In our last module, we examined assessment. In this module, we'll look at prioritization, or what I call the art of psychological triage. Now, just by definition, you'll remember the word triage is of French derivation. It means to pick, select or create a hierarchy, and that's what we must do based on the knowledge we have gained in assessment. You've heard a story, you've heard an event described. You've heard personal reactions to that event. Now, we must decide for whom immediate care is most warranted. We must create a hierarchy of needs and respond to those needs. Prioritization is really an extension of assessment which represents the application of basic triage principles. Attention is focused upon those people and those needs which require emergent care. Emphasis is placed upon assisting basic functional capacity. That is can the person in crisis actually do what they need to do? Now what you may find surprising is prior to 1999 there was virtually nothing written on psychological triaging In the wake of disaster. I guess that's good news and bad news. The good news is, it's a field ripe for inquiry and advancement. Bad news is, we're probably making a lot of mistakes along the way. We're learning as we go. But let's start with some basic principles that I think are pretty bedrock. We go to the work of a guy by the name of Abraham Maslow. Dr. Maslow was a clinical psychologist writing his seminal papers in the 1940s. And according to Maslow, he said people have needs. There's a hierarchy of needs. Meet basic medical and physical needs first. When in doubt, assume that a complaint is medical and have it assessed. You will see on one of the slides in this section, a pyramid. And you'll see that it represents Maslow's hierarchy, and starting at the bottom are physical needs. Basic medical, physical needs. Meet them first. Then it says move to safety. Now here is the conundrum. Maslow's work didn't really take into consideration disasters or wars for that matter. And what we have seen is a need to adjust Maslow's hierarchy just a bit. because what we find is that once physical needs have been satisfied, to a rudimentary level at least, people will often leapfrog to the third level, which is affection Affiliation, acceptance and support. And what that really means is, seeking interpersonal support from friends, families, coworkers and community aid services in order to achieve the second level. Now, according to Maslow's early writings, you must ascend the hierarchical ladder step by step. There is no such thing as skipping steps. But the field of disaster mental health has taught us that clearly that is not only possible but an inclination that people have. Stop and think about it a minute. When you're afraid, what do you do? You seek out the support of others. So when you're feeling unsafe you go from physical needs to the support, interpersonal support needs in order to feel safe. Why do kids in high crime areas join gangs? It's not because they have a desire to commit crimes. It is often times to feel safe. This may sound a little silly, but when you sent your son or daughter away to college, perhaps, and they insisted on joining a sorority or fraternity. And you thought it was all about the partying. Well, sometimes it is, but sometimes, being away from home, strange environment, large school, you don't know anybody. What do you do? You seek out a subset, a group of people who will learn to understand you and learn to support you. So we take into consideration Maslow's Hierarchy of Needs when we formulate our intervention plans and medical and basic physical needs always come first. But now it gets harder. There are two approaches to triaging once we have met basic medical and physical needs. One we'll refer to is evidence-based. The other we will refer to as risk-based. It's important to understand these are not mutually exclusive, rather, you should be cognizant of both approaches, both perspectives. They serve as lenses, or filters, if you will. The evidence-based triage approach. We focus on what is sometimes been called as the acute crisis triad. The evidence-based triage approach, we are looking for evidence of diminished cognitive capacity in survivors. We are looking for those people who are compromised in their ability to exercise prudent insight, memory and problem solving. But most importantly a diminished to understand the consequences of one's actions. As another prong to the crisis triad we are observing survivors, we are listening to third party reports of survivors who have an impulsive urge to act in a self-defeating or self-injurious manner. We are looking for the loss of future orientation, feelings of helplessness or hopelessness, utter despair perhaps. And lastly we are looking for diminished functional capacity in the sence of an inability to perform the necessary functions of living. Self-care, caring for others, working perhaps, personal hygiene. All of these things must be taken into consideration within the context of the logistics of the disaster site itself. So just because someone is having difficulty with personal hygiene doesn't mean that they are necessarily compromised, from a psychological standpoint, it may simply mean that such resources are just minimally available. So this is where, again, we ask questions to put things in context. So to review, the evidence-based triage system is a system that is predicated on your observation of people who exhibit evidence of dysfunction. And as we examined in the previous module, evidence of dysfunction is usually a cue for us to take a very direct and active role with intervention. However, there's a second approach to triage as well and that's called risk-based. The risk-based triage approach, we rely on the three Ds, we call it, for sub-acute concern. Death, dislocation and disabling impact. What does that mean? Here, we are learning from the survivor what risk factors they have encountered that increase their risk of psychological distress, disability and impairment. Could be acute, or could be sub-acute. Could be days later, or weeks later. Even months later. We ask the question, did the person see human remains? Why? Because we know that people that saw human remains who are unfamiliar with seeing human remains, those images are often seared into their memory. And serve as a diathesis, a vulnerability for weeks, months, years, perhaps an entire lifetime. Did the person think he or she was going to die? We know that some people will say, and I thought I was going to die. But, nah, they didn't really think that, that's just something they said. The person that says to you, and I thought I was going to die. Is the person who looks at you or looks through you, their pupils dilate and you have assessed that did, now this is different. They really thought they were going to die. Sometimes, they will say things like, and my life literally flashed before my eyes. Those types of experiences one never forgets. You move past them, certainly, but you never forget them. The second D, dislocation, is the person separated from family and loved ones? We've been emphasizing the importance of interpersonal support. This person is dislocated from such support. Does the person have a place to stay? Did they lose their home? Often times a house is more than a house, it's a home. Disabling impact is our third D. Was the person physically injured in such a manner that required immediate medical care? Did the person experience what's called peri-traumatic dissociation? The prefix peri you will remember means around. So, did the person experience dissociation feeling they were floating out of their body? Feeling disconnected from their body perhaps? In close proximity to the traumatic event itself. Parenthetically risk-based triage should never be used in the absence of evidence-based triage to formulate your triage plan or approach. With regard to triaging, the key is recognizing and prioritizing dysfunctional inclinations and behaviors. Let's not lose sight of what assessment and triage are all about. To summarize, assessment is our ability to listen to, observe the impact that some on toward event has had on a person or group of people. This is not done in a vacuum. It's done for a purpose. The assessment is done in order to decide how best to help survivors recover from adversity. I made the point earlier that intervention is predicated on the story on your assessment, if you will. I've been doing this work for 40 years I don't know that I've ever done two interventions exactly the same. Why? No two people are ever alike and no two situations are ever alike. And even though two people may be in the same situation, they may have experienced that situation very differently. So I must listen. I must gain rapport. I must listen. I must assess. And once I've assessed, I take it to the next level of prioritization triaging if you will and I create a, an order the hierarchy. I must decide when burdened with limited resources I must decide to whom I will focus or for whom I will focus our resources and in an order if you will. In some instances, you'll have more than enough resources. Concept of triage Is less important there, but the two approaches to triage remain important. The evidence based and the risk based approach. We know, for example, that the effects of disasters linger months and years. Some people will even define themselves. Who they are going forward in life. As a survivor. You've certainly seen t-shirts. I survived x y and z. I survived the great flood. I survived the tsunami. And most of those t-shirts are just offered as a remembrance. Some people take those words and internalize them and that's who they are from that day on. Sometimes it's uplifting. Sometimes it keeps them in the role of a victim rather than a survivor. Those are the subtle aspects of triaging. Our criteria for evidence and risk-based triaging, again, offered as a not comprehensive list, but basically a framework, a heuristic, to view your job of determining who should I attend to first.