Introduction
In many European Union countries, the need for psychosocial care for the people affected by disasters, terrorism, and other events is growing. Psychosocial care should be offered in accordance with the latest practices that were effective. However, on various issues, discrepancies were identified between the scientific results of effective psychosocial interventions and the field practice. A European standard for providing post-disaster psychosocial support will be discussed.
The project supported by the European Commission and named European Guideline for Target Group Oriented Psychosocial Aftercare—Implementation (EUTOPA-IP) has integrated the work of two programs: (1) the German “Target Group Intervention Programme”; and (2) the Dutch “Multidisciplinary Guideline”, with the experiences of experts in the area of psychosocial support from the other European Union countries.
The goals of the project are to: (1) develop a guideline for the uniformed services on the basis of the Multidisciplinary Guideline for Early Psychosocial Interventions; (2) adapt the Target Group Oriented Intervention Program (TGIP) to the International Classification of Functioning, Disability and Health (ICF); and (3) prepare and implement training programs for various professional groups.
This project aimed to standardize psychosocial aftercare in case of disasters and the development of European network based on current findings in psychotraumatology, as well as early screening, supportive context, early preventive and curative psychosocial interventions, management of interventions, implications for the clinical field, and future research.
Specification of the Project
This project was funded under the European Commission, Directorate-General Environment, Unit ENV.A.4—Civil Protection, Prevention and Preparedness, for the period of 24 months, and was started in September 2009. Members of the project included: (1) City of Cologne, Germany (coordinator); (2) Centre of Psychotraumatology, Hospital Maria-Hilf GmbH Krefeld, Cooperative Partner of the University of Cologne (Germany) (scientific coordination); (3) Impact—Dutch Knowledge and Advice Centre for Post-disaster Psychosocial Care, Amsterdam, The Netherlands; (4) The Spanish Society for Psychotraumatology and Traumatic Stress, Madrid, Spain; (5) Charles University in Prague, Faculty of Arts, Czech Republic; and (6) Capital City of the Federal State of North-Rhine Westphalia, Düsseldorf, Department of Public Health, Germany. The project EUTOPA–IP aimed at the implementation of the results of the former project EUTOPA.
The main goals of EUTOPA were: (1) the development of a consensus product of the Multidisciplinary Guidelines in French, German, English, and Spanish; and (2) the adaption of the TGIP to a situation in which substantial damage has occurred and publication; and (3) establishing a pan-European network in psychosocial care and a useful Internet platform (http://www.eutopa-info.eu/).
The objectives of the new EUTOPA-IP project included: (1) the development of guidelines for the psychosocial care of uniformed services personnel based on the Multidisciplinary Guidelines for Early Psychosocial Interventions; (2) the adaption of the manual of TGIP-Rehabilitation to the World Health Organization's International Classification of Functioning, Disability, and Health (ICF); (3) integration of return-to-work programs for survivors and uniformed services for long-term intervention plans; (4) training of different vocational groups in TGIP rehabilitation, early interventions, and psychotraumatology (i.e., uniformed services, social workers, and mental health professionals); (5) evaluation of the application of EUTOPA project on the break down of the Historical Archive of the City of Cologne (03 March 2009); and (6) further consolidation of the European network for psychosocial crisis management (http://eutopa-info.eu).
Multidisciplinary Guidelines
The European Multidisciplinary Guideline—Early Psychosocial Interventions after Disaster, Terrorism and Other Shocking Events is one of the key outputs from the EUTOPA project. This material was created in 2008 by the Dutch foundation, Impact, and was reviewed by the plenary of experts from the European Union countries during the conference of the EUTOPA project in September 2008.
Psychosocial interventions should achieve the following aims: (1) promotion of natural recovery and use of natural resources; (2) identification of affected people in need of acute psychological help; and (3) referral and treatment of people who need acute psychological help.
Main Recommendations with Regard to the Early Interventions Screening
1. Do not use PTSD questionnaires when screening affected people who have a high risk for PTSD;
2. Translate and validate the screening instruments for particular languages;
3. Perform diagnostics and treatment in case of already pre-existing mental disorders;
4. Do not use acute stress disorder (ASD) as a predictor for people at high risk for PTSD—further research and observations are required;
5. Perform further studies on screening instruments based on risk factors in populations affected by disasters, shocking events, or terrorist attacks;
6. Assess the effectiveness of population-wide screening after traumatic events;
7. If it is decided to screen children and adolescents for symptoms of ASD, information gathering is needed from both the child and parents/caregivers;
