NUTS AND BOLTS OF TRAUMA RESPONSE Lenore B. Behar, PhD, Director Child & Family Program Strategies Durham, North Carolina.

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’ families & close friends




Emergency responders





Vulnerable people, teachers, neighbors






Vulnerable people


Other children & parents





Vulnerable people


Entire population

Other children & parents




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


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


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


INSPECTORTEACHERS

CLASSMATES

FRIENDS

FAMILY

INJURED CHILDREN,

OTHER CLASSESWITNESSES

PRINCIPAL

ALL THE STAFF

PARENTS

CIRCLES OF VULNERABILITY

OTHER SCHOOLS

PEOPLE IN THE NEIGHBOURHOOD


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



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.


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


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


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


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?

NUTS AND BOLTS OF TRAUMA RESPONSE Lenore B. Behar, PhD, Director Child & Family Program Strategies Durham, North Carolina.

Documents

eyewitnessesdisaster

media trauma

trauma response teamsgain

bolts of trauma responselenore

affected populations

evidencebased practices

evidence informed approachwhat

psychological proximity