The Effectiveness of Early Crisis Intervention Model with Families in Alleviating the Psychological Symptoms after Experiencing Traumatic Event Dr. Mahmud Said
The Effectiveness of Early Crisis Intervention Model with
Families in Alleviating the Psychological Symptoms after Experiencing Traumatic
Event
Dr. Mahmud
Said
Affiliation:
Ph.D. of Social and Clinical Psychology,
Senior Educational Psychology, Specialist in Clinical Psychology, Trainer in
Traumatic Incident Reduction. Algaleel center
for Psychological services in Nazareth.
E-mail: [email protected]
Abstract
This study assessed the effectiveness of early intervention model
on preventing the development of psychological symptoms among family members
experienced a traumatic event. The study included four family members after
loss of five children from the family resulted from missile attack during the
Israeli escalation during May 2022. The researcher used in vivo early exposure-focused intervention
approach within the first week of the trauma event. Severity of symptoms were
measured by using Early Intervention Model and PTSD Symptom Scale – Interview
(PSS-I). Assessment of clients was conducted on four phases (before
intervention, immediately after intervention, at one month after intervention,
and at three months after intervention). The results showed significant
reduction in PSS-I score at one month (P, 0.002) and at three months (P, 0.010)
compared to pre-intervention scores, which
indicated significant reduction in psychological symptoms. The study concluded
that in vivo early
exposure-focused intervention model was effective in reducing the psychological
symptoms among family members who witnessed or experienced a traumatizing
event.
Keywords: Traumatic event, Cognitive Behavior Therapy, Early intervention, Gaza Strip.
Introduction
Exposure to traumatic events and the impacts on health and
well-being can vary greatly depending on socio-economic, environmental,
cultural, and historical factors (Do et al., 2019). Most people who
have a traumatic event will have reactions that may include shock, anger,
nervousness, fear, and even guilt. These reactions are common, and for most
people, they go away over time. For a person with PTSD, however, these feelings
continue and even increase, becoming so strong that they keep the person from
going about their life as expected. People with PTSD have symptoms for longer
than one month and can’t function as well as before the event that triggered it
happened (Bhandari, 2022). PTSD is
characterized by profound psychological distress, intrusive symptoms of
re-experiencing of the trauma, including thoughts, flashbacks, or nightmares,
avoidance of trauma reminders, negative alterations in cognition and mood, and
hyperarousal or elevated trauma-related reactivity (American Psychiatric
Association - APA, 2013).
The effects of wars on mental health, physical health, economic security, and political stability are long-lasting. A systematic review on long-settled refugees estimated the prevalence of any psychiatric morbidity to be about 20% in a population that has resettled for at least 5 years, and acknowledges risk factors predicting higher rates of psychiatric symptoms such as post-traumatic stress and the adverse socio-economic situation (Bogic et al., 2015). Studies report that the psychological impact of war trauma may affect the whole family, even when only one member has been directly exposed to stressful events (Kiser & Black, 2005). Furthermore, immediate and long-term responses to trauma can either reinforce or mitigate the dysfunctional reactions of one or more members of a family affected by trauma. Strategies of prevention and care for war-affected populations should, therefore, take into account the socio-ecological dimensions of suffering, and specifically target family transactions and processes. In line with strong empirical evidence on the impact of trauma at the family level (Zerach et al., 2013).
Cognitive Behavioral (CBT) intervention in war-affected
individuals
Cognitive Behavior Therapy (CBT) is
evidence-based psychotherapy, used in the prevention and treatment of
psychological as well as physical issues (Schure et al., 2019). CBT includes methods that aim to help a person to identify
his stress levels and modify his beliefs and behaviors and such methods include
cognitive restructuring, behavioral changes, and social support. It helps a
person to eliminate or reduce psychological distress symptoms and helps the
individual to return to normal day-to-day life. Many studies had found that
after receiving cognitive behavior therapy, there is a significant drop in
anxiety, improvement in somatic symptoms and psychological stress, and an
increase in quality of life (Hartley et al., 2016). CBT is the most economical and effective psychotherapy in
reducing and relieving psychological distress (Tang & Kreindler, 2017). Several studies
indicated that CBT was effective in reducing psychological symptoms, reduction
in nightmares, and reduction in post-traumatic stress symptoms (Germain et al.,
2012; Rhudy et al., 2010; Talbot et al., 2014; Walters et al., 2020).
