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Diese Leitlinien für psychosoziale Unterstützung wurden speziell im Hinblick auf die komplexen Herausforderungen von Krisenmanagern entwickelt. Die zugrunde liegende Forschung entstand im Rahmen eines, von der Europäischen Kommission geförderten, internationalen Projektes. Neben einem neuen Katastrophenphasen-Modell, gehört auch eine innovative, evidenzbasierte online Applikation zu den Hauptergebnissen dieser Forschung. Die Arbeit könnte daher nicht nur für Krisenmanager, sondern auch andere Führungskräfte, entsprechende Entscheidungsträger, Wissenschaftler oder Leitlinien-Entwickler von Interesse sein. This set of recommendations for psychosocial support was developed particularly for disaster managers with strategic responsibilities. The development process was part of an international research project, which had received funding from the European Commission. Besides producing a novel disaster phase model, the process yielded an innovative, evidence-based online application of strategic recommendations for psychosocial support. The findings and challenges may be of interest not only for disaster managers, but middle and higher management in general, policy makers, researchers and guideline developers.
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MARKOS MARAGKOS
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30. J
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Abstract
A set of recommendations for psychosocial support was developed particularly for disaster managers with strategic responsibilities. This development process was part of the research project PsyCris (PSYchosocial support in CRISis Management), which had received funding from the European Union’s Seventh Framework Programme for research, technological development and demonstration under grant agreement number 312395. The overall process was based on the methodology laid out in the Handbook for Supporting the Development of Health System Guidance (Bosch-Capblanch, 2011) and drew on evidence from 46 existing guidelines related to the topic, which were appraised using the AGREE II online tool. Additional supplementary data included colloquial evidence from European crisis managers and other stakeholder, which had been collected via qualitative methods such as incident templates, questions sheets and interviews, or observations of large-scale exercises. The data collection process was designed as a QUAL-qual mixed method paradigm and data was synthesized using a combination of the “best fit” framework synthesis, which includes the creation of an a priori framework against which data was coded, and the critical interpretative synthesis to enable flexible and dynamic analyses of different types of data.
The process generated recommendations that could broadly be categorised as: “psychosocial support provided by the disaster managers”, “psychosocial support provided for disaster managers” and “further considerations”. The process also generated eight novel descriptions of disaster phases. Upon the external review and acceptance by the Research Executive Agency of the European Commission, the guidelines were further developed into an online application. Experts on guideline development, and psychosocial support in disaster settings from the European Federation for Psychologists’ Associations’ (EFPA) Standing Committee on Disaster, Crisis and Trauma Psychology evaluated the online version by means of a Nominal Group Technique. The evaluated guidelines were then prepared to fit the requirements of the envisioned PsyCris training and networking platform.
Besides contributing to general research in guideline development, the process yielded an innovative, evidence-based online application of strategic recommendations for psychosocial support, alongside a novel disaster phase model. Findings and challenges are discussed in the context of this process and expected to be of interest not only for disaster managers, but policy makers, researchers and guideline developers.
Acknowledgements
I would like to thank my research supervisor PD Dr. Markos Maragkos, without whom this research would not have been possible. I would also like to thank Prof. Dr. Corinna Reck for assessing this dissertation as well as Prof. Dr. Johannes Moser for his support. I also thank Prof. Dr. Thomas Ehring, who encouraged me through his constructive feedback, and would have even trusted me to take over the project coordination when times got tough. Tremendous gratitude belongs to Prof. Dr. Vera Kempe, who initially had offered me a PhD position, and has remained a source of encouragement, and a friend ever since.
Special thanks also belongs to Prof. Dr. Lars Weisæth, Marc Stein, and Guy Weis for their advice during critical stages of the development process as well as Prof. Dr. Avi Kirschenbaum, Simon van Dam, and Dr. Pandelis Perakakis. I am also enormously grateful for the support of the following members of the European Federation for Psychologists‘ Assosiations (EFPA) Standing Committee for Crisis and Disaster Psychology, who thoroughly evaluated these recommendations in light of the current state-of-the-art: Lucia Formenti, Nathalie Garcia Manitz, Eva Håkanson, Eva Münker-Kramer, Dr. Julia Richter, Magda Rooze, Dr. Salli Saari, Márcio Simão Pereira, Dr. Dominique Szepielak, and Prof. Dr. William Yule as well as all other project partners, with whom I had the privilege of sharing the PsyCris experience. Another very special thanks belongs to the exceptional Attila Sirman.
Last, but certainly not least, I am of course also very grateful to my wife for her tireless support.
