Transcript Slide 1

CHILD
FAMILY
CHILD AND
AND FAMILY
CHILD
&
FAMILY
DISASTER
DISASTER RESEARCH
RESEARCH
DISASTER
MENTAL
HEALTH
TRAINING
EDUCATION
TRAINING AND
AND EDUCATION
RESEARCH TRAINING &
EDUCATION
Northwest Center for
Public Health Practice
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Federal Sponsors
NIMH
National Institute of Mental Health
NINR
National Institute of Nursing Research
SAMHSA
Substance Abuse and Mental Health Services Administration
Northwest Center for
Public Health Practice
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Principal Investigators
Betty Pfefferbaum, MD, JD
University of Oklahoma Health Sciences Center
Alan M. Steinberg, PhD
University of California, Los Angeles
Robert S. Pynoos, MD, MPH
University of California, Los Angeles
John Fairbank, PhD
Duke University
Northwest Center for
Public Health Practice
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Children’s Psychosocial
Services in Disasters
Gil Reyes, PhD
Associate Dean for Clinical Training at
Fielding Graduate University
Northwest Center for
Public Health Practice
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Learning Objectives
Upon completion of this Module, participants will be able to:
• Recognize the current status and limitations of child
disaster mental health services and interventions
• Describe the goals and elements of psychological first
aid and other early interventions
• Identify the reasons screening is needed after disasters
• Describe the rationale for providing child disaster
mental health interventions in schools
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Services
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Types of Services
• Educational Interventions
– Pre-disaster preparedness
• Red Cross Masters of Disaster
– Injury prevention
– Coping self-efficacy
– Stress-inoculation
– Post-disaster coping education
• Mastery of reactions
– Verbal group processing of reactions and coping
– Class-room projects
– Coloring books
Reyes et al. 2005
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Types of Services
• Crisis Intervention
– Psychological First Aid (e.g., Pynoos & Nader, 1988)
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Establishing rapport and comforting presence
Protecting and reassuring
Mobilizing support
Connecting with significant others
– Crisis Hotlines (e.g., Ponton & Bryant, 1991)
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Suicide prevention
Substance abuse intervention
Coping assistance
Often operate indirectly through parenting assistance
Reyes et al. 2005
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Types of Services
• Crisis Intervention (continued)
– Psychological debriefing (e.g., Stallard & Law, 1993)
• Adapted from adult format (e.g., CISD)
– Verbal group processing of reactions and coping
– 1 or 2 lengthy (e.g., 3 hr.) group sessions
– Share perceptions, thoughts, and feelings about the
event
– Reflect on treatment they’d received
– Explore psychological effects of traumatic experiences
– Discuss problems and methods of coping
– Normalize response similarities
Reyes et al. 2005
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Types of Services
• Crisis Intervention (continued)
– Caregiver Support
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Parenting support
Informational support
Coping support
Respite care
Disaster Childcare
Critical Response Childcare (aviation events and terrorism)
Reyes et al. 2005
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Types of Services
• Community Outreach
– Mobilization, Consultation, and Capacity-Building
• Political and Social Leaders
• Primary Healthcare Systems
– Pediatric facilities and providers
• Mental Health Systems
– Community mental health centers
– Public and private provider networks
• Childcare facilities and providers
• Schools
– Teacher and other personnel education
– Screening
– Direct education of students
Reyes et al. 2005
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Types of Services
• Group Interventions
– General emphasis groups
• Addressing fears and concerns
• Stress management education
• Coping education and modeling
– Issue oriented groups
• Grief groups (Saltzman et al. 2001)
Reyes et al. 2005
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Recommendations
• National Initiatives modeled after the National Child
Traumatic Stress Network
– Raise the profile and priority of children’s psychosocial needs
following potentially traumatic events.
– Improve dissemination of accurate and useful information and
training.
• Developing a National Public Health Model for disaster
mental health
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Address and redress the existing inadequacies (surge capacity).
Emphasize population level preventive efforts.
De-emphasize immediate direct “clinical” intervention.
Define and incorporate key roles for pediatricians, schools, and
other systems of care for children (not mental health specific).
– Coordinate efforts across multiple disaster systems of care.
Reyes et al. 2005
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Recommendations
• Develop culturally sensitive and appropriate approaches
for serving a diverse range of communities
– Recognize “subtle” cultural differences and how they inform
differential responsiveness to a generalized model of care.
– Adapt generalized models of care in collaboration with key
cultural informants.
– Don’t assume that proximity or similarity confer equivalency.
