nuts and bolts of trauma response lenore b. behar, phd, director child & family program...
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NUTS AND BOLTS OF NUTS AND BOLTS OF TRAUMA RESPONSETRAUMA RESPONSE
Lenore B. Behar, PhD, DirectorLenore B. Behar, PhD, DirectorChild & Family Program StrategiesChild & Family Program Strategies
Durham, North CarolinaDurham, North Carolina
BibliographyBibliography
Go to: www.lenorebehar.com
See: Presentations Community Based Interventions In
Two Parts: Systems of Care and Approaches to Recovery from Psychological Trauma
orE-Mail: [email protected]
Learning ObjectivesLearning Objectives
Gain understanding of how to develop Gain understanding of how to develop and use trauma response teamsand use trauma response teams
Gain understanding of group Gain understanding of group interventions to reduce the impact of interventions to reduce the impact of traumatrauma
Gain understanding of when to refer Gain understanding of when to refer adolescents to professional treatment adolescents to professional treatment following exposure to traumafollowing exposure to trauma
Types of TraumaTypes of Trauma
Significant lossesSignificant losses Domestic violenceDomestic violence Community and school violenceCommunity and school violence Complex traumaComplex trauma (multiple trauma) (multiple trauma) Medical traumaMedical trauma Refugee and war zone traumaRefugee and war zone trauma Natural disastersNatural disasters TerrorismTerrorism
National Child Traumatic Stress Network, National Child Traumatic Stress Network, 20062006
What Do We Use as Evidence?What Do We Use as Evidence?
Scientific literatureScientific literature
Data/Experience from the field:Data/Experience from the field:• Reports from key informantsReports from key informants
Expert consultationExpert consultation
Needs assessment dataNeeds assessment data
What Can an What Can an Evidence Informed Approach Evidence Informed Approach
Tell Us?Tell Us?
Who will need helpWho will need help Critical issuesCritical issues When to interveneWhen to intervene What to do and what not to doWhat to do and what not to do What we might expect from interventionsWhat we might expect from interventions Important clues on group differencesImportant clues on group differences
What to Do when Evidence-What to Do when Evidence-Based Practices Have Not Been Based Practices Have Not Been
EstablishedEstablished
Use anUse an
“ “Evidence Informed Approach”Evidence Informed Approach”
What Does the Evidence Indicate?What Does the Evidence Indicate?
Proximity to disaster affects the psychological Proximity to disaster affects the psychological impactimpact
Previous exposure to trauma affects the Previous exposure to trauma affects the impactimpact
Cultural groups respond differently Cultural groups respond differently Impairments affect how people respondImpairments affect how people respond Perception is realityPerception is reality Most people recover without problemsMost people recover without problems
How Do Children/Youth How Do Children/Youth Respond to Trauma?Respond to Trauma?
