Transcript Learning Objectives

NUTS AND BOLTS OF
TRAUMA RESPONSE
Lenore B. Behar, PhD, Director
Child & Family Program Strategies
Durham, North Carolina
Bibliography
Go to: www.lenorebehar.com
See: Presentations
Community Based Interventions In
Two Parts: Systems of Care and
Approaches to Recovery from
Psychological Trauma
or
E-Mail: [email protected]
Learning Objectives



Gain understanding of how to develop
and use trauma response teams
Gain understanding of group
interventions to reduce the impact of
trauma
Gain understanding of when to refer
adolescents to professional treatment
following exposure to trauma
Types of Trauma








Significant losses
Domestic violence
Community and school violence
Complex trauma (multiple trauma)
Medical trauma
Refugee and war zone trauma
Natural disasters
Terrorism
National Child Traumatic Stress Network, 2006
What Do We Use as Evidence?


Scientific literature
Data/Experience from the field:
• Reports from key informants

Expert consultation

Needs assessment data
What Can an
Evidence Informed Approach
Tell Us?






Who will need help
Critical issues
When to intervene
What to do and what not to do
What we might expect from interventions
Important clues on group differences
What to Do when EvidenceBased Practices Have Not Been
Established
Use an
“Evidence Informed Approach”
What Does the Evidence Indicate?






Proximity to disaster affects the psychological
impact
Previous exposure to trauma affects the
impact
Cultural groups respond differently
Impairments affect how people respond
Perception is reality
Most people recover without problems
How Do Children/Youth
Respond to Trauma?



They worry about their own safety
They may become re-traumatized
through overexposure to media
Trauma seems ubiquitous and not
isolated
Children React Differently

Reaction depends on developmental level—the
capacity to understand

Reaction depends on family functioning and other
support systems

Reaction depends on resiliency

Reaction depends on physical or psychological
proximity to the traumatic event

Reaction depends on culture
Other Ways to Describe
Responses




Reactions unfold over time
May follow a process of shock, sadness,
anger, acceptance, then adjustment
The unmoved or detached child may be
concerning but is sometimes normal
Prolonged behavior may signal need to
intervention
Responses to Trauma





Related to amount of destruction or
amount of loss
Related to perceived support
Related to resiliency
Nightmares and sleep disorders
common
Persistent thoughts or triggers shape
behavior
Macy, 2006
Maslow’s Hierarchy of Needs
Scweitzer & Knutson-Eide, 2005
Peak
Experiences
SelfActualization
Aesthetic needs:
Symmetry – Order - Beauty
Cognitive needs:
Knowledge – Understanding – Novelty
Esteem needs:
Competence – Approval - Recognition
Belongingness and Love needs:
Affiliation – Acceptance – Belongingness
Safety needs:
Comfort – Security – Freedom from Fear
Physiological needs:
Food – Water - Oxygen
Human Stress Response
Continuum
• Overwhelming stress
• Traumatic stress
• Persistent stress
• PTSD
Macy, 2006
Range of Responses
Normal








Shock
Numbness
Crying
Sadness
Anger
Feeling guilty
Keep concerns
inside
Increased
clinging
Signs of Problems







Deny or avoid feelings
Repeated crying
Depression or suicidal
thoughts
Persistent anger
Persistent unhappiness
Social withdrawal
Decreased school
performance
Feldman-Winter & Christie, 2004
Disaster Trauma:
Affected Populations
Evans, 2003
Victims,
eyewitnesses
Disaster Trauma:
Affected Populations
Evans, 2003
Victims,
eyewitnesses
Victims’
families
& close
friends
Disaster Trauma:
Affected Populations
Evans, 2003
Victims,
eyewitnesses
Victims’
families &
close
friends
Emergency
responders
Disaster Trauma:
Affected Populations
Evans, 2003
Victims,
eyewitnesses
Victims’
families &
close friends
Vulnerable
people,
teachers,
neighbors
Emergency
responders
Disaster Trauma:
Affected Populations
Evans, 2003
Victims,
eyewitnesses
Other
children
& parents
Vulnerable
people
Victims’
families &
close
friends
Emergency
responders
Disaster Trauma:
Affected Populations
Evans, 2003
Victims,
eyewitnesses
Other
children
& parents
Vulnerable
people
Entire
population
Victims’
families &
close
friends
Emergency
responders
The seriousness of the response is
related to durability/longevity
primarily, and somewhat to
intensity
80% recover—no PTSD
Disaster Stages
Before
Preparedness
After
Recovery
During
Acute/
Intermediate
Other Players in Crisis
Response
Public Safety
Public Health
Behavioral Health
Forming a Trauma
Response Team
Members of “The Team”
• Mental health providers
• School counselors and teachers
• Community leaders
• Police
• Faith-based leaders
• Community-based workers
• Pediatricians/health providers
Implications