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Living nearby
Looking alike
Migrating from the same country, region, or continent
Sharing a salient demographic characteristic
– Age
– Gender
– Sexual orientation
Reyes et al. 2005
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Public Mental Health
Approach
Pynoos, Goenjian, & Steinberg, 1998
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Organization
• Sources of population-based mental health
interventions for children involve three levels
of organization:
– Governmental and Social Institutions
• Mobilization of public, private, and volunteer resources
– Educational Systems
– Healthcare Systems
– Mental Health Systems
– School-based services
– Community-based intervention teams
Pynoos et al. 1998
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Components
• Screening
• Triage and assessment
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Traumatic exposure (objective and subjective)
Loss exposure
Acute difficulties
Ongoing adversities
Traumatic reminders
Recent traumatic exposure or loss (one year)
Current levels of distress
• Mental health interventions
Pynoos et al. 1998
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Guidelines
• Augment children’s self-report with other sources:
– Parent reports
– Teacher reports
• Conduct periodic screening to track the course of
recovery
– Surveillance for more than trauma
• Depression
• Adverse circumstantial stressors
– Choose continuous scales over categorical decisions
– Use results to promote effective dedication of mental
health resources where most needed
Pynoos et al. 1998
• Example of school-based services
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Disaster Mental Health
Services for Children
Covell et al. 2006
Hoven et al. 2002
Stuber et al. 2002
Fairbrother et al. 2004
Pfefferbaum et al. 2003
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September 11 Project Liberty Services
• 753,015 service logs (inception through 2003)
– Group education
– Individual (including family) counseling
• Agencies
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Large and small mental health agencies
Consumer-run organizations
Faith-based social service agencies
Agencies serving particular ethnic, cultural, or racial
groups
Covell et al. 2006
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Project Liberty Services for Children – 1
• 15% of service logs for first and follow-up visits were for
children either individually or in family counseling
• 9% of first visits were for children
– Significantly fewer than represented in census data
• 69% of first visits for children were for those aged 12 to
17 years
• 41% of first visits for children were provided in schools
• Children were more likely than adults to receive followup visits
Covell et al. 2006
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Project Liberty Services for Children - 2
• Elementary school children were more likely than older
(12-17 yr) children to exhibit
– Isolation and withdrawal
– Anxious and fearful reactions
– Concentration difficulties
• Older children more similar to adults and more likely than
younger children to exhibit
– Avoidance and numbing reactions
– Abuse of substances
• Possible major depressive disorder and PTSD appeared
to increase with age
Covell et al. 2006
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September 11 School-based Study
~ 2/3 of children with PTSD and impaired functioning
had not sought treatment 6 months after the attacks
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25
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Ground Zero
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Remainder of NYC
10
5
0
School
counselor
Outside
professional
Either
Representative sample of > 8000
students in grades 4-12
6 months after the attacks
Hoven et al. 2002
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September 11 Counseling
22% received counseling
58% of those receiving counseling received them at school
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30
25
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2121
school teacher
20
school psychologist
15
psychologist/psychiatrist
10
social worker
5
0
% receiving
counseling
Telephone survey of 112 parents in lower Manhattan
5-8 weeks after incident
Stuber et al. 2002
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10
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September 11 Counseling
10% received counseling
44% in schools
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30
30
25
20
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15
14
school teachers
school psychologists/counselors
Of those receiving counseling
47% had severe or very severe
posttraumatic stress
50% had moderate
posttraumatic stress
3% had mild posttraumatic
stress1/3 had received
counseling before 9/11
mental health
10
religious leaders/others
5
NYC parents 4-5 months after incident
0
% receiving
counseling
Fairbrother et al. 2004
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Early Psychological
Interventions
NIMH 2002
APA 1954
Everly and Flynn 2006
NCTSN and NCPTSD 2006
ARC
IFRC
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Early Psychological Interventions
Recommendations from
Mental Health and Mass Violence:
Evidence-Based Early Psychological
Intervention for Victims/Survivors of
Mass Violence. A Workshop to Reach
Consensus on Best Practices
(NIMH 2002)
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Hierarchy of Needs
• Early assessment and intervention should focus
on a hierarchy of needs
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Survival
Safety
Security
Food
Shelter
Health (physical and mental)
Triage
Orientation (to immediate service needs)
Communicate with family, friends, and community
Other forms of psychological first aid
NIMH 2002
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Assumptions and Principles
• In the immediate post-event phase, expect
normal recovery
• Presuming clinically significant disorder in the
early post-event phase is inappropriate except in
those with a pre-existing condition
NIMH 2002
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Key Aspects of Early Intervention
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Psychological first aid
Needs assessment
Monitoring the recovery environment
Outreach and information dissemination
Technical assistance, consultation, and training
Fostering resilience, coping, and recovery
Triage
Treatment
NIMH 2002
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Technical Assistance, Consultation,
and Training
• Improve capacity of organizations and
caregivers to provide what is needed to
– Reestablish community structure
– Foster family recovery and resilience
– Safeguard the community
• Provide assistance, consultation, and training to
relevant organizations, other caregivers and
responders, and leaders
NIMH 2002
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Monitor Rescue and Recovery
Environment
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Observe and listen to those most affected
Monitor the environment for toxins and stressors
Monitor past and ongoing threats
Monitor services that are being provided
Monitor media coverage and rumors
NIMH 2002
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Outreach and Information
Dissemination
• Offer information/education and “therapy by
walking around”
• Use established community structures
• Distribute flyers
• Host websites
• Conduct media interviews and programs and
distribute media releases
NIMH 2002
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Fostering Resilience and Recovery
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Foster but do not force social interactions
Provide coping skills training
Provide risk assessment skills training
Provide education on
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Stress responses
Traumatic reminders
Coping
Normal versus abnormal functioning
Risk factors
Services
Offer group and family interventions
Foster natural social supports
Care for the bereaved
Repair organizational fabric
Northwest Center for
Public Health Practice
NIMH 2002
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Needs Assessment
• Assess current status of
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Individuals
Groups
Populations
Institutions/systems
• Ask
– How well needs are being addressed
– What the recovery environment offers
– What additional interventions are needed
NIMH 2002
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Triage
• Conduct clinical assessments using valid and
reliable methods
• Refer when indicated
• Identify vulnerable, high-risk individuals and
groups
• Provide for emergency hospitalization
NIMH 2002
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Treatment
• Reduce or ameliorate symptoms or improve
functioning through
– Individual, family, and group psychotherapy
– Pharmacotherapy
– Short- or long-term hospitalization
NIMH 2002
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Follow-up
• Follow-up should be offered to those at risk of
developing adjustment difficulties including those
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Who have ASD or clinically significant symptoms
Who are bereaved
Who have preexisting psychiatric disorder
Who have required medical or surgical attention
Whose exposure was intense and of long duration
Who request it
NIMH 2002
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Expertise, Skills and Training for
Providers of Early Intervention
• Providers must
– Practice within the scope of their expertise and
education
– Practice within the structure responsible for
coordinating the response
– Make referrals when appropriate
– Avail themselves of training
NIMH 2002
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Research and Evaluation
• The scientific community has an obligation to examine
the relative effectiveness of early interventions
• A national strategy should be developed to ensure that
adequate resources are available for research
• A standard taxonomy and terminology are needed for
program evaluation to identify
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The most significant variables to monitor
Post-event physical and psychosocial environment
Subgroups of the affected population including responders
Mental health interventions that are provided
Characteristics of those deemed the most appropriate providers
• The broader research community should be informed of
need for research
NIMH 2002
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Key Research Questions
• What ethical issues are introduced by widespread use of unproven
interventions?
• How acceptable is research to potential subjects?
• What is the best process for seeking informed consent; what
information should be given in the consent process?
• Can a standard taxonomy and terminology be developed?
• How effective is public education?
• Is screening in itself an effective intervention?
• Can screening cause harm; if so, what is the nature of the harm and
is the risk offset by risk of failing to screen?
• Is it acceptable to screen if care is not provided or accessible?
• How feasible are studies of early interventions ?
• How can clinical demand be balanced with inadequacies in the
empirical evidence-base?
NIMH 2002
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Psychological First Aid
• Goals:
– Should be concerned only with the immediate situation.
– Restore people to reasonably good functioning.
– Make people as comfortable as possible until more complete care can be
arranged.
• Five types of reactions:
– Normal reactions to stress (transient states, not to be confused with
abnormal adjustment).
– Panic (a rare, but contagious risk).
– Immobility or numb detachment.
– Hyperactivity and over confidence (hypomanic).
– Somatic complaints.
• Four principles of care
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Accept people’s right to their own feelings
Accept a person’s limitations as real.
Size up a casualty’s potentialities as accurately and quickly as possible.
Accept your own limitations in a relief role.
American Psychiatric Association 1954
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Psychological First Aid
• Protect survivors from further harm
• Reduce physiological arousal
• Mobilize support for those who are most
distressed
• Keep families together and facilitate reunions of
loved ones
• Provide information and foster communication
and education
• Use effective risk communication techniques
NIMH 2002
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Public Health Practice
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Principles and practical procedures for
acute psychological first aid training for
personnel without mental health experience.
• Physical First Aid
• Psychological First Aid
– Stabilize physiological
functioning
– Stabilize psychological and
behavioral functioning by meeting
physical needs and then
addressing psychological needs
– Mitigate physiological distress
and dysfunction
– Mitigate psychological distress
and dysfunction
– Achieve return to acute
adaptive physiological
– Achieve return to acute adaptive
functioning
psychological and behavioral
functioning
– Facilitate access to next level
of care
– Facilitate access to continued
care
Everly & Flynn 2006
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Psychological First Aid
• Several organizations have developed
manuals to guide the delivery of psychological
first aid
– International Federation of Red Cross and Red
Crescent Societies
– American Red Cross
– National Child Traumatic Stress Network and
National Center for PTSD
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International Federation of Red Cross and Red
Crescent Societies (IFRC) PFA - Modules
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Community-based Psychological Support (PFA)
Stress Responses and Coping Skills
Developing Supportive Communication
Promoting Community Self-help
Caring for Populations with Special Needs
Helping the Helper
IFRC, 2003
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American Red Cross (ARC) PFA - Actions
• Psychological first aid actions
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Make a connection
Help people be safe
Be kind, calm, and compassionate
Meet people’s basic needs
Listen
Give realistic reassurance
Encourage good coping
ARC, 2006
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NCTSN and NCPTSD PFA
Core Actions and Goals - 1
• Contact and engagement
– To respond to contacts initiated by survivors, or initiate contacts
in a non-intrusive, compassionate, and helpful manner
• Safety and comfort
– To enhance immediate and ongoing safety and provide physical
and emotional comfort
• Stabilization
– To calm and orient emotionally overwhelmed or disoriented
survivors
• Information gathering: current needs and concerns
– To identify immediate needs and concerns, gather additional
information, and tailor PFA interventions
NCTSN & NCPTSD 2006
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NCTSN and NCPTSD PFA
Core Actions and Goals - 2
• Practical assistance
– To offer practical help to survivors in addressing immediate
needs and concerns
• Connection with social supports
– To help establish brief or ongoing contacts with primary support
persons or other sources of support, including family members,
friends, and community helping resources
• Information on coping
– To provide information about stress reactions and coping to
reduce distress and promote adaptive functioning
• Linkage with collaborative services
– To link survivors with available services needed at the time or in
the future
NCTSN & NCPTSD, 2006
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Screening
Limitations and Rationale for Child
Screening
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Reasons Screening Needed
• Adults may not recognize or acknowledge
children’s reactions and needs
• Identify need for services
• Focus limited services on those with greatest
need
Stallard et al. 1999
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Adults May Underestimate
Children’s Distress
• Concordance between parent- and child-report
of disaster reactions is low
– Children do not want to burden parents
– Parents deny problems in children
– Parental distress decreases ability to identify child
suffering
McDermott & Palmer 1999
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Screening
• May increase communication about children’s
reactions and concerns
• May facilitate service delivery decisions and the
appropriate use of scarce resources
• May increase the demand for services
McDermott & Palmer 1999
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Potential Problems With Screening
• False positives may result in
– Unnecessary treatment with attendant cost and
inconvenience
– Inappropriate labeling of children
– Focus on “illness behavior”
• False negatives may create a barrier to later
care-seeking
McDermott & Palmer 1999
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Value of Screening - 1
• Simplicity
– Easy to administer
– Administered by paraprofessional
• Acceptability
– Acceptable to those being screened; usually voluntary
• Accuracy
– True measure of what is being assessed
Cochrane and Holland 1971
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Value of Screening - 1
• Expense
– Cost is reasonable in relation to benefit of early detection
• Precision (Repeatable)
– Consistent results in repeated trials
• Sensitivity
– Test is positive when the condition is present
• Specificity
– Test is negative when the condition is not present
Cochrane and Holland 1971
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Interventions
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Psychoeducation
and
Supportive Group Therapy
Galante and Foa 1986
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Elementary School Children
Exposed to Earthquake in Italy
• Three phase process
– Pretest at 6 months
– Treatment with children in village with largest number
of children at risk according to pretest
– Posttest at 18 months
Galante & Foa 1986
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Treatment Sample and Program
• Sample
– All grade 1-4 students in village with largest number
of children at risk
• Techniques included
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Normalizing reactions
Projective techniques
Psychoeducation
Review of death, funerals, and the future
Survival techniques
Galante & Foa 1986
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Session Objectives and Activities
•
Communicate about the event
– Draw and listen to stories about San Francisco’s recovery
•
Discuss fears and demonstrate that fear was common
– Draw and listen to story about frightened child too shy to ask for help
– Discuss drawings and feelings including what they did when afraid
•
Discuss myths and beliefs about earthquakes
– Draw and listen to story about child fearful that the earthquakes would recur
– Discuss beliefs
•
Discharge feelings about the earthquake and place earthquake in the past
– Make joint drawing of the community
– Focus on what children did to resume a normal life after the earthquake
•
Release the power of death images and focus on the future
– Role play and funeral rituals
– Discuss the future of a new village
•
Develop the idea that children can take an active role in their own survival
– Role play being parents teaching children to survive various emergencies
•
Raise topics associated with closure
– Free drawing and discussion
Galante & Foa 1986
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Change in Risk Scores
50
47
45
40
35
34
30
6 months
18 months
25
20
15
10
5
0
% at risk
Galante & Foa 1986
Northwest Center for
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Psychosocial Intervention
After Hurricane Iniki
Chemtob et al. 2002
Northwest Center for
Public Health Practice
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Methods
•
Sample
– 4258 children in grades 2 – 6 from all 10 public elementary schools on island of
Kauai (91% of the enrolled children) were screened to identify children for the
intervention study
– 248 children met criteria for treatment and were randomly assigned to
• Group (176 children)
• Individual (73 children)
– 214 completed treatment
•
Methods
– 2 years after hurricane, children with highest levels of trauma symptoms were
randomly assigned to 1 of 3 consecutively treated cohorts
• Children in the cohorts awaiting treatment served as wait-list controls
– Within each cohort, children were randomly assigned to either individual or group
treatment to allow comparison of the efficacy of the two treatment modalities
•
Instruments
– Reaction Index
– Semi-structured interview
Chemtob 2002
Northwest Center for
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Sample
4285 in grades 2-6
3864 (91%) screened
248 met treatment criteria
65 in cohort 1
64 (99%) completed
101 in cohort 2
85 (84% completed)
82 in cohort 3
65 (79% completed)
Chemtob et al. 2002
Northwest Center for
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Treatment Eligible Sample
• Demographics
– 6 to 12 years of age (mean 8.2, SD 1.3)
– Race/ethnicity
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•
•
•
Hawaiian/part-Hawaiian 30%
White 25%
Filipino 20%
Japanese 9%
• Compared to all screened children, treatment eligible
children were more likely to
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Fear death or injury to self
Fear death or injury to family
Have more intense fear reactions to hurricane
Be girls
Be poor
Chemtob et al. 2002
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Intervention
• Groups included 4 to 8 children
• Manual-based intervention with 4 weekly
sessions using protocols that outlined session
content and activities to elicit relevant material
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Session 1: safety and helplessness
Session 2: loss
Session 3: mobilizing competence and anger
Session 4: ending and going forward
Chemtob 2002
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Results
Post-treatment < Pre-treatment
Follow-up (1 year) < Pre-treatment but not Post-treatment
50
45
40
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46
42
42 41
46
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41 40
38
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44
41 41
39 40
36
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30
pretreatment
25
posttreatment
follow-up
20
15
10
5
0
group 1
group 2
group 3
individual 1
individual 2
individual 3
Group and individual treatments did not differ in efficacy
Fewer children dropped out of group treatment
Chemtob et al. 2002
Northwest Center for
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Clinician Ratings
25
20
20
15
12
treated
10
untreated
5
0
Posttraumatic
stress
Random sample of 21 treated and 16 untreated
p = .01
Chemtob et al. 2002
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Cognitive Behavioral Group
Psychotherapy
March et al. 1998
Northwest Center for
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Sample and Design
• 14 participants with PTSD completed treatment
– 10 to 15 years of age
– Single-incident stressor
• 10 had 2 or more stressors
• Recruited through schools
• 18 weekly group sessions
• Single case across setting design
March et al. 1998
Northwest Center for
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Status at Initiation of Treatment
• As a group, at the start of treatment, participants experienced mild to
moderately severe
– PTSD
– Anxiety
– Depression
• Children with severe disruptive behavior were excluded
• Average duration of PTSD symptoms was
– 1.5 years for younger participants
– 2.5 years for older participants
• None had received mental health treatment
• Most were doing reasonably well in school
March et al. 1998
Northwest Center for
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Improvement
Significant group differences occurred early and persisted
None relapsed
80
74
71
70
60
54
50
40
45
Baseline
Final
Follow-up
33
30
20
19
14
10
12
8
4
2
2
0
PTSD
Depression
Anxiety
Global
March et al. 1998