The early psychological
interventions after traumatic events were documented during World War I
(Greenberg et al., 1999), and eventually described as brief crisis
interventions performed within days of the trauma. Increasing efforts have been
made to develop psychological and pharmacological interventions that can
prevent the onset of disorders or alleviate early symptoms (Kearns et al.,
2012; McNally et al., 2033). For a time, psychological debriefing was a widely
used form of early intervention. However, it use has been rejected as evidence
has emerged questioning its effectiveness (Bastos et al., 2015; Rose et al.,
2022). In the last 20 years, a number of other approaches have emerged, mainly
based on established CBT (Kearns et al., 2012).
In this study, a unique model of in vivo early
exposure-focused intervention approach with all the family members have been
used. The model was developed by the
researcher. The researcher intended to examine the effectiveness of this model
as an approach to be used with all the family members who experienced a
traumatizing event, in preventing the development of psychological symptoms as
a result of the event.
Goal of the study
The study aimed to examine the effects of early intervention model
on preventing the development of PTSD among family members experienced a
traumatized event.
Methodology
This study is a case study, in which the
researcher used intervention model at early stage within the first week after
exposure to a traumatic event. The family (Nijm family) lives in northern area
of Gaza Strip. During the Israeli military escalation on 5th of
August 2022, five children were killed while they were playing in front of
their house as a result of Israeli missile attack. The researcher implemented
the intervention with assistance from local specialized volunteers. The
intervention was implemented on 4 family members who witnessed the event on the
fourth day after the traumatic event.
Instruments of the study
The researcher used two instruments: Early Intervention Model and PTSD Symptom Scale – Interview (PSS-I).
1.
Early Intervention Model:
The early intervention model is a
psychological interventional model with all the family members who experienced
a painful traumatic event that could impose negative effects on many aspects of
life. The model was developed by the researcher (Dr. Mahmud Said). The intervention
model aims to avoid the development of psychological symptoms and disturbances after
witnessing or experiencing a traumatic event. The model focuses on direct
exposure of the intended family members. The model was first developed in 2002
after attacking Jenin camp, then the model was further modified and implemented
during the Israel Lebanon war in 2006. The implementation of the model pass in
4 stages:
First stage: The stage
of acceptance; including meeting the family members to obtain their agreement and
willingness to actively participate in the intervention. During the meeting,
the researcher explained the intervention phases to the
family members, the researcher enquired about the changes that had occurred in
the family as a result of the event, including the day-to-day customs and
interaction of the family members before and after the event. The symptoms of
each individual participant were then recorded via a clinical-diagnostic
interview.
Second stage:
Psychological preparedness; including psychological education preparing the
family members psychologically to participate in the intervention.
Third stage: Exposure
stage; including intervention at the site where the traumatic event occurred.
Fourth stage: Closing stage; including summarizing, feedback, advising, expectations, and ending the intervention sessions.
2.
PTSD Symptom Scale – Interview (PSS-I)
To evaluate the effectiveness of the
intervention model, the researcher used the PSSI-17 to assess the presence of psychological
symptoms. The PSSI-17 consists of 17 items focusing on presence of symptoms
that may occur after the experience of a traumatic event. The total scores of
the scale ranging between (0 – 51). Scoring of the scale as the following:
|
Score |
Interpretation |
|
0 |
Never, or happened one time only. |
|
1 |
One time in the week. |
|
2 |
2 – 4 times in the week. |
|
3 |
5 times or more in the week, or all the time. |
Evaluation of psychological symptoms:
Based on assessment scores of the client,
the evaluation of PTSD symptoms will be as the following:
|
Total score of PSSI |
Severity of symptoms |
|
10 |
No disturbance |
|
15 |
Mild disturbance |
|
20 |
Moderate disturbance |
|
25 |
Above moderate disturbance |
|
30 |
High disturbance |
|
35 |
Severe disturbance |
|
40 - 51 |
Extreme disturbance |
Results
The researcher used the PSSI-17 to assess
the psychological symptoms at four phases:
Phase 1: Before intervention.
Phase 2: Within one week after intervention.
Phase 3: At one month after intervention.
Phase 4: At three months after
intervention.
