Providing Crisis Intervention at School: A Team Effort

Transcription

1 Providing Crisis Intervention at School: A Team Effort How Peers, Parents, Teachers, and School and Community Based Mental Health Professionals Can Help Students Cope With Crises Stephen E. Brock, Ph.D., NCSP, LEP California State University, Sacramento Sacramento City Unified School District November 7 & 15,

2 Providing Crisis Intervention at School: A Team Effort Adapted from the California Association of School Psychologist s School Crisis Interventions Workshop by Stephen E. Brock, Ph.D., NCSP California State University, Sacramento Shane R. Jimerson, Ph.D., NCSP University of California, Santa Barbara Richard Lieberman, M.A., NCSP Los Angeles Unified School District Ross Zatlin, M.S., NCSP Sweetwater Union High School District Lee Huff, M.S., NCSP Huntington Beach Union High School District 2

3 An Introduction to School Crisis Intervention This introduction provides a brief overview of The Standardized Emergency Management System (SEMS) and how school crisis intervention fits into the larger school crisis response. The Elements of School Crisis Intervention to be explored during this Workshop. 3

4 School Crisis Response School crisis intervention is one part of the comprehensive school crisis response. The Standardized Emergency Management System (SEMS) is a commonly used crisis response system. SEMS is used to centralize, organize, and coordinate a school s response to a critical incident. It follows the organizational structure of the Incident Command System (ICS). The SEMS model can be used to show how school crisis intervention fits into the comprehensive school crisis response. 4

5 Crisis Intervention as a Part of the Comprehensive School Crisis Response The Incident Command Structure (ICS) has five leadership roles 1. Incident Command (Managers) 2. Plans/Intelligence Section (Thinkers) 3. Operations Section (Doers) Student Care Coordinator Crisis Intervention Specialist 4. Logistics Section (Getters) 5. Administration & Finance Section (Payers) 5

6 Crisis Intervention as a Part of the Comprehensive School Crisis Response E m e rgen c y Ope rati on s C e nt e r D ire ctor / S choo l Inc iden t Co mm ande r C ri sis M anage m en t Te am Public Inform ation O fficer Safety O fficer Li a ison O ffi ce r (Th inkers) Intelligence Section (Doer s) Ope rati ons Section (Ge tters) L ogi sti cs Section (Pay ers) Fi nance Section S ecu rit y and S af et y F ac iliti es St uden t C ar e Emergen cy Medical S upp li es and E quip me nt St aff & Co mm un it y Vo lun tee r A ss ign m en t T ran sl ati on Co mm un ica ti on s 6

7 Operations Section Flowchart (Doers) School Operations Section Chief School Security and Safety Coordinator School Student Care Coordinator School Emergency Medical Coordinator School Translation Coordinator Facilities & Grounds Specialist Search, Rescue & Accounting Specialist Crowd Management Specialist Traffic Safety Specialist Crisis Intervention Specialist Student Assembly & Release Specialist Shelter, Food, Water & Supplies Specialist First Aid Specialist Morgue Specialist 7

8 The Elements of School Crisis Interventions Immediate Prevention Protect from harm/danger Minimize crisis exposure Ensure actual and perceived safety Support System Re-establishment Reunite with/locate primary caregivers Reunite with/locate close friends and teachers Facilitate community communication Return to school 8

9 The Elements of School Crisis Interventions Risk Screening & Referral (AKA triage) Initial risk screening Individual risk screening School-wide screening Referral Mental Health Financial (clothes, food, shelter) Legal American Read Cross Federal Emergency Management Agency (Victim/Witness) 9

10 The Elements of School Crisis Interventions Psychological Education Psycho-educational crisis groups Caregiver training Mass Education Disseminate informational handouts Media disseminated psycho-education Psychological Interventions Psychological first aid Individual Group Psychotherapy 10

11 The Phases of School Crisis Group cr Intervention Psych. Interventions Psychological first aid Psychological Education Psycho-educationgroups Caregiver tra inings Different Informational interventions flyers Informational flyers take RiskScr ening & Refe ral place during Initial scree ning different Individual screen ing phases of a crisis Support Systems Reunite with/locatecareg ivers and lovedones Psychological first aid isis debriefings Psychotherapy Crisis prevention and readine s Psycho-educationgroups Caregiver tra inings Referra l procedures School wide screen ing Reunite with friends & eacher t s Returnto school Crisis prevention/prepare dness Anniversary react ion support Psychotherapy Anniversary preparedne s Caregiver tra inings Informational flyers Individual screen ing Immediate Prevention Protect from harmand danger Minimize cr isis exposure Ensure ac tual and percei ved safety Crisis Preparedness Crisis education Crisis drills Crisis planning Preimpact The period before the crisis Impact During the crisis Recoil Immediately after thecrisis Postimpact Days toweeks after the crisis Recovery/Reconstru ction Months/years afterthecrisis 11