Northwest Center for
Public Health Practice
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Outstanding Issues
• The study did not ascertain
– If CBT was unique in its effectiveness
– Which specific aspects of the intervention were
responsible for outcomes
– If results would extend to children with more severe
illnesses or comorbid conditions
March et al. 1998
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74
Trauma/Grief Focused
Group Psychotherapy
Goenjian et al. 1997
Northwest Center for
Public Health Practice
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75
Trauma/Grief Focused Group
Psychotherapy After Earthquake
• Early adolescents in severely damaged schools after a massive
Armenian earthquake
– 35 students received intervention
– 29 students received no therapy
• Intervention
– Delivered over a 6 week period 1.5 years after earthquake
– Included
• 4 ½-hour group sessions in classroom
• an average of 2 1-hour individual sessions
– Focused on
•
•
•
•
•
Trauma
Traumatic reminders
Post disaster stresses and adversities
Bereavement and the interplay of trauma and grief
Developmental impact
Goenjian et al. 1997
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Results
• Treated group
– Improved in posttraumatic stress
– No worsening in depression
• Non-treated group
– Worsening in posttraumatic stress
– Worsening in depression
• Treatment benefits did not appear transient and
were evident 1.5 years after the intervention
Goenjian et al. 1997
Northwest Center for
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77
Posttraumatic Stress after Treatment
50
45
47.2
45.3
Severity decreased in treated
Severity increased in not treated
41.1
40
32.2
35
30
Treated
25
Not Treated
20
15
10
5
0
1.5 Years*
3 Years**
*1.5 Years: No difference between treated and non-treated groups
**3 Years: Treated < non-treated group
**3 Years: Treated: 3-year score < pretreatment
**3 Years: Not treated: 3-year score > 1.5-year score
Goenjian et al. 1997
Northwest Center for
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78
Depression after Treatment
25
20.2
20
16.8
15.3
Severity did not change in treated
Severity increased in not treated
16
15
10
Treated
5
Not Treated
0
1.5 Years*
3 Years**
*1.5 years: No difference between treated and non-treated groups
**3 years: Treated < non-treated
**3 years: Treated: no change from 1.5 years
**3 years: Non-treated: score increased from 1.5 years
Goenjian et al. 1997
Northwest Center for
Public Health Practice
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79
Implications
• Treatment may prevent worsening of posttraumatic
stress and depression
• Worsening in posttraumatic stress may be due to
reminders; treatment may have decreased reactivity to
reminders
• Increased severity of depression may have been due to
– Increased severity of posttraumatic stress
– Persistent severe posttraumatic stress interfering with grief
resolution
– Difficulty coping with secondary adversities
Goenjian et al. 1997
Northwest Center for
Public Health Practice
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80
Cognitive-Behavioral Therapy
for Childhood Traumatic Grief
Stubenbort et al. 2001
Cohen et al. 2004
Cohen et al. 2006
Northwest Center for
Public Health Practice
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81
Group CBT for Bereaved Children
• Sample: 12 children (aged 5 – 12 years) and 18
adults some parents of the children
• Event: Airplane crash with dramatic media
portrayals of the event
• Intervention: 7 weeks of treatment with parallel
child and adult groups
Stubenbort et al. 2001
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Intervention Sessions
• Introduction, definition, group treatment rules
• Psychoeducation to normalize the experience and
increase coping skills
• Coping with traumatic death
• Strengthening group cohesion by exploring loss and
unfinished business
• Continuing to explore loss and unfinished business
• Increasing coping skills
• Closure and moving on
Stubenbort et al. 2001
Northwest Center for
Public Health Practice
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83
Methods
• Sample:
– 22 children (aged 6-17 years) with significant child
traumatic grief and posttraumatic stress disorder
symptoms
– Children’s primary caretakers
• Intervention:
– 16 week manual-based individual treatment with
sequential trauma- and grief-focused components
– 2 joint parent-child sessions in each module
• Design: open uncontrolled treatment design
Cohen et al. 2004
Northwest Center for
Public Health Practice
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84
Intervention Components
• Trauma-focused components
– Improve affective modulation and stress reduction (sessions 1 to
4)
– Trauma-specific exposure and cognitive processing (sessions 5
to 8)
• Grief-focused components
– Naming and accepting the loss (sessions 9 to 12)
– Preserving positive memories and making meaning of the loss
(sessions 13 to 16)
• Two joint parent-child sessions in each module
Cohen et al. 2004
Northwest Center for
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Results
PTSD symptoms improved during the trauma-focused component
Grief improved during the trauma- and grief-focused components
18
17
*
16
14
11.4
**
12
10
8
9.25
*
Pre-4 weeks
*
6.8
4-8 weeks
6
4.5
4
1.8 1.95
2
**
1.4
8-12 weeks
12-16 weeks
0
PTSD Symptoms
* p < .001
** p < .01
Traumatic Grief
Cohen et al. 2004
Northwest Center for
Public Health Practice
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86
Limitations
• Lack of a control group makes it impossible to
determine if improvements represented treatment
response or natural recovery
• The small sample size, with no minority children
other than African Americans, makes it