They worry about their own safetyThey worry about their own safety
They may become re-traumatized They may become re-traumatized through overexposure to media through overexposure to media
Trauma seems ubiquitous and not Trauma seems ubiquitous and not isolatedisolated
Children React DifferentlyChildren React Differently
Reaction depends on developmental level—the Reaction depends on developmental level—the capacity to understandcapacity to understand
Reaction depends on family functioning and other Reaction depends on family functioning and other support systems support systems
Reaction depends on resiliencyReaction depends on resiliency
Reaction depends on physical or psychological Reaction depends on physical or psychological proximity to the traumatic event proximity to the traumatic event
Reaction depends on cultureReaction depends on culture
Other Ways to Describe Other Ways to Describe ResponsesResponses
Reactions unfold over timeReactions unfold over time
May follow a process of shock, sadness, May follow a process of shock, sadness, anger, acceptance, then adjustmentanger, acceptance, then adjustment
The unmoved or detached child may be The unmoved or detached child may be concerning but is sometimes normalconcerning but is sometimes normal
Prolonged behavior may signal need to Prolonged behavior may signal need to interventionintervention
Responses to TraumaResponses to Trauma
Related to amount of destruction or Related to amount of destruction or amount of lossamount of loss
Related to perceived supportRelated to perceived support Related to resiliencyRelated to resiliency Nightmares and sleep disorders Nightmares and sleep disorders
commoncommon Persistent thoughts or triggers shape Persistent thoughts or triggers shape
behaviorbehaviorMacy, 2006Macy, 2006
Maslow’s Hierarchy of NeedsMaslow’s Hierarchy of Needs Scweitzer & Knutson-Eide, 2005Scweitzer & Knutson-Eide, 2005
Peak Experiences
Self-Actualization
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 Human Stress Response ContinuumContinuum
• Overwhelming stressOverwhelming stress• Traumatic stressTraumatic stress• Persistent stressPersistent stress• PTSDPTSD
Macy, 2006Macy, 2006
Range of ResponsesRange of Responses
Shock Shock NumbnessNumbness CryingCrying SadnessSadness AngerAnger Feeling guiltyFeeling guilty Keep concerns Keep concerns
insideinside Increased Increased
clingingclinging
Deny or avoid feelingsDeny or avoid feelings Repeated cryingRepeated crying Depression or suicidal Depression or suicidal
thoughtsthoughts Persistent angerPersistent anger Persistent unhappinessPersistent unhappiness Social withdrawalSocial withdrawal Decreased school Decreased school
performanceperformance
Feldman-Winter & Christie, 2004Feldman-Winter & Christie, 2004
Normal Signs of Problems
Victims, eyewitnesses
Disaster Trauma:Disaster Trauma:Affected PopulationsAffected Populations
Evans, 2003Evans, 2003
Victims, eyewitnesses
Victims’ families & close friends
Disaster Trauma:Disaster Trauma:Affected PopulationsAffected Populations
Evans, 2003Evans, 2003
Victims, eyewitnesses
Emergency responders
Victims’ families & close friends
Disaster Trauma:Disaster Trauma:Affected PopulationsAffected Populations
Evans, 2003Evans, 2003
Victims, eyewitnesses
Vulnerable people, teachers, neighbors
Emergency responders
Victims’ families & close friends
Disaster Trauma:Disaster Trauma:Affected PopulationsAffected Populations
Evans, 2003Evans, 2003
Victims, eyewitnesses
Vulnerable people
Emergency responders
Other children & parents
Victims’ families & close friends
Disaster Trauma:Disaster Trauma:Affected PopulationsAffected Populations
Evans, 2003Evans, 2003
Victims, eyewitnesses
Vulnerable people
Emergency responders
Entire population
Other children & parents
Victims’ families & close friends
Disaster Trauma:Disaster Trauma:Affected PopulationsAffected Populations
Evans, 2003Evans, 2003
The seriousness of the response is The seriousness of the response is related to durability/longevity related to durability/longevity primarily, and somewhat to primarily, and somewhat to
intensityintensity
80% recover—no PTSD80% recover—no PTSD
Disaster StagesDisaster Stages
BeforePreparedness
DuringAcute/
Intermediate
AfterRecovery
Other Players in Crisis Other Players in Crisis ResponseResponse
Public Safety
Behavioral HealthPublic Health
Forming a Trauma Forming a Trauma Response TeamResponse Team
Members of “The Team”Members of “The Team”• Mental health providersMental health providers• School counselors and teachersSchool counselors and teachers• Community leadersCommunity leaders• PolicePolice• Faith-based leadersFaith-based leaders• Community-based workersCommunity-based workers• Pediatricians/health providersPediatricians/health providers
ImplicationsImplications
Need outreach and direct careNeed outreach and direct care Build community capacityBuild community capacity Rely on existing resourcesRely on existing resources Utilize a phased approachUtilize a phased approach Build in diverse strategiesBuild in diverse strategies Form new collaborations and Form new collaborations and
partnershipspartnerships
Operational AssumptionsOperational Assumptions
No new resources for ongoing development No new resources for ongoing development and maintenanceand maintenance
Address surge capacityAddress surge capacity Connect to local and regional emergency Connect to local and regional emergency
response systemsresponse systems Community needs assessmentCommunity needs assessment Population basedPopulation based
ResultsResults
Intensive training of trauma response Intensive training of trauma response team membersteam members
Identification of key members in Identification of key members in communities communities
Identification of local resources for Identification of local resources for referral referral
Linkages to hospitals/emergency medical Linkages to hospitals/emergency medical servicesservices
Linkages to public safety/public health Linkages to public safety/public health response networks response networks
Tasks of Trauma Response TeamTasks of Trauma Response Team
PREVENTIONPREVENTION
Develop/train trauma response teamsDevelop/train trauma response teams
Provide information and training for Provide information and training for teachers, specialists and parents (early teachers, specialists and parents (early warning signs, violence prevention, ...)warning signs, violence prevention, ...)