12 Workshop Agenda & Key Questions 1. Characteristics of Crises What are the events that require crisis intervention? 2. Consequences of Crises What are the consequences of crises? What consequences can be addressed by natural caregivers? What consequences require a school/communitybased mental health response? 12

13 Workshop Agenda & Key Questions 3. Psychological Triage How are crisis victims identified? Among these victims who can be supported by natural caregivers? who will require mental health intervention? 4. Crisis Interventions What are the different school crisis interventions? Where does school crisis intervention end and mental health intervention begin? 5. Care for the Caregivers How do we take care of ourselves during crisis interventions? 13

14 Characteristics of Crises What are the events that require crisis intervention? Adapted from S. E. Brock & S. R. Jimerson. (2004). Characteristics and consequences of crisis events: A Primer for the school psychologist. In E. R. Gerler Jr. (Ed.), Handbook of school violence (pp ). Binghamton, NY: Haworth Press. 14

15 Crisis Event Characteristics For an event to be a crisis it must be perceived as Extremely negative Involves actual and/or threatened death/physical injury. Uncontrollable Difficult to stop, mitigate, or predict. Depersonalizing Is not sensitive to status, wealth, power, or position. Sudden and unexpected Typically occurs without warning. 15

16 Crisis Events Acts of war (e.g., terrorism) Violent deaths (e.g., homicide, suicide) Criminal acts (e.g., robbery, kidnapping) Unexpected natural deaths (e.g., heart attack) Industrial accidents/disasters (e.g., electrical fires, dam failures) Natural disasters (e.g., earthquake, tornado) Severe illnesses (e.g., cancer) Accidental injuries (e.g., car accident, burns) 16

17 Variables That Affect Traumatic Potential Disaster Type Natural disasters are typically less traumatic than are man-made disasters or human caused crises. Source of Threat/Injury Physical threat or injuries due to accidents/illness are less traumatic than are threats and/or injury due to assaultive violence. Fatalities Crises resulting in non-fatal trauma to significant others are less traumatic than are events that result in sudden and unexpected death. In addition, events that involve sudden and unexpected death will be complicated by grief reactions. 17

18 Consequences of Crises What are the consequences of crises? What consequences can be addressed by natural caregivers? What consequences require a school/community mental health response? Adapted from S. E. Brock & S. R. Jimerson. (2004). Characteristics and consequences of crisis events: A Primer for the school psychologist. In E. R. Gerler Jr. (Ed.), Handbook of school violence (pp ). Binghamton, NY: Haworth Press. 18

19 Effects of Crises on School Functioning The success of school crisis intervention can be assessed by measuring these variables. Academic achievement drops School absenteeism increase School behavior problems increase Aggressive behaviors Delinquent Criminal 19

20 Common vs. Pathological Distress A distinction needs to be made between common and pathological crisis related distress. Unless there is pre-existing psychopathology, it is assumed that initial crisis reactions are typical responses to abnormal circumstances (NIMH, 2001). Natural caregivers are the appropriate initial crisis interveners for students with common distress reactions. Mental health professionals are required when pathological distress is demonstrated. 20

21 Adaptive vs. Maladaptive Coping Crises are times of both danger and opportunity. The strategies developed to cope with these events can be either adaptive or maladaptive. Natural caregivers are the appropriate initial crisis interveners for students making adaptive coping efforts. Mental health professionals may be required when maladaptive coping is utilized by a crisis victim. 21

22 Common Distress Reactions Emotional: shock, anger, despair, emotional numbing, terror, guilt, phobias, depression, grief, helplessness/hopelessness, loss of pleasure from activities, dissociation. Cognitive: impaired concentration, decision making ability and memory, disbelief, confusion, distortion, decreased self-esteem and self-efficacy, self-blame, intrusive thoughts and memories, worry. 22

23 Common Distress Reactions Physical: fatigue, insomnia, hyperarousal, somatic complaints, impaired immune response, headaches, gastrointestinal problems, decreased appetite, decreased libido, startle response. Interpersonal/Behavioral: alienation, social withdrawal, increased relationship conflicts, vocational/school impairment, avoiding reminders, crying easily, change in appetite. 23

