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TG 545
Peace Corps
Technical Guideline 545
September 1, 2013
Page 1
The Volunteer
should be encouraged to speak with a licensed mental health professional with specific
evidence-supported trauma treatment expertise.
Many Volunteers are worried about what to say and how to handle the reactions of people
who know about their experience. The utmost care must be taken in observing medical
confidentiality and in respecting the privacy of the Volunteer. PCMOs play a role in
providing education to all non-medical staff involved of the confidentiality requirements.
3. PCMO RESPONSIBILITIES
The PCMOs responsibility is to attend to the immediate emotional and physical needs of
the Volunteer. The PCMO should:
Assure the Volunteers physical safety and help her gain a sense of control.
Offer calm acceptance of the Volunteers range of feelings, and provide psychoeducation
about post-trauma reactions, including reassurance that whatever the reactions are, the
Volunteer will be supported and helped.
Help the Volunteer identify people and things that she would find supportive and
comforting.
After any SAFE is performed, evaluate the Volunteers psychological and physical
condition. Refer to Technical Guideline 540 Clinical Management of Sexual Violence.
Maintain clinical notes regarding emotional support and counseling in a separate Sexual
Assault Medical record to attach to the regular Volunteer health record (See TG 540).
Identify locally trained counselors willing to complete specific online training (course
information provided by Peace Corps) in trauma-focused treatment; this will enable
them to meet Peace Corps standard for managing sexual assault survivors mental
health care (i.e., provide evidence-supported trauma-informed treatment);
Follow-up with the locally trained providers to identify those who have completed
recommended training, and are therefore ready to manage mental health care for
cases of sexual assault;
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Familiarize yourself with TG-545, especially the symptoms and assessment tools of
Acute Stress Disorder and PTSD.
Attend Peace Corps-sponsored and other continuing medical education avenues to
keep general counseling skills relevant, and to update knowledge and skills regarding
best practices for responding to sexual assault and other survivors;
Maintain psychoeducational material in the office on traumatic stress reactions, what
facilitates recovery, and services available to the Volunteer.
screening after a sexual assault is to normalize post-trauma reactions and to identify individuals
most at risk for developing PTSD (Gartlehner, et al., 2013)). It is normal for individuals to have
strong reactions in the immediate aftermath of an assault. More severe reactions are predictive of
post-trauma difficulties (Rothbaum, et al., 1992; Steenkamp, et al., 2012) .
The screening assessment begins to determine severity of reactions. It is a means for quantifying
traumatic stress reactions, and one way to attempt to identify potential problems in emotional
recovery post-assault. The screening process begins one of several opportunities to discuss and
educate the Volunteer on several topics: stress reactions, what facilitates recovery, and services
available to the Volunteer to support recovery.
Proactive discussion of emotional responses after an assault normalizes reactions, and gives
permission to the Volunteer to share concerns about her reactions. This also promotes recovery:
it discourages avoidance of memories, thoughts and feelings about the rape and denial of
psychological reactions; at the same time, it communicates acceptance of the Volunteer, her
experience, and her struggle to recover from the assault (Ehlers, Mayou & Bryant, 2003; Halligan,
Michael, Clark, & Ehlers, 2003; Koopman, Classen & Spiegel, 1994; Resick, Monson, & Chard, 2010; Ullman &
Filipas, 2001; Ullman, Townsend, Filipas & Starzynski, 2007).
Please Note: Most survivors immediately post assault will screen positive (i.e. have symptoms of
PTSD); only a few will be at risk for PTSD long term (Gartlehner, et al., 2013). In the immediate
aftermath (from 24 hours to one month post assault) a positive screen means further mental
health assessment, including assessment of Acute Stress Disorder (ASD) is warranted.
First, perform an overall mental health assessment.
A. Mental Health Assessment
The Mental Health Assessment and ASD/PTSD Screening requires a PCMOs
observations and the Volunteers responses to a series of questions.
o Volunteers appearance (can choose all that apply): Neat/groomed; appropriate dress;
poor hygiene; under/overweight; poorly nourished
o Volunteers behavior (can choose all that apply): Un/Cooperative, relaxed, agitated,
aggressive, suspicious, guarded, preoccupied, withdrawn, evasive, bizarre, tearful,
nervous
o Volunteers speech: Normal, soft, mumbled, loud, slurred, hostile, pressured
Office of Health Services
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o Affect (can choose all that apply): Restricted, cold, flat, superficial, labile, giggly,
apathetic, ambivalent, tense, anxious, apprehensive, worried, afraid, panicked angry,
enraged, ecstatic, euphoric, irritable, sad, depressed, hopeless, worthless
o Mood: Ask, How are you feeling? Document the PCVs reponse in their exact
words with quotation marks.
o Suicidal: Ask, Do you have feelings of wanting to hurt yourself?
