes. It is often times to feel safe. This may sound a little silly, but

when you sent your son or daughter away to college, perhaps, and they insisted

on joining a sorority or fraternity. And you thought it was

all about the partying. Well, sometimes it is, but

sometimes, being away from home, strange environment, large school,

you don't know anybody. What do you do? You seek out a subset,

a group of people who will learn to understand you and

learn to support you. So we take into consideration Maslow's

Hierarchy of Needs when we formulate our intervention plans and medical and

basic physical needs always come first. But now it gets harder. There are two approaches to triaging

once we have met basic medical and physical needs. One we'll refer to is evidence-based. The other we will refer to as risk-based. It's important to understand

these are not mutually exclusive, rather, you should be cognizant of

both approaches, both perspectives. They serve as lenses, or

filters, if you will. The evidence-based triage approach. We focus on what is sometimes been

called as the acute crisis triad. The evidence-based triage approach,

we are looking for evidence of diminished cognitive

capacity in survivors. We are looking for

those people who are compromised in their ability to exercise prudent insight,

memory and problem solving. But most importantly a diminished

to understand the consequences of one's actions. As another prong to the crisis

triad we are observing survivors, we are listening to third

party reports of survivors who have an impulsive urge to act in

a self-defeating or self-injurious manner. We are looking for the loss of future

orientation, feelings of helplessness or hopelessness, utter despair perhaps. And lastly we are looking for diminished

functional capacity in the sence of an inability to perform

the necessary functions of living. Self-care, caring for others,

working perhaps, personal hygiene. All of these things must

be taken into consideration within the context of the logistics

of the disaster site itself. So just because someone is having

difficulty with personal hygiene doesn't mean that they are necessarily

compromised, from a psychological standpoint, it may simply mean that such

resources are just minimally available. So this is where, again,

we ask questions to put things in context. So to review, the evidence-based

triage system is a system that is predicated on your observation of people

who exhibit evidence of dysfunction. And as we examined in the previous module,

evidence of dysfunction is usually a cue for us to take a very

direct and active role with intervention. However, there's a second

approach to triage as well and that's called risk-based. The risk-based triage approach,

we rely on the three Ds, we call it, for sub-acute concern. Death, dislocation and disabling impact. What does that mean? Here, we are learning from the survivor

what risk factors they have encountered that increase their risk of psychological

distress, disability and impairment. Could be acute, or could be sub-acute. Could be days later, or weeks later. Even months later. We ask the question,

did the person see human remains? Why?

Because we know that people that saw human remains who are unfamiliar

with seeing human remains, those images are often

seared into their memory. And serve as a diathesis,

a vulnerability for weeks, months, years,

perhaps an entire lifetime. Did the person think he or

she was going to die? We know that some people will say,

and I thought I was going to die. But, nah, they didn't really think that,

that's just something they said. The person that says to you, and

I thought I was going to die. Is the person who looks at you or

looks through you, their pupils dilate and you have assessed that did,

now this is different. They really thought

they were going to die. Sometimes, they will say things like, and

my life literally flashed before my eyes. Those types of experiences

one never forgets. You move past them, certainly,

but you never forget them. The second D, dislocation, is the person

separated from family and loved ones? We've been emphasizing the importance

of interpersonal support. This person is dislocated

from such support. Does the person have a place to stay? Did they lose their home? Often times a house is more than a house,

it's a home. Disabling impact is our third D. Was the person physically injured in

such a manner that required immediate medical care? Did the person experience what's

called peri-traumatic dissociation? The prefix peri you will

remember means around. So, did the person experience

dissociation feeling they were floating out of their body? Feeling disconnected

from their body perhaps? In close proximity to

the traumatic event itself. Parenthetically risk-based triage

should never be used in the absence of evidence-based triage to formulate

your triage plan or approach. With regard to triaging,

the key is recognizing and prioritizing dysfunctional

inclinations and behaviors. Let's not lose sight of what

assessment and triage are all about. To summarize, assessment is our

ability to listen to, observe the impact that some on toward event

has had on a person or group of people. This is not done in a vacuum. It's done for a purpose. The assessment is done

in order to decide how best to help survivors

recover from adversity. I made the point earlier that

intervention is predicated on the story on your assessment, if you will. I've been doing this work for 40 years I don't know that I've ever

done two interventions exactly the same. Why? No two people are ever alike and

no two situations are ever alike. And even though two people

may be in the same situation, they may have experienced that

situation very differently. So I must listen. I must gain rapport. I must listen. I must assess. And once I've assessed, I take it to the

next level of prioritization triaging if you will and I create a,

an order the hierarchy. I must decide when burdened with

limited resources I must decide to whom I will focus or for whom I will focus our

resources and in an order if you will. In some instances,

you'll have more than enough resources. Concept of triage Is less important there,

but the two approaches to

triage remain important. The evidence based and

the risk based approach. We know, for example, that the effects

of disasters linger months and years. Some people will even define themselves. Who they are going forward in life. As a survivor. You've certainly seen t-shirts. I survived x y and z. I survived the great flood. I survived the tsunami. And most of those t-shirts

are just offered as a remembrance. Some people take those words and

internalize them and that's who they are from that day on. Sometimes it's uplifting. Sometimes it keeps them in the role

of a victim rather than a survivor. Those are the subtle aspects of triaging. Our criteria for evidence and

risk-based triaging, again, offered as a not comprehensive list,

but basically a framework, a heuristic, to view your job of

determining who should I attend to first.