24 Mental Health Referral Indicators Signs of psychopathology include EXTREME crisis reactions. Dissociation Intrusive re-experiencing Avoidance Hyper-arousal Anxiety Depression Psychotic Symptoms Mental health referral indicators also include common crisis reactions that occur for more than 4 weeks. 24

25 Mental Health Referral Indicators Maladaptive coping includes Extreme substance abuse Homicidal ideation Self-medication Inappropriate anger towards others Suicidal ideation Physical abuse of self (e.g., cutting) and/or others (e.g., fighting). 25

26 Crisis Event Consequences: Positive Outcomes of a Crisis Event Activity In small groups identify some of the positive outcomes (or the opportunities) that may result from a crisis event. Identify potential positive outcomes for both individuals as well as the school (or school district). 26

27 Psychological Triage: Risk Screening and Referral Adapted from S. E. Brock. (2002). Identifying psychological trauma victims. In S. E. Brock, P. J. Lazarus, & S. R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp ). Bethesda, MD: National Association of School Psychologists. 27

28 Psychological Triage The process of evaluating and sorting victims by immediacy of treatment needed and directing them to immediate or delayed treatment. The goal of triage is to do the greatest good for the greatest number of victims (NIMH, 2002, p. 27). 28

29 The Rationale for Risk Screening 1. Risk screening is offered in response to the fact that not all individuals will be equally affected by a crisis event and that different individuals will likely require different interventions. 2. In addition, it is important to acknowledge that when it comes to crisis intervention one size does not fit all. 29

30 The Rationale for Risk Screening 3. While virtually anyone with sufficient exposure to a traumatic event will display initial crisis reactions: A sensible working principle in the immediate post-incident phase is to expect normal recovery. The presumption of clinically significant disorders in the early postincident phase is inappropriate, except for individuals with preexisting conditions (NIMH, 2001, p. 6, emphasis added). 30

31 The Rationale for Risk Screening 4. While the need to identify and assist students who are in need of support is readily apparent, less obvious is the need to identify students who may not require assistance and to allow them to manage the crisis independently. a) Providing crisis intervention assistance to students who do not need it may unintentionally send the message that they are not capable of coping with the crisis independently. b) It may also stigmatize individuals or generate self-fulfilling prophecies. 31

32 The Rationale for Risk Screening Population exposed to a crisis Individuals effected by a crisis. Needs meet by social supports Individuals effected by a crisis. Needs meet by school psychological interventions. Individuals effected by a crisis. Need psychotherapy. 32

33 Individual Crisis Experience Variables Physical Proximity: Where were individuals when the crisis occurred (how close were they to the trauma)? High Risk for Psychological Trauma. Those who required medical or surgical attention (NIMH, 2002). Those who had exposures that were particularly intense and of long duration (NIMH, 2002). Lower Risk for Psychological Trauma Those who were more physically distant from the crisis. 33

34 Individual Crisis Experience Variables Residence between 110 th St. and Canal St., 6.8% report PTSD symptoms. Residence South of Canal St, 20% report PTSD symptoms. Those who did not witness the event, 5.5% report PTSD symptoms. Those who witnessed the event, 10.4% report PTSD symptoms. Source: Galea et al. (2002) 34

35 Individual Crisis Experience Variables On Playground In School On Way Home 8.6 In Neighborhood At Home Absent 5.4 Out of Vicinity For seven levels of exposure, the number of posttraumatic stress symptoms increased as the degree of exposure increased. Analysis of variance indicated that there are significant differences between mean Reaction Index scores for children grouped by exposure level (F = 16.06, df = 6, p <.001) (Pynoos, et al., 1987, p. 1059). 35

36 Individual Crisis Experience Variables 60% 50% 49% 50% 56% 56% 40% 30% 20% 10% 6% 17% 29% 11% 22% 17% 19% 19% 7% 28% 13% 5% 0% Playground At School Not at School Off Track No PTSD Moderate PTSD Mild PTSD Severe PTSD Using PTSD Reaction Index categories (< 7 = no PTSD; 7 to 9 = mild; 10 to 12 = moderate; > 12 = severe),... a χ 2 analysis indicated significant differences in the proportion in these categories across the four exposure levels (χ 2 = 61.5, df = 9, p = <.001) (Pynoos, et al., 1987, p. 1059). 36

