Textbook of Maritime Medicine

17.1 Introduction

For the purpose of this chapter crisis intervention is defined as encompassing all measures that may be offered as psychological help to individuals who are exposed or have been exposed to a disturbing event in which the usual coping mechanisms of the individual have failed in the face of a perceived challenge or threat. In the context of crisis intervention for these disturbing events the Diagnostic and Statistical Manual of Mental Disorders, DSM (1) and the International Classification of Diseases, ICD-10 (2) use the terms traumatic event. Traumatic events have the potential to cause a number of reactions described by the terms traumatic stress (International Society for Traumatic Stress Studies), (psychological) trauma (2) or psychological distress (3). In their crisis intervention model “Critical Incident Stress Management”, CISM) Mitchell and Everly (4) use the term critical incidents synonymously for the traumatic event, and critical incident stress synonymously for traumatic stress. Traumatic stress may result in functional impairment which may range from mild to severe and may be quite disabling (see 17.2).

There are considerable differences in the reaction of people to traumatic events. An event may be traumatizing for one individual while another individual does not suffer from trauma. Consequently, it would be appropriate to call a traumatic event a potentially traumatizing event (5).

Seafaring poses to the seamen a great deal of risks of experiencing such events onboard ships:

• fire
• severe accidents with death or serious injuries of other seamen
• massive destructions caused by collisions
• salvage of dead bodies from the sea
• near drowning
• abortive rescue of a colleague who has fallen over board
• suicide or sudden death of a colleague
• violence
• sexual assault
• robbery
• piracy, being taken hostage
• events in which extreme feelings of fear, helplessness, loss of control or horror have occurred

 Also observing the above events or listening to narrations on such events may be traumatizing (vicarious trauma or secondary traumatization (6, 7)). Moreover, news about disturbing events at home, such as death of a loved one, serious accidents of family members or friends, natural disasters, uprisings, may have traumatic effects on a seaman, all the more, if he cannot help.

 Frequent attributes of these exceptionally stressful events are: 1) they come sudden; 2) they come without warning; so that the individual has no means to prepare for the event; 3) they are outside the normal range of situations which the seaman encounters in his or her life; they imply a discrepancy between threatening factors of the situation and individual coping ability; 4) they are accompanied by feelings of helplessness and defenceless surrender; 5) they may change the individual’s beliefs and self-understanding.

 During the last decades, the understanding of traumatic stress after critical incidents has taken on greater significance. Focus has been laid more and more on developing measures to reduce the amount of traumatic stress and to mitigate its consequences.

 The importance of providing appropriate crisis intervention to individuals who have experienced traumatizing events has been increasing since 1980. Then the diagnosis “post-traumatic stress disorder” appeared for the first time in the Diagnostic Statistical Manual (DSM-IV, 1) as a description of emotional and mental problems observed in veterans of the Vietnam War.

 Crisis intervention was first introduced in the emergency services (medical, fire fighting). Soon it spread out practically all over the world and was used after various events with traumatizing potential for large groups, e.g. mass disasters, natural catastrophes and violence at schools. It entered the catalogue of psychological methods in the military and law enforcement organizations. The United Nations introduced it for its peacekeeping operations (8).

 As a new system of helping methods in cases of psychological problems after potentially traumatic events crisis intervention met with considerable scepticism, especially in fields where “tough” men (and women) were convinced that withstanding adverse mental and emotional effects of critical incidents was part of their job. Police men, firefighters, military men, and emergency service personnel had to be convinced of the benefit to their health which crisis intervention provided. It took some time to bring to them the message that being psychologically disturbed after having experienced a potentially traumatizing event was normal and was not a sign of excessive softness or mental illness. Likewise, they have had problems to admit the aforesaid disturbances.

 Similar to military and police, seafarers belong to a community of traditionally „tough“men and women. It is not surprising that the introduction of crisis intervention into shipping is still in the beginning. Starting in the military Navies of various countries regulations have been established for crisis intervention, e.g. German Navy (9), United States Navy (10). Also for the merchant navies and for maritime search and rescue units recommendations for crisis intervention were released. In the 5^th edition of the German Medical Guide for Ships, edited by the German Employers’ liability insurance association, a chapter “Stress after an accident at sea” was inserted (11). The International Maritime Organization together with the International Civil Aviation Organization added sections on Critical Incident Stress Counselors and crisis intervention into their International Aeronautical and Maritime Search and Rescue Manual (12).

 The progress in crisis intervention in seafaring is also indicated by the number of scientific conferences, popular and scientific publications, and guidebooks. Jensen (13) describes the various problems in providing psychological help on ships with multi-ethnical and multi-cultural crews, and Rademacher and Zielke (14) propose a curriculum for preparing captains and nautical officers for providing psychological help on board.

 It is obvious that in many places, where the “ideal of masculinity” with its unlimited ability to suffer in particular from psychological stress, a “change of culture” is necessary, so that men as well as women consider traumatic reactions as “normal reactions to non-normative situations”.    

 This chapter contains definitions of terms related to trauma and traumatic reactions, information on methods of crisis intervention, on possibilities of integration of crisis intervention in the maritime environment, and on some aspects of trauma therapy.

17.2            Definitions of Terms

17.2.1  Acute Stress Reaction (ASR)

 When people are faced with a traumatic event they often experience changes in their body, in their cognitive functions, in their feelings and in their behaviour. These physical, cognitive, emotional and behavioural changes after a traumatic event are called traumatic reactions.

 Acute Stress Reaction is the diagnosis which is used by WHO International Classification of Diseases ICD 10, F43.0 (2) to describe typical examples of traumatic reactions which are experienced in and following a critical incident.

 Acute stress reaction is a temporary severe disturbance as a reaction to extraordinary physical or psychic stress. It develops in mentally and emotionally normal individuals who have been exposed to an overwhelming traumatic event (critical incident). During the event they respond with fear, helplessness or horror.

17.2.2  Trauma Phases 

 Frequently the concept of trauma phases is used to describe what people may experience during, immediately following, and for some time after a traumatic event. This concept implies three phases:

• Shock
• Impact phase
• Recovery phase

Fig. 17.2.1  Chronological order of traumatic processing (adopted from (30))

This figure which was adopted from Lucas (30) describes the trauma phases, the reactions pertinent to the phases, and the processes of recovery (return to equilibrium) and of development of post-traumatic stress disorder (PTSD), respectively.

Shock

 This phase starts with the very beginning of the traumatic event and may last for an hour to one week. Affected individuals are overwhelmed, dazed; their consciousness may be constraint, attention may be limited (tunnel vision); they have difficulty to process the excessive amount of information; disorganization, feelings of helplessness, anxiety, fear of death and fainting occur. The individual may lose control over the situation. A broad range of physical reactions may appear, such as tachycardia, sweating, paleness, diarrhea, nausea. The mind may try to distance itself from the experience (dissociation). On the one hand, there may be total withdrawal from the surrounding situation, on the other hand agitation and over-activity (fugue) may occur.

