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Systemic Wilderness Adventure Therapy

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Title: Systemic Wilderness Adventure Therapy Author: Simon Crisp Last modified by: Simon Created Date: 4/10/2001 5:52:39 AM Document presentation format – PowerPoint PPT presentation

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Title: Systemic Wilderness Adventure Therapy


1

Fraser Island, Qld. 2003
A fresh approach to how we learn and grow. . .
2

Psychological First Aid in Adventure Therapy
Dr. Simon Crisp Clinical Child Adolescent
Family Psychologist Melbourne, Australia
3
Key Learning Objectives
  • Ability to DETECT mental health / behavioural /
    personal safety issues
  • Confidence in applying a RESPONSE (Psychological
    first-aid)
  • Increased knowledge of resources, options and
    REFERRAL processes

4
Jahari Window - knowledge
What you know you know
What you know you dont know
What you dont know you dont know
What you dont know you know
5
Medical First Aid Analogy
First Responder Field staff, Outdoor Educator,
etc.
Paramedic Counsellor
Accident Emergency Team Program Coordinator,
Child Protection,
Surgeon / Physician Psychologist, Mental Health
Service
6
Ways Adolescents Cope
  • Non-Productive Coping
  • Worrying about the problem
  • Using wishful thinking about the problem
  • Not coping and becoming ill
  • Letting off steam / tension reduction
  • Avoidance of the problem
  • Self Blaming
  • Keeping to oneself / not talking to others
  • Seeking spiritual support (ie. Praying to God to
    fix it)
  • Depending on a professional and not trying to cope

7
Ways Adolescents Cope cont.
  • Productive Coping
  • Seeking social support, talk to others (help
    seeking)
  • Actions aimed at solving the problem
  • Applying themselves to make changes
  • Spending time with boy/girl friend
  • Improve relationships with others
  • Join others with similar concerns
  • Focus on the positives of a situation
  • Seek relaxing diversions or leisure activities
  • Maintain fitness and health physical recreation

8
PREP D anger R eadiness Resources
A ct B
rainstorm C
onsult D ecide
Recap Follow-up
Psychological First Aid
9
Response gt approach engagement
  • P.R.E.P.
  • P rivacy discretion see how it might look
  • R eassuring manner and approach de-role
  • E ngage adolescent open up communication
  • P roblem define it as a shared concern,
  • normalise it, seek collaboration

10
Response gt approach engagement
  • Small group discussion
  • What are effective ways to PREP adolescents
    before responding with Psychological First Aid?

11
P.R.E.P.
  • PRIVACY
  • Private place how does this set the scene? What
    messages does this communicate?
  • Timing may compromise privacy
  • How will a private discussion be perceived?

12
P.R.E.P.
  • REASSURING manner approach
  • De-role from your usual manner?
  • Approach at their level
  • Be aware of body language actions speak louder
    than words
  • Appear calm and confident instills trust
  • Humor to reduce anxiety?

13
P.R.E.P.
  • ENGAGE - open communication
  • Be patient
  • Be an active and interested listener be
    receptive
  • Wait until the adolescent is relaxed and more
    open with feelings and information
  • If still reluctant acknowledge it and validate /
    normalise it

14
P.R.E.P.
  • PROBLEM describe normalise
  • Express your concerns simply and directly
  • Seek to learn how and if they see a problem
  • Be ready to acknowledge differing perspectives
  • Seek to find a shared concern
  • Outline implications of this concern why it
    deserves attention
  • Find leverage for how the client might
    collaborate on the problem

15
PREP D anger R eadiness Resources
A ct B
rainstorm C
onsult D ecide
Recap Follow-up
Psychological First Aid
16
Demonstration of Response
  • ? Presentation of all of the stages of Response
    gt
  • - 16 year old female student
  • - Teacher (Year Level Co-ordinator)
  • 25 minutes