8. Perform further studies into the most appropriate time for screening after the traumatic events are needed; and
9. Perform further studies into the potentially negative effects of affected people's screening.
Supportive Context
1. Provide listening, support, solace, and openness to the immediate, practical needs of the affected persons;
2. Provide factual and up-to-date information about the event;
3. Mobilize social support from their own social surrounding;
4. Reunification with the closest people, keeping families together; and
5. Provide reassurance for affected people who display normal stress reactions.
Early Preventive Psychosocial Interventions
1. Provide information—reassuring explanations about normal reactions; knowledge of when to seek help, advising to tackle daily routine;
2. Do not offer preventive psychoeducation;
3. During the acute phase, mental health professionals should provide support for trained volunteers and relief workers;
4. For psychological triage, a distinction must be made between those affected who do not have a mental disorder or serious clinical symptoms, people who might have a mental disorder or serious symptoms and those who have a mental disorder or serious clinical symptoms for whom proper diagnosis and treatment should be offered immediately;
5. The avoidance of once-only psychological debriefing (including Critical Incident Stress Defusing (CISD) as a prevention of PTSD to the affected people and members of the emergency services;
6. Provide practical and emotional support from colleagues (peer support);
7. Do not offer Critical Incident Stress Management (CISM) to a wide population; and
8. Perform further studies of the effectiveness of CISM, the Psychological First Aid module, and the Structured Relief Protocol for Children.
Early Curative Psychosocial Interventions
1. Provide treatment for ASD or PTSD symptoms using Trauma-Focused Cognitive Behavioral Therapy (CBT) within the first month after the event;
2. Provide relaxation only as a part of CBT, not on its own;
3. Perform further studies into the effectiveness of the Eye Movement Desensitization and Reprocessing (EMDR) method within the first six weeks after the event for adults and children;
4. Consider pharmacotherapy for sleep problems, depression, and anxiety disorders;
5. Perform further studies into the pharmacological interventions in children;
6. Employers should offer counseling if the event took place at work; and
7. Provide maximum of culture-specific interventions, such information, in native language, involving key figures from the ethnic minority group, etc.
Organization of Early Psychosocial Care
1. Care should be carried out by people who are trained or have been given special instructions;
2. Ensure early collective intervention;
3. Implement a good support system within the first six weeks after the event;
4. Provide one central point for information and interventions; and
5. Perform profession-specific implementation of multidisciplinary guidelines.
Target Group Intervention Programme (TGIP)
Screening for stressors in affected individuals may be important in the planning of psychosocial support for the various groups. The TGIP framework used the Cologne Risk Index (CRI). The CRI was developed first as a semi-standardized rating scale for victims of domestic violence or rape. Later, it was adapted for the military service, and survivors of terrorist attacks and disasters. Clinical research used a meta version of this self-report questionnaire, but further longitudinal research is needed.
Target Group Intervention Programme results from the “Time Course of Traumatic Stress” (Fischer & Riedesser, 1998). An integral part of the procedure of target group intervention is the rating of victims into three groups: (1) “Group of Recovery”; (2) “Group of Switchers”; and (3) “People at Risk” using the CRI checklist.
Recovery Groups—This group is composed of victims that are within the natural course of the self-healing process using their
own resources and the potential over time to manage the trauma without lasting impairments.
Switchers Group—This group is composed of trauma victims who are able to manage the trauma like the previous group within the natural process of coping when there are no additional “disturbing factors” after the hard experience (e.g., familial or social problems, re-traumatization, etc.). If there are any disturbing factors existing within the process of coping, the victims “sweep” into the People-at-Risk Group who are vulnerable for developing lasting complaints and psychological impairments because of the trauma.
People-at-Risk Group—This group is composed of victims that are at high risk for developing chronic PTSD and/or comorbid disorders, such as alcohol dependency, depression or anxiety disorders.
The early assignment of victims to the respective Group is important, as the predicted courses in the sense of the TGIP need different offers of help and support for the prevention of a chronic course. The CRI checklist allows a risk profile to be drawn up from which graduated interventional measures from Psychological First Aid to Acute Trauma Therapy can be applied.
Conclusions
The main intention of the EUTOPA-IP project is the adaption of the TGIP to the World Health Organization's International Classification of Functioning, Disability and Health (ICF), as well as integration of return to work programs for disability management for survivors and uniformed services and development of risk profile identification for uniformed services.
This project includes training for mental health professionals, fire brigades, social workers, officials responsible for disability management, and students from related fields. Some of these persons already were organized (Spain, Germany). In 2011, the Czech Republic and Germany will provide further programs with the participation of foreign experts.
The group met in September 2010 in Amsterdam with the participation of the experts from various uniformed service organizations, followed by a meeting in November 2010 in Madrid and EUTOPA III Conference in April in Cologne.
For more information, please visit project's website: http://www.eutopa-info.eu/
Abbreviations:
ASD = acute stress disorder
CBT = Cognitive Behavioral Therapy
CISM = Critical Incident Stress Management
CRI = Cologne Risk Index
EUTOPA-IP = European Guidelines for Target Group Orientated Psychosocial Aftercare—Implementation
PTSD = post-traumatic stress disorder
TGIP = Target Group Oriented Intervention Programme