Table of Contents
Abstract
Acknowledgements
List of Figures
List of Tables
List of abbreviations
Introduction
1.1. Research context and theoretical background
1.1.1. The PsyCris project
1.1.2. Disaster description
1.1.3. Disaster phases
1.1.4. Psychosocial support description
1.1.5. Disaster management description
1.1.6. Guideline development for strategic psychosocial support
1.2. Theoretical implications
1.2.1. Terminology in the context of strategic recommendations for psychosocial support
1.2.2. Psychosocial support in the context of strategic recommendations
1.2.3. Guideline development in the context of strategic psychosocial support
1.2.4. Disaster phases in the context of strategic recommendations for psychosocial support
Methodology
2.1. Guidance Development Group
2.2. Framing the problem and scoping the guidance
2.3. Searching for evidence
2.3.1. The “best fit” framework synthesis
2.3.2.The critical interpretative synthesis
2.4. Building the
a priori
framework
2.4.1. Affected population description
2.4.2. Preliminary disaster phase model
2.5. Initial
a priori
framework
Process
3.1. Retrieving existing guidelines
3.1.1. Appraising existing guidelines
3.1.1.1. Appraisal results of existing guidelines
3.2. Collection of supplementary primary data
3.2.1. Qualitative Rapid Appraisal, Rigorous Approach
3.2.2. Equity considerations for supplementary primary research
3.2.3. Case specific data collection
3.2.4. Data collection across project partner countries
3.2.4.1. Question sheets
3.2.4.2. Country profiles
3.2.5. Disaster exercise observations
3.2.5.1. Observation of the “Puchberg” exercise in Austria
3.2.5.2. Observation of the “EU Modex” exercise in Luxembourg
3.2.5.3. Observation of the “Luxair” exercise in Luxembourg
3.2.6. Summary of collection of supplementary data
Analyses and results
4.1. Disaster phase model for psychosocial support
4.2. Evidence on psychosocial support
4.3. Updating the
a priori
framework
4.3.1. Disaster Resilience Manager description
4.4. Boundaries of psychosocial support
4.5. Write up of draft recommendations
4.5.1. Draft recommendations for strategic psychosocial support
Discussion of results
5.1. Discussion of the eight disaster phases
5.2. Discussion of the psychosocial support results and the Disaster Resilience Manager
5.3. Discussion of writing up the draft recommendations
Reviewing and finalising the strategic recommendation for psychosocial support
6.1. Internal review of draft
6.2. External review of draft
6.3. Finalising recommendations
Development of online version
7.1. Overview of the online application’s features
Evaluation with external stakeholders
8.1. The Nominal Group Technique
8.2. Results of the Nominal Group Technique
8.3. Discussion of the Nominal Group Technique evaluation
Preparation for project use
9.1. Structure to present recommendations via PPP Platform
Monitoring and updating guidelines
10.1. Framework to monitor recommendations
10.2. Framework to update recommendations
Limitations and future research
11.1. Limitations of the rationale
11.2. Limitations of the implementation or adherence
11.3. Limitations of the use of existing guidelines
11.4. Limitations of the use of supplementary data
11.5. Limitations of evidence on interventions and implementation issues
11.6. Limitations of the syntheses of findings
11.7. Limitations of the review procedure
11.8. More general limitations
Final remarks
References
Appendices
List of Figures
Figure 1.PsyCris work package structure (DoW, 2013).
Figure 2.Schematic outline of methodology used to develop this set of recommendations
Figure 3.Schematic overview of potentially affected population
Figure 4.Depiction of the initial a priori framework used for the “best fit” framework synthesis
Figure 5.Flowchart of searches for and retrieval of existing guideline material
Figure 6.Overall assessment scores for each of the 46 documents appraised with AGREE II
Figure 7.Appraisal scores for scope and purpose, stakeholder involvement, and clarity of presentation for each of the 46 documents appraised with AGREE II
Figure 8.Appraisal score for rigour and development for each of the 46 documents appraised with AGREE II
Figure 9.Appraisal score for applicability for each of the 46 documents appraised with AGREE II
Figure 10.Appraisal score for editorial independence for each of the 46 documents appraised with AGREE II
Figure 11.Data extraction concerning civil protection and disaster management according to phase descriptions based on findings from appraised guidelines (visualisation adapted from Cuny, 1986)
Figure 12.Depiction of the updated a priori framework
Figure 13.Screenshot of online application home page of strategic recommendations
Figure 14.Screenshot of online application of strategic recommendations with expanded phase.
Figure 15.Median ranks in reference to total number of received ranks per note of final top ten notes
Figure 16.Median ranks in reference to total number of received ranks per note of order 11-30.