17
D anger What are common dangers that need to be
assessed?
Psychological First Aid
18
D anger - remove the student from danger or
danger from the student ( medical FA if
necessary) - secure the environment - ensure
supervision - anticipate how the student might
harm you, others or self-harm (in that order)
- risks medium long term
Psychological First Aid
19
D anger questions to ask - Do you feel
unsafe? Should I be concerned? - How much
control do you have over? - What could happen
that might reduce your level of control, or make
you less safe? - Can you easily talk to someone
about feeling unsafe? - Do you have thoughts
about hurting yourself or anyone else?
Psychological First Aid
20
R eadiness - Resources - What are common
reasons why you may be unready to respond? -
What are common resources you or your student may
be able to draw on?
Psychological First Aid
21
R eadiness - Resources ? Readiness am I the
best person? What is my mental state? Am I
adequately prepared? When is the best time for
me, when is the best time for the student? ?
Resources who, or what else can I access what
person or resources can the student access for
themselves (empowerment)
Psychological First Aid
22
R eadiness Resources questions - How do you
feel with me talking to you about this? - What
response do you expect from me? - Have you
spoken to anyone about this before? - Who else
can help you with this? - Who has tried to help
you with this in the past? Was it helpful?
Psychological First Aid
23
A ct within your limits / role / boundaries -
Is it ethical / legal /good practice for me to
intervene? - How far do I go? - What is the
best role for me to take on? - What does my
student expect of me? - Could I compromise my
relationship role with my student?
Psychological First Aid
24
A ct within your limits questions - What
are you expecting I would do in this
situation? - Often there are things that are
best talked about with a counsellor, is this one
of those times? - I wonder if you may feel it is
more private and easier to talk to someone less
involved with you everyday / in the way I am?
Psychological First Aid
25
A ct - How Receptive are you? (Johnson ,2000)
  • Receptivity
  • continuum of psychological closeness to
    clients
  • Continuum of Receptivity
  •  
  • Absent Objective Distant Empathetic
    Sympathetic Identified Fused
  • Destructive at risk OK Ideal OK
    at risk Destructive

26
A ct - Boundaries Self Disclosure
  • Self disclosure has the potential to confuse /or
    interfere with boundaries
  • Immediacy appropriate self-disclosure
  • The helping relationship will lead to feelings of
    imbalance for staff - this important
    asymmetry in relationship defines roles of helper
    and recipient of help
  • These feelings must be held, and the tendency
    to equalise the relationship must be resisted
  • Seek alternative responses to self-disclosure

27
A ct - Keeping Boundaries
  • Avoid
  • Acknowledging or discussing own mental health
    issues, family issues, drug use, school
    experiences - including telling client of own
    similar issue or problem and how you overcame it
  • Expressing personal rather than professional
    feelings about the client
  • Telling personal issues partner / spouse, sexual
    or relationship history, family, political or
    religious views

28
A ct - Keeping Boundaries
  1. Whose needs am I meeting by disclosing?
  2. Do they really want to know about me,
    or if I can understand their situation?
  3. Is their question really about themselves?
  4. Does a personal question about me, result in
    avoidance of own issues?

29
  • If I disclose, will the adolescent begin to worry
    about me (role reversal)?
  • Could I keep my own personal feelings about my
    issues contained and boundaried within myself?
  • Is a adolescent pushing disclosure about wanting
    to equalise or gain more power?

30
When asked a personal question, ALWAYS
  • Keep answer general, or in principle
  • Describe the concept or reasoning behind your
    answer
  • Broaden a question to a discussion about values
    and guidelines for behaviour or relationships
  • Remember it is always good to say That is
    personal and I want to keep that private

31
B rainstorm strategies - What can my student
do? - What can I do? - Take a collaborative
problem solving approach
Psychological First Aid
32
B rainstorm strategies questions - What has
worked in the past? - What havent you tired
that might help? - What do you think needs to
happen to take this in a more positive direction?
what do other people think? - If you had more
information, would that make it easier to deal
with?
Psychological First Aid
33
C onsult - with peers / senior / parent /
expert - share responsibility with your
superior - utilize the resources of the parents
or an expert to your students benefit
Psychological First Aid
34
C onsult questions (to yourself) - Do I have
all the pertinent info? - How much do I know
about this type of issue? Have I dealt with this
type of problem before? - Is there something
unique to this situation that suggests I should
consult? - Do my reactions / confidence suggest
that I should get support? - Is specialised
assessment indicated?
Psychological First Aid
35
C onsult Who could you consult to
peer / senior / expert?
Psychological First Aid
36
D ecide - Monitor OR Manage myself OR Refer?
- Re-assess Danger (repeat DRABCD if necessary)
Psychological First Aid
37
D ecide questions (to yourself) - What might
hinder this student accepting referral? - What
can I do to ensure the student follows through?
- How can I ensure that the referee get all the
info? - What are my obligations to parents about
the referral? - What is the best way to review
this? make a plan
Psychological First Aid
38
Response gt termination
  • Re-cap Follow-up
  • Re-cap
  • Key points of information
  • Strategies to use
  • Plan of action
  • Follow-up
  • Who / what / when

39
Morning Tea? Something to eat?
40
Specific Problems Anxiety Disorders
  • Generalised Anxiety Disorder
  • Panic Disorder
  • Phobias Social Phobia / Agoraphobia
  • Obsessive- Compulsive Disorder (OCD)
  • Post-Traumatic Disorder (PTSD)