 Impact phase

  The impact phase follows the shock phase and may last up to two weeks. Although the most intense arousal has subsided, individuals may have problems to concentrate on the work they are doing, and they may suffer from sleep disturbances. Individuals may have a subjective sense of numbing and detachment. They may lack in emotional responsiveness, in awareness of their surroundings, they may feel unsecure. Their interest in friends, colleagues, or in activities they have liked before the event may decrease. Depressed moods and hopelessness may occur; individuals have a higher risk of committing suicide or taking aggressive actions towards themselves or others. Also anger may occur. Affected people often have doubts about the correctness of what they have done. They may state accusations against themselves or against other people who may have been responsible for what has happened. Their attention and judgment may be reduced. They may ignore own risks and may also constitute a risk for others. It is possible that commands are not obeyed to and skills cannot be applied. Affected individuals are still absorbed from the event they have experienced. Many of them feel a strong compulsion to talk about the events again and again; however, others don’t want to talk at all.

 Recovery phase

 After a period between two and four weeks affected individuals start to recover from the trauma. Further depressing events or stressful work and life situations may interfere with the recovery. Interest in friends and in formerly preferred activities returns.

 All the reactions which have been described for the three phases are considered as normal reactions to an event which was outside the everyday realm of experience.

 If the adverse effects of the trauma last longer than one month a state occurs in which symptoms develop that are attributed to the clinical diagnosis post-traumatic stress disorder (PTSD, see 17.2.3).

 A large part of the population is able to deal with the trauma by means of their own self-healing-power in a few weeks. Protective factors (see below) like social support or relief of additional work or life stress foster the healing process.

 Methods of crisis intervention are applied to give help to individuals in the three trauma phases, in particular to support the third phase of the trauma process, the recovery phase, in which the individual can recuperate from this emotionally and mentally disturbing state.

17.2.3  Post Traumatic Stress Disorder (PTSD)

 Avoidance and numbing: Persistent avoidance of stimuli associated with the trauma, and numbing of general responsiveness as indicated by e.g. efforts to avoid thoughts, feelings, or conversations associated with the trauma, by efforts to avoid activities, places or people that arouse recollections of the trauma, or by feeling of detachment or estrangement of others, or by restricted range of affect. Individuals often are not able to experience pleasure from usually pleasurable life events such as eating, exercise, and social interaction. Thoughts of suicide which are also symptoms of the acute stress reaction are not infrequent.

 Arousal: Persistent symptoms of arousal as indicated by e.g. difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hyper vigilance or exaggerated startle response.

 These disturbances follow the traumatic event with a latency ranging from one to six months

 Not every ASR is followed by a PTSD. However, PTSD sometimes has a delayed onset. Even in individuals who did not develop ASR symptoms, PTSD may occur.

17.2.4  Risk factors and protective factors

 Not all individuals who were victims of a potential traumatizing event experience symptoms of an Acute Stress Reaction, and even less develop a Post-Traumatic Stress Disorder. In the United States, the National Comorbidity Survey found that during their whole lifetime statistically, 56% of Americans experience a trauma, and 8% develop PTSD (15). Deahl (16) reported an incidence of 1 – 2 % in the general British population, of 30 % and more in people who witnessed severe accidents or catastrophes and in rescue personnel, and of 30 to 50 % and more in military personnel deployed in fighting.

 By conducting follow-up screenings of people who had experienced potentially traumatic events several factors could be identified which distinguished those who were able to recover from a traumatic experience, and those who developed PTSD or other problems following a traumatic event. Factors which were observed in individuals who experienced distinct symptoms of ASR, had difficulty to recover, or developed PTSD are called risk factors or vulnerability factors; factors which appeared to minimize ASR symptoms, to foster recovery, and to prevent PTSD development are called protective factors.

 Not surprisingly, a large amount of observations related to risk and protective factors were made in the military, as examples: Iversen et al (17) and Deahl and Bisson (18) investigated risk factors for PTSD among UK Armed Forces personnel; Price (19) reported findings from the US National Vietnam Veteran’s Readjustment Study.

 It would exceed the scope of this chapter to describe all the factors which have been observed as increasing or lowering the threshold of experiencing traumatic reactions or developing PTSD. So in the following lists the focus will be laid on examples of risk and protective factors that may play a role in experiencing ASR onboard and possibly developing PTSD afterwards. More comprehensive overviews of risk and protective factors may be found in various guides in the literature and fact sheets in the internet.

 Risk factors (vulnerability factors)

 Risk factors related to the trauma:

• Kind of trauma:

1. Man-made traumas (e.g. accidents, terrorism, piracy, robbery). They may destroy the confidence in the reliability of other people.
2. Natural disasters (floods, tornados, rogue waves). Individuals concerned may experience a long-term sense of uncertainty, they may loose their conviction of safety and security, and they may lose their confidence in the future and their belief in the predictability in the world.

• Continuance of the trauma: short events vs. ongoing trauma such as being held as a hostage.
  • Severity and intensity of the event.
  • Feeling of not having control over the things going on, not having a chance to act.
  • Subjective appraisal of the event as threat to one’s own life.
  • Feeling of fear of death.
  • Dissociation.

Risk factors related to the person

• Personality traits, e.g. compulsive or asthenic (2)
• Previous trauma experience (may increase vulnerability of the individual)
• Fatigue
• Sleep loss
• Poor physical health
• Poor coping skills
• Lack of adequate training
• Lack of preparation or poor preparation for possible critical incidents
• Lack of mastering the stressful situation
• Lack of satisfaction with one’s job and/or with one’s life
• Low morale
• Lower rank
• Low educational level

• Protective factors related to social relations (social environment)
• Self-disclosure to loved ones
• Having social support available
• Being connected with others (family, friends)
• Having the opportunity to get in contact with the family or with friends at home
• Providing social support for coping

Risk factors related to the working and living conditions:

• Excessive workloads, e.g. tight deadlines, high time pressure, chronic sleep deprivation
• Working in dangerous situations
• Poor quality of leadership
• Inadequate preparation and briefing
• Lack of possibilities for recreation after the event

Risk factors related to social relations (social environment)

• Communication difficulties due to personality and cultural differences
• Isolation from one’s familiar social support network
• Poor social relations within the crew
• Poor sense of identity
• Lack of family relationship or poor relationship
• Being single
• Lack of good support system of family and friends
• Lack of support in coping with the trauma

Risk factors related to the reactions from colleagues and superiors

• Denying the opportunity to talk about trauma and feelings
• Lack of support in coping
• Devaluating reactions of colleagues or superiors (“It is his own fault, why did he act that way?”)
  • Demand from colleagues to pull oneself together
  • Lack of expression of appreciation by superiors or employers

The risk factors should be controlled in order to decrease the vulnerability of humans. In addition, there are protective factors that affect the level above which an individual experiences ASR or develops PTSD.