Figure 17.Mock-up of landing page for PPP Platform integration of guidelines
Figure 18.Mock-up of entry level for PPP Platform integration of guidelines
Figure 19.Mock-up of advanced level for PPP Platform integration of guidelines
Figure 20.Mock-up of expert level for PPP Platform integration of guidelines
List of Tables
Table 1PsyCris project consortium
Table 2Input, process and output components of strategic recommendations for psychosocial support
Table 3Framing the problem in reference to the scope of guidance and methodological implications
Table 4Preliminary disaster phase model for psychosocial support showing the development from four to eight phases
Table 5Generic search strategy for recommendations on psychosocial support in a disaster context including disaster management aspects
Table 6Key terms for full text eligibility assessment
Table 7Domains and items of the AGREE II instrument with comments for possible adaptations
Table 8Overview of sources used for the four incident templates according to disaster scenario and project partner
Table 9Overview of sources used for the six question sheets according to project partner and country
Table 10Descriptive properties of eight disaster phases for strategic psychosocial support
Table 11Themes used to extract evidence for psychosocial support from a strategic perspective
Table 12Types of evidence and their inclusion in the recommendation write up
Table 13Set of draft recommendations for strategic psychosocial support
Table 14Summary of internal review in relation to inclusion process
Table 15Summary of external review in relation to inclusion process
Table 16Revised stages of the salutogenic notion in light of the strategic recommendations for psychosocial support
Table 17List of themes (families) based on groups of items
Table 18Types of items and corresponding symbols
Table 19Overview of top ten notes including descriptions, and summaries of further process
Table 20Example of attributes of applicability and transferability for strategic psychosocial support recommendations by measures of uptake (blank version)
List of abbreviations
AGREE II
Appraisal of Guidelines for Research and Evaluation (Online Guideline Appraisal Tool)
APA
American Psychiatric Association
ASD
Acute Stress Disorder
BayFOR
Bayerische Forschungsallianz GmbH (Bavarian Research Alliance), Germany
BBK
Bundesamt für Bevölkerungsschutz und Katastrophenhilfe (German Federal Office of Civil Protection and Disaster Assistance)
BFFS
Best Fit Framework Synthesis
BSO
Blended Solutions GmbH, Germany
CBT
Cognitive Behavioural Therapy
CHC
Amuta LeYeladim beSikun - Cohen-Harris Resilience Center for Trauma and Disaster Intervention, Israel
CIS
Critical Interpretative Synthesis
CISD
Critical Incident Stress Debriefing
CISM
Critical Incident Stress Management
CPG
Clinical Practice Guideline
COPAO
Colegio Oficial de Psicólogos de Andalucía Oriental (Official College of Psychology of Eastern Andalusia), Spain
DG ECHO
European Commission’s Director General for Humanitarian Aid and Civil Protection
DSM-5/DSM-V
Diagnostic and Statistical Manual of Mental Disorders, 5th edition
DoW
Description of Work (research project proposal/contract)
EFPA
European Federation for Psychologists’ Associations
EMDR
Eye Movement Desensitization and Reprocessing
EUNAD
European Network for Psychosocial Crisis Management – Assisting Disabled in Case of Disaster (research project)
FP7
European Union’s Seventh Framework Programme for research, technological development and demonstration
GP
General Practitioner (medical doctor)
GSG
Guidance Steering Group
GSP
Groupe de Support Psychologique (Psychological Support Group), Luxembourg
HSG
Health System Guidance
IASC
Inter-Agency Standing Committee
IFRC
International Federation of the Red Cross and Red Crescent
ISI
Insight Instruments, Austria
KKP
Kitokie projektai, Lithuania
LMU
Ludwig-Maximilians-Universität München (University of Munich), Germany
NGT
Nominal Group Technique
NICE
National Institute for Clinical Excellence
OPSIC
Operationalising Psychosocial Support in Crisis (research project)
PFA
Psychological First Aid
PPP
Preparedness-Planning-Prevention (PsyCris online platform)
PSS
Psychosocial support
PsyCris
PSYcho-Social Support in CRISis Management (research project)
PTSD
Post Traumatic Stress Disorder
Q-RARA
Qualitative Rapid Appraisal, Rigorous Approach
QUAL-qual
Mixed method paradigm combining different qualitative methods
REA
Research Executive Agency of the European Commission
SNRI
Serotonin Noradrenalin Reuptake Inhibitors
SSRI
Selective Serotonin Reuptake Inhibitors
UGR
Universidad de Granada (University of Granada), Spain
UMIT
Private Universität für Gesundheitswissenschaften, Medizinische
Informatik und Technik (The Health and Life Sciences University Hall/Tyrol), Austria
UNHCR
United Nations High Commissioner for Refugees
WHO
World Health Organization
WP
Work package
1. Introduction
In light of the tragic consequences of any type of disaster, it is not surprising to find an abundance of recommendations, guidelines or instructions on how to prevent, prepare or respond to such events. Among this body of literature, one will find various specifications depending on such parameters as: purpose, target audience or author/commissioning body of the respective document. One group among these documents may be categorised as “psychosocial support” or “mental health” guidance documents that focus on such aspects within the context of disaster preparation, response or recovery. While each of these pieces of literature is valuable in its own right by contributing to the safety and well-being of those involved, it appears only few such documents exist that specifically target disaster managers, and more precisely that provide guidance concerning psychosocial support in disaster management (see Te Brake & Dückers, 2013).
