Interview: Emergency response psychology in Madrid

Although psychologists work with the emergency services across the world, Madrid is one of the few cities that have a team of emergency response psychologists that attend incidents alongside police, the fire service and paramedics. Teresa Pacheco Tabuenca has been with the service since its earliest days and worked in the immediate aftermath of the bombings of the Madrid train network and Terminal 4 of Barajas airport. She talked to me about her work as an emergency responder and the development of disaster psychology in Madrid.

Could you tell us a little about the psychology emergency response team in Madrid?
The SAMUR-Protección Civil emergency services are part of the Madrid municipal government, and at first the service was just focused on physical health. However, in 1999 we saw the need for specialist attention in dealing with complex psychological situations, and so a team of voluntary psychologists was created within SAMUR, principally responsible for passing on bad news to relatives after traffic accidents.

Because of the evolution of emergency psychology and the success of the team, in 2003 the psychology emergency response team was formally created. It consists of six people, on call 24 hours a day, for any psychological emergencies that might occur. To ensure an effective and consistent response we have developed procedures for a range of diverse situations for which a psychologist might be required, including extreme anxiety reactions, overdose, communicating bad news, child abuse, sexual violence, multiple victim accidents and large-scale catastrophes.

We have three main areas of work: the first is organising psychosocial interventions in emergency or catastrophe situations (designing procedures, crisis interventions, and coordinating the volunteer psychologists); the second is with other members of the emergency services (training, psychological evaluations and treatment); and the third is research and education (we give presentations on our approach and results of our work in various pre- and postgraduate courses). Within the day-to-day running of the service, without counting major catastrophes, the service has attended more than 4500 incidents from 2004 to 2008.

What is your role in the service?
I attend to people who require psychological attention and psychosocial support after living through a critical incident, such as sudden death of a family member, a road traffic accident or sexual assault; I write reports and follow them up. I also work with members of the emergency services, such as the police or fire service, who may have been affected by an incident. I also coordinate training and monitor the performance of volunteer or trainee psychologists during incidents as well as giving lectures.

What do the other emergency services think of the team?
I think that in the last few years, their view of us has changed a great deal. Initially we were 'the unknown', that is to say, they didn't know what a psychologist could be useful for in an area where there weren't any before. However, I think the effectiveness of the service was demonstrated not only into the day-to-day running of the service, but also after the Madrid train bombings in 2004, the 2006 ETA terrorist attack on Terminal 4 of Barajas airport and in the recent Madrid plane crash. Multidisciplinary work is fundamental in our field, and if we don't work with other services, the response will remain incomplete. There is a phrase I read once which I think sums this up well: After the police, the paramedics and the fire service, a team of psychologists now promptly arrive at the scene of a disaster ready to collect the broken spirits.

What are the principles that you use in the treatment of trauma in emergency situations?
Our principles are drawn from the theories of Lindemann, developed after a fire that caused 492 deaths, where he studied the psychological and grief reactions in survivors. Also we use the work of Caplan on preventative psychiatry, focusing on secondary prevention, immediately after the incident has occurred. We work, in the majority of cases, about seven to ten minutes after the event. Both theories form the basis of our work, where the effectiveness of the care increases directly in relation to the proximity of the treatment in time and place.

The general principles are proximity: to act as close as physically possible to the location of the event to avoid stigmatising those affected by transferring them to a mental health clinic or hospital; and immediacy: to intervene as soon as possible to avoid the emergence of symptoms, or, in the case of certain reactions, to work with them. An example of this work would be in the case of sudden or unexpected deaths where feelings of guilt or denial often appear, or in cases of sexual violence where feelings of self-blame, feeling 'dirty' or fear can emerge. We also work with an expectation of coping, we communicate positive information about the capacity of the person to deal with the situation, activating their personal resources; and our interventions are based on the principle of simplicity so we rely on brief, simple methods adapted to the emotional state of the affected person. Finally, we focus on what we call unity, or the necessity to integrate and accept lived experience.

Which models of trauma have you found to be most useful in your work?
The models we use are far from the type used in structured consultation or therapy as we work in the here and now, in the same place where the event has occurred, only a few minutes after. However, we do use techniques from brief psychotherapies. Principally, the orientation is cognitive-behavioural, using, for example, relaxation techniques, distraction, cognitive restructuring, problem-solving and so forth. Also, psychoeducational work is very important: to communicate and normalise possible reactions that could occur in the short-, medium- and long-term; to allow identification of risk factors; to be the link between the first response team and the family and to pass on information about necessary tasks like the identification and collection of bodies, autopsies, and so on.

With regard to the limitations of our interventions, perhaps it is in following the longer-term progress of the patients we attend to. We follow up some patients by phone, depending on criteria to do with the type of incident, age, social support and their presentation, but not everyone is contacted. However, the follow-up serves to inform us about the progress of the patient, if there have been changes in various areas of their life (work, social, family, physical and mental health). In cases where it is possible to detect a problem, we can direct them to the most appropriate services.

The treatment of trauma immediately after the event has been a controversial topic in the academic literature. What is the evidence base for the approach of the psychological response team?
The team is pioneering in its approach, and we don't solely respond to large-scale situations, but to any situation with a high emotional impact. We treat the first step of the 'health assistance pyramid' in mental health [a stepped care approach], based on basic principles of crisis intervention. We intervene with people who have suffered a life event or a sudden or unexpected loss, by carrying out an in situ evaluation of the mental state of the person and their immediate reactions to the situation. We work with their form of emotional expression and their own coping skills, working with the onset of grief, feelings of guilt, denial, and so on. The ultimate objective of our work is prevention – detection of risk factors, intervention and referral to appropriate services if necessary.

However, we realise the importance of paying attention to the quality of our service, so we have a system for evaluation of our performance in the field, and we have a reporting system for the degree of care we provide and an annual assessment of user satisfaction. Furthermore, we also have an emergency psychology research group that evaluates our approach and gives rise to different lines of study.

What type of research is lacking in emergency psychology at the moment?
I think that because the field is quite new, there are many areas that would be extraordinarily interesting to research. The research in this area normally focuses on catastrophes and the reaction of first-response teams, their resilience, and so on. However, much remains to be studied – for example, immediate psychological reactions, coping strategies, the initial stages of shock in survivors of everyday emergency situations. The other area that seems interesting is the possibility of applying concepts from positive psychology in our area.

What are the most important qualities for a psychologist in the emergency response service?
An emergency psychologist has to have specific aptitudes, skills and knowledge – to be especially skilled in non-verbal communication, active listening and empathy, both to give instructions and to work face-to-face; the ability to make decisions under pressure; to be able to lead; to work in a team with professionals from diverse fields; emotional self-control, because we work with people experiencing extreme emotions; to have a high tolerance of frustration as the work is outside the office, in the here and now, where we improve the mental state of the person and help people cope with difficult and unfamiliar situations but without providing the relief of months of therapy; and to know how to formulate constructive self-criticism after each intervention. All of this must be on top of knowledge of protocols, first aid, material used during emergencies and catastrophes and psychological techniques specifically employed in the field (defusing, debriefing, EMDR, etc.).

What has been the most challenging situation in your work with SAMUR?
Personally, the most difficult situation that I have encountered was the Madrid train bombings. Spain had never experienced an incident of this nature and the communal suffering was immense and difficult to work with. On a personal and professional level, there is a before and an after that day.