Protective Factors

The most prominent protective factor for coping with trauma is Antonovsky’s concept of sense of coherence (20). Sense of coherence means manageability, comprehensibility and meaningfulness. These are important prerequisites for effectively coping with trauma. However, in this connection cultural differences have to be considered. According to the cognitive control theory by Frey and Jonas (21) members of the East Asian cultural circle prefer a secondary control strategy, i.e. they adapt by means of cognitive reframing to a seemingly unchangeable situation and they choose a rather fatalistic attitude.

Other protective factors

Protective factors related to the person:

• Psychological resilience
• Having access to competent help
• Ability to cope with stress effectively and in a healthy manner
• High school degree or college education
• Being resourceful
• Having good problem-solving skills
• Seeking help more likely
• Holding the belief that there is something one can do to manage one’s feelings and to cope
• Spirituality
• Self estimation as survivor as opposed to victim
• Helping others
• Finding positive meaning in the trauma
• Attitudinal components (pre-incident preparation)

Protective factors related to social relations (social environment):

• Self-disclosure to loved ones
• Having social support available
• Being connected with others (family, friends)
• Having the opportunity to get in contact with the family or with friends at home
• Providing social support for coping

 To know the risk and protective factors which may influence an individual’s trauma processing means being able to predict whether an individual has sufficient self-healing resources or whether suitable methods of crisis intervention have to be applied to prevent the development of PTSD.

 In a research project the Institute for Clinical Psychology and Psychotherapy of the Cologne University (Germany) developed a screening instrument by means of which the severity of risk factors and the availability of protective factors, respectively, can be assessed, and the necessary intervention can be recommended. This instrument is available for victims of violence in the general population – Cologne Risk Index – (22) and for the military – Cologne Risk Index – Military Version – (23). According to the risk factors the identified persons are assigned to one of three groups:

•  Group of Recovery: The individuals appear to have enough self-healing resources to cope with the traumatic event and to recover.
•  Switchers: The individuals are “on the verge of chronifying” (23). The process of recovery will probably be successful if no severe additional social and institutional stress is imposed on the affected persons following the traumatic situation.
•  High Risk Group: These individuals show a high potential risk of developing a Post Traumatic Stress Disorder.

For each group the necessary crisis intervention methods are assigned: For all three groups guidance for self-help; for the Recovery Group information about professional help; for the Switcher Group additional psychological aftercare; and for the Switcher Group and the High Risk Group psychotraumatological diagnostic and trauma therapy (for the Switcher Group only if needed).

 There are three groups of measures which can be applied to prevent PTSD. Vitzthum (24). In referencing Wiederhold and Wiederhold (25) she suggests three categories of measures which can be applied to help prevent PTSD:

 Primary preventive intervention encompassing adequate selection and training prior to exposure to traumatizing events.

• Secondary preventive interventions consisting of methods of crisis intervention after the event (see 17.3).
• Tertiary preventive intervention including therapeutic measures done by professionals.

17.3  Methods and instruments of crisis intervention

17.3.1  Purpose

Crisis Intervention is the urgent and acute psychological support sometimes thought of as „emotional first-aid“ (4). Important features are:

• Immediacy (early intervention).
• Proximity (frequently close to the place of the critical incident).
• Expectancy (both, the individual concerned and the person who does crisis intervention expect that the intervention will be directed towards the goal of stabilization and reduction of symptoms; it will not be cure).
• Simplicity (the intervention methods won’t be complicated and therapy strategies won’t be part of the intervention).
  • Innovation (adjusting crisis intervention to the specific case).
  • Pragmatism (not theoretical but practical).
  • Brevity (the intervention will be short).

Crisis intervention may be addressed to

 Primary victims (those directly traumatized by the event)Secondary victims (emergency service personnel who witnessed or managed the traumatic event)Tertiary victims (family, friends, and those to whom the traumatic event may be indirectly communicated)Crisis intervention is provided to help the individual during and after stressful critical incidents.

 Crisis intervention aims at

1.        Reduction of the intensity of an individual’s emotional, mental, physical and behavioural reactions to a crisis.

2.         Stabilization of acute symptoms of traumatic stress.

3.         Mitigation of dysfunction.

4.         Supporting recovery from the trauma, so that individuals may regain the level of performance they had before the crisis.

5.         Giving information on symptoms which may occur later.

6.         Providing psychological education in the sense of informing on adequate and on ineffective ways of coping.

7.         Teaching effective coping skills for future problems.

8.          Decreasing the probability of developing serious long-term problems (e.g. PTSD).

9.          Supporting next of kin, giving them information on how to deal with traumatized loved ones.

10.         Supporting the individual’s self-healing abilities.

11.         Provision of access to further help.

12.         Identification of risk and of protective factors that may foster or slow down the healing of the individual.

In helping the affected individuals getting back to the level of performance and to the quality of life they had before the critical incident, the benefit of crisis intervention is not only a humanitarian matter but has also economic advantages. The individuals can stay in their workplaces or can soon return to work.

 Crisis intervention starts as soon as possible after the critical event and may be extended over several days. In an early state of crisis intervention the help may consist merely of being present and being prepared to listen to the individual concerned (26). In some cases, when the event is longer lasting, e.g. when rescue activities continue over many hours, on-scene support may be indicated. This support usually is a one-on-one activity (see below). Crisis intervention personnel should make sure that the ongoing rescue activities are not disturbed. It is important that through the whole process of crisis intervention always the proper method is applied taking into account the psychological state of the individual concerned.

17.3.2  Levels of psychological help

Depending on the kind of care and the qualification of the provider the care that is rendered to individuals affected by traumatic stress may be categorized in three levels:

Level 1

This level comprises self help and help by colleagues (buddy help). Help may consist of breathing techniques, relaxation techniques (56), and positive self-instruction (57). Moreover superiors may apply the SAFER-technique. For the effectiveness of the help it is advantageous if training in self help and in help by colleagues was provided beforehand. Superiors should be trained as peers (see level 2).

Level 2

Level 2 contains preventive measures which go beyond level 1.These measures are provided by peer support personnel or by crisis intervention teams.

Peers (or peer support personnel) are seamen who know work and life conditions of the affected individuals. They should have specific knowledge of traumatic stress, critical incident stress management, and communication techniques for specific crisis situations. They have been trained in providing care in and after psychological crisis.

Crisis intervention teams consist of a mental health person and peers. They perform most of the methods listed below, depending on the composition of the team.