In 2011 however, under the Seventh Framework Programme for research, technological development and demonstration (FP7), the European Union had issued the call SEC-2012.4.1-2 (European Commission, 2011), which had asked for proposals to address aspects of psychosocial support for those in charge, namely the crisis management. The “PsyCris” (PSYchosocial support in CRISis management) consortium’s proposal had been accepted in response to this call and - among other objectives - set out to contribute to this body of literature by developing a set of recommendations for psychosocial support regarding the responsibilities of disaster managers. This dissertation describes the scientific development of this particular set of recommendations.
1.1. Research context and theoretical background
In order to better understand how this process came to be and was operationalized, a few underlying concepts and definitions will be presented in the following paragraphs. A European perspective will be taken whenever possible and appropriate, due to the European Union’s foci inherent in most FP7 funding programmes. Since the primary rationale for the development of these guidelines is rooted in the abovementioned call (SEC-2012.4.1-2), these theoretical concepts will only be briefly discussed. While these, or certain inherent aspects certainly provide grounds for further discussion, such explorations have been undertaken elsewhere (e.g., Alexander, 2002; Boin & Bynander, 2015; Bosch-Capblanch, Liaqat, & Garner, 2011; Dombrowsky, 1995; Dückers, 2013; Jones, Greenberg, & Wessely, 2007; Shultz & Forbes, 2014; Weiss, Saraceno, Saxena, & van Ommeren, 2003) and would exceed the scope of this document. It is however recognised that the concepts and definitions presented here neither are conclusive, complete nor claim to be beyond debate. Instead, they may be regarded as a necessary framework of concepts or assumptions, and to a certain extent even a preceding rationale, from which further insights could be induced (cf., Hume, 1779).
1.1.1 The PsyCris project
PsyCris, which stands for “Psychosocial support in crisis management”, was the name of a research and development project that received funding under the European Union’s Seventh Framework Programme (FP7) under Grant Agreement Number 312395. The envisioned runtime of the project was 36 months (starting July 2013). The project consortium was made up of ten partners shown in Table 1 under the coordination of Ludwigs-Maximilians-Universität München. The partners represented five European member states and Israel, which is considered a fully associated partner country under FP7.
Table 1 PsyCris project consortium
The basis of the work proposed by any FP7 research project is documented in the so-called Description of Work (DoW). Aside from the underlying rationale and administrative matters, the DoW outlines the thematic and operational structure of the project in work packages (WP) as well as the objectives of each work package, which are further broken down into tasks. Figure 1 depicts the proposed nine work packages of PsyCris and their names and structure as shown in the DoW (DoW, 2013).
Figure 1. PsyCris work package structure (DoW, 2013).
The overall objectives of PsyCris aimed to improve psychosocial support in crisis management by developing “various components (e.g., stress assessment, stress management, contingency planning, help the people help themselves) [that] will be integrated in an overall PsyCris Tool Kit Demonstrator, which will be based on a comprehensive knowledge system (Preparedness-Planning-Prevention [PPP] Platform)” (DoW, 2013). As shown in Figure 1, this PPP Platform (i.e., WP7) may be perceived as the main exploitable output produced by the project, since it takes up elements (called “tools”) of the other work packages so as to arrive at a final product (Adler, Sauter, Meyer, Hagl, & Raich, 2015).
