THE 1999 ACISA - GLENELG DECLARATION
GUIDELINES FOR GOOD PRACTICE FOR EMERGENCY RESPONDER GROUPS
IN RELATION TO EARLY INTERVENTION AFTER TRAUMA AND CRITICAL
INCIDENTS
1. BACKGROUND TO GUIDELINES FOR GOOD PRACTICE
1.1 Calls for evidence-based practice recognise the advisability of having agreed and sanctioned guidelines about good practice. This is especially so for early intervention after trauma, since experience and systematic investigations have revealed a marked discrepancy between outcomes once presumed to be achievable and those that can be reliably delivered.
1.2 These guidelines for emergency responder groups seek to build an accumulated experience about good practice and are underpinned by a belief that considered early intervention, appropriately delivered in accordance with appropriately communicated expectations held and understood by all parties involved, is a core element in comprehensive service provision for populations exposed to trauma and critical incidents
1.3 These guidelines for good practice, are the product of a consultation process initiated in 1998 by the European Society for Traumatic Stress Studies (ESTSS) and a workshop convened by the Australasian Critical Incident Stress Association (ACISA) during its September 1999 conference in Adelaide, Australia.
2. INTENDED USES OF GUIDELINES
2.1 The guidelines have been prepared as a discussion document for individuals and organisations seeking to sanction and adopt policies and practices supported by currently available evidence, taking account of specific requirements that may pertain to each and every service or organisation.
2.2 These guidelines seek to describe good practice for emergency responder groups deployed to front line (e.g. disaster or major incident site) and second line duties (e.g. hospitals, reception centres) where they have contact with primary and secondary victims.
2.3 The guidelines also describe good practice in respect of planning and delivering staff support services for emergency services personnel deployed for major incident response, or help the individuals concerned with reactions to traumatic stressors accumulating over time.
2.4 The guidelines can be read on their own or in conjunction with ‘Treatment Guidelines for Post-Traumatic Stress Disorder' published by the International Society for Traumatic Stress Studies1.
3. EXCLUSIONS
3.1 These guidelines do not deal with pre-incident education, response planning, exercises and prevention. Ideally, each of these should also be delivered according to separate guidelines for good practice.
3.2 Each of the above can, and do, have a crucial influence on standards of practice attained in delivering post incident support services.
4. POSSIBLE TARGET POPULATIONS FOR THESE GUIDELINES
4.1 These guidelines should be of interest to all emergency services and related organisations, helping professionals within statutory and voluntary organisations, staff in humanitarian aid organisations, managers and policymakers as well as legal, welfare and compensation agencies plus academic institutions.
4.2 The guidelines may be used as a reference source for survivors of trauma or critical incidents and all organisations and professions representing victim interests.
5. QUALIFICATIONS
5.1 These guidelines represent a consensus view of the ACISA Workshop convened in September 1999 and later sanctioned by the ACISA Australasian Executive at the Executive meeting in November 1999.
5.2 In sanctioning these guidelines ACISA also recognises this document to be one that will have to be developed, reviewed and updated to take account of new evidence as well as the introduction of emergent technologies or staff deployment policies.
5.3 ACISA considers its Australasian conferences to provide regular venues for formally consulting with members regarding future development of these guidelines. Proposed changes to the guidelines are to be referred back to the ACISA Executive for consideration and, if appropriate, approval.
6. PRACTICAL AND THEORETICAL UNDERPINNINGS OF THESE GUIDELINES
6.1 A pre-condition for good practice in early intervention for victims of trauma, as well as post incident support services for emergency responder groups, is that practical action must be taken to ensure the safety, security and physical needs of all individuals concerned. Only once these have been addressed should psychological crisis support be implemented for victim groups and populations at risk.
6.2 In these guidelines, early intervention is not defined chronologically. Rather, it is taken to ean any personal supportive steps taken once the physical safety, security and health needs of those involved are being addressed.
6.3 Crucially important to these guidelines is the principle of agreement being reached about appropriate staged phases of help and support for victims. This can be achieved through establishing agreed policies and practices for at risk professional groups, or in direct negotiation with incident commanders/controllers. This may occur at the scene of an incident as well as in subsequent stages of recovery and rehabilitation.
6.4 To date, evidence has not been reported to give priority to any one form of early intervention. Therefore, these guidelines for good practice make general recommendations. In time these may become more technique focused.
6.5 In the first instance, help and support to victims should endeavour to contain or reduce the arousal state precipitated by a recent trauma, as well as the behavioural, cognitive and emotional reactions associated with it.