If yes, ask, Do you have a plan on how you would hurt yourself?
If yes, ask, What is the plan and do you have access to the method (weapon,
drugs, rope, etc.)?
o Homicidal: Ask, Do you have feelings of wanting to hurt someone (e.g. assailant)?
If yes, ask, Do you have a plan on how you would hurt someone?
If yes, ask, What is the plan and do you have access to the method (weapon,
drugs, etc.)?
o Thought Processes: goal-directed, goes off topic easily, vague, repeats self, illogical,
flight of ideas, gives minimal answers, cant find words, loose associations
o Hallucinations: olfactory, tactile, visual, auditory, gustatory
o Delusions: Control, persecution, sexual, grandeur, religious, somatic
o Perceptions: Magical thinking, phobias, obsessive thoughts, impulse to perform
repetitive behaviors
o Orientation to person, place and time (do they know who they are, where they are,
and the date/time).
o Consciousness: clear, clouded, delirious, comatose, drowsy, lethargic/intoxicated
Second, assess for acute traumatic stress symptoms, acute stress disorder, and post traumatic
stress disorder in this order as assessment results indicate. Use the following assessment tools for
this purpose.
B. Assessing for General Acute Stress Symptoms, Acute Stress Disorder, and Post
Traumatic Stress Disorder
The PC-PTSD screening instrument (PC-PTSD; Prins, et al., 2003) is a good tool to use
in the INITIAL screening for posttraumatic stress reactions because it is short, it covers
the basic groups of posttraumatic stress reactions, and works well as a springboard for
discussion of the Volunteers emotional response to the assault. As you ask the questions
on the PC-PTSD screen, help the Volunteer understand these reactions, provide psychoeducation about stress reactions, and explore her experience of each symptom she
endorses.
1) Administer the Primary Care PTSD Screen (PC-PTSD)
a. Use the PC-PTSD to determine if the Volunteers reactions are in response to the
assault for which they are seeking care.
b. If the assault is recent, then alter the timeframe on the screening instrument (e.g.
if the assault happened last week, ask the Volunteer, In the past week, have you
had.(symptoms)?
c. Tell the PCV that you are going to administer a few questions that will help
determine the severity of the Volunteers reactions to the assault. This screening
tool is used by primary care clinicians to assess if a person may need extra
emotional support after a traumatic event.
d. You may either ask the questions by phone or in person or ask the Volunteer to
complete the instrument herself.
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Yes or No
Yes or No
Yes or No
Yes or No
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Provide concrete help (e.g. food, warmth, and shelter) (US Department of Veterans
Affairs, 2010).
Soothe and reduce states of extreme emotion (US Department of Veterans Affairs, 2010).
Increase controllability (US Department of Veterans Affairs, 2010).
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o Support the Volunteer as being in charge of when, to whom, where she talks
about the incident and other aspects of her personal history. The Volunteer should
be in charge of her history and tell it as she is able.
o Provide good information and psycho-education can help survivors make the
decisions they need to make. She needs to regain control of her life, starting with
the small decisions, such as what to take with her to the capital and where to stay
o Assist the Volunteer in making her own decisions regarding whether she wishes
to work within her own support network on her recovery, or her interest and
readiness to accept professional help from a trauma expert.
o Offer medical evacuation to Washington or home of record for counseling,
recuperation, and management of the trauma in a safe and familiar environment
o Discuss options with her:
Does she want to go to Washington for additional medical or psychological
support?
Does she want her family or friends notified?
Is there another Volunteer in the country who is able to provide companionship
and support?
As she is able, discuss any concerns about returning to her site. Should other
sites be considered?
She may be considering using annual leave or early termination instead of
medical evacuation. Reassure her that she is in control of these decisions, and
that medevac may be the best way for her to get help after an assault.
Assist survivors to help manage distress (US Department of Veterans Affairs, 2010).
o Provide psycho-education about trauma reactions, recovery post-trauma, and what
is known about what facilitates recovery (i.e., talking through the experience,
allowing feelings, talking about ones thoughts about why it occurred, etc).
o Provide psycho-education about the availability of highly effective treatments for
Volunteers who may struggle with post-trauma recovery, and that these
treatments may be available by phone in-country from COU staff, or in person
with COU staff via medevac to DC.
o Offer emotional support, and professional counseling (locally or with COU) as
appropriate.
o Consult COU if distress symptoms warrant consideration of medication
o See section 10 of this TG for further information about managing post traumatic
stress during a clinical examination.