The work described in this dissertation fell under work package 2 (WP2). However, it only constituted part of the general WP2 objectives, which had been proposed as follows: “[…] an optimisation of psychosocial and medical intervention for disaster victims, intervention forces and the larger community during and after crisis situations. Most effective intervention tools and their availability in EU countries are identified for immediate (e.g., Acute Stress Disorder, [ASD]) and long-term (e.g., Post-Traumatic Stress Disorder, [PTSD]) consequences of crises. Applied analysis methods include e.g., qualitative interviews with experts, meta-analyses of empirical intervention studies1, and analyses of evaluation reports of psycho-medical care following mass emergencies. The impacts of cultural differences and gender on treatment efficacy are also regarded.” (DoW, 2013). The development of guidelines has been further outlined in task 2.3 (T2.3) by emphasizing the “identification of efficient interventions for immediate/ post-immediate and long-term treatment” and in task 2.4 (T2.4) by placing a focus on “best practice models” and “minimal standards for working cross-border” (DoW, 2013). In addition, crisis managers have been proposed as the main target audience in line with the general project objectives2. Ethical approval had been obtained from the Ethics Commission of the Department of Psychology and Educational Sciences at Ludwigs-Maximilians-Universität München for the entire project, based on the DoW, prior to its commencement. Thus, no separate ethical approval had to be obtained for this dissertation.
In the following, a few underlying concepts, working definitions and descriptions will be presented, of which most had already formed parts of the theory and rationale presented in the proposal and subsequent DoW. Apart from minor modifications necessary to fit the format of this dissertation, these concepts were developed by, or at least in agreement with, the project consortium. They will be referred to throughout sections of this dissertation, since they form the general theoretical background or research context.
1.1.2 Disaster description
Already in 1986, Korver had found more than 40 scientific definitions of what may constitute a “disaster” (Korver, 1986; see Weisæth, 1995). Such incidents, which may generally be referred to as a “disaster” or “crisis”, have also been described as “major incidents” and sometimes “mass casualty incidents” or “mass emergencies”and it seems that no international consensus on a definition or even terminology could be found to date (Mayner & Arbon, 2015). Nevertheless, these events are usually distinguishing between either natural disasters (earthquakes, floods, etc.) or human-made disasters (technical accidents, terror attacks, etc.) (Sementelli, 2007).
The PsyCris consortium did not venture to agree on a working definition of “disaster”, possibly because of the many attempts that already exist. Instead, drawing on Wulf, Brands, and Meissner (2010), who investigated how a scenario-based approach can be used to facilitate strategic planning, the consortium had agreed on the identification of three crisis scenarios (see WP1) that would exemplify realistic disaster situations across Europe. These scenarios were:
The airplane crash in Luxembourg on 6th November 2002
The terror attacks in Madrid (a.k.a. 11-M) on 11th March 2004
The floods in Europe (mainly along the Elbe and Danube rivers) in the summer of 2013
Similar to the case examples presented in the European Policy Paper (Seynaeve, 2001), these scenarios were used to describe what sort of catastrophic events PsyCris is referring to as well as provide a contextual framework to which different parts of the project could draw reference to in their research to various degrees.
For the purpose of developing a set of recommendations however, a more generic description was needed that could serve as a methodological benchmark. The following aspects based on the World Health Organisation’s ([WHO], 1992) definition and description of a disaster have been considered helpful in describing such events and will serve as a definition used for the development of the recommendations, while trying to capture the highly circumstantial features by which universal definitions have been challenged:
Significance/Impact of the incident
Disasters usually have a high significance/impact in terms of damage and number of affected people. However, the significance/impact of an incident varies according to its nature and circumstances (e.g., terror attack vs. earthquake), thus rendering the respective features to be relative in comparison. Variables such as individual/collective capacities to adapt, and available help may moderate the impact of such events (see Abdallah & Burnham, 2000; Quarantelli, 1980).
Character/dimension of the incident3
Disasters are usually outweighing available resources and exceed the capacities (social mechanisms, financial, human resources, etc.) of the affected communities (e.g., Quarantelli, 1980). In addition, such events are often highly unforeseeable, uncontrollable and unpredictable. However, the responses (from preparation to longer-term efforts and consequential improvements) usually differ significantly between events with a sudden/rapid onset (e.g., terror attack) or a slower onset (e.g., flood) (see Barton, 1970).
Extent of (potential) damage
Generally, larger extents of structural damage (e. g., material, financial, geographical, etc.) are helpful indicators to describe such incidents (Sundnes, 2014d). However, structural damage may also severely compromise societal functions, which may exceed the structural damage (Sundnes, 2014e). Quantitative as well as qualitative parameters need to be considered when assessing the magnitude of the damage and the significance of the event (see Quarantelli & Dynes, 1977). Geographic settings also need to be considered (e.g., central disasters, like floods where an entire community is affected vs. peripheral disasters like an aircraft accident in an unpopulated area, where individual survivors return to respective geographic homes) (Green, 1982).