Develop linkages to helpers/ informantsDevelop linkages to helpers/ informants
Develop linkages to referral sourcesDevelop linkages to referral sources
Tasks of Trauma Response TeamTasks of Trauma Response Team
INTERVENTIONINTERVENTION
Support schools or community groups to Support schools or community groups to manage crisis situations manage crisis situations
Cooperate with other crisis intervenors Cooperate with other crisis intervenors (mental health, police, psychologists, (mental health, police, psychologists, priests, ...priests, ...
Deal with individuals and groups to Deal with individuals and groups to overcome traumatic experiencesovercome traumatic experiences
Provide information about the effect of Provide information about the effect of traumatrauma
Tasks of Trauma Response TeamTasks of Trauma Response Team
POST-INTERVENTIONPOST-INTERVENTION
Develop follow-up care-plan for victims Develop follow-up care-plan for victims and concerned peopleand concerned people
Arrange for counseling in the school or Arrange for counseling in the school or referral in the aftermath of crisis referral in the aftermath of crisis situationssituations
Provide guidance to school personnel to Provide guidance to school personnel to help them identify those with continuing help them identify those with continuing needs.needs.
Check in for follow-upCheck in for follow-up
• SOCIAL / COMMUNITY WORKERSSOCIAL / COMMUNITY WORKERS (TEAM LEADER (TEAM LEADER))
• NURSE AND OR MEDICAL DOCTORNURSE AND OR MEDICAL DOCTOR
• PSYCHOLOGIST (PSYCHIATRIST-ON DEMANDPSYCHOLOGIST (PSYCHIATRIST-ON DEMAND))
• COMMUNITY COMMUNITY / / TRANSLATOR / VOLUNTEERTRANSLATOR / VOLUNTEER
• LOGISTICS REPSLOGISTICS REPS..
• SCHOOL’S EMERGENCY INTERVENTION TEAMSCHOOL’S EMERGENCY INTERVENTION TEAM
• ARTS INSTRUCTORARTS INSTRUCTOR
COMMUNITY STRESS PREVENTION CENTER
GEOGRAPHICALGEOGRAPHICAL
PROXIMITYPROXIMITY
POPULATIONPOPULATION AT RISKAT RISK
PSYCHOSOCIALPSYCHOSOCIALPROXIMITYPROXIMITY
MAPPING BY THREE DIMENSIONSMAPPING BY THREE DIMENSIONS
COMMUNITY STRESS PREVENTION CENTER
INSPECTORTEACHERS
CLASSMATES
FRIENDS
FAMILY
INJURED CHILDREN,
OTHER CLASSESWITNESSES
PRINCIPAL
ALL THE STAFF
PARENTS
CIRCLES OF VULNERABILITY
OTHER SCHOOLS
PEOPLE IN THE NEIGHBOURHOOD
COMMUNITY STRESS PREVENTION CENTER
WHO IS GOING WHO IS GOING TO HELP?TO HELP?