6.6 The objective of this initial help and support is to engender an enhanced sense of personal and situational control.
6.7 Early intervention is an initial step which seeks to minimise the impact of trauma through structured and staged responses. The aim of effecting improvements in the quality of the recovery environment of individuals or groups.
6.8 Early interventions should be provided in a staged manner with stage being defined by the objectives and aims they seek to achieve.
6.9 Early help and support provided in a systematic and staged manner as described above should help individuals and teams to re-establish their usual functions (e.g. operational readiness), taking account of the event that has occurred.
6.10 Examples of good practice may include: calming down, providing non-verbal support, shielding from the media, organisation of transport, early unification with family or close friends and providing food, drink, shelter, heat etc.
6.11 After certain traumatic incidents emergency responders mobilised for major incident response may themselves be recipients of support services.
6.12 These guidelines also recognise specific situations (e.g. war, displaced communities, incidents involving children) may require a redefinition of the objectives and aims of early intervention.
7. FOR WHICH EVENTS ARE EARLY INTERVENTION INDICATED
7.1 These guidelines are not prescriptive about the types of events for which early intervention may be indicated. Each event has to be assessed according to its own unfolding characteristics and reactions experienced in its aftermath.
7.2 Negotiations between incident commanders/managers and providers of support services are therefore essential elements of defining an event as critical or traumatic.
7.3 These negotiations should lead to agreement about which staff support services are indicated for each incident, and at what stage.
7.4 The event (Criterion A) for a DSM-IV diagnosis of Post Traumatic Stress Disorder (APA, 1994), offers a useful guide as to the characteristics of events that may be deemed traumatic.
7.5 Criterion A states: 'The person has been exposed to a traumatic event in which both the following are present: (1) the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self and others and (2) the persons response involved intense fear, helplessness or horror.
7.6 The latter sub-criterion may, in some instances, not apply for emergency responder groups due to their active operational role during an incident. In some such cases the listed reactions may be experienced at a later stage.
7.7 Reference to assessment tools and research material, such as the Life Events Checklist from the Clinician Administrated Interview for Post Traumatic Stress Diagnosis (CAPS-DX) offers particular suggestions about the range of events that may be considered traumatic.
7.8 The DSM IV event criterion, the Life Event checklist or other reference materials are not to be considered exclusive. Impressionistic and opportunistic assessment will, in most instances be necessary. This should be recognised by all parties involved in negotiating appropriate early intervention.
7.9 Negotiations between incident commanders/managers and providers of support services are therefore essential elements of defining an event as possibly traumatic and suggest crisis psychological support be provided.
7.10 These negotiations should lead to formalised agreement about which psychological crisis support services are indicated for each incident, at what stage of the recovery process and for which victim populations.
8. WHO PROVIDES EARLY INTERVENTION AND WHERE
8.1 Providers are likely to be:
Ø Front line emergency services personnel at site of major incident (police, fire, ambulance staff etc). This may, on occasions, also include healthcare staff.
Ø Second line emergency service personnel, usually in hospitals or reception centres (hospital staff, social services staff, non hospital based clinicians, and volunteers).
Ø Generalist clinicians and counsellors at various venues. Their clinical expertise is usually not called upon during an incident or its immediate aftermath. Some response co-ordination or planning may be asked for.
Ø Specialist clinicians through referral some time after the incidents. May provide advisory input to planning of care response. See also 9.16.
8.2 All the above professional groups may have an involvement in planning and delivering post incident staff support services. Ideally, this should form part of a co-ordinated and agreed response protocol.
9. ASSUMED COMPETENCIES OF PROVIDERS OF EARLY INTERVENTION
9.1 Front line emergency services personnel should have been trained in and have experience of providing basic crisis support (emotional first aid) to contain and possibly reduce arousal in victims survivors and even bystanders.
9.2 This may be achieved by reassurance and helping to establish levels of order and control as appropriate in what others may perceive as chaotic situations.
9.3 Emergency responders providing basic crisis support may have to accept and tolerate high levels of distress in victim survivors and bystanders. They should recognise there may be little that can be done immediately to reduce these reactions, and that they are not expected to effect relief of expressed distress.
9.4 Second line emergency responders also have a role in providing crises support (emotional first aid) to contain and possible reduce arousal in victim survivors as well as their closest relatives and friends.
9.5 Second line emergency responders also have to accept and tolerate high levels off distress in their charges and will, especially in the early stages of their response, need to offer reassurance and helping to establish levels of order and control as appropriate.
9.6 In this initial stage response should be informed by a priority consideration to offer practical help, comfort and consolation of distress, give support for victims to address immediate practical tasks and facilitate early reunion with family, friends and loved ones.
9.7 A crucial aspect of this stage of crises support is to have access to correct information about the incident and ensure this is systematically and appropriately reported to victims. If such information is not available statements to this effect should be made.