37 Individual Crisis Experience Variables Emotional Proximity: Relationship(s) with victim(s) After physical proximity, emotional proximity is the next most powerful predictor of crisis reactions. Individuals who have/had close relationships with crisis victims should be made crisis intervention treatment priorities. Those who are bereaved are an especially high risk group (NIMH, 2002). 17.8% of Manhattan residents who had a friend or relative killed on 9-11 reported symptoms of depression 5-8 wks after the attack [vs. 8.7% who did not suffer such a loss (Galea et al., 2002)]. 37

38 Individual Crisis Experience Variables Emotional Proximity: Perceived threat Subjective impressions can be more important than objective crisis facts. Traumatized individuals will have perceived the event as extremely negative. Adult reactions are important influences on children s threat perceptions. Developmental immaturity can be protective (because of social, emotional, and cognitive development, young children may not perceive an event as traumatic). 38

39 Initial crisis reactions Extreme stress reactions will adversely influence the capacity to adaptively respond. Particular attention should be directed toward those who panic or dissociate during the trauma. have been diagnosed with Acute Stress Disorder (NIMH, 2002). have ongoing difficulty regulating their arousal levels. 39

40 Personal Resiliency and Vulnerability Internal Resiliency Variables Active coping style. Mental health. Good self regulation of emotion. High intellectual functioning and problem solving skills. 40

41 Personal Resiliency and Vulnerability Internal Vulnerability Variables Avoidance coping style. Pre-existing mental illness (NIMH, 2002). Poor self regulation of emotion. Low developmental level and poor problem solving skills. History of prior psychological trauma. WTC/9-11 survivors (Manhattan residents) No trauma history 4.2 report PTSD. 2+ stressful events during 12 months prior to the attacks, 18.5 reported PTSD. No trauma history 5.6% report depression. 2+ stressful events during 12 months prior to the attacks, 24.1% reported depression (Galea et al., 41

42 Personal Resiliency and Vulnerability Other Internal Factors Self confidence and esteem. Locus of control. Resilient faith or belief system. 42

43 Personal Resiliency and Vulnerability External Resiliency Variables Familial resources Living with nuclear family member. Effective & caring parenting (e.g., sensitivity and responsivity). Extended family relationships and guidance available. Caregivers cope well with trauma. Access to support services and resources (including financial resources). Social resources Close peer friendships. Access to positive adult models. Connection with pro-social institutions. 43

44 Personal Resiliency and Vulnerability External Vulnerability Variables Familial resources Not living with nuclear family. Ineffective & uncaring parenting. Family dysfunction (e.g., alcoholism, violence, mental illness). Parental PTSD. Child maltreatment. Poverty/Financial Stress. Social resources Social isolation. Lack of perceived social support. 44

45 Summary: Factors Involved in Psychological Trauma Crisis Event Crisis Experience & Reactions Personal Vulnerability Psychological Trauma 45

46 Psychological Triage Tools Private Practitioner Referral Questionnaire. Psychological Triage Checklist Initial Risk Screening Summary Secondary Risk Screening Summary Referral Form Triage Summary Sheet Available in Brock, S. E., Sandoval, J., & Lewis, S. (2001). Preparing for crises in the schools: A manual for building school crisis response teams. New York: Wiley 46

47 Risk Screening Practice In small groups discuss the crisis situations listed in your handout with regard to important risk screening and referral issues. Record your thoughts and be prepared to share them with the larger group. 47

48 The Importance of Psychological Triage J. E. Ormrod (1999) 1 With the effects of teacher expectations in mind, we should note that teacher assistance,while often a valuable source of scaffolding on difficult tasks, may be counter productive if students don t really need it. When students struggle temporarily with a task, the unsolicited help of their teacher may communicate the message that they have low ability and little control regarding their own successes and failures. In contrast, allowing students to struggle on their own for a reasonable period of time conveys the belief that students do have the ability to succeed on their own. (p. 451) 1 Ormrod, J. E. (1999). Human learning (3rd ed.). Upper Saddle River: NJ: Prentice Hall 48

49 School Crisis Interventions Adapted from Brock. S. E., & Jimerson, S. R. (2004). School crisis interventions: Strategies for addressing the consequences of crisis events. In E. R. Gerler Jr. (Ed.), Handbook of school violence (pp ). Binghamton, NY: Haworth Press. 49

50 School Crisis Interventions 1. Immediate Prevention Protect from harm/danger Minimize crisis exposure Ensure actual and perceived safety 2. Support System Re-establishment Reunite with/locate primary caregivers Reunite with/locate close friends and teachers Facilitate community communication Return to school 50