Need outreach and direct care
Build community capacity
Rely on existing resources
Utilize a phased approach
Build in diverse strategies
Form new collaborations and
partnerships
Operational Assumptions





No new resources for ongoing development
and maintenance
Address surge capacity
Connect to local and regional emergency
response systems
Community needs assessment
Population based
Results





Intensive training of trauma response
team members
Identification of key members in
communities
Identification of local resources for
referral
Linkages to hospitals/emergency medical
services
Linkages to public safety/public health
response networks
Tasks of Trauma Response Team
PREVENTION
Develop/train trauma response teams
Provide information and training for
teachers, specialists and parents (early
warning signs, violence prevention, ...)
Develop linkages to helpers/ informants
Develop linkages to referral sources
Tasks of Trauma Response Team
INTERVENTION
Support schools or community groups to
manage crisis situations
Cooperate with other crisis intervenors
(mental health, police, psychologists,
priests, ...
Deal with individuals and groups to
overcome traumatic experiences
Provide information about the effect of
trauma
Tasks of Trauma Response Team
POST-INTERVENTION
Develop follow-up care-plan for victims
and concerned people
Arrange for counseling in the school or
referral in the aftermath of crisis
situations
Provide guidance to school personnel to
help them identify those with continuing
needs.
Check in for follow-up
COMMUNITY STRESS PREVENTION CENTER
• SOCIAL / COMMUNITY WORKERS (TEAM LEADER)
• NURSE AND OR MEDICAL DOCTOR
• PSYCHOLOGIST (PSYCHIATRIST-ON DEMAND)
• SCHOOL’S EMERGENCY INTERVENTION TEAM
• COMMUNITY / TRANSLATOR / VOLUNTEER
• LOGISTICS REPS.
• ARTS INSTRUCTOR
COMMUNITY STRESS PREVENTION CENTER
MAPPING BY THREE DIMENSIONS
GEOGRAPHICAL
PROXIMITY
POPULATION
AT RISK
PSYCHOSOCIAL
PROXIMITY
COMMUNITY STRESS PREVENTION CENTER
WHO IS GOING
TO HELP?
CIRCLES OF
VULNERABILITY
PRINCIPAL
TEACHERS
INSPECTOR
CLASSMATES
FRIENDS
INJURED
CHILDREN,
FAMILY
ALL THE PEOPLE IN THE
STAFF
NEIGHBOURHOOD
PARENTS
WITNESSES
OTHER CLASSES
OTHER
SCHOOLS
COMMUNITY STRESS PREVENTION CENTER
CIRCLES OF
SUPPORT
PRINCIPAL
PRINCIPAL
INSPECTOR
TEACHERS
TEACHER
PSYCHOLOGIST
FRIENDS
SOCIAL
WORKER
CIRCLES OF
VULNERABILITY
INSPECTOR
CLASSMATES
FRIENDS
ALL THE THE WHOL
STAFF
NEIGHBOURHOOD
INJURED
CHILDREN,
FAMILY
PARENTS
FAMILY
COLLEAGUES
NEIGHBOURS
COMMUNITY
MEMBERS
WITNESSES
OTHER CLASSES
OTHER
SCHOOLS
COMMUNITY STRESS PREVENTION CENTER
HELPING WITH INFORMATION & LOCATING
RELATIVES.
OUTREACH & SUPPORT TO PEOPLE IN NEED.
ACTIVATING EDUCATIONAL AND COMMUNITY-BASED
PLANS.
PSYCHOLOGICAL FIRST AID - CIPR
INTERVENTION vs TREATMENT.
COMMUNITY STRESS PREVENTION CENTER
TRACING, FOLLOW UP & ADMINISTRATING
PSYCHOLOGICAL REHABILITATION INTERVENTIONS.
ENCOURAGING & PROMOTING GETTING BACK TO
ROUTINE.
COORDINATING THE GRADUAL ASSIMILATION OF
EMOTIONALLY & PHYSICALLY INJURED PEOPLE
IN THEIR NATURAL ENVIRONMENT.
PREPARING FOR THE FUTURE.
For further information please contact
[email protected]
www.icspc.org
Another Model of Crisis
Management
Crisis intervention
(caring for people
during the crisis)
Short term relief in
order to prevent
collapsing of persons
or systems
Crisis prevention
(caring for people
before the crisis)
Long term planning of
prevention; optimizing
crisis management
Caring for people after
the crisis (support &
long-term healing)
Support short- to long-term
copings, preventing secondary
symptoms
Englbrecht & Storath, 2005
Basics of Work







Model of crisis management
Psychological first aid
Circles of vulnerability and support
Basic elements of crisis intervention
Focus on resiliency: BASIC - PH
Neurophysiological approach
Systemic approach
Psychological First Aid
Goal: To increase coping skills
and restore functioning





Establish safety
Provide comfort
Work toward stabilization
Provide clarifying information
Identify support systems
Psychological First Aid
Is Not






