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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

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NUTS AND BOLTS OF TRAUMA RESPONSE

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Nuts and bolts of trauma response l.jpg

NUTS AND BOLTS OF TRAUMA RESPONSE

Lenore B. Behar, PhD, Director

Child & Family Program Strategies

Durham, North Carolina


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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]


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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


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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


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What Do We Use as Evidence?

  • Scientific literature

  • Data/Experience from the field:

    • Reports from key informants

  • Expert consultation

  • Needs assessment data


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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


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What to Do when Evidence-Based Practices Have Not Been Established

Use an

“Evidence Informed Approach”


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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


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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


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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


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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


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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


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


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Human Stress Response Continuum

  • Overwhelming stress

  • Traumatