After a traumatic event: early intervention — a therapist's manual

1. The programme at a glance

Indication. An adult exposed, within the past month, to a traumatic event in the strict sense: a death, a threat of death, a serious injury or sexual violence, experienced directly, witnessed, or learned about when it concerns someone close. The monitoring contacts concern every exposed person who is referred to you; the brief protocol, those who present acute stress disorder, or significant symptoms that are not coming down (section 10).

Reference model. Stepped care. For everyone, psychological first aid, that is, humane, practical and non-intrusive help, centred on safety, needs and connection (World Health Organization et al., 2011), and active monitoring, that is, scheduled contacts that follow how the symptoms evolve without treating them (National Institute for Health and Care Excellence, 2018). For those whose symptoms remain marked, a brief trauma-focused cognitive behavioural therapy (CBT), built on the trials of Bryant and his colleagues (section 11).

Format. The programme has two kinds of meeting, named differently because they do not play the same role. Contacts are the active monitoring, for everyone being followed: three meetings of 45 to 60 minutes, as soon as the referral is made, then between the tenth and the eighteenth day, then between the twenty-eighth and the thirty-fifth day; the last two can be done by telephone. Sessions are the brief protocol, for those who need it: at most five weekly sessions of 90 minutes after contact 2, four if the response criterion is reached at the fourth (section 22); the session that falls around the fourth week takes the place of contact 3. In all: three contacts and a call three months after the event for people who are only monitored; two contacts, five sessions at most and three booster sessions, at one, three and six months, for those who receive the protocol.

Mechanism targeted. Letting natural recovery work where it works, and, in those in whom it stalls, removing what is blocking it: avoidance of the memory and of situations, and the threatening meanings the person gives to the event and to their own reactions (section 5).

Contact or session	Focus	Output
Contact 1, as soon as referred	Welcome, make safe, inform	Practical needs dealt with, record handed over, next contact dated
Contact 2, day 10 to day 18	Measure and sort	Trend read, written decision: monitor or treat
Contact 3, day 28 to day 35	Reassess and direct	Follow-up closed, extended, or handed on to the PTSD manual
Session 1	Understand and decide	Circle drawn, avoidance list rated
Session 2	The account	First full account, update done
Session 3	The hot spots and what they make the person think	Hot spots revisited, beliefs re-rated
Session 4	Going back into situations	In vivo exposure done, account held in full
Session 5	Review and next steps	Measures repeated, written plan, decision

What the person takes away. Eight printable worksheets, one of them for those close to the person (section 33). The public guide Understanding trauma and the window of tolerance can be given to them from the first contact.

What distinguishes this programme from the other manuals on this site. It is the only one that deals with the first month, before a disorder has become established: Post-traumatic stress disorder in adults: a therapist's manual treats the established disorder, whereas this one first decides who needs treatment, and, for the majority of exposed people, the answer is that none is needed. It also describes what is done for everyone without treating, and what is refrained from: psychological debriefing and preventive medication.

2. Before you begin

The four preliminary decisions

Is the person safe today? An event can be over without the danger being over: a known perpetrator who is still at large, violence in the couple, a threat of reprisals, a destroyed home. As long as the danger lasts, you protect before working on the memory (section 9).

Is there a medical or psychiatric emergency? An injury that has not been examined, a head injury, confusion, intoxication or acute suicide risk come before everything else (sections 8 and 9).

How long ago, and in which direction are things moving? In the first three days, no diagnosis is made. Up to one month, one speaks of an acute reaction or of acute stress disorder; beyond that, of a possible post-traumatic stress disorder (PTSD). What counts above all is the trend: symptoms that decrease from week to week do not call for the same response as symptoms that hold steady (section 10).

And which event are we talking about? A single accident in a person with no prior history is not followed in the same way as a bereavement through violent death, a sexual assault, or an event that reawakens another, older one (sections 8 and 28).

What this programme does not treat

It does not treat established PTSD. Beyond one month, when the criteria are met or the symptoms remain significant, the person is handed on to Post-traumatic stress disorder in adults: a therapist's manual (section 18).

It does not treat the consequences of repeated and prolonged trauma, such as violence suffered during childhood or years of domestic violence, even when a recent event is what brings the person. Complex PTSD falls under Complex post-traumatic stress disorder: a therapist's manual.

It does not treat the distress that follows a hard blow with no threat to life, such as a redundancy or a break-up. If it becomes overwhelming, it falls under Adjustment disorder: a therapist's manual.

And it does not apply as it stands to children and adolescents. Section 27 says what changes and which manual to turn to.

How to use it

Read the whole manual before the first contact, in particular sections 3, 9, 12 and 25: sorting, safety, what is not done, and psychological first aid. The brief protocol borrows its exposure technique from the adult PTSD manual: read its sections 30 to 33 before session 2, as well as section 26 of this manual, which says what changes in the first month.

Three warnings specific to this moment.

The first risk is doing too much. Offering treatment to everyone, having people tell the event while it is still raw, reading expected reactions as symptoms: these gestures, made out of kindness, do not help, and some do harm (section 12).

The second risk is doing nothing afterwards. Saying "come back if things are not going well" leaves alone those who are doing badly, because avoidance is part of the picture and they will not come back of their own accord. It is you who calls back, on a fixed date.

And supervision matters here too, because these accounts expose the clinician (section 31).

3. Four pictures not to be confused

Four situations present themselves in the first month, and they do not call for the same approach.

1. The expected reaction

What you observe. In the days that follow, images that come back, broken sleep, startling, irritability, sadness, a sense of unreality, the urge to avoid what recalls the event. This is the rule after an event of this kind, not the exception.

What points the way. The trend and functioning: the symptoms are decreasing, and the person goes on doing the essentials, even if more slowly. This is the most frequent course. In a review of 54 studies that followed exposed people, the most common trajectory was resilience, symptoms that remained low throughout follow-up, on average in 65.7% of people; next came recovery, symptoms that were high at first and then declined, in 20.8% (Galatzer-Levy et al., 2018).

What it implies. Psychological first aid, information, gradual resumption of activities, and a dated contact. No treatment, no forced account, no debriefing (section 12).

2. Acute stress disorder

What you observe. Between three days and one month after the event, a rich and intense picture: memories and nightmares that force themselves on the person, a flattened mood, dissociation, clear avoidance, hyperarousal, with marked distress or impairment (section 7).

What points the way. The number of manifestations, their intensity, and the impact: the person no longer sleeps, no longer goes out, no longer works. This diagnosis describes severe distress, but on its own it predicts the course poorly, because the majority of people who later develop PTSD had not presented it (Bryant, 2011).

What it implies. The brief protocol in sections 19 to 23, offered from the second contact.

3. Clear symptoms without the full picture

What you observe. Real re-experiencing and avoidance, but not enough manifestations for acute stress disorder, or distress that is not decreasing.

What points the way. The level and the trend: a partial picture that is improving has nothing to gain from early treatment, whereas high symptoms that are not coming down identify people who recover poorly on their own (section 10).

What it implies. Active monitoring, and the brief protocol if the symptoms reach the intensity marker in section 10, with clear impairment, and do not come down (section 17).

4. Another disorder, appearing or reawakened by the event

What you observe. Depression, panic attacks, alcohol use that is spiralling, or the return of an old disorder, in the foreground ahead of re-experiencing.

What points the way. What dominates, and the history: a previous depressive episode, an old PTSD reawakened by the recent event, a substance use disorder that was already there.

What it implies. The manual for the dominant disorder, for example Treating depression in adults: a therapist's manual or Alcohol use disorder: a therapist's manual, and continuation of the contacts (section 8).

The three other things to have ruled out

A head injury, which changes the interpretation of memory and concentration problems; confusion or intoxication, which can resemble dissociation (section 8); and current danger, because hypervigilance in someone who remains under threat is not a symptom (section 9).

The three sorting questions

"Since what happened, what comes back without your calling it up, and how many times a day?" It isolates re-experiencing and its frequency.

"What do you no longer do, or no longer do in the same way?" It isolates avoidance, the main maintaining factor (section 5).

"Over the past week, has it been decreasing, staying the same, or increasing?" It gives the trend, which governs what you do.

4. Reactions in the first month

What the person goes through

Intrusions. Images, sounds, smells or sensations from the event that force themselves on the person, often triggered by tiny reminders, and nightmares.

Dissociation. A sense of unreality, of seeing oneself from outside, or gaps in memory. It is frequent during the event and in the hours that follow.

Avoidance. No longer going down that street, no longer taking the car, changing the subject, keeping busy without a break, drinking to sleep.

Hyperarousal and mood. Startling, vigilance at every moment, irritability, insomnia; sadness, guilt, anger, shame.

What is specific to the first month

Everything is still in motion. Symptoms change from one day to the next, and the formalities follow one after another: medical care, the police complaint, insurance, the funeral, the return to work. Part of the distress comes from these formalities more than from the memory, and it calls for practical help.

The person interprets what is happening to them. "I'm going mad", "I'll never be the same again": these interpretations, which you hear from the first contact, weigh on what follows (section 5).

Those close to the person organise themselves around the event. They go with them everywhere, filter information, avoid talking about it. This is often precious support, and sometimes a way of sharing the avoidance (section 29).

What should not worry you, and what should

Should not worry you on its own: symptoms, even intense ones, in the first few days; dissociation during the event; a harder week after a police interview or a return to the scene.

Should worry you: symptoms that do not decrease after two to three weeks, avoidance that spreads, dissociation that persists beyond the first few days, rumination that takes up the days, increasing substance use, suicidal ideas, a massive impact on sleep, work or medical care (sections 5 and 10).

5. What makes a reaction take hold

Risk factors, and their limits

Those that come before. Psychiatric history, previous trauma, violence in childhood, family history. Taken one by one, their effects are modest (Brewin et al., 2000).

Those that relate to the event and its aftermath. The severity of the event, lack of support and the difficulties that pile up afterwards weigh a little more than the prior factors (Brewin et al., 2000). Perceived threat to life, emotions and above all dissociation during the event also count (Ozer et al., 2003). The type of event plays a part: after intentional violence, the frequency of PTSD tends to increase over the first year instead of falling (Santiago et al., 2013).

What they allow, and what they do not. They help decide whom to call back first; they do not tell you who will develop a disorder. That is why this programme measures instead of predicting.

What keeps it going

Ehlers and Clark's (2000) cognitive model of PTSD explains why some reactions do not die away: the person keeps a sense of current threat, for two reasons, and adopts strategies that prevent this sense from being corrected.

Threatening meanings. What the person concludes from the event, "the world is dangerous", "it's my fault", and from their own reactions, "I'm going mad", "I'm damaged for ever". In a cohort of 967 people seen in the emergency department after a road traffic accident, negative interpretation of the intrusions and rumination at three months were among the best predictors of symptoms at one year (Ehlers et al., 1998).

The poorly filed memory. It remains fragmented, sensory, without time markers, and it is triggered by elementary cues, a noise or a smell, rather than by deliberate recall: that is what gives the impression that the event is happening again (Ehlers and Clark, 2000).

The strategies that prevent correction. Avoidance of reminders, thought suppression, rumination, that is, going round in circles over questions that have no answer ("why me?", "what if I had left earlier?"), safety behaviours, those unnecessary precautions that give a sense of having kept the danger away, such as checking constantly or sitting with one's back to the wall, and alcohol. They bring relief in the moment, and they prevent the memory from being filed and the predictions of danger from being disconfirmed. Four weeks after an accident, persistent dissociation and rumination predicted the course better than the initial reactions (Murray et al., 2002).

The circle, in one sentence

A reminder triggers an intrusion; the person sees it as a sign that they are not well or that the danger is returning; they avoid, ruminate or drink; the memory remains raw and the interpretation intact; and the next reminder triggers more. This is the circle you draw with them at session 1.

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