51 School Crisis Interventions 3. Psychological Education Psycho-educational crisis groups Caregiver training Mass Education Disseminate informational handouts Media distributed education 4. Psychological Interventions Psychological first aid Individual Group Psychotherapy 51

52 Immediate Prevention Rationale and Goal These are techniques that occur during the impact and recoil phases. The need for these activities is documented by research that demonstrates the relationship between degree of exposure to a crisis event and subsequent stress reactions. Primary goals are to mitigate 1. physical harm 2. emotional harm. 52

53 Specific Immediate Prevention Techniques 1. Remove students from dangerous/harmful situations Implement disaster/crisis response procedures (e.g., evacuation, lockdown, etc.) 53

54 Specific Immediate Prevention Techniques 2. Minimize exposure to crisis images. Direct ambulatory students away from the crisis site. Do not allow students to view medical triage. Restrict television viewing. Gurwitch et al. (2002) suggested that following the 95 Oklahoma City bombing, children who were not physically or emotionally proximal to the bombing, but who reported having had extensive television viewing of the event, also reported having a higher number of traumatic stress symptoms than did other children who reported lower amounts of such viewing. 54

55 Specific Immediate Prevention Techniques 3. Restore both actual and perceived safety. It is not enough for students to actually be safe following a crisis. For recovery to begin, students must believe that the potential for harm has past and that they are no longer in any danger. Thus, it is important to make certain that the steps taken to ensure student safety following crises are not only effective, but also concrete and visible (e.g., having a strong police presence on campus following acts of violence). 55

56 Re-establishment of Social Supports Individuals with strong familial and social support systems are better able to cope with life stressors than those without such supports. Among elementary grade students who survived a hurricane it was found that higher levels of social support were associated with lower levels of traumatic stress reactions. Among adults living in Manhattan, higher levels of pre-existing social support was associated with lower levels of PTSD and depression. 56

57 Re-establishment of Social Supports Given expectations for recovery, re-establishing and empowering social support systems should be a primary school crisis intervention. These support systems include family, peers, and other community-based organizations with whom the individual is affiliated. Other school crisis interventions should complement the assets of naturally occurring social support systems, and/or be prepared to pick-up where they leave off. In other words, provide assistance to students who either have inadequate social support and/or are so affected by the crisis that natural support systems are insufficient. 57

58 Re-establishment of Social Supports Social support systems have certain limitations and may not be able to meet the needs of all crisis victims Some crisis victims may be so severely traumatized that they will need psychotherapy. Some social supports may be significantly affected by the crisis themselves and thus not able to support crisis victims. 58

59 Re-establishment of Social Supports: Specific Techniques 1. Reunite students with primary caregivers (during the Recoil Phase). Priority should be given to reuniting younger children with their parents. Preschool and kindergarten age children show the strongest reactions (when compared to older students) when separated form parents during stressful events. Following an earthquake preschool children showed more behavior problems if they had been separated from their parents during the quake. 59

60 Re-establishment of Social Supports: Specific Techniques 2. Reunite students with their close friends, teachers, and classmates (during the Recoil and/or Postimpact phases). Children report friends as primary providers of emotional processing coping. Consider the importance of peer relations during adolescence. Teachers are also reported to be important social supports. 60

61 Re-establishment of Social Supports: Specific Techniques 3. Return students to school and familiar routines as soon as possible. Children s self reports reveal an association between more severe traumatic stress symptoms and relative lack of a return to pre-disaster roles and routines. Significantly higher disaster related fear and school problems are found among children who were evacuated and unable to return to their community (as compared to those were either not evacuated or who were evacuated but had returned to the community). 61

62 Re-establishment of Social Supports: Specific Techniques 4. Facilitate communication among families, students, and community agencies and organizations and encourage use of social supports. Levels of depression among 3rd, 4th, and 5th graders were lower among those students who had sought out social support (vs. those who did not seek such support). 62

63 Re-establishment of Social Supports: Specific Techniques 5. Provided psycho-education (which will be discussed in greater depth as a separate crisis intervention). Empower caregivers (parents, teachers, and students themselves) with the information needed to be a productive social supports provider. 63

64 Re-establishment of Social Supports: Small group discussion From the information just presented identify ways that you might be able to facilitate the reestablishment of social support systems. What are some thoughts you have on how school crisis intervention can help to ensure the reestablishment of social supports. Discuss this in small groups and be prepared to later share your discussions in the larger group 64