9.8 At this and subsequent levels of response, distribution of information booklets describing reaction to extremely stressful events is appropriate and advisable. These booklets should explain how reactions to trauma can be monitored over time and should offer advice on when to seek further help and where specialist care services are based.
9.9 Information leaflets should also emphasise the value to victims of using their family's social and collegial support networks for practical assistance and to talk about what has happened during the recovery phase.
9.10 On occasions early referral to relevant or specialist professionals may be indicated by second line emergency responders.
9.11 Generalist clinicians, counsellors and specialist clinicians shall have the formal qualifications required to assume their particular professional roles.
9.12 The appropriateness of using their professional skills and techniques, to deliver early intervention strategies for trauma victims should be a matter of negotiation with incident controllers or managers and not be left to the professional discretion of generalist clinicians and counsellors.
9.13 Whenever possible and predictable, service receivers should be consulted as to the appropriateness of provision being made available and other services they might welcome.
9.14 It is strongly recommended that professionals involved at this level of response should receive supervision and guidance from more qualified or experienced members of their respective disciplines, or more specialist disciplines specifically trained in early intervention after trauma.
9.15 Early intervention strategies agreed and adopted through negotiation with incident controllers/ managers should be referenced to published evidence.
9.16 Specialist clinicians might become involved in early crisis support alongside their generalist colleagues. In addition they may assume or be asked to fulfil specialist roles involving providing advice and supervision to less specialised colleagues.
9.17 Comprehensive care planning should include an independent referral channel granting complete confidentiality to a service user.
9.18 Specialists may also have maintained an active role in planning and negotiating the specific responses in each stage of post incident support, assessment, counselling and therapy for victims.
9.19 Specialist functions should be commensurate with those sanctioned by the practitioner's professional organisations.
9.20 Supervision from most experienced colleagues is strongly recommended.
9.21 For all responder groups, at all levels of competency, it is deemed consistent with good practice to ensure that supervision needs and continuous education requirements are addressed.
9.22 After every major incident all the above responder groups should undertake operational reviews, list major learning points and make recommendations for effecting improved services in future.
9.23 It is also considered good practice to ensure that written reports dealing with incident response and key learning points both from operational and psychological support points of view are published in the public and professional domains.
9.24 Wherever an incident evokes overwhelming emotional response or marked dissociation in emergency responders it is recommended that the co-ordination, and possibly delivery of services be delegated to specialist clinicians.
9.25 Professional responders have a duty to themselves, their colleagues and their employing organisation to recognise the scope and limitations of their response competence both at a professional and personal level. If it is felt incident demands exceed personal resources this should be communicated to appropriate incident controllers/managers.
9.26 At the levels of the clinical disciplines, practitioners should have a demonstrated competence with respect to assessment, evaluation and intervention treatment techniques for post incident reactions.
10. SUMMARY AND RECOMMENDATIONS
10.1 Support strategies for victims of trauma or critical incidents as well as those put in place for emergency responder groups should be pre-planned and integrated within major incident response protocols.
10.2 These should be tested through exercises so that the continuing training needs of staff involved can be established and addressed.
10.3 The theoretical foundation for these guidelines is that the immediate purpose of early intervention is to contain and possibly reduce arousal levels precipitated by an incident(s) once the primary requirements of safety security and health have been addressed.
10.4 This arousal may be expressed as intense and overwhelming distress, which may not amenable to immediate intervention. Emergency responders therefore need to develop a stance of tolerance towards this emotional state in others, and themselves in the short term.
10.5 Emergency responders can set an example by conveying a sense of control, offer reassurance and pass on information in a correct and appropriate manner.
10.6 Information leaflets are a core element of support in the initial stage. These should emphasise the value to victims of their using their social and collegial support networks during the recovery phase.
10.7 Actual provision of support should reflect agreements reached between providers and those responsible for incident control.
10.8 The declared intention, of early intervention, is to be limited to effecting some improvement in the quality of the recovery environment and not necessarily to eliminate distress.
10.9 Follow-up and closure arrangements should also be agreed.
10.10 These Guidelines are offered on the understanding they will require review, development and updating as new evidence is published and new techniques develop for incident response.
10.11 Since it is only at the level of involvement of clinicians and that specific therapeutic techniques are currently being used these guidelines make recommendation only at the broadest level of generality. In time, these to may be revised towards more specific recommendation for all parties concerned.
REFERENCE
1. Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Charney, D.S. and Keane, T.M. (1997). Clinician-administered PTSD scale for DSM-IV. Current and lifetime diagnostic version. Boston: National Centre for Posttraumatic Stress Disorder.