The term mental health person (or mental health support person) is defined differently in different countries. In this chapter the definition of Mitchell and Everly (4) is used. In their opinion mental health personnel have academic training, diplomas, certifications or licenses. According to these authors ordained chaplains may be mental health persons as well.

Level 3

This level encompasses psychotherapy techniques. They are provided by psychological psychotherapists or psychiatrists (see 17.5).

17.3.3  Critical Incident Stress Management (CISM)

General

In this chapter, from the various methods available for crisis intervention, the focus will be laid on the comprehensive system of Critical Incident Stress Management (CISM). This is an integrated combination of methods developed in the USA in the 1980s (4). It was first applied to emergency medical service (EMS) personnel. Today, it is the system with the highest application rate in institutions all over the US, such as emergency and fire services, US Navy, US Army, US Air Force, Coast Guard and many others. It has been adopted (sometimes in a somewhat modified manner) into many services in Europe and Asia, especially into the military and the United Nations (2, 9, 10, 12).

 The highly structured CISM methods may be used to help the individual during and after stressful events. The process of using these methods is confidential, voluntary and educative.

 The general goal of CISM is the prevention of acute, disabling psychological discord and the rapid restoration of adaptive functioning in the wake of a critical incident. In particular, CISM aims at reducing the incidence, duration, severity of traumatic stress and of impairment arising from crisis situations. Furthermore, it is applied to facilitate advanced follow-up mental health interventions, if necessary.

Components of CISM

The basis for these descriptions is the manual of Mitchell and Everly (4). Concerning demobilization, defusing and debriefing Mitchell (40, 58) introduced alternate terms and descriptions. This was done when the United Nations adopted CISM for support for his personnel. In all cases, the terms given in the manual (the traditional terms) and the new terms may be used alternatively. Mitchell (40) emphasized that the processes of the CISM components, although alternatively labeled, do not change. The International Critical Incident Stress Foundation (ICISF) accepts the new terminology in parallel with the traditional one.

• Pre-incident preparation
• Individual crisis intervention (One-on-One)
• Large scale intervention programs - demobilization - crisis management briefings (CMB)
• Defusing
• Critical Incident Stress Debriefing
• Pastoral crisis intervention
• Family crisis intervention, organizational consultation
• Follow-up; Referral mechanism for assessment and treatment

Pre-incident preparation

• Pre-incident preparation
• Individual crisis intervention (One-on-One)
• Large scale intervention programs - demobilization- crisis management briefings (CMB)
• Defusing
• Critical Incident Stress Debriefing
• Pastoral crisis intervention
• Family crisis intervention, organizational consultation
• Follow-up; Referral mechanism for assessment and treatment

Pre-incident preparation has two goals. One is to set the appropriate expectancies for personnel as to the nature of the crisis and trauma risk factors they face. This includes establishment and maintenance of incident awareness, i.e. to achieve the attitude that a critical incident may happen. This activity is accompanied by teaching basic crisis coping skills in a proactive manner. The other goal is to teach skills for psychological first aid (self help and buddy help).

Pre-incident preparation is usually carried out by superiors, e.g. nautical officers or personnel from the shipping company. Frequently it is conducted in cooperation with psychologists. The appropriate time is before entering the professional field of seafaring. Periodic refreshing and adaptation to new situations should be provided.

Individual crisis intervention

This component of CISM is most important. Social support, especially by a colleague, one of the peer group, is highly appreciated by affected persons because they find understanding and have the opportunity to talk.

 On-scene and directly after the event, self and buddy help will be applied, thus carrying out supporting measures for stabilizing affected individuals.

Most crisis response interventions are done individually. On scene or immediately after the event the SAFER model may be used for an individual who is in crisis. Its goal is to mitigate the acute distress and to facilitate access to follow-up mental health assessment and treatment, if needed. In addition, this type of intervention serves to avoid infection. The five stages of the model are

 Stabilization of the situation: removal of the person in crisis from provocative stressors, thereby mitigating further escalation and constituting the possibility for assessing the mental status of the person.

• Acknowledgement of the crisis: letting the person describe what happened and in which way he or she reacted, thereby giving way for ventilation and for reduction of arousal.
• Facilitating of understanding: explaining symptoms in context of traumatic stress symptoms, thereby conveying the impression that the reactions are normal, although problematic for the person.
• Encouragement of adaptive coping: teaching basic stress/crisis management techniques, thereby improving immediate and short-term coping.
• Restoration of independent functioning, or referral for continued care: assessing current adaptive functioning as adequate or seeking further assistance, thereby re-establishing psychological equilibrium and creating the possibility of continued care.

Activities of SAFER belong to the one-on-one techniques (one individual support person assisting one, or perhaps two, individual(s) in crisis). It is important to note that these activities give the opportunity for assessment of mental status, for improving motivation for accepting further assistance, for deciding whether further monitoring is needed and/or whether additional help must be called in, e.g. a crisis intervention team.

SAFER activities may be carried out on-scene or after the event whenever necessary (and possible) by superiors preferably with peer support personnel training.

 One-on-one (or individual crisis intervention) may be carried out all over the range of crisis intervention after a critical incident. As necessary, there may be more than one contact. In this application it may have a format similar to the defusing, i.e. peer support or mental health personnel may follow the general line of defusing. Individual crisis intervention lacks in giving the individual the feeling of “normal reaction to a not normal situation”. This is easier to accomplish in group programs.

Large scale intervention programs

Demobilization

Demobilization can be used with large numbers of affected individuals immediately after the event has ended or the personnel are disengaged from the scene. The goal is to bring the personnel back to normality, to take the stress from the persons, to set realistic expectations for the psychological consequences of the crisis event, to provide education concerning practical stress management techniques, and to give some advice with reference to other psychological and/or physical support systems. Normally, in a safe area an informational briefing about stress, trauma and coping techniques takes place. It usually takes 20 - 30 minutes.

The alternative term (40) is “Rest, Information and Transition Session (RITS)”. The aim is to give people rest, information and to allow them transition to other activities.

 Demobilization should be carried out by peers or mental health professionals.

 Crisis Management Briefing (CMB)

 The group informational briefing is a technique which is used with large groups that have been affected by a critical incident. It aims at providing relevant information pertaining to the event, at reducing subsequent rumours and misinformation, and at facilitating access for follow-up resources, if necessary. It reviews the relevant facts surrounding the incident, presents the psychological dynamics of the incident, and introduces professional resources which can be used for follow-ups.

 CMB may be carried out by peers or mental health professionals up to several days after the event.

Defusing

Defusing may be done at the crisis venue after disengagement from the crisis activity or anywhere in the post-crisis phase within 12 hours after a crisis. Defusing is a 20 - 45 minute group discussion of the crisis event designed to reduce acute stress and tension levels. Defusing has three phases:

• Introduction: introduction of the intervention team, explanation of the reason and the goals of the intervention, and setting expectations as to the goals.
• Exploration: exploration of the nature and impact of the crisis, asking about the facts and asking about the individual reactions to the crisis.
• Information: educational phase as to the normal nature of the symptoms and to practical coping strategies.