INSPECTORTEACHERS
CLASSMATES
FRIENDS
FAMILY
INJURED CHILDREN,
OTHER CLASSESWITNESSES
PRINCIPAL
ALL THE STAFF
PARENTS
CIRCLES OF SUPPORT
CIRCLES OF VULNERABILITY
PSYCHOLOGIST
COMMUNITY MEMBERS
TEACHER
NEIGHBOURS
COLLEAGUES
FRIENDS
FAMILY
SOCIALWORKER
OTHER SCHOOLS
INSPECTOR
PRINCIPAL
THE WHOL NEIGHBOURHOOD
COMMUNITY STRESS PREVENTION CENTER
COMMUNITY STRESS PREVENTION CENTER
HELPING WITH INFORMATION & LOCATING HELPING WITH INFORMATION & LOCATING RELATIVES.RELATIVES.
OUTREACH & SUPPORT TO PEOPLE IN NEED.OUTREACH & SUPPORT TO PEOPLE IN NEED.
ACTIVATING EDUCATIONAL AND COMMUNITY-BASED ACTIVATING EDUCATIONAL AND COMMUNITY-BASED PLANS.PLANS.
PSYCHOLOGICAL FIRST AID - CIPR PSYCHOLOGICAL FIRST AID - CIPR INTERVENTION vs TREATMENT.INTERVENTION vs TREATMENT.
COMMUNITY STRESS PREVENTION CENTER
TRACING, FOLLOW UP & ADMINISTRATING TRACING, FOLLOW UP & ADMINISTRATING PSYCHOLOGICAL REHABILITATION INTERVENTIONS.PSYCHOLOGICAL REHABILITATION INTERVENTIONS.
ENCOURAGING & PROMOTING GETTING BACK TO ENCOURAGING & PROMOTING GETTING BACK TO ROUTINE.ROUTINE.
COORDINATING THE GRADUAL ASSIMILATION OF COORDINATING THE GRADUAL ASSIMILATION OF EMOTIONALLY & PHYSICALLY INJURED PEOPLE EMOTIONALLY & PHYSICALLY INJURED PEOPLE IN THEIR NATURAL ENVIRONMENT.IN THEIR NATURAL ENVIRONMENT.
PREPARING FOR THE FUTURE.PREPARING FOR THE FUTURE.
For further information please contactFor further information please contact
[email protected]@telhai.ac.il
www.icspc.orgwww.icspc.org
Crisis intervention (caring for people during the crisis)
Caring for people after the crisis (support & long-term healing)
Crisis prevention (caring for people before the crisis)
Support short- to long-term copings, preventing secondary symptoms
Long term planning of prevention; optimizing crisis management
Short term relief in order to prevent collapsing of persons or systems
Englbrecht & Storath, 2005
Another Model of Crisis Another Model of Crisis Management Management
Basics of WorkBasics of Work
Model of crisis managementModel of crisis management Psychological first aidPsychological first aid Circles of vulnerability and supportCircles of vulnerability and support Basic elements of crisis interventionBasic elements of crisis intervention Focus on resiliency: BASIC - PHFocus on resiliency: BASIC - PH Neurophysiological approachNeurophysiological approach Systemic approachSystemic approach
Psychological First Aid Psychological First Aid
Goal: To increase coping skills Goal: To increase coping skills and restore functioningand restore functioning
Establish safetyEstablish safety Provide comfortProvide comfort Work toward stabilizationWork toward stabilization Provide clarifying informationProvide clarifying information Identify support systemsIdentify support systems
Psychological First Aid Psychological First Aid Is NotIs Not
PsychotherapyPsychotherapy ResearchResearch An emergency responseAn emergency response A long-term interventionA long-term intervention A “stand-alone” interventionA “stand-alone” intervention A chance to identify future clientsA chance to identify future clients
Normal AssumptionsNormal AssumptionsWhen Threat is MinimalWhen Threat is Minimal
I am in controlI am in control I am safeI am safe I am worthyI am worthy The world is meaningfulThe world is meaningful It can’t happen to meIt can’t happen to me
Traumatic Stress Response & Traumatic Stress Response & Shattered AssumptionsShattered Assumptions
I am not in controlI am not in control I am not safeI am not safe I am not worthyI am not worthy The world is not meaningfulThe world is not meaningful It can happen to me or those I loveIt can happen to me or those I love
The Human Stress Response The Human Stress Response ContinuumContinuum
Magnitude of Impact IMagnitude of Impact I
Single eventSingle event Repeated eventsRepeated events Amount of stress in your lifeAmount of stress in your life Prior trauma historyPrior trauma history Prior exposure(s) to critical incidentsPrior exposure(s) to critical incidents