41
Anxiety Process
  • Visual stimulus cues the person to appraise the
    situation as either safe OR threat
  • Physiological symptoms Perspiration increased
    respiration, blood pressure, etc.
  • Cognitive anticipating a catastrophe something
    bad is about to happen loss of confidence or
    self-efficacy memory disturbance attentional
    disruption (over-focus on threat)
    hypervigilance, etc.
  • Behavioural agitation restlessness
  • AVOIDANCE OF THREATENING SITUATION

42
Gereralised Anxiety Disorder
  • Reassure the student things are OK and under
    control
  • Be firm, supportive and directive take control
    for the student
  • Encourage the student to reality check their
    fears, bring things in to perspective use
    visual cues
  • Allow the student to talk through their fears if
    possible
  • Gentle distraction and humor can be useful if
    done supportively

43
Panic Disorder
  • Acute experiences of heightened anxiety
  • Difficulty breathing feelings of chocking or
    hyperventilation trembling or shaking racing
    heart beat dizziness abdominal pain fear of
    loosing control, etc.
  • Person may feel they are going to die
  • Hyperventilation may appear
  • as asthma
  • Usually transitory and will
  • abate after a few minutes

44
Panic Disorder
  • If unsure if a medical condition, treat as one
  • Move to quiet and safe location if necessary
  • Encourage slow, relaxed breathing
  • Reassure and explain what is happening to student
    get them to focus on reassuring using visual
    cues
  • Explain that attack will soon pass and they will
    fully recover
  • Assure them you will stay until it has passed
  • Dont restrict them from moving

45
Psychological First Aid Role Play
  • Managing acute anxiety
  • In groups of 3, role play the scenario described,
    especially focusing on management of anxiety
    symptoms
  • In a large group, discuss how to ensure you stay
    within the limits of your expertise

46
Extreme Anxiety Dissociation
  • Usually an adaptive response developed to cope
    with abuse, trauma or extreme anxiety, triggered
    by trauma related stimulus
  • Person psychologically disconnects from their
    physical body to avoid uncomfortable sensations
    of fear, anxiety or pain
  • Can experience feelings of derealisation and
    depersonalisation
  • May have very high pain threshold danger of
    accidental / deliberate self-harm or suicide

47
Dissociation
  • May be difficult to tell if it is happening can
    looks as if person is floating and indifferent
  • May report being OK or fine and have no
    awareness of their state
  • May refuse to move away from danger stay
    stuck or trance-like with fear
  • Usually occurs for seconds / minutes and usually
    resolves itself

48
Dissociation
  • Assess if person is orientated time/place/person
  • Ask how they feel may report nothing, or that
    they are fearful but not show congruent signs
  • Gently take charge simple, gentle, firm
    directions, but avoid appearing coercive
  • Have them maintain eye contact with you or fix on
    a reassuring visual point

49
Dissociation
  • Encourage them to talk about their fears
  • not tune out to what I happening
  • Move to safer / less stressful location
  • Encourage relaxation strategies breathing, etc.
  • Normalise their experience affirm their ability
    to put up with the fear

50
Specific problems Depression
  • Equally common in both sexes
  • Often first noticed
  • - fatigue, drop in general performance
  • - hopeless and nihilistic themes in verbal
    comments
  • - social withdrawal, failure to engage with
    peers
  • - friend reports that the student appears sad

51
Depression
  • Clinical assessment usually required
  • May be in denial that they have a problem, highly
    secretive, avoid interactions, may be expressed
    as irritability or anger
  • Hopelessness may make it difficult to motivate
    them towards solving the problem

52
Depression
  • Do
  • Take seriously
  • Persist in talking to adolescent about their mood
  • Assume the presence of suicidal thoughts
  • Attempt to find out about recent stressors,
    family/peer situation

53
Depression
  • Dont
  • Take their response that everything is fine on
    face value
  • Take sarcasm or anger towards you personally
  • Give glib advice snap out of it or list
    reasons why they dont have cause to feel sad
  • Raise concerns or comment in the presence of
    others

54
Depression
  • Responds best to
  • Directness, patience, measured concern
  • Closed questions about their mood
  • Confidence about how you approach the situation
  • Empathy

55
Depression
  • When high priority
  • Any signs of suicidality, self-harm, high risk
    behaviour
  • If no professional involved (that you know of)
  • Prior history of depression/suicidality/self-harm
  • Recent stressor (especially loss)
  • Adolescent rejects help or denies a problem in
    the face of contradictory evidence

56
Suicide and Self-harm
  • Continuum of self-harming behaviour
  • Deliberate Suicide Attempt Suicide
  • Self-harm
  • Tension release, Call for help or failed
    Deliberate wish to
  • expression of anger serious attempt
    die or accidental etc. death