Defusing is an intervention that is a shorter, less formal version of a Critical Incident Stress Debriefing. It should be done within 12 hours of the crisis.

 The alternative term for this small group intervention tool is “Immediate Small Group Support”. Requirements for carrying out this component are according to Mitchell (40):

• The group must be homogeneous.
• The mission must be completed. The event must have come to an end.
• The participants must have had roughly equal exposure to the event.

This component should be done by peers, mental health professionals, or a crisis intervention team.

Critical Incident Stress Debriefing (CISD)

Critical incident Stress Debriefing (CISD) is used with a homogeneous (!) group of individuals who have experienced a crisis or a traumatic event. As with defusing, the goal is to mitigate the adverse impact of a traumatic event by reducing the intensity and chronicity of symptoms related to the trauma. It differs from defusing in several aspects: 1) it is carried out later than a defusing; 2) it is more detailed and more structured than defusing; 3) it is designed to bring psychological closure to a traumatic event.

 The alternative term is “Powerful Event Group Support (PEGS)”. With the exception of the introduction all phases are named alternatively.

 CISD has seven phases:

• Introduction: introduction of the crisis intervention team, explanation of the process.
• Fact phase (new term “Brief situation review”): participants are encouraged to describe the traumatic event from his/her perspective.
• Thought phase (new term “First impressions”) : participants describe their cognitive reactions to the event; and start to transition to the affective domain.
• Reaction phase (new term “Aspect of greatest personal impact”): identification of the most traumatic aspect of the event and thus giving the opportunity of ventilation.
• Symptom phase (new term “Signals of distress”): identification of symptoms of distress or psychological discord, transition back to the cognitive domain.
• Teaching phase (new term “Stress information and recovery guidelines”): supporting the return to the cognitive domain by normalization and psychological education.
• Re-Entry phase (new term “Summary”): provision of closure to the CISD process.

CISD is usually most effective if done two to ten days after the crisis has concluded. In some cases, CISD may be effectively done three to four weeks after the event. It usually takes one to three hours to complete. It is provided by a crisis intervention team.

Pastoral crisis intervention

Mitchell and Everly integrated this method into CISM in one of the later editions of their book.

It is the integration of crisis intervention with pastoral-based support services. There may be more parts than the traditional crisis intervention tools, such as scriptural education, rituals, and sacraments. This intervention may not be appropriate for all individuals concerned. Nevertheless, it should be offered where possible. Often individuals find a “closing point” of the event through participation in a pastoral service.

Pastoral crisis intervention should be carried out several days after the event. For seamen Christian Centres, Chaplaincies and other Seamen’s Welfare Agencies could assist with this intervention.

Family crisis intervention, organizational consultation

Support services are provided for families and/or organizations of which the affected individual is part. The goal is to convey information how to deal with the affected individual and, in case of organizations, to which degree the individual’s work capacity may be reduced and what the organization can do to facilitate the return to normal functioning.

These activities may be carried out by mental health professionals, crisis intervention teams or chaplaincy any time after the event whenever required.

Follow-up, Referral mechanism for assessment and treatment

After conclusion of the intervention activities it is necessary to check whether the activities were successful or not. On the basis of the individual and group intervention activities, and following assessment of the mental status individuals may be referred to additional professional psychological or psychiatric help. This should be done by mental health professionals after the conclusion of the activities or later, whenever needed.

Aspects to consider

Emergency medical measures

Sedatives should be used only in cases of acute crisis. The Medical Guide for Ships (11) recommends for the treatment of Trauma (C.1.6.3) stronger sedativa and suggests making use of the Radio Medical Advice.

Special care has to be provided to affected individuals who show risk of suicide. They have to be observed carefully.

In order to prevent suicide fixation may be recommended.

General advice for applying crisis intervention methods

All crisis intervention activities should be carried out without being intrusive. Nobody should be forced to speak about his feelings. Affected individuals may not admit that they need help. They may be afraid that this could interfere with their job security or career opportunities. Persons doing crisis intervention should assure the affected individuals that their reactions are normal after an extraordinary situation. They should make an effort to convince the individuals of the benefit of the methods, and they shall ensure them confidentiality of the intervention.

It is important that crisis intervention is offered to all the persons who experienced the critical incident in one way or the other.

Criticism against CISM

There has been a considerable number or criticism against Critical Incident Stress Debriefing (CISD) from the research community and from practitioners. In the so called “Debriefing Discussion” criticism has ranged from stating the ineffectiveness of CISD to speculating that application of the method may be injurious for participants.

 This chapter will not go into the details of the discussion. Mitchell and Everly (4) summarized the studies and meta-studies which came to results pro and con, respectively. It appears that all of the studies suffered from methodological shortcomings, and therefore cannot be taken as support of either position.

 This conclusion was supported by recent studies. Regel (27), Boudreaux and McCabe (28) and Beck et al (29) listed various shortcomings of the studies pertaining to CISD:

 Focusing on one component of CISM, namely CISD, without taking into account, that CISM is an integrated combination of methods (4).

• Contrary to the CISM idea CISD is evaluated as a single session and stand-alone process.
• Misconceptions of the purpose of CISD: it is viewed in some studies as counseling or even as a kind of psychotherapy.
• Small sample size.
• Absence of a control group.
• Traumatic experiences not comparable.
• Lack of uniformity of debriefing.
• Evaluation of outcomes by means of questionnaires instead of interviews.
• Different debriefers in one study.
• Differences in training of debriefers.

Most of the authors (Riddel and Couse (31), Wagner (32), Regel (27), Hawker et al. (33)) agree that there is not enough evidence to terminate the use of a method which is considered helpful by most of the participants. Negative and/or harmful outcomes may be prevented by suitable application of CISM.

 Some authors (Bledsoe (34) and Rose and Bisson (35)) recommend not to make participation in CISD mandatory.

 There is only one large organization which has decided to cessate the use of CISD, the UK Royal Army and Navy. Citing Mitchell (36), Frayne (37) reports on a 1996 lawsuit of the Royal Marines against the British government. The complaints were that soldiers who had fought on the Falkland Islands in 1982 and in the Persian Gulf War 1990/91 could have been prevented from developing PTSD had the government provided support services like crisis intervention or debriefing. This lawsuit concerned economic liability of the British government. It was finally decided in 2003 by the High Court of England and Wales. McGeorge et al (38) gave a report on the trial and the judgment. The points concerning support services were: “Immediate psychological debriefing after stressful incidents is not supported” and “There is an obligation on a person experiencing symptoms to inform their employer if they wanted treatment”. According to Mitchell the court’s decision was based on studies which had too much flaws to be taken as an adequate ground.