Table (1): Scoring of PSSI (case No. 1)
|
No. |
Item |
Phase 1 |
Phase 2 |
Phase 3 |
Phase 4 |
|
1 |
Have memories and views from the traumatic event are
coming intrusively? |
3 |
1 |
2 |
1 |
|
2 |
Have
you been having bad dreams or nightmares related to the trauma? |
2 |
1 |
0 |
0 |
|
3 |
Have
you had the experience of feeling as if the trauma were actually happening
again? |
3 |
1 |
0 |
0 |
|
4 |
Have
you been very emotionally upset when reminded of the trauma (awesome, anger, sadness, guilty feeling)? |
3 |
1 |
1 |
1 |
|
5 |
Have
you had physical reactions when reminded of the trauma (e.g., sweating, heart
racing)? |
3 |
1 |
0 |
0 |
|
6 |
Have
you been making efforts to avoid thoughts or feelings related to the trauma? |
3 |
1 |
2 |
2 |
|
7 |
Have
you been making efforts to avoid activities, situations, or places that
remind you of the trauma or that feel more dangerous since the trauma? |
3 |
0 |
0 |
0 |
|
8 |
Are
there any important parts of the trauma that you cannot remember?. |
1 |
1 |
2 |
0 |
|
9 |
Have
you lost interest in activities you used to do? |
3 |
2 |
0 |
0 |
|
10 |
Have
you felt detached or cut off from others? |
2 |
0 |
0 |
0 |
|
11 |
Have you experienced emotional blunting such as
inability to cry or love. |
0 |
0 |
0 |
0 |
|
12 |
Feeling that the future is negative and my goals
will not be achieved (job, marriage, sons, long life). |
3 |
0 |
0 |
0 |
|
13 |
Difficulty falling or staying asleep. |
3 |
0 |
0 |
0 |
|
14 |
Have you had feeling of uneasiness, and episodes of
anger. |
3 |
1 |
1 |
0 |
|
15 |
Have
you had difficulty concentrating? |
3 |
0 |
1 |
0 |
|
16 |
Have you been overly suspicious (e.g. bad thing will
happen). |
3 |
0 |
0 |
0 |
|
17 |
Have
you been overly alert or on-guard (e.g., checking to see who is around you,
etc.)? |
3 |
0 |
0 |
0 |
|
|
Total |
44 |
10 |
9 |
4 |
|
Level of symptoms |
Extreme symptoms |
No disturbance |
No disturbance |
No disturbance | |
|
Changes in symptoms | |||||
|
|
Onset |
Change percent | |||
|
|
Phase 1 vs. phase 2 |
77.27 | |||
|
|
Phase 1 vs. phase 3 |
79.54 | |||
|
|
Phase 1 vs. phase 4 |
90.90 | |||
Case No. 1 (H.N): The total score of PSSI at
phase (1) was 44 indicating extreme disturbance. The total score of PSSI at
phase (2) decreased to 10, indicating no disturbance, at phase (3) the total
score of PSSI was 9 indicating no disturbance, and at phase (4), the total
score of PSSI was 4 indicating no disturbance. The change percent in total
score between phase 1 and phase 2 was 77.27%, the change between phase 1 and
phase 3 was 79.54%, and the change between phase 1 and phase 4 was 90.9%. These
results indicated a considerable reduction in the PSSI scores after the
intervention.