57
Suicide and Self-harm
  • Signs
  • Depressed, anxious, angry, agitated, mood swings,
    concentration or memory problems
  • Often high risk-taking behaviour
  • Poor coping, may have eating disorder,
    personality problems
  • May be aggressive towards others
  • Sometimes have difficulty being assertive

58
Suicide and Self-harm
  • Do
  • Always take seriously, regardless of frequency
  • Gently persist in talking to adolescent about
    self-harming behaviour / suicidal thoughts
  • Assume even fleeting thoughts can be deadly
  • Affirm telling someone is best thing to do

59
Suicide and Self-harm
  • Dont
  • Avoid or put off investigating the issue, or hope
    it will subside with time
  • Convey anger, disgust, or a punitive attitude
  • Believe you can tell the students real
    motivation, ie. just trying to get attention

60
Suicide and Self-harm
  • Remain non-judgmental
  • Encourage verbalisation of feelings
  • Affirm your role is to keep student safe from
    harm
  • Set clear limits about not tolerating self harm
    in your presence (if necessary)

61
Suicide and Self-harm
  • Dont reinforce/reward the behaviour accidentally
    give a neutral response
  • Dont attempt to physically restrain if actively
    self-harming move away, avoid watching, but
    remain in close proximity
  • Ensure student is directly supervised at all
    times if suicidal
  • Seek expert consultation as soon as possible

62
Psychological First Aid Role Play
  • Managing suicide / self-harm risk
  • In groups of 3, role play the scenario described,
    especially focusing on engagement, building
    rapport and direct questions about mood and
    suicidal thoughts
  • In a large group, discuss how to ensure you stay
    within the limits of your expertise

63
Psychological First Aid Role Play
  • Key points
  • Develop sufficient rapport to allow student to
    open-up
  • Normalise the adolescents experience
  • Ask direct, closed questions to determine risk
    factors
  • Ensure you have a clear plan student adherence
    to it
  • Plan for follow-up or monitoring

64
Acute Stress PTSD
  • Definition of Psychological Trauma
  • An adverse psychological reaction to a stressful
    and extraordinary event
  • Eg.s
  • Accident, near accident, injury, death
  • Assault, threat of harm, extreme behaviour
  • Self harm, threats of self harm, suicide
    gestures, completed suicide
  • Natural disasters and extreme environmental
    conditions
  • Observing or in any way being a witness to any of
    the above

65
Comfort Zones Trauma
66
Trauma
  • Typical (normal) Stress Response Symptoms
  • Shock, disbelief
  • Heightened arousal, fear
  • Hopelessness, abandonment
  • Flight or escape behaviour
  • Protective postures
  • Holding others
  • Family oriented behaviours
  • Heroic behaviour
  • Time distortion brief, suspended
  • Emotional shutting down
  • Panic is rare

67
Acute Stress Disorder PTSD
  • Acute Stress Disorder
  • Occurs within 2 days to 4 weeks post incident
  • lt20 of people are likely to experience it
  • 75 of ASD continue onto PTSD

68
Acute Stress Disorder PTSD
  • Acute Stress Disorder - Features
  • Persistent dissociation
  • Re-experiencing of the event (e.g. flashbacks)
  • Avoidance of being reminded of the traumatic
    event
  • Regressed behaviour
  • Increased arousal startle response,
    hypervigilence
  • Derealisation, depersonalisation, dissociative
    amnesia

69
Acute Stress Disorder PTSD
  • Post Traumatic Stress Disorder
  • Post Acute Stress Disorder gt 4 weeks
  • lt 15 of all survivors develop PTSD
  • Symptoms may worsen with time
  • Likely to seriously effect functioning school,
    family, peers, adult relationships
  • Can be foundation to depression, substance
    abuse, self-harm, suicide

70
Managing Critical Incidents
  • Ensure physical safety
  • Take personal inventory
  • Take charge
  • Seek and give personal support
  • Develop a routine
  • Balance activity and restore normalcy
  • Establish links to social supports ASAP

71
Trauma Reactions of Adolescents
  • Withdrawal
  • Depression
  • Less responsible, more demanding - regress
  • Rebellious, competitive
  • Frustrated angry
  • Physical complaints

72
Traumatic Events
  • Needs of Adolescents
  • Education about the crisis what happened and why
  • Talk about their feelings / frustrations
  • Encouragement to re-engage in activities and
    socialise
  • Encouragement to become actively involved in
    getting things back to normal

73
Traumatic Event Hypothetical
  • Managing a traumatic incident
  • In groups of 3, discuss how to manage the
    scenario described. Plan your response in points
    and chronological order.
  • In a large group, discuss what action you
    planned, what order you would apply them and why?

74
Round Up
  • Hows your Jahari Window?
  • Outstanding questions?
  • Most helpful thing?
  • Where to now?
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