 The widespread use of CISM shows, that in the opinion of a vast majority of organizations the advantages of the (suitably applied) CISM outweigh possible negative outcomes which the users of CISM are aware of.

In order to reach the intended target of crisis intervention by means of CISM several aspects have to be considered (4):

 CISM methods provide effective crisis intervention which is able to reduce signs and symptoms of distress in individuals who have experienced a potentially traumatizing event.

• CISM is a multifaceted system of method.
• No method of CISM shall be applied as a stand-alone intervention.
• CISM methods have to be performed following the manual.
• People who implement CISM must be properly trained and must have sufficient experience in crisis intervention.
• The group for CISD has to be homogeneous, i.e. all members have the same background and have had the same experiences during the event. This will minimize the risk of secondary traumatization of participants while listening to narrations of observations they did not have.  
• It is advantageous that individuals have been informed during pre-incident preparation about the help which they can use.

 Anecdotal reports from large organizations, such as police and rescue services in some states of Germany, indicate that some modifications of CISM are viewed practical, e.g. emphasizing the cognitive domain in the CISD, as Pieper (26) recommends, and examining, whether CISD may be replaced by other intervention methods.

 In a review of current models and use of psychological debriefing within organizations in UK Regel (27) states that the past controversy has led a number of organizations to develop a new CISM model, e.g. critical incident processing which “contains all the elements recommended by Everly and Mitchell”. In his opinion this means calling CISM by another name. The same is true with the trauma risk management (TRiM) which was developed by the British Royal Marines and is described in detail by Greenberg et al. (39). Regel summarizes that “in close inspection, models which purport to be offering different solutions to post trauma support are all seen to be practising CISM under new acronyms”.

Current status of CISM  

Briefly outlining the eventful history of CISM, Mitchell (36) states that “CISM has recently emerged from the hostile inspection process stronger and more organized, in many ways, than earlier in history”. The most important issue is the adoption of the CISM concepts by the United Nations for support of his personnel. This was connected with a change of terminology. Considering that the terms demobilization, defusing, and debriefing are also used by other professions, in particular the military, and that this may be the reason for misinterpretations, Mitchell (40) suggested new terms which may be used alternatively for those components of CISM (cf. 17.3.3.2).

17.4 Implementation of Crisis Intervention in the Maritime Setting and Shipboard Environment

17.4.1 Consideration of the operational conditions and peculiarities related to personnel

When performing psychological first help as part of crisis intervention after potentially traumatizing events one has to take into account the specific operational conditions of shipping. The following requirements, limitations, and difficulties have to be considered.

Limited culture of confidence

The multicultural and multilingual composition of a crew is an essential feature of today’s ship’s crews. Many crew members come from East Asia (Republic of the Philippines, Kiribati, Gilbert Islands, Burma (Myanmar)), others from Eastern and Southeastern Europe (Russia, Ukraine, Poland, Bulgaria, Kroatia etc.) (41). In a multicultural crew the development of a feeling of mutual confidence and reliance is impeded by the rather hierarchical organization on board, fixed roles, and, above all, the barriers against social contact and communication which are determined by different language and culture. Interpersonal communication requires a minimum in emotional concordance. There is only a slim chance for identification and social relationship, the cornerstones for a confidential community encompassing the whole crew. Identification, commitment and reliance are limited, at best, to the ethnic group on board.

 As an example, particularly seamen from East Asia have a distinct tendency towards relationships within their group, strong collective identification, and a traditional mutual responsibility of the group members. Social imperatives focus on the affinity with each other, and the individual behaviour is aligned specifically to the expectations of the own social community (42). Due to different relief rhythms within the crew the seaman has to adjust repeatedly to changing social and communicative relationships. While nautical officers from Middle Europe usually are relieved after three to four months on board, the foreign crew members, in particular ratings, especially from East Asia, stay on board for nine to twelve months.

Caused by the different relief rhythms seamen from foreign countries may experience quite diverse superiors.

Differences in language competence and style of communication

Although the Standard Marine Communication Phrases, introduced in 2001, requires communication within the ship in English, there are in some cases considerable differences with reference to English language competence. In addition, in a multicultural and multilingual crew there are various culturally determined styles and execution of communication. For example, crew members from East Asia use a more indirect and contextual style of communication. Answers and statements are given more nonverbally or paraverbally than verbally. Control of emotions and face-saving play a critical role in the Asian cultural cycle, in particular during emotionally stressing communication settings. People from Middle Europe, who are used to direct communication and unambiguous messages, may have difficulties to adapt to an indirect and contextual style of communication. The latter means to control the gaze behaviour, to pay attention to nonverbal reactions, and to consider taboos related to body contact.

Limited readiness to use crisis intervention after potentially traumatizing events due to fear of losing the job and of jeopardizing one’s career

Seamen from foreign countries, especially from outside Europe, usually have contracts of limited duration. After relief from the ship a renewed deployment with the ship’s company is not always granted. Even minor health impairments may put redeployment in their job on board at risk. As an example, reports give account from suicides of Philippine seamen after having lost their jobs because of physical impairments. Knudsen’s (43) investigations of Philippine seamen confirm the job insecurity in seafaring. On the other hand, officers and cadets may feel that traumatic reactions may place their career in jeopardy.

Concerning crisis intervention this may lead to a refusal of the officers and the crew to admit psychological problems and to make use of beneficial crisis intervention activities.

 Similar to the situation in shipping, in the military the refusal to utilize help after potentially traumatic events is frequently observed, even if traumatic reactions have already occurred.

Weller (44) asked military personnel who experienced traumatic reactions why they did not make use of crisis intervention which was provided. He got the following answers:

• 65 %: I don’t want to be rated as soft.
• 59 %: My comrades would no longer trust me.
• 51 %: My superiors would treat me differently.
• 50 %: It would jeopardize my career.
• 55 %: I could not go off duty.
• 22 %: I didn’t know where I could get help.
• 38 %: I have no confidence in psychiatric help.
• 25 %: Psychiatric support doesn’t help.

Image of masculinity in shipping

The still existing image of masculinity of the seaman requires to “swallow” experiences of traumatic events without any problem. This is true particularly, if one has a leading function on board. For a captain or officer in charge, who has endeavoured successfully to save the lives of his crew in case of a large damage, it is quite inacceptable to suffer from a trauma and to be a victim without being able to cope. McKay (45) investigated Philippine seamen. He mentions “Constructing Masculinities”. These seamen have a self-image as “new heroes” (“Bagong Bayani”) because in their home country they enjoy high prestige on the basis of being the breadwinners of their family and being of great relevance to their country because of their money transfer.