65 Psycho-education Psycho-education includes a variety of activities provided primarily during the Recoil and Postimpact phases. During Recovery and Reconstruction phase these activities are also designed to predict and prepare the school community for anniversary reactions. The primary goal is to help students, staff, and parents acquire knowledge that assists them in understanding, preparing for, and responding to the crisis, and the problems and reactions it generates. 65

66 Psycho-education Study of elementary school children in Oklahoma City following the bombing of the Murrah building highlights the importance of these interventions. Especially among younger children, a lack of understanding of the event was observed, confusion most likely, and more incorrect beliefs held. In addition, this same study highlights the need to provide students (particularly younger children) with adaptive coping strategies, as this group was most likely to use avoidance as a coping mechanism. 66

67 Psycho-education: Specific Techniques 1. Psycho-educational groups Are directive and involve dissemination of information designed to understand the crisis and facilitate coping with crisis problems and reactions. 67

68 Psycho-education: Psycho-educational Groups Subgoals include: Crisis facts are understood and rumors are dispelled. Students understand the event. Common crisis reactions are normalized. Students are prepared for reactions that might be seen in themselves or among their peers. Stress management strategies are identified and/or taught. Students develop their own plan for coping with crisis reactions. Problematic (psychopathological) crisis reactions and coping strategies are discussed and referral procedures identified. Students are able to identify psychopathological reactions and coping strategies, and know how to make referrals for professional assistance. 68

69 Psycho-education: Psycho-educational Groups Group Outline Introduce (students to the lesson) Answer (questions and dispel rumors) Prepare (students for the reactions that may follow crisis exposure) Teach (students how to manage crisis reactions) Close (the lesson by making sure students have a crisis reactions management plan) 69

70 Psycho-education: Psycho-educational Groups Introduce (students to the lesson) Approximate duration: 5 min. Goals: Explain the purpose of the lesson Identify facilitators Introduce process/steps Review/Establish rules 70

71 Psycho-education: Psycho-educational Groups Answer (questions and dispel rumors) Approximate duration: 20 min. Goals: Answer questions Stop rumors Strategies: Discussion Repetition Caution: Information transmission of PTSD. Don t give students unasked for details about the crisis that could be frightening 71

72 Psycho-education: Psycho-educational Groups Prepare (students for the reactions that may follow crisis exposure) Approximate duration: 15 min. Goals: Identify and prepare students for common crisis reactions Normalize reactions Strategies: Teach common crisis reactions Teach the normality of reactions Clarify self-referral procedures 72

73 Psycho-education: Psycho-educational Groups Teach (students how to manage crisis reactions) Approximate duration: 15 min. Goals: Identify coping strategies that will help to manage crisis reactions Take some kind of action Strategies: Teach stress management Identify accessible supports Brainstorm prevention strategies 73

74 Psycho-education: Psycho-educational Groups Close (the lesson by making sure students have a crisis reactions management plan) Approximate duration: 5 min. Goals: Ensure that students know how to obtain assistance. Strategies: Have students develop self care plans Be positive about the ability to cope Summarize what has been learned 74

75 Psycho-education: Caregiver trainings Very similar to the psycho-educational group, however, its focus is on caregiver knowledge. These gatherings are also typically very directive and involve the dissemination of information that will help parents, teachers, and other caregivers to effectively support their children. The importance of this type of psycho-education is documented by research suggesting that among adult sexual assault survivors, it was empathic reactions occurring early after the assault were associated with more successful coping than were non-empathic reactions. Thus, it would appear that at least among some groups of trauma victims, there are certain types of care giving reactions that are helpful and certain types that are not. 75

76 Psycho-education: Caregiver trainings Specifically, these gatherings hope to achieve the following goals: Crisis facts are understood and rumors are dispelled. Caregivers have the facts needed to help children understand the crisis event. Common crisis reactions are normalized. Caregivers are prepared for common crisis reactions that might be seen in their children and/or among themselves. Stress management strategies are identified and/or taught. Caregivers are given tools that can be used to help their children cope with crisis reactions and/or problems. 76

77 Psycho-education: Caregiver trainings (goals continued ) Specific helpful reactions (i.e., empathetic reactions) to children s traumatic stress are identified. Caregivers are instructed on how to best respond to their children. This includes educating them about the importance of their own crisis reactions in shaping their child s perceptions of the crisis event. Parental reactions to disaster are better predictors of child post-traumatic stress reactions, than is direct exposure to the disaster. 77