Macy, 2006Macy, 2006
The Human Stress Response The Human Stress Response ContinuumContinuum
Magnitude of Impact IIMagnitude of Impact II
Nature of eventNature of event Involvement, degree of control, threat lossInvolvement, degree of control, threat loss Degree of warningDegree of warning Ego strength/coping style/resiliencyEgo strength/coping style/resiliency Prior mastery of experience (challenges)Prior mastery of experience (challenges) Proximity variables: time & distanceProximity variables: time & distance Nature & degree of social support/resourceNature & degree of social support/resource
Macy, 2006Macy, 2006
Traumatic Stress ResponseTraumatic Stress ResponseTime Lines: 0 - 72 HoursTime Lines: 0 - 72 Hours
Fight & flight & appraisal systemsFight & flight & appraisal systems Freeze systemsFreeze systems The “crying curve” The “crying curve” Temporary cognitive distortionsTemporary cognitive distortions Temporary performance interruptionsTemporary performance interruptions
Macy, 2006Macy, 2006
Traumatic Stress ResponseTraumatic Stress ResponseTime Lines: 72 Hrs – 3 WeeksTime Lines: 72 Hrs – 3 Weeks
Disruption of self regulatory capacityDisruption of self regulatory capacity Neurobiology of attachment disruptionNeurobiology of attachment disruption Memory interruptionMemory interruption Distorted perceptionsDistorted perceptions Recognized shattered assumptionsRecognized shattered assumptions Approach & withdrawal cycleApproach & withdrawal cycle Incident identityIncident identity
Traumatic Stress ResponseTraumatic Stress ResponseTime Lines: 3 Weeks – 12 WeeksTime Lines: 3 Weeks – 12 Weeks
Memory distortionMemory distortion Amnesia or memory intrusionsAmnesia or memory intrusions Longer lasting dissociationLonger lasting dissociation Cognitive impairment, perseverationCognitive impairment, perseveration Blunted/numbered emotionsBlunted/numbered emotions Flashback/nightmaresFlashback/nightmares Performance declinePerformance decline Chronic sleep disturbanceChronic sleep disturbance
Types of InterventionsTypes of Interventions
Provided in school, in shelters, communityProvided in school, in shelters, community
settingssettings Orientation groupsOrientation groups
Stabilization groupsStabilization groups
Coping groupsCoping groups
Individual stabilization and referralIndividual stabilization and referral
Goals of Group OrientationGoals of Group Orientation
Clarify information; provide factsClarify information; provide facts Teach survivors about traumatic Teach survivors about traumatic
stress responsestress response Teach survivors about self-care Teach survivors about self-care
techniquestechniques Help survivors identify personal Help survivors identify personal
coping strategiescoping strategies
First StepsFirst Steps
Provide comfortProvide comfort Help to provide safetyHelp to provide safety Limit TV and other visual reminders of Limit TV and other visual reminders of
violence or deathviolence or death Provide understanding of what really Provide understanding of what really
happenedhappened Help parents, teachers, other caregivers Help parents, teachers, other caregivers
understand what to dounderstand what to do
The Goals of Coping GroupsThe Goals of Coping Groups
Mitigate the impact of a critical Mitigate the impact of a critical incidentincident
Accelerate normal recovery in Accelerate normal recovery in normal people who are having normal people who are having normal reactions to abnormal eventsnormal reactions to abnormal events
Provide education and discussion Provide education and discussion regarding stress and copingregarding stress and coping
Assessment & screening of survivorsAssessment & screening of survivors
Before: PreparednessBefore: Preparedness
Debrief from previous eventsDebrief from previous events Focus on Focus on preventionprevention
Strengthen community resilience, reduce Strengthen community resilience, reduce risk factors, improve coping capacityrisk factors, improve coping capacity