Reduced possibilities of withdrawal or shielding of affected individuals

The 24-hours-operation of a ship requires a seaman to be constantly available for unforeseen, sudden demands or in critical situations. Personal life is completely subjected to operational requirements and is, consequently, determined by the work. In this environment a feeling of privacy and autonomy can hardly emerge. In the closed social system ship there is no clear division between working and living zones, and it is difficult to shield a crew member from the environment after an extremely stressing event. Likewise, practically all crew members are concerned in case of a potentially traumatizing event, such as damage or external violence, e.g. a pirate attack. However, this is also possible, if only one crew member is injured or killed in a severe accident. In the closed social system ship a secondary traumatization of crew members not directly involved cannot be excluded. The probability of this effect is the more likely the more the secondary victims (bystanders, rescuers) see things from the primary victim’s perspective, and, at the same time, are not able to help.

Impossibility of short-term Psychological First Aid

Worldwide operation of a ship and short stays in ports frequently preclude a Psychological First Aid, the more so as suitable support systems (e.g. crisis intervention teams) usually are not available. All the same, after a potentially traumatizing event a crew member showing traumatic reactions will not be relieved, due to the tight situation with reference to ship manning. This means that the crew members are on their own after an extremely stressing event (42).

Absence of support of family and friends

Caused by the occupational separation from family, friends and from the society at home the seaman cannot make use of these resources after traumatic events. This might hold particularly for Philippines who, according to McKay (45), depend on a pronounced traditional family orientation. Barnett and Hyde (46) state that a change between the work role and the family role is an essential psychogenic protective factor which fosters coping with stress and depressing emotions.

Cultural differences related to experiencing traumata and to coping with traumatic effects

Emergencies and damages to the ship are exceptional situations for the people concerned. The extent to which they have the feeling of having control of the situation themselves may have a strong effect on experiencing threat and showing stress reactions. This coping competence can be viewed in close relationship with locus of control (in the person) and control strategy. According to Antonovsky (20), manageability, comprehensibility, and meaningfulness of a potentially traumatizing event are important prerequisites for coping with trauma. However, in this connection cultural differences have to be considered. The cognitive control theory by Frey and Jonas (21) state that members of the East Asian circle prefer a secondary control strategy, i.e. they adapt by means of cognitive reframing to a seemingly unchangeable situation and they choose a rather fatalistic attitude. In many cases an increasing belief in fate emerges.

17.4.2 Development of systems for primary and secondary prevention and for family counseling and support

Primary prevention

Selection

As a matter of fact, individuals who are most vulnerable to developing long lasting traumatic stress reactions should be excluded from high-risk occupations (16). In the shipping industry selection of these individuals is very difficult. In the selection process with applicants for an unlimited contract (mainly captains and officers) shipping companies would have to rely on what the applicant tell them in an interview. The applicants may not be aware of their “vulnerable personality” or they may dissimulate in order to get the job. In a similar way results of personality tests which are not normally applied in these companies could be falsified. A further problem arises by the fact that seamen with a temporary contract are recruited by crewing agencies that are often far away from the companies.

Preparation and training

These measures have been described in detail by Rademacher and Zielke (14) on the basis of Kowalski and Hansen (47).

The shipping companies should prepare their crews for possible emergencies and potentially traumatizing events. A suitable procedure could be based on Meichenbaum’s “Stress Inoculation Training”, SIT (48, 49). The components are:

• Information on possible emergencies and traumatic situations and on appropriate coping strategies.
• Gradual confrontation with possible emergencies and traumatic events; teaching how to cope and how to maintain a feeling of control.
• Exercises of effective techniques for breathing and for distancing oneself from victims.
• Strategies of cognitive reframing of highly stressing images, thoughts and emotions.

This pre-incident preparation should be provided to the crew, at least to the officers. This preparation serves to give information on dealing with a critical incident. As mentioned in 4.1, the crew often is on their own immediately after a severe accident on board or a pirate attack. Therefore a reaction after traumatic events has to take place within the crew. For this reason, it seems necessary to train one or more qualified crew members so that they can give psychological first aid. Since the nautical officers are responsible for health care on board, the task of psychological first aid could be assigned to this occupational group, provided pertinent aptitude. In context with their medical training they could be prepared for psychological first aid, and through further training they could qualify for peer support personnel (peers).

Davies from Maersk Training Centre (50) described a training for “Surviving Piracy and Armed Robbery” (SPAR) of which Psychological First Aid (PFA) was a part.

Secondary prevention          

Psychosocial care by the shipping company

In spite of the above mentioned difficulties and limitations which a maritime crisis intervention encounters, the development, organization, and implementation of psychosocial support for seafarers after potentially traumatizing events constitutes a new challenge for the shipping industry (51). In these cases seamen should be provided a support which is comparable to that which is given to police men, firefighters and the military.

 Dealing with traumatic events in ship operation depends to a great amount on the attitude and the behaviour of the shipping company. E.g. it is crucial, to which extent the company is prepared and willing,

 to render personal support to affected crew members after critical incidents,

• to express appreciation after accomplishment of a excessively stressing event,
• to provide resources for preventive measures,
• overtly to deal with errors, and to deduce and implement appropriate measures,
• to render psychosocial support to partners and families.

The shipping company should provide the following:

• Development of a concept for assistance in accordance with the emergency planning as instructed by the ISM-Code (52).
• Information sheet, understandable by laymen, if possible in the native language of the seamen, containing

1. Possible typical physical and psychological reactions after the event
   1. Simple behaviour recommendations
   2. Advice how and where to get further help and support.

• Cooperation with appropriate welfare institutions.
• After having been informed of a potentially traumatizing event initiating measures for psychological support.
• Establishment of a telephone/internet hotline for affected individuals and their families and partners – preferably actively contact them.
• Specific care for risk persons.
• Follow-up services.

In the context of first aid after severe damages, pirate attacks and hostage takings, respectively, the shipping company should provide for immediate crisis intervention. For this purpose well trained peers or disaster and crisis psychologists who are experienced in shipping are required. They should perform immediate crisis intervention on board or in appropriate locations in the next harbour. Similarly to the crisis intervention teams set up by the military, firefighting agencies and the police, shipping companies should take into consideration the establishment of a maritime crisis intervention team. To this effect they might cooperate with other shipping companies and/or with suitable maritime institutions, the radio medical service, seamen’s welfare agencies, and the ITF (International Transport Workers’ Federation). The members of such a maritime team should be enabled to be deployed fast and worldwide. Supervision of the team members should be provided after their mission.

 In establishing an appropriate crisis intervention organization it should be taken into account that there may be considerable reservation and opposition on the side of the affected seamen

concerning psychological first help. They may be anxious to lose their contract or to place their career in jeopardy. In addition, the sometimes low culture of confidence has to be kept in mind. In these cases crisis intervention should be organized in a manner, which guarantees the seamen anonymity and data security.