Table (2): Scoring of PSSI (case No. 2)
|
No. |
Item |
Phase 1 |
Phase 2 |
Phase 3 |
Phase 4 |
|
1 |
Have memories and views from the traumatic event are coming
intrusively? |
3 |
1 |
0 |
0 |
|
2 |
Have you been
having bad dreams or nightmares related to the trauma? |
2 |
0 |
0 |
0 |
|
3 |
Have you had
the experience of feeling as if the trauma were actually happening again? |
3 |
0 |
1 |
0 |
|
4 |
Have you been
very emotionally upset when reminded of the trauma (awesome, anger, sadness, guilty feeling)? |
2 |
1 |
1 |
0 |
|
5 |
Have you had
physical reactions when reminded of the trauma (e.g., sweating, heart
racing)? |
2 |
0 |
0 |
0 |
|
6 |
Have you been
making efforts to avoid thoughts or feelings related to the trauma? |
3 |
1 |
0 |
0 |
|
7 |
Have you been
making efforts to avoid activities, situations, or places that remind you of
the trauma or that feel more dangerous since the trauma? |
0 |
1 |
2 |
1 |
|
8 |
Are there any
important parts of the trauma that you cannot remember?. |
1 |
1 |
0 |
0 |
|
9 |
Have you lost
interest in activities you used to do? |
3 |
2 |
1 |
1 |
|
10 |
Have you felt
detached or cut off from others? |
3 |
1 |
0 |
0 |
|
11 |
Have you experienced emotional blunting such as inability to cry or
love. |
3 |
1 |
1 |
1 |
|
12 |
Feeling that the future is negative and my goals will not be achieved
(job, marriage, sons, long life). |
3 |
1 |
2 |
1 |
|
13 |
Difficulty falling or staying
asleep. |
2 |
0 |
0 |
0 |
|
14 |
Have you had feeling of uneasiness, and episodes of anger. |
1 |
0 |
0 |
0 |
|
15 |
Have you had
difficulty concentrating? |
2 |
3 |
1 |
0 |
|
16 |
Have you been overly suspicious (e.g. bad thing will happen). |
1 |
1 |
1 |
0 |
|
17 |
Have you been
overly alert or on-guard (e.g., checking to see who is around you, etc.)? |
3 |
2 |
0 |
0 |
|
|
Total |
37 |
16 |
11 |
4 |
|
Level of symptoms |
Severe symptoms |
Moderate disturbance |
Mild disturbance |
No disturbance | |
|
Changes in symptoms | |||||
|
|
Onset |
Change percent | |||
|
|
Phase 1 vs. phase 2 |
56.75 | |||
|
|
Phase 1 vs. phase 3 |
70.27 | |||
|
|
Phase 1 vs. phase 4 |
89.18 | |||
Case No. 2 (A.N): The total score of PSSI
at phase (1) was 37 indicating severe disturbance. The total score of PSSI at
phase (2) decreased to 16, indicating moderate disturbance, at phase (3) the
total score of PSSI was 11 indicating mild disturbance. The change percent in
total score between phase 1 and phase 2 was 56.75%, and the change between
phase 1 and phase 3 was 70.27%. These results indicated a considerable
reduction in the PSSI scores after the intervention.
Table (3): Scoring of PSSI (case No. 3)
|
No. |
Item |
Phase 1 |
Phase 2 |
Phase 3 |
Phase 4 |
|
1 |
Have memories and views from the traumatic event are coming
intrusively? |
3 |
2 |
2 |
1 |
|
2 |
Have you been
having bad dreams or nightmares related to the trauma? |
2 |
2 |
1 |
0 |
|
3 |
Have you had
the experience of feeling as if the trauma were actually happening again? |
3 |
2 |
2 |
1 |
|
4 |
Have you been
very emotionally upset when reminded of the trauma (awesome, anger, sadness, guilty feeling)? |
3 |
2 |
1 |
1 |
|
5 |
Have you had
physical reactions when reminded of the trauma (e.g., sweating, heart
racing)? |
3 |
1 |
0 |
0 |
|
6 |
Have you been
making efforts to avoid thoughts or feelings related to the trauma? |
3 |
1 |
1 |
2 |
|
7 |
Have you been
making efforts to avoid activities, situations, or places that remind you of
the trauma or that feel more dangerous since the trauma? |
1 |
1 |
0 |
0 |
|
8 |
Are there any
important parts of the trauma that you cannot remember?. |
1 |
0 |
0 |
2 |
|
9 |
Have you lost
interest in activities you used to do? |
3 |
2 |
1 |
0 |
|
10 |
Have you felt
detached or cut off from others? |
3 |
1 |
2 |
0 |
|
11 |
Have you experienced emotional blunting such as inability to cry or
love. |
1 |
0 |
2 |
3 |
|
12 |
Feeling that the future is negative and my goals will not be achieved
(job, marriage, sons, long life). |
3 |
2 |
0 |
0 |
|
13 |
Difficulty falling or staying
asleep. |
3 |
2 |
2 |
1 |