impossible to generalize to diverse groups
Cohen et al. 2004
Northwest Center for
Public Health Practice
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87
Implications
• The study lends tentative support to the conceptualization
of traumatic grief as the impingement of trauma symptoms
on the normal grief process and to the importance of
sequential treatment of trauma and grief
• The final four sessions addressing positive aspects of
grieving may have contributed to grief resolution or grief
may have resolved on its own once trauma symptoms
were treated
• The study suggests the importance of including parents in
treatment of children
Cohen et al. 2004
Northwest Center for
Public Health Practice
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88
Teacher-mediated
Intervention after 1999
Earthquake in Turkey
Wolmer et al. 2005
Northwest Center for
Public Health Practice
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89
Advantages of Locating
Interventions in Schools - 1
• Disaster reactions may emerge in the context of school
• School settings provide access to children and the
potential for enhanced compliance
• School personnel are familiar with, and deal with,
situational and developmental crises
• School personnel have opportunities to observe children
• Schools are a natural support system where stigma
associated with treatment is diminished
• Services in schools help normalize children’s
experiences and reactions
• Classroom settings are developmentally-appropriate
Wolmer et al. 2003;
Wolmer et al. 2005
Northwest Center for
Public Health Practice
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90
Advantages of Locating
Interventions in Schools - 2
• Classroom settings provide
–
–
–
–
–
Predictable routines
Consistent rules
Clear expectations
Immediate feedback
Stimulus for curiosity and engaging learning skills
• School-based interventions facilitate peer interactions
and support which may prevent withdrawal and isolation
• Supervision, feedback, and follow-up are possible
• School curricula already address prevention in other
mental health areas
Wolmer et al. 2003;
Wolmer et al. 2005
Northwest Center for
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Teachers as Clinical Mediators
• Teachers may help as clinical mediators
because they
– Occupy a central role in children’s lives
– Are trusted by children and parents
– May be amenable to being trained
Wolmer et al. 2003;
Wolmer et al. 2005
Northwest Center for
Public Health Practice
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Role of Teachers
•
•
•
•
•
•
•
Model children’s responses
Provide factual information and correct rumors
Reinforce coping skills
Facilitate mutual support
Identify children who are suffering
Prepare the class for future experiences
Encourage students to contribute to their family,
school, and community
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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93
Sample
• 202 displaced children
– 44% boys, 56% girls
– Mean age 8.2 years; grades 1-5
• Comparison sample of 101 children 300 miles
away who were not directly affected
– 46% boys, 54% girls
– Mean age 8.83 years
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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94
Methods
• Teachers interviewed children individually at
school 4 months after the earthquake and before
any interventions
• Intervention lasted 4 weeks with 2 meetings per
weeks
• Assessed 6 weeks after the intervention series
was completed
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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95
Instruments
• Traumatic Dissociation and Grief
– Grief factor
• Irritability
• Guilt/anhedonia
– Dissociative factor
• Body/self distortions
• Perceptual distortions
• Child PTSD Reaction Index
– 20 reactions
• Traumatic exposure questionnaire
– Risk index reflected extent of risk ranging from 0 to 5
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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Intervention
• Trained, supervised, and supported school
leadership and teachers
• Intervention consisted of 8 two-hour sessions of
psychoeducation and cognitive-behavioral
techniques
• Teachers conducted the intervention over the
course of 4 weeks
Wolmer et al. 2003;
Wolmer et al. 2005
Northwest Center for
Public Health Practice
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97
Intervention Modalities
• Modalities
–
–
–
–
Psychoeducational modules
Cognitive-behavioral techniques
Play activities
Documentation in personal diaries
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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98
Intervention Sessions
•
•
Introductory session with parents to
– Engage them
– Provide information related to the program
– Educate them about children’s disaster reactions
8 two-hour sessions with children to
– Restructure traumatic experiences
– Deal with intrusive thoughts
– Establish a safe place
– Learn about the earthquake and prepare for future earthquakes
– Mourn the ruined city
– Control body sensations
– Confront posttraumatic dreams
– Understand reactions in the family
– Cope with loss, guilt, and death
– Deal with anger
– Extract life lessons
– Plan for the future
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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99
Results at 6 Weeks
35
Trauma and dissociative symptoms decreased
Grief symptoms increased
32
30
28
25
22
Before
20
18
After
15
13
12
10
5
0
Trauma
Grief
Dissociation
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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100
Increased Grief Symptoms
• Normal grief may have begun after other