78 Psycho-education: Caregiver trainings (goals continued ) Problematic crisis reactions and coping strategies are discussed and referral procedures identified. Caregivers are able to identify psychopathological reactions and coping strategies, and know how to make referrals for professional assistance Caregivers understand the crisis, are prepared for possible crisis reaction (both in themselves and among students), acquire strategies for supporting students, and know how to make referrals for additional support 78

79 Suggestions for Caregivers: How to Help Children Cope (NIMH, 2001) 1. Give yourself a bit of time to come to terms with the event before you attempt to reassure children. 2. Take care of yourself so that you can take care of children. 3. Explain the episode of violence or disaster. Replace crisis rumors with crisis facts. At the same time, however, do not give children unasked for details that might increase their threat perceptions. 4. Encourage children to express their feelings and listen without passing judgment. 5. Let children know that it is normal to feel upset. 79

80 Suggestions for Caregivers: How to Help Children Cope (NIMH, 2001) 6. Allow time for children to experience and talk about their feelings. 7. Don t try to rush back to ordinary routines too soon. However, a gradual return to routine can be reassuring. 8. If children are fearful, reassure them that you will take care of them. 9. Stay together as much as possible. 10. If behavior at bedtime is a problem, give children extra time and reassurance. Let him or her sleep with a light on or in your room for a limited time if necessary. 11. Reassure children that the traumatic event was not their fault. 80

81 Suggestions for Caregivers: How to Help Children Cope (NIMH, 2001) 12. Do not criticize regressive behavior or shame children with words like babyish. 13. Do your best to let children know that you understand their perception of the crisis event. Try to put yourself in their shoes. 14. While it is important to understand children s crisis event perceptions, it is also important to correct misperceptions. 15. Allow children to cry or be sad. 16. Encourage children to feel in control. Let them make some decisions about meals, what to wear, etc. 17. Encourage children to develop coping and problem solving skills and age-appropriate methods for managing 81

82 Psycho-education: Informational bulletins or handouts Informational handouts are made available (through the school and/or the media) that facilitate understanding of the crisis and its possible effects, and identify available supports. Parallel/Complement/Supplement the information disseminated through psycho-educational groups and caregiver trainings. Designed to facilitate understanding of the crisis event, predict possible crisis consequences, and to identify available supports. See attached for an example Go to for a collection 82

83 Psycho-education: Anniversary preparations o These activities may employ group discussion and/or informational handouts. o The primary goal is to ensure that students, staff, and caregivers are prepared for the possible effects of crisis anniversaries and other significant dates. 83

84 Psychological Interventions o Crisis intervention techniques are not psychotherapy, nor a substitute for psychotherapy. o more complex interventions for those individuals at highest risk may be the best way to prevent the development of PTSD following trauma (Bisson et al., 2000, p. 54). o They are best conceptualized as a form of first aid. Thus, the term psychological first aid. o While for minor injuries these interventions will be sufficient, for major injuries they will be only the first step in the treatment process. 84

85 Psychological Interventions: Group Psychological First Aid (GPFA) o GPFA (AKA Debriefing, Group Crisis Intervention) is typically provided during the Postimpact phase. o GPFA activities are very similar to psycho-educational groups. However, unlike psycho-educational groups, GPFA actively explores and processes individual crisis experiences and asks for sharing of individual crisis reactions. These interventions hope to help students feel less alone and more connected to classmates by virtue of common experiences/reactions. They also help to normalize experiences and reactions. GPFA can assist in the process of psychological triage. 85

86 Psychological Interventions: Group Psychological First Aid (GPFA) GPFA has recently been the subject of empirical investigation. However, no study has focused on children. Furthermore, generalization is difficult, because of the unique effects of different types of exposure to different types of crisis events. Some have suggested that the available data does not support the continued use of GPFA following crises. 86

87 Psychological Interventions: Group Psychological First Aid (GPFA) Conclusions about GPFA: Promising when used as a more involved (more than 60 min. and/or combined with other interventions) intervention. as a group intervention. with adults who have experienced a crisis, but were not physically injured. 87

88 Psychological Interventions: Group Psychological First Aid (GPFA) Conclusions about GPFA: Contraindicated as a brief (less than 60 min.) intervention. as a stand alone (one-off) intervention. as an individual (1:1) intervention. for adult acute physical trauma victims. 88

89 Psychological Interventions: Group Psychological First Aid (GPFA) Considerations Who should participate? What is the optimal size? Where should GFPA be offered? When should GPFA be offered? Who are the GPFA facilitators? What is the role of the teacher? The need for follow-up. GPFA contraindications. 89