|
14 |
Have you had feeling of uneasiness, and episodes of anger. |
3 |
1 |
1 |
0 |
|
15 |
Have you had
difficulty concentrating? |
3 |
2 |
1 |
1 |
|
16 |
Have you been overly suspicious (e.g. bad thing will happen). |
1 |
0 |
1 |
0 |
|
17 |
Have you been
overly alert or on-guard (e.g., checking to see who is around you, etc.)? |
3 |
1 |
0 |
0 |
|
|
Total |
42 |
22 |
17 |
12 |
|
Level of symptoms |
Extreme disturbance |
Moderate to above moderate |
Mild to moderate |
No disturbance to mild | |
|
Changes in symptoms | |||||
|
|
Onset |
Change percent | |||
|
|
Phase 1 vs. phase 2 |
47.61 | |||
|
|
Phase 1 vs. phase 3 |
59.52 | |||
|
|
Phase 1 vs. phase 4 |
71.42 | |||
Case No. 3 (E.N): The total score of PSSI
at phase (1) was 42 indicating extreme disturbance. The total score of PSSI at
phase (2) decreased to 22, indicated moderate to above moderate disturbance, at
phase (3) the total score of PSSI was 17 indicating mild to moderate
disturbance, and at phase (4) the total score of PSSI was 12 indicating no
disturbance to mild disturbance. The change percent in total score between
phase 1 and phase 2 was 47.61%, and the change between phase 1 and phase 3 was
71.42%. These results indicated a considerable reduction in the PSSI scores
after the intervention.
Table (4): Scoring of PSSI (case No. 4)
|
No. |
Item |
Phase 1 |
Phase 2 |
Phase 3 |
Phase 4 |
|
1 |
Have memories and views from the traumatic event are coming
intrusively? |
3 |
2 |
2 |
0 |
|
2 |
Have you been
having bad dreams or nightmares related to the trauma? |
0 |
0 |
0 |
0 |
|
3 |
Have you had
the experience of feeling as if the trauma were actually happening again? |
3 |
2 |
1 |
0 |
|
4 |
Have you been
very emotionally upset when reminded of the trauma (awesome, anger, sadness, guilty feeling)? |
3 |
1 |
1 |
1 |
|
5 |
Have you had
physical reactions when reminded of the trauma (e.g., sweating, heart
racing)? |
3 |
0 |
0 |
0 |
|
6 |
Have you been
making efforts to avoid thoughts or feelings related to the trauma? |
3 |
2 |
1 |
1 |
|
7 |
Have you been
making efforts to avoid activities, situations, or places that remind you of
the trauma or that feel more dangerous since the trauma? |
3 |
0 |
1 |
0 |
|
8 |
Are there any
important parts of the trauma that you cannot remember?. |
3 |
1 |
0 |
0 |
|
9 |
Have you lost
interest in activities you used to do? |
3 |
0 |
0 |
0 |
|
10 |
Have you felt
detached or cut off from others? |
2 |
0 |
0 |
0 |
|
11 |
Have you experienced emotional blunting such as inability to cry or
love. |
3 |
2 |
0 |
0 |
|
12 |
Feeling that the future is negative and my goals will not be achieved
(job, marriage, sons, long life). |
3 |
0 |
0 |
0 |
|
13 |
Difficulty falling or staying
asleep. |
3 |
1 |
0 |
0 |
|
14 |
Have you had feeling of uneasiness, and episodes of anger. |
3 |
0 |
2 |
1 |
|
15 |
Have you had
difficulty concentrating? |
3 |
2 |
2 |
1 |
|
16 |
Have you been overly suspicious (e.g. bad thing will happen). |
2 |
0 |
0 |
0 |
|
17 |
Have you been
overly alert or on-guard (e.g., checking to see who is around you, etc.)? |
3 |
0 |
1 |
0 |
|
|
Total |
46 |
13 |
11 |
4 |
|
Level of disturbance |
Extreme disturbance |
No disturbance to mild |
No disturbance to mild |
No disturbance | |
|
Changes in symptoms | |||||
|
|
Onset |
Change percent | |||
|
|
Phase 1 vs. phase 2 |
71.73 | |||
|
|
Phase 1 vs. phase 3 |
76.08 | |||
|
|
Phase 1 vs. phase 4 |
91.30 | |||
Case No. 4 (A.J.N): The total score of PSSI
at phase (1) was 46 indicating extreme disturbance. The total score of PSSI at
phase (2) decreased to 13, indicated no disturbance to mild disturbance, at
phase (3) the total score of PSSI was 11 indicating no disturbance to mild
disturbance, and at phase (4) the total score of PSSI was 4 indicating no
disturbance. The change percent in total score between phase 1 and phase 2 was
71.73%, the change between phase 1 and phase 3 was 76.08%, and the change
percent between phase 1 and phase 4 was 91.30%. These results indicated a
considerable reduction in the PSSI scores after the intervention.
