VIOLENCE
exposed to violence are more likely to be depressed, to contemplate
suicide, abuse substances, and enter the criminal justice system at
a younger age (3-5). Another consequence of repeated violence is
the development of post-traumatic stress disorder (PTSD) in the
residents of the most commonly effected neighborhoods. PTSD is
a debilitating psychiatric disorder that may develop after exposure
to a traumatic event, and is characterized by intrusive and avoid-
ance symptoms, as well as hyperarousal and poorer cognition and
downswings in mood (6). Research has demonstrated that nearly
90 percent of urban, low-income residents living in the inner-city
have been traumatized with a lifetime PTSD prevalence of at least
40 percent (4). This incidence exceeds the relative risk of acquiring
PTSD as a combat veteran (15.2 percent of males and 8.1 percent
of females in Vietnam Veterans (13), and 10.1 percent In Gulf War
Veterans (14). Comparatively, the general population develops PTSD
at rates ranging from 7-9 percent over a lifetime, demonstrating the
extreme mental stress caused by urban violence. Development of
PTSD in inner-city civilians has also been strongly associated with
future violent criminal offenses (5).
Given that PTSD is so common in the inner city population,
health care practitioners in Louisville should be familiar with the
current criteria utilized to screen for PTSD.
Questions that may be helpful when taking the history of an at-
risk patient may include:
“In the past month have you directly experienced a traumatic
event yourself?”
“Have you witnessed one in others, such as a close family member
or friend?”
“If so, have you experienced any of the following:
1. Nightmares about event or thought about the event
you did not want to?
2. Tried hard not to think about event or went out of your
way to avoid situations that reminded you of the event?
3. Been constantly on guard, watchful or easily startled?
4. Felt numb or detached from people, activities or your
surroundings?
5. Felt guilty or unable to stop blaming yourself or oth-
ers for the event or any problems the event may have
caused?”
If your patient answers “yes” to any three of five questions he
or she may be developing PTSD and would benefit from being
referred on to a mental health provider.
Because of the debilitating effects of post-traumatic stress, there
has been an increasing incentive to identify and develop effective
early interventions that may prevent the development of the com-
plete disorder. Several interventions often referred to generically
as “debriefing,” such as Crisis Intervention and Critical Incident
Stress Debriefing (or Management) can be tried. They have shown
varying, but generally positive results in the treatment of PTSD.
The patient went on to say, “Doctor, as bad as I feel, some of my
friends and neighbors feel even worse. We want to support each
other, but we don’t really know how. When these things happen,
I don’t know what to say or to do for my neighbors or family that
have sustained a loss. Is there anything that can be done right then
and there to support people when these kinds of tragedies happen?”
Actually, there is. Psychological First-Aid (PFA) is an evi-
dence-informed approach to providing individuals following a
serious crisis event (9). The term “evidence-informed” is a reference
to the fact that many of the PFA components have been derived by
research and that there is general consensus among experts in the
disaster mental health field that these components are effective in
helping those traumatized by perceived tragedies such as violence
resulting in critical injury or death. The aim of PFA is to reduce
the initial distress of the traumatic event and to promote adaptive
functioning and coping, both in the short and long term. The current
techniques of PFA were developed in the wake of such tragedies
as war, natural disasters and most recently, school shootings (7).
PFA assumes that individuals may experience a broad range of
reactions following a traumatic event but that not all individuals
will develop mental health problems. Potential recipients of PFA
include children, adolescents, adults, families, first responders such
as police and paramedics, and even bystanders who have witnessed a
violent act or death. Not all individuals who experience a traumatic
event will need or want PFA. In general, PFA should not be forced
on these people (8).
Access to PFA providers is an important key in utilization to
provide aid to the most people possible and as early as possible
following a tragic event. PFA may be provided by a number of
individuals, and these providers do not need to be mental health
professionals. Such individuals will include first responders, family,
friends and community members. It can be provided in a number of
settings, including at the scene of a homicide or other violent crime,
health centers and schools. One of PFA’s valuable attributes is its
portability and the ability to directly render aid when and where it’s
needed. PFA has been described as being similar to physical first-
aid which is provided by the general population and not medical
professionals, but also provides for referral to medical professionals
when the need is greater than a minor injury.
The PFA manual that was developed by the National Child Stress
Network and the US National Center for PTSD is currently the
most accepted conceptualization of PFA (11). A detailed review of
the PFA manual and current techniques of PFA is out of the scope
of this article, but a brief review of the “core actions” of PFA can
be described. The core actions are the basic principles of providing
early assistance. Providers’ choice of actions and time spent on each
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