NUTS AND BOLTS OF TRAUMA RESPONSE

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

2. 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: lbehar@nc.rr.com

3. 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

4. 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

5. What Do We Use as Evidence? • Scientific literature • Data/Experience from the field: • Reports from key informants • Expert consultation • Needs assessment data

6. 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

7. What to Do when Evidence-Based Practices Have Not Been Established Use an “Evidence Informed Approach”

8. 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

9. 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

10. 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

11. 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

12. 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

13. Maslow’s Hierarchy of NeedsScweitzer & Knutson-Eide, 2005

14. Human Stress Response Continuum • Overwhelming stress • Traumatic stress • Persistent stress • PTSD Macy, 2006

15. Shock Numbness Crying Sadness Anger Feeling guilty Keep concerns inside Increased clinging Deny or avoid feelings Repeated crying Depression or suicidal thoughts Persistent anger Persistent unhappiness Social withdrawal Decreased school performance Feldman-Winter & Christie, 2004 Range of Responses Normal Signs of Problems

16. Disaster Trauma:Affected PopulationsEvans, 2003 Victims, eyewitnesses

17. Disaster Trauma:Affected PopulationsEvans, 2003 Victims, eyewitnesses Victims’ families & close friends

18. Disaster Trauma:Affected PopulationsEvans, 2003 Victims, eyewitnesses Victims’ families & close friends Emergency responders

19. Disaster Trauma:Affected PopulationsEvans, 2003 Victims, eyewitnesses Victims’ families & close friends Emergency responders Vulnerable people, teachers, neighbors

20. Disaster Trauma:Affected PopulationsEvans, 2003 Victims, eyewitnesses Other children & parents Victims’ families & close friends Emergency responders Vulnerable people

21. Disaster Trauma:Affected PopulationsEvans, 2003 Victims, eyewitnesses Other children & parents Victims’ families & close friends Emergency responders Vulnerable people Entire population

22. The seriousness of the response is related to durability/longevity primarily, and somewhat to intensity80% recover—no PTSD

23. Disaster Stages Before Preparedness During Acute/ Intermediate After Recovery

24. Other Players in Crisis Response Public Safety Public Health Behavioral Health

25. 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

26. 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

27. 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

28. 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

29. Tasks of Trauma Response Team

30. Tasks of Trauma Response Team

31. Tasks of Trauma Response Team

32. COMMUNITY STRESS PREVENTION CENTER NEIGHBOURHOOD COMBINED TEAM • 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

33. COMMUNITY STRESS PREVENTION CENTER GEOGRAPHICAL PROXIMITY POPULATION AT RISK PSYCHOSOCIAL PROXIMITY CIRCLES OF VULNERABILITY MAPPING BY THREE DIMENSIONS

34. COMMUNITY STRESS PREVENTIONCENTER CIRCLES OF VULNERABILITY PRINCIPAL WHO IS GOING TO HELP? TEACHERS INSPECTOR CLASSMATES FRIENDS ALL THE STAFF PARENTS PEOPLE IN THE NEIGHBOURHOOD INJURED CHILDREN, FAMILY WITNESSES OTHER CLASSES OTHER SCHOOLS

35. COMMUNITY STRESS PREVENTION CENTER CIRCLES OF VULNERABILITY CIRCLES OF SUPPORT PRINCIPAL PRINCIPAL INSPECTOR TEACHERS INSPECTOR CLASSMATES TEACHER PSYCHOLOGIST FRIENDS FRIENDS ALL THE STAFF PARENTS THE WHOL NEIGHBOURHOOD INJURED CHILDREN, SOCIAL WORKER COLLEAGUES FAMILY FAMILY NEIGHBOURS WITNESSES OTHER CLASSES COMMUNITY MEMBERS OTHER SCHOOLS

36. COMMUNITY STRESS PREVENTION CENTER SECONDARY PREVENTION HELPING WITH INFORMATION & LOCATING RELATIVES. OUTREACH & SUPPORT TO PEOPLE IN NEED. ACTIVATING EDUCATIONAL AND COMMUNITY-BASED PLANS. PSYCHOLOGICAL FIRST AID - CIPR INTERVENTION vs TREATMENT.

37. COMMUNITY STRESS PREVENTION CENTER TERTIARY PREVENTION 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.

38. Thank you THE COMMUNITY STRESS PREVENTION CENTER For further information please contact cspc@telhai.ac.il www.icspc.org

39. 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) Caring for people after the crisis (support & long-term healing) Long term planning of prevention; optimizing crisis management Support short- to long-term copings, preventing secondary symptoms Englbrecht & Storath, 2005

40. 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

41. Psychological First Aid Goal: To increase coping skills and restore functioning • Establish safety • Provide comfort • Work toward stabilization • Provide clarifying information • Identify support systems

42. Psychological First Aid Is Not • Psychotherapy • Research • An emergency response • A long-term intervention • A “stand-alone” intervention • A chance to identify future clients

43. Normal AssumptionsWhen Threat is Minimal • I am in control • I am safe • I am worthy • The world is meaningful • It can’t happen to me

44. 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

45. The Human Stress Response ContinuumMagnitude of Impact I • Single event • Repeated events • Amount of stress in your life • Prior trauma history • Prior exposure(s) to critical incidents Macy, 2006

46. The Human Stress Response ContinuumMagnitude 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

47. Traumatic Stress ResponseTime Lines: 0 - 72 Hours • Fight & flight & appraisal systems • Freeze systems • The “crying curve” • Temporary cognitive distortions • Temporary performance interruptions Macy, 2006

48. Traumatic Stress ResponseTime 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

49. Traumatic Stress ResponseTime 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

50. Types of Interventions Provided in school, in shelters, community settings • Orientation groups • Stabilization groups • Coping groups • Individual stabilization and referral