symptoms were relieved
• Interventions may not have addressed
depression adequately
• Children may have been more comfortable
expressing grief symptoms after the intervention
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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101
Grief at Follow-up
• 26 children who still had
moderate to severe
posttraumatic stress were
interviewed 6 months
after treatment
• Their grief score was
significantly lower at
follow-up than posttreatment and
significantly higher than
at pre-treatment
25
23
20
20
17
15
Grief
10
5
0
PrePostFollow-up
treatment treatment
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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102
Severe to Very Severe Posttraumatic
Stress
• The percent of children with severe to very
severe posttraumatic stress, associated with a
diagnosis of PTSD, decreased from 30% to
18%, the latter similar to the 15% found in the
baseline control sample
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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103
Posttraumatic Stress Severity at 6
Months for Children Who Received
the Intervention
• 33.5% remained stable
• 39% decreased in severity
• 27.5% increased in severity
Wolmer et al. 2003
Northwest Center for
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104
Children Without Symptoms
• Reasons children without risks or without
symptoms should participate
– Only a minority were without risk or symptoms
– Intervention had a preventive element and focused on
rehabilitation of the whole school and intent to prevent
children who participate from being labeled
– Asymptomatic children lent support to others and
served as models for coping
– Increase in grief was moderate and significantly
decreased 6 months later
Wolmer et al. 2003
Northwest Center for
Public Health Practice
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105
Three Year Follow-up of Teachermediated Intervention
• Sample: 287 children from 3 schools
– 9-17 years (mean 11.5)
– 67 children participated and 220 did not participate in
the earlier intervention
• All 3 schools included both children who did and did not
participate in the intervention
– Groups were comparable on sex, age, and risk
• Studied 3.5 years after the event with child,
mother, and teacher (blind to which children
participated) ratings
Wolmer et al. 2005
Northwest Center for
Public Health Practice
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106
Follow-up of Children Who Received
the Intervention
Significant decrease post-intervention to 3 year follow-up
35
30
30
25
24
23
20
Post-intervention
3 Year Follow-up
13
15
10
10
4
5
0
Posttraumatic
stress
Grief
Dissociation
Wolmer et al. 2005
Northwest Center for
Public Health Practice
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107
Posttraumatic Stress Severity at 3
Years for Children Who Received the
Intervention
•
•
•
•
30% remained stable
41% decreased
29% increased
18% continued to have severe trauma
symptoms
Wolmer et al. 2005
Northwest Center for
Public Health Practice
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108
Intervention and Comparison Group
at Three Years
• No significant differences between the two
groups at 3 years in child self-report for
– Posttraumatic stress
– Grief
– Dissociation
Wolmer et al. 2005
Northwest Center for
Public Health Practice
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109
Daily Functioning in Intervention
and Comparison Groups at Three
Years
5
4.5
4.3
4.1
4
3.5
3.8
3.8
3.9
3.3
Intervention
Intervention group had significantly
higher daily functioning in:
Academic performance
Social behavior
General conduct
3
Comparison
2.5
Predictors of daily functioning:
Functioning before disaster
Group (intervention v. no intervention)
Trauma symptoms
2
1.5
1
0.5
0
Academic
performance
Social
behavior
General
conduct
Wolmer et al. 2005
Northwest Center for
Public Health Practice
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110
Summary of Findings
• Significant trauma and dissociative symptom decrease and grief
symptom increase 6 weeks after the intervention
• Significant symptom decrease over 3 years in posttraumatic stress,
grief, and dissociation
– A large proportion of both treated and untreated children reported
moderate 30-35%) or severe (17-18%) posttraumatic stress
– In some children, symptoms appeared within 6 months and crystallized
into the full-blown syndrome months or years later
• Symptom levels similar in treated and untreated groups at 3 years
• Teacher-rated functioning better in treated than untreated children
– Correlations between children’s symptoms and daily functioning were
small and non-significant supporting previous findings that children can
function despite internal struggles
Wolmer et al. 2003;
Wolmer et al. 2005
Northwest Center for
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111
Conclusions
Northwest Center for
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112
Conclusions - 1
• There is some evidence that treatments
(psychosocial, psychoeducation, CBT, EMDR)
are effective for posttraumatic stress; grief and
depression may be especially difficult to treat
• There is some evidence for the sequential
treatment of trauma and grief
Northwest Center for
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113
Conclusions - 2
• It remains unclear what elements of an
intervention are responsible for effects
• Interventions have not been compared; thus, it is
unclear if some interventions are better than
others
• It remains unclear if interventions are superior to
natural recovery
Northwest Center for
Public Health Practice
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114