Psychotherapy
Research
An emergency response
A long-term intervention
A “stand-alone” intervention
A chance to identify future clients
Normal Assumptions
When Threat is Minimal





I am in control
I am safe
I am worthy
The world is meaningful
It can’t happen to me
Traumatic Stress Response &
Shattered Assumptions





I am not in control
I am not safe
I am not worthy
The world is not meaningful
It can happen to me or those I love
The Human Stress Response
Continuum
Magnitude of Impact I





Single event
Repeated events
Amount of stress in your life
Prior trauma history
Prior exposure(s) to critical incidents
Macy, 2006
The Human Stress Response
Continuum
Magnitude of Impact II







Nature of event
Involvement, degree of control, threat loss
Degree of warning
Ego strength/coping style/resiliency
Prior mastery of experience (challenges)
Proximity variables: time & distance
Nature & degree of social
support/resource
Macy, 2006
Traumatic Stress Response
Time Lines: 0 - 72 Hours





Fight & flight & appraisal systems
Freeze systems
The “crying curve”
Temporary cognitive distortions
Temporary performance interruptions
Macy, 2006
Traumatic Stress Response
Time Lines: 72 Hrs – 3 Weeks







Disruption of self regulatory capacity
Neurobiology of attachment disruption
Memory interruption
Distorted perceptions
Recognized shattered assumptions
Approach & withdrawal cycle
Incident identity
Traumatic Stress Response
Time Lines: 3 Weeks – 12 Weeks








Memory distortion
Amnesia or memory intrusions
Longer lasting dissociation
Cognitive impairment, perseveration
Blunted/numbered emotions
Flashback/nightmares
Performance decline
Chronic sleep disturbance
Types of Interventions
Provided in school, in shelters, community
settings
 Orientation groups

Stabilization groups

Coping groups

Individual stabilization and referral
Goals of Group Orientation




Clarify information; provide facts
Teach survivors about traumatic
stress response
Teach survivors about self-care
techniques
Help survivors identify personal
coping strategies
First Steps





Provide comfort
Help to provide safety
Limit TV and other visual reminders of
violence or death
Provide understanding of what really
happened
Help parents, teachers, other caregivers
understand what to do
The Goals of Coping Groups




Mitigate the impact of a critical
incident
Accelerate normal recovery in normal
people who are having normal
reactions to abnormal events
Provide education and discussion
regarding stress and coping
Assessment & screening of survivors
Before: Preparedness

Debrief from previous events
Focus on prevention
 Strengthen community resilience, reduce
risk factors, improve coping capacity
Build response infrastructure
 Coalitions, partnerships, networks
 Model and role definition
 Curriculum development, training
 Communications/command structures

Develop rapid response plan


During: Acute phase







Immediate response
Comfort, support, psychological first aid
Clinical screening
Attend to needs of directly affected and
vulnerable populations
Individual, family/group interventions
Public messages
Support to caregivers
After: Recovery phase





Expect most people will be OK
Identify those with delayed effects
Clinical work with people who have PTSD and
lasting psychological effects
Broad community outreach - information
dissemination/education
Lessons learned, evaluation, research
Change in Roles






Traditional Role
Office-based treatment


Multiple treatment
sessions
Therapeutic relationship 

Client comes to you
Spectrum of disorders 
Main contact = provider 
New Role
School/communitybased treatment
Brief intervention, focus
on here and now
Psychological first aid
You go to client
Focus on recovery
Community Team =
multiple people involved
Exercise
Deadly climbing accident
You are the leader of the Crisis Response Team.
You get the call from the principal of the school.
He tells you that there has been a climbing
accident at a school outing. A 14 year old boy has
fallen from a rocky ledge and died in front of his
classmates and teachers.
victims/concerned
community
administration
neighbourhood
classroom
teacher
family,
classmates
friends
teachers
fellow
students
principal
relatives
the whole
school
schools in the
neighbourhood
Circles of Vulnerability
Community Stress Prevention Centre, Kyriat Shmonah, Israel
)
victims/concerned
helpers/supporters
community
administration
neighbourhood
social
workers
classroom
teacher
teachers
family,
friends
The media
external
counselors
churches,
priests
classmates
principal
fellow students
the whole
school
relatives
internal counselors
community
members
psychologists
schools in the
neighbourhood
Circles of Support
Community Stress Prevention Centre, Kyriat Shmonah, Israel
FOOLS RUSH IN!!!
What do you do? How do you plan?
• What information do you need?
• What do you plan for the return to
school?
• What do you tell the principal about the
next morning, when all of the students and
teachers come to school.
Intervention: Acute Phase

What should the Trauma Response Team
do to take care of
• the traumatized teachers
• the traumatized climbing classmates
• the parents
• the classmates and their parents
• the principal of the school
• the teaching staff at school
Afterwards: Recovery Phase
What does the Trauma Response Team
do?
 Check-ins
 Routines and rituals
 Debriefing—what did we learn from
this experience?