 Welfare agencies normally maintain good contact to seamen, and therefore, especially in their centres established throughout the world, their personnel can offer relieving talks with affected seamen. Their personnel often are trained in crisis intervention methods. These relieving talks may take place in context with a first crisis intervention on board or in the centres in the ports. In the Preliminary Guidelines for Post-Piracy-Care of seafarers, edited 2010 by the Seaman Church Institute in New York (53), measures for medical and psychological care of affected seamen during and after a pirate attack or hostage taking are described. In this guideline also the information and possible supervision of seamen’s families are recommended.

In cooperation with the German Seemannsmission and on the basis of a survey, the authors of this chapter are developing a concept for the organization and performance of crisis intervention of traumatized seafarers.

 17.4.3 Recommendations concerning behaviour towards and communication with traumatized seamen

The Medical Guide for Ships (11) gives the following recommendations for taking care of seamen after potentially traumatizing events:

After an incriminating event each concerned crew member should

• Speak about the experiences, reactions and in particular about the feelings (by talking the consequences of a traumatic experiences can be diminished),
• Remain physical active,
• Exercise controlled breathing, breathe in and out slowly and deeply inhale and exhale,
• Find a support and security group or familiar one on one,
• Respect culture-specific norms and value system,
• Realize that they survived an emergency and recall what factor contributed to overcome the situation. Perhaps this will help in successfully being able to cope.

It is very helpful in dealing with acute load reactions after a traumatic event to use the application of learnt relaxation procedures; these can be like muscle relaxation, meditation etc.

 Behaviour and conversation readiness toward crew members with acute load reactions:

1. After a traumatic event the possibility should be available for a crew member to start speaking about their experiences. However such conversation is neither a consultation nor a psychotherapeutic treatment.
2. No one should be pressured to speak about their experiences if they are not ready to do so.
3. The offered one-to-one conversation should occur in an open and trusting conversation atmosphere without pressure of time and, perhaps, in a spatial distance to the place of event. Guidance of such conversation is to show interest, respect, openness and active listening.
4. Point out to the fact that the physical and psychic symptoms are normal reactions after such a traumatic event.
5. The subjective experience of the affected crew member, their reactions and particular their feelings must be taken seriously and not devalued, run through or even minimized.
6. Put understanding questions, point out to the successful accomplishment of coping with the emergency situation and do not stress the “dreadfulness” of this incident.
7. Adapt the language to the linguistic understanding of questioned crew member; this is a big problem with foreign crew members, because often, already in the normal work routine, language and communications problems exist.
8. In spite of understanding pay attention to emotional distance of the affected person, i.e. refrain from statement and feelings of the crew member concerned and do not identify with their experience.

 The behaviour towards one or several affected crew members and the conversation after a traumatic incident depend on the leadership and culture on board and the composition of the crew. Thus, such an event can be experienced by crew members of different nationalities much more intensely and more threateningly and can lead to completely different behavioural reactions and feelings. In addition, cultural norms can hinder their reactions, also missing trust and hierarchical gradation hinders the conversation readiness of these crew members after traumatic experiences. Here the question is how to develop a bond of trust as a condition for a strain relieving talk after a case of distress or heavy accident on board.

17.5 Trauma Therapy

 If the trauma symptoms described above do not fade away with an affected crew member, or if they even increase, the experiences should possibly be processed with professional help of a trauma therapist.

17.5.1 Cognitive Behaviour Therapy

Procedures of cognitive behaviour therapy are in their mode of actions well evaluated. There are two groups of the cognitive behavioural interventions:

• Exposure Therapy
• Cognitive Restructuring

Exposure Therapy 

This therapy concept assumes that the avoidance of trauma-related cues (sign-stimuli) and of the associated feelings and memories lead to the preservation of post-traumatic stress disorder. Thus new experiences and the normalization of traumatic memories are blocked, and possible coping with the experienced traumatic situation is hampered. In agreement with the patient and after an appropriate preparation, he or she is confronted with the trauma related sign-stimuli in the therapy. The target of this procedure is to let the traumatized patient repeatedly re-experience the emotions, thoughts and body sensations associated with the traumatic cues, until the perceived stress intensity has subsided. The feeling of subjective control over the trauma-related memory is an important feature of an incipient normalization.

Cognitive Restructuring

According to the theoretical concept of cognitive restructuring, symptoms of PTSD are maintained by dysfunctional and inflexible thoughts and appraisals of the traumatic experiences and their reaction sequences. In therapy, these dysfunctional and affective cognitions should be identified and modified to the extent, that a more realistic perception and evaluation of the event emerge. This theoretical approach states, that the extremely negative perceptions and evaluations of the event are often related to frustration experiences and feelings of guilt: e.g., having failed in the extreme situation, or being responsible for the traumatic event. With support from the therapist, the patient recognizes his negative affective thoughts and appraisals, records them, and develops, step by step, alternative and supportive cognitions.

17.5.2 Eye Movement Desensitization und Reprocessing (EMDR)

This method of treatment was developed by Shapiro (54). Eye movement provides neurological and psychological effects that enhance the processing of traumatic memories. According to this therapy concept, trauma can “trigger off” a so-called “speechless terror”. This “speechless terror” is localized in form of images in the right cortex, while the speech-centre is suppressed. The traumatized person cannot put the extremely stressful event into words, and thus the processing of the experience is hindered. By frequent eye movements, a bilateral stimulation and, in this way, a synchronization of the two hemispheres takes place. The target of the therapy is to retrieve a speech approach to the “speechless terror”. After appropriate preparation, rapid eye movements of the patient are triggered by the therapist by means of quickly waving his fingers or his hand. The therapy can also be performed using sounds or touch stimuli. The target is that in this eye-movement phase the patient relives the traumatic experience again. The process is repeated until the patient has completely relived his traumatic memories, and until trauma-related sign-stimuli no longer trigger intensive physical and psychological stress responses. This therapy may be very useful for persons who don’t want to disclose shameful experiences.

17.5.3 Integrative Trauma Therapy (55)

The therapy includes the following phases:

1. Establishment of safety: differentiated treatment of symptoms, activation of social resources, learning of relaxation and breathing technique.
2. Stabilization: improving self-awareness and self-acceptance, activation of boundaries in interpersonal relationships.
3. Confrontation: cognitive and emotional confrontation with the effects of trauma, working with memory.
4. Integration: acceptance of the trauma and of the change.

Trauma therapy is indicated if symptoms and unfavourable psychological conditions after the traumatic event have not decreased after a period of four to six months. A chronified PTSD without treatment may lead to depression, aggressive behaviour, misuse of alcohol, drug consumption, etc. The prognosis of favourable outcome of therapy is the more likely the earlier the individuals start therapy.

Information and training related to possible traumatic events as well as psychological first aid and support are important measures for preventing PTSD.

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