Assist survivors on how to manage the repetitive, compulsive need to understand why it
happened or to attribute fault. (US Department of Veterans Affairs, 2010).
o Do not label the incident anything other than what the Volunteer calls it. If she
does not think a rape took place, but her history reveals that it does meet the
definition, do not use the term rape unless the Volunteer does. You may help her
to consider how not calling it an assault affects her thoughts and feelings and help
her understand that what one calls an upsetting event can affect ones recovery.
September 1, 2013
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Offer support to other Volunteers who may be experiencing guilt, anger, or anxiety in
relation to the assault.
Recognize that the sense of belonging to the Peace Corps community can be therapeutic.
Peace Corps affiliation is healing because it offers a group identity at a time when the
victims identity is temporarily shaken.
With the Volunteers permission, perform the PC-PTSD screening at these intervals to
assess for recovery status and to coincide with medical follow up testing:
Recommended Follow-up Services (if checked):
At 72 hours post assault:
PEP evaluation and tolerance (if PEP given)
Review of laboratory results (serum and cultures)
Assess mental and physical health
Perform a PC-PTSD
Give Hepatitis B booster
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At 2 weeks:
Repeat Pregnancy Test
Repeat Gonorrhea and Chlamydia test if symptomatic
CBC (if PEP given)
LFT (if PEP given)
Assess mental and physical health
At 4 weeks:
Perform a PC-PTSD.
HIV Test
At 8 weeks:
Repeat CBC and/or LFT if abnormal at 2weeks
Assess mental and physical health
Perform a PC-PTSD ( Can be done by phone if PCV not coming
into the office for medical testing.)
At 3 Months:
Serum test for Syphilis (VDRL or RPR)
HIV Test
Assess mental and physical health
Perform a PC-PTSD
At 6 Months:
HIV test
Hepatitis C Test
Assess mental and physical health
Perform a PC-PTSD
Research does not support encouraging the victim to repeatedly explain what happened
outside of the strict constructs of evidence-supported trauma treatment (Gartlehner, et al.,
2013) pp. 89, 96). Should the Volunteer express a desire to tell you, a trusted other or
writing about what happened may aid recovery. Volunteers should be encouraged to not
avoid thoughts, feelings and memories of the trauma.
Respect her wishes regarding the quality and quantity of communication with you.
Trauma experiences are often accompanied by feelings of grief and a sense of loss. The
Volunteer may have lost her sense of safety and security and may sense that shes lost her
way of life.
Encourage her to express all feelings regarding the assault, the assailant, and the
situation. Most reactions are understandable as related to traumatic assaults.
Recognize any fear, and respect it. Help her identify what is causing the fear, and
address any situations that still pose a threat. If fears are pervasive yet the Volunteer can
acknowledge she is not currently in danger, help her understand how fight/flight reactions
can fuel feelings of fear, and that this is normal and may persist for some time when
remembering the assault.
Recognize any feelings of anger and help her to identify its direction or target. Anger at
being helpless to prevent or stop the assault should be directed toward the assailant.
Volunteers who are distressed by their reactions may be offered a phone consult with a
therapist/trauma expert from COU. Explore this option the Volunteer at any timepoint in
the process.
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Increased use of alcohol and/or drugs or other means to decrease intrusive thoughts of the
trauma.
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Feelings of paranoia that other people are talking about her or laughing at her.
Speak in a calm, matter of fact voice and avoid any sudden movements
Reassure the Volunteer that she is in a safe environment, and although she is having a
reaction, she will be okay.
Explain that you are examining her asking permission to continue the examination.
If the Volunteer requests, stop the examination.
Ask the patient (or remind her) where she is.
Offer the patient a drink of water, an extra gown (to cover up), or a warm or cold
washcloth for her face.
If possible, go with her into a different room to provide a change of environment..
Understand the differences in how the PCMOs culture and American culture define and
legally manage rape and sexual assault. Knowing ones own cultural biasesand keeping
them to oneselfis very important when working with traumatized individuals.
Common inappropriate responses are denial, downplaying the trauma, and telling the
Volunteer that things really arent so bad.
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Volunteer that people who respond in such a way probably do not mean to judge as much
as they need to deal with their own anxiety about the event.
Some may respond with criticism or judgment of the Volunteer. In particular, some men
may be dealing with their own anxiety about the aggressive use of sexuality by members
of their own sex. Men who are able to respond with sensitivity and understanding may
have a particularly helpful effect in providing support.
When working with a Volunteer, if the PCMO senses culture is interfering with
understanding of the situation or the ability to comfort the Volunteer, the PCMO should
feel free to (and be encouraged to) connect the Volunteer to COU for a consult. High
distress can exacerbate cultural and language differences straining communication and
the patient-provider relationship.
Take care of yourself. Recognize how hard it is to provide this kind of support and care.
Be sure to allow yourself some space, distance and support when managing a sexual
assault. Be informed about the effects of vicarious trauma.
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