Table (5): Overall changes in symptoms
|
Case |
Total
score | |||
|
Phase (1) |
Phase (2) |
Phase (3) |
Phase (4) | |
|
Case No. (1) |
44 |
10 |
9 |
4 |
|
Case No. (2) |
37 |
16 |
11 |
4 |
|
Case No. (3) |
42 |
22 |
17 |
12 |
|
Case No. (4) |
46 |
13 |
11 |
4 |
Table (5) showed significant reduction in
psychological symptoms among all the cases, as initially before intervention (phase
1) there were extreme symptoms, and after early intervention, there were
apparent reduction in symptoms as noticed in (phase 4) with minimal symptoms.
This result reflected the effectiveness of early intervention model in reducing
or preventing the development of psychological symptoms after witnessing or
experiencing a traumatic event.
Table (6): Differences in PSSI at
different phases
|
Phase |
Mean |
SD |
t |
P value | |
|
Pair 1 |
Phase 1 |
42.250 |
3.862 |
7.173 |
0.006 * |
|
Phase 2 |
15.250 |
5.123 | |||
|
Pair 2 |
Phase 1 |
42.250 |
3.862 |
11.000 |
0.002 * |
|
Phase 3 |
12.000 |
3.464 | |||
|
Pair 3 |
Phase 1 |
44.000 |
2.000 |
10.058 |
0.010 * |
|
Phase 4 |
6.666 |
4.618 | |||
*Significant
at 0.05
Table (6) indicated statistically
significant difference in the PSSI scores between phase one and phase two (P=
0.006), significant differences in PSSI between phase one and phase three (P=
0.002), and significant differences in the PSSI score between phase one and
phase four (P= 0.010). These results reflected that the early intervention
reduced the post-traumatic stress symptoms significantly.
Discussion
This study aimed to examine the
effectiveness of early exposure-focused intervention after experiencing
traumatic event. The intervention was implemented on four members of (Nijm
family). The family lost five children as a result of missile explosion during
the Israeli military escalation on May 2022 against Gaza Strip. Assessment of
the four family members indicated initial extreme psychological symptoms, and
the symptoms reduced significantly after the early exposure-focused
intervention. In this study, the researcher used in vivo exposure to reminders
of the trauma, and cognitive restructuring. This approach encourage family members to share their individual narratives, so
that each can contribute to the co-creation of a family narrative, and to
elaboration of the unique meaning of the family’s experience and learning. The
interaction between the family members re-enacts specific family based survival
skills, thus helping the family to draw on the resources naturally available to
them in adjusting to trauma (Veronese
et al., 2014). Rothbaum et al. (2008) found that the brief exposure-based
intervention approach was not only safe and feasible, but also resulted in
lower levels of depression and distress. Recent research has shown that people want
early outreach help by competent professionals (Dyregrov, 2003). Early
intervention may help in forming adequate appraisals and counteracting misunderstandings
and misperceptions, whereas not intervening may lead to the consolidation of
maladaptive thoughts and behaviors (Dyregrov
& Regel, 2012). In addition, Foa et al. (2006) reported that CBT
intervention produced lower rates of PTSD and anxiety at a 2-month follow-up. Another
study have examined the efficacy of CBT on PTSD, that CBT which can include either long or brief imaginal
exposure, is efficacious in reducing PTSD (Bryant et al., 2019).
Conclusion: The early in vivo early exposure-focused intervention approaches
highlighted the potential benefit of CBT in recently traumatized individuals,
especially exposure techniques.
Acknowledgement
The author is grateful to the local volunteers for their assistance
in arranging for the intervention sessions and their help in data collection.
Funding
This work did not receive any grant from funding agencies in the
public, commercial, or not-for profit sectors.
Conflict of interest
There are no conflicts of interest to be declared.
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