90 Psychological Interventions: Group Psychological First Aid (GPFA) Elements for GPFA Introduction Provide Facts and Dispel Rumors Sharing Stories Share Reactions Empowerment Closing 90

91 Psychological Interventions: Group Psychological First Aid (GPFA) Goals of GPFA 1. Understand the trauma 2. Make sense of their experiences/reactions 3. Learn how to cope 4. Begin took forward 91

92 Psychological Interventions: Group Psychological First Aid (GPFA) Introduction Approximate duration: 15 min. Goals: Explain the purpose of GPFA Identify facilitators Introduce process/steps Review/Establish rules 92

93 Psychological Interventions: Group Psychological First Aid (GPFA) Provide Facts and Dispel Rumors Approximate duration: 30 min Goals: Provide understanding of facts Stop rumors Strategies: Discussion Newspapers Repetition Caution: Information transmission of PTSD 93

94 Psychological Interventions: Group Psychological First Aid (GPFA) Sharing Stories Approximate duration: 45 min. Goals: Facilitate expression of experiences Identify common experiences Strategies: Ask for volunteers Move around the classroom Art activities Validate experiences Identify commonalties 94

95 Psychological Interventions: Group Psychological First Aid (GPFA) Share Reactions Approximate duration: 30 min. Goals: Facilitate expression of reactions Identify common reactions Normalize reactions Strategies: Teach common crisis reactions Ask survivors to share reactions Point out commonalties Teach the normality of various and varied reactions Mention self-referral procedures 95

96 Psychological Interventions: Group Psychological First Aid (GPFA) Empowerment Approximate duration: 60 min. Goals: Move from sharing to solving Identify coping strategies Take some kind of action Strategies: Teach stress management Identify accessible supports Brainstorm prevention strategies 96

97 Psychological Interventions: Group Psychological First Aid (GPFA) Closing Approximate duration: 30 min. Goal: Begin to look forward Strategies: Prepare for funeral attendance Supervised memorial development Creating cards, writing letters Deciding what to do with belongings Be positive about the ability to cope Summarize what has been learned Reiterate self-referral procedures 97

98 Psychological Interventions: Group Psychological First Aid (GPFA) Post GPFA Activities Communicate with families (psycho-education) How to help their children cope How to make referrals Continue to be visible Spend time on the playground Drop in on the class Be present when students are entering school Continue psychological triage Who needs psychotherapy? Who needs grief support services? Support each other Crisis interveners are affected Arrange appropriate debriefing sessions Provide additional support as appropriate 98

99 Psychological Interventions: Individual Psychological First Aid Goal Re-establish immediate Coping Subgoals: Provide Support Reduce lethality Link to resources 99

100 Psychological Interventions: Individual Psychological First Aid Elements of Individual Psychological First Aid Make Psychological Contact Explore Dimensions of Crisis Problems Examine Possible Solutions to Crisis Problems Assist in Taking Concrete Action Follow-Up 100

101 Psychological Interventions: Individual Psychological First Aid 1. Make Psychological Contact Empathy Facts and Feelings are identified Respect Pausing to listen Not trying to smooth things over Not dominating the conversation Warmth Non-verbals Touch Explore Dimensions of Crisis Problems 101

102 Psychological Interventions: Individual Psychological First Aid 2. Direct inquiry about immediate past (crisis precursors) present (the crisis story) immediate future (crisis problems) Goals identify crisis problems identify future concerns 102

103 Psychological Interventions: Individual Psychological First Aid Demonstration of individual psychological first aid This crisis situation begins with an intermediate grade student, Chris, crying in a corner of a school yard, just out of view of the playground. Two days earlier, Chris had witnessed a school yard shooting. 103

104 Psychological Interventions: Individual Psychological First Aid 3. Examine Possible Solutions to Crisis Problems Ask about coping attempts already made. Facilitate exploration of additional coping strategies. Propose other alternatives. Note: Survivors do as much as they can by themselves. 104

105 Psychological Interventions: Individual Psychological First Aid 4. Assist in Taking Concrete Action If lethality is low then take a facilitative stance If lethality is high then take a directive stance Goal Solution(s) for crisis problems are identified. 105

106 Psychological Interventions: Individual Psychological First Aid 5. Follow-Up Secure identifying information Specify follow-up procedures Set a contract for re-contact Assess attainment of goals support received lethality reduced linkage to resources accomplished If not accomplished then recycle the process implement later solutions 106

107 Mnemonic Device for Psychological First Aid M ake psychological contact E xplore dimensions of the problem E xamine possible solutions Assist in T aking concrete action Follow- U p 107