Number of affected people
Higher numbers of affected people (both directly and indirectly) usually mean more damage. However, the significance of the incident serves as an important indicator when determining quantities (e.g., four casualties in a train accident vs. four casualties in a terror attack). Disruption (sudden-/ or slow-onset) of social structures may also have significant effects on the population (see Davis, 2013; Quarantelli, 1980).
In summary, a disaster may be described as a severe disruption of societal functions and structures that exceeds the readily available resources of the affected community. Concerning psychosocial support, it needs to be noted that individuals or groups may be affected to different degrees, at different times and rates. Thus, their needs as well as the corresponding response and recovery measures may also differ significantly from each other (e.g., Bolin, 1985; Reifels et al., 2013; WHO, 1992).
1.1.3 Disaster phases
The idea of disaster phases has been utilised by researchers and practitioners alike, regardless of the challenges to theoretically define disaster (Neal, 1997; Quarantelli, 1994). Disaster research has employed phases to describe, categorise, classify, code or organise data, findings and recommendations about the studied events (e.g., Dynes, 1976; Mileti, Drabek, & Haas, 1975), whereas practitioners, such as crisis managers, have relied upon disaster phases to better plan, prepare and respond (Neal, 1997; see WHO, 1992).
Over 80 years ago, Carr (1932) was among the first to formerly describe four distinctive phases (or sequence-pattern, as he also called them) associated with a disaster, while focusing on aspects of social change. His descriptions essentially covered the time from before the actual onset of the event (i.e., preparedness) to regaining similar levels of control as were before the disaster struck (i. e., recovery). Carr’s effort of breaking down the concept of disaster into selectively observable units for research purposes alongside his working hypothesis of interconnected phases, has since been taken up by a large number of successors in the field. Depending on the research and/or application focus, several such models have since been developed, ranging from the often quoted four disaster phases (i.e., mitigation, preparedness, response, and recovery) (National Governors’ Association, 1979), over models of five phases (Barton, 1970), to models of six phases (Mileti, Drabek, & Haas, 1975; Sundnes, 2014a), seven phases (Stoddard, 1968 as cited in Neal, 1997), or eight phases (e.g., Dynes, 1976). All of these models try to cover all phases of a disaster, meaning from some the time before the actual onset to returning to a normative level of pre-event functioning.
Some authors have tried to categorise their phases temporally (e.g., Dynes, 1976; Pan American Health Organization, and WHO, 1982); however this notion has been criticised due to the idiosyncratic nature of disasters (q.v. Disaster description) and the varying subjective perception of different groups of affected people (i.e., who defines before, while, or after a disaster strikes?) (see Carr, 1932; Neal, 1997). Others have described their phases functionally (e.g., Sundnes, 2014a), while some have proposed to combine both temporal and functional parameters (e. g., Barton, 1970). With its focus on psychosocial support, the European Policy Paper proposes a functional model based on needs of the affected population, which only differentiates between three phases: acute phase, transition phase, and long-term phase (q.v. Psychosocial support description). Although being one of the very few models used in the context of psychosocial support, it merely illustrates a decrease in the extent of (collective) psychosocial needs (see Seynaeve, 2001). Regardless of the approach, already Haas, Kates, and Bowden (1977) noted how various variables (e.g., temporal, political, social, economical, or structural) (cf., Quarantelli, 1980) may make any distinctions between phases rather arbitrary, and at best can only roughly differentiate functional activities.
There seems to be relative agreement on the interconnectedness as well as overlap of disaster phases however, in that most scholars and crisis managers agree (already since Carr proposed this notion in 1932; see Neal, 1997) that no single phase or action associated with it, can be viewed in exclusion of the rest, leading to what Sundnes (2014a) calls “longitudinal phases of a disaster”. This model assumes an almost complete overlap of its six phases ([1]pre-event; [2]event; [3]damage; [4]changes in function(s); [5]relief; and [6]recovery), which consequently disregards the respective possible duration of each phase. The exceptions being the onset of the actual event, which in turn defines the “pre-event” phase, and to an extent the “recovery” phase, which presumes damage. Despite this potentially large overlap, the model is based on consistent properties of each phase, meaning that the respective activities need to be assigned to the phase not vice versa. Such matching of actions and phase however, presupposes an analysis of the aim of the response (i. e., is the activity considered relief, recovery, or development?) (Sundnes, 2014a). This approach also takes up feedback from practitioners (e.g., as already reported by the National Governors’ Association, 1979), which has led to the widely accepted perception that any model of disaster phases could be described as cyclical (i.e., after the disaster is before the [next] disaster) (see Cuny, 1986), yet not linear due to the overlap of phases.