Build response Build response infrastructureinfrastructure Coalitions, partnerships, networksCoalitions, partnerships, networks Model and role definitionModel and role definition Curriculum development, trainingCurriculum development, training Communications/command structuresCommunications/command structures
Develop Develop rapid responserapid response plan plan
During: Acute phaseDuring: Acute phase
Immediate responseImmediate response Comfort, support, psychological first aidComfort, support, psychological first aid Clinical screeningClinical screening Attend to needs of directly affected and Attend to needs of directly affected and
vulnerable populationsvulnerable populations Individual, family/group interventions Individual, family/group interventions Public messagesPublic messages Support to caregiversSupport to caregivers
After: Recovery phaseAfter: Recovery phase
Expect Expect most peoplemost people will be will be OKOK Identify those with delayed effectsIdentify those with delayed effects Clinical workClinical work with people who have PTSD and with people who have PTSD and
lasting psychological effectslasting psychological effects Broad Broad community outreachcommunity outreach - information - information
dissemination/education dissemination/education Lessons learnedLessons learned, evaluation, research, evaluation, research
Traditional RoleTraditional Role Office-based treatmentOffice-based treatment
Multiple treatment Multiple treatment sessionssessions
Therapeutic relationship Therapeutic relationship Client comes to youClient comes to you Spectrum of disordersSpectrum of disorders Main contact = providerMain contact = provider
New RoleNew Role School/community-based School/community-based
treatmenttreatment Brief intervention, focus Brief intervention, focus
on here and nowon here and now Psychological first aidPsychological first aid You go to client You go to client Focus on recoveryFocus on recovery Community Team = Community Team =
multiple people involvedmultiple people involved
Change in RChange in Rolesoles
ExerciseExercise
Deadly climbing accidentDeadly 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 climbingaccident at a school outing. A 14 year old boy hast a school outing. A 14 year old boy hasfallen from a rocky ledge and died in front of hisfallen from a rocky ledge and died in front of hisclassmates and teachers.classmates and teachers.
community administration
neighbourhood
teachers
family, friends
fellow students
classroom teacher
relativesthe whole
school
classmates
principal
schools in the neighbourhood
Circles of Vulnerability
Community Stress Prevention Centre, Kyriat Shmonah, Israel
)
victims/concernedvictims/concerned
community The mediaadministration
neighbourhood
teachers family, friends
fellow students
classroom teacher
relatives the whole school
classmates
principal
schools in the neighbourhood
external counselors
internal counselors
community members
churches, priests
Circles of Support
Community Stress Prevention Centre, Kyriat Shmonah, Israel
victims/concernedvictims/concerned helpers/supporters
psychologists
social workers
FOOLS RUSH IN!!!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 PhaseIntervention: Acute Phase
What should the Trauma Response Team What should the Trauma Response Team do to take care ofdo to take care of• the traumatized teachersthe traumatized teachers• the traumatized climbing classmatesthe traumatized climbing classmates• the parentsthe parents• the classmates and their parentsthe classmates and their parents• the principal of the schoolthe principal of the school• the teaching staff at schoolthe teaching staff at school
Afterwards: Recovery PhaseAfterwards: Recovery Phase
What does the Trauma Response TeamWhat does the Trauma Response Team
do?do? Check-insCheck-ins Routines and ritualsRoutines and rituals Debriefing—what did we learn from Debriefing—what did we learn from
this experience?this experience?