1.1.4 Psychosocial support description
Similar to the vast literature of guidelines for disaster settings, the description of what may be considered psychosocial support in this context also seems to depend on parameters such as: purpose (e.g., Young, 2006), target audience (e.g., Bering, Schedlich, Zurek, & Fischer, 2006), or the respective disaster phase (e.g., Rooze et al., 2008). Overall, psychosocial support is understood to include the short-, mid- and long-term provision of all offered strategies and intervention methods that are geared to maintain or reach a normative level of pre-event functioning of the affected population (e.g., Sundnes, 2014a). Analogous to the terminology of short-, mid- and long-term support, is the abovementioned model of acute, transitional and long-term phases. Adapted from Seynaeve (2001), these three stages are summarised below:
Psychosocial support during the acute phase
During the acute phase of a disaster, a focus is placed on triage, medical care as well as the re-establishment of security measures. Regarding psychosocial support, special trauma interventions are neither feasible nor effective (see American Psychiatric Association [APA], 2013). Instead, efforts are being directed to meet fundamental needs of the affected population (e. g., food, rest, security, hygiene, information, orientation, and other pragmatic help) (see Bevan, P., Williams, R., Kemp, V., Alexander, D., Hacker Hughes, J. &. Rooze, M., 2008); provide emotional support (e. g., normalisation, activation of self-help resources, psychological first aid [PFA]) (see Hobfoll et al., 2007; Vernberg et al., 2008) as well as screen for the potential need of acute medical and/or psychological assistance via an event-related response structure. According to Flannery and Everly (2000), such forms of psychological crisis intervention try to achieve the main goal of stabilization, mitigation of acute signs and symptoms of distress, the restoration of adaptive independent functioning as well as the facilitation of access to a higher level of care (if indicated and possible). Psychosocial support providers need to be able to flexibly respond to these requirements.
Psychosocial support during transition phase
During the transition phase more emphasis is placed on secondary prevention with the aim to reduce the risk of developing mental disorders. For that purpose, organisational preparations are also made in order to transition to long-term support, since such interventions can usually not be provided solely through event-related structures. Thus, psychosocial support during this phase builds on ongoing screening to also provide access to acute medical care in close cooperation with emergency medical units (i.e., hospitalization or access to rescue medication). Additional efforts include continued normalization of stress reactions, provision of adequate information (usually via several routes: e.g., telephone hotline, official website, information events), psychosocial counselling (e. g., active listening, identification of individual resources, and fostering of self-efficacy), mourning and bereavement rituals, or the encouragement of social support (e. g., contact with family and friends, groups and events for affected people) (cf., Brymer et al., 2006; Juen, Siller, & Gstrein, 2011; Ruzek et al., 2007). Further provisions include setting up a coordination centre as a point of contact for affected people, which offer “low-threshold” support, meaning that there are as few obstacles as possible for the affected population to make use of the respective offers.
Psychosocial support during long-term phase
During the long-term phase psychosocial support aims more and more at providing access to measures of tertiary prevention, while still providing assistance with practical matters. While systematic diagnostic screening is still recommended since mental health consequences may develop over time, tertiary prevention efforts cannot be provided via event-related structures or coordination centres. Hence, establishing secondary healthcare networks (incl. briefing of general practitioners, [GPs]) becomes an essential part of psychosocial support and has ideally commenced already during the previous phases. Current, evidence-based interventions or therapeutic methods include approaches based on cognitive behavioural therapy (CBT), such as exposure focused therapy (see Foa, Hembree, & Rothbaum, 2007), or Eye-Movement Desensitization and Reprocessing (EMDR) (see Shapiro & Laliotis, 2015). In addition, Selective Serotonin Reuptake Inhibitors (SSRI) and related agents such as Serotonin Noradrenalin Reuptake Inhibitors (SNRI) have been suggested as a treatment of PTSD-related symptoms, in case trauma-focused psychological interventions are not an option or do not suffice, e.g., in patients with severe comorbid depression (Friedman & Davidson, 2014), or even as a possible option for combined long-term treatment together with trauma-focused psychotherapy (Baldwin et al., 2014). It needs to be noted that such medical or therapeutic interventions are not considered psychosocial support anymore.
The PsyCris consortium had agreed on a working definition of “psychosocial support” during the Kick-off meeting of the project. This definition was also based on the European Policy Paper (Seynaeve, 2001) and took up a number of its concepts, which in turn had already been introduced to the project during the proposal stage and can thus also be found in the DoW. Among these concepts are: a salutogenic notion4, the aim to foster resilience, and the provision of psychosocial support to directly and (potentially) indirectly affected people (DoW, 2013). This working definition has been further elaborated to fit the format of this dissertation and will be the definition used for the development of the recommendations:
Psychosocial support
In the context of disasters, psychosocial support (PSS) includes the short-, mid- and long-term provision of primary, secondary and tertiary prevention (cf., Gordon, 1987; see Rooze et al., 2008). Among the general objectives are early recognition of stress-related consequences after major incidents (e.g., Norris, 1990, 1992; Ruggiero, Rheingold, Resnick, Kilpatrick, & Galea, 2006) as well as the provision of adequate, needs-based support (i.e., psychological, social, structural, etc.) (for a detailed description of such needs across phases see Seynaeve, 2001; or Sundnes, 2014b) for individuals and groups of directly or indirectly affected people as well as rescue/emergency personnel and the crisis management (e.g., psychological first aid, processing of experiences, peer support, appropriate help to access treatment for trauma- and stress-related disorders) (e.g., Bevan et al., 2008; Creamer et al., 2012; Hobfoll et al., 2007; O’Sullivan, Kuziemsky, Toal-Sullivan, & Corneil, 2013; Vernberg et al., 2008). Hence knowledge of regional and/or national structures (formal and informal) and close collaboration with existing regional networks is considered advantageous (e.g., Marinker, 2006). Within its limitations (e.g., medical and therapeutic interventions), psychosocial support comprises the preparation, provision, implementation, and coordination of all offered strategies and intervention methods that are geared to maintain or reach a normative level of pre-event functioning (e.g., Sundnes, 2014a) and aim to promote public health and foster resilience/collective-efficacy (e.g., Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008; Pfefferbaum, Reissman, Pfefferbaum, Klomp, & Gurwitch, 2007). This is done in close cooperation with respective psychosocial operatives, medical units and existing community structures as well as by forming secondary and tertiary (health-)care networks (e.g., WHO, 2013; Williams et al., 2009). In that regard, psychosocial support is not considered a consequence of a demand, but a task automatically generated by the disaster itself. That is to say, at least in the sense of screening the potential need for such support. Sufficient and adequate psychosocial support can significantly contribute to: damage limitation (e.g., Doll, Bonzo, Mercy, & Sleet, 2007), (re-)establishing order and a sense of safety (e.g., Hobfoll et al., 2007), fostering resilience and self-efficient functioning of individuals and communities (e.g., Boin & McConnell, 2007) as well as the prevention of often costly longer-term effects on health and the affected communities (e.g., Eyre, 2010). Thus, psychosocial support is usually needed to different degrees throughout all phases associated with a disaster (e.g., Seynaeve, 2001).
1.1.5 Disaster management description
In order to better understand, who the target audience of the developed set of recommendations is supposed to be, and how the PsyCris consortium viewed disaster management, the terms strategic and tactical are briefly explained according to Sundnes (2014c):
Strategic and tactical planning5
For the purpose of this set of recommendations, the term strategic will refer to measures that consider the broader concepts rather than the specific steps, thus forming the top decision-making level of crisis management. Hence, strategic planning would refer to the overarching aims of disaster management and describes broad, general and sometimes abstract (non-specific) aspects of what needs to be achieved. The term tactical will refer to the operationalisation of strategic planning and usually includes the definition of concrete objectives. Strategic and tactical planning requires close cooperation and information exchange. The lowest level of decision-making in disaster management will be referred to as operational and includes less planning and focuses on the execution of strategic and tactical plans and the achievement of the respective objectives.
In an organisational context, DuBrin (2013) described crisis leadership as the act of leading people through an event that is characterised by its abrupt and often unpredictable nature, with adverse and emotionally exhausting circumstances. In light of disasters, such processes would generally include strategic responsibilities for risk, information and need assessments, management of disaster preparedness and response plans, activation and coordination of involved response agencies, and provision and coordination of support strategies for the affected population (incl. psychosocial support) (see Hadley et al., 2011).
Together with the working definition on psychosocial support, the PsyCris consortium had also agreed on a description of “disaster managers”6 as well as “disaster managers psychosocial prevention and aftercare”. Both descriptions follow those presented in the European Policy Paper (Seynaeve, 2001) and by the German Federal Office of Civil Protection and Disaster Assistance (Bundesamt für Bevölkerungsschutz und Katastrophenhilfe [BBK], 2012), while already considering psychosocial aspects. These descriptions have slightly been rewritten to fit the format of this dissertation and will serve as definitions used for the development of the set of recommendations:
Disaster managers (strategic/tactical)
The main task of disaster managers [in Seynaeve (2001) this role is called: “management” or “group leaders”] is the strategic coordination of missions and actions following a major incident (i. e., civil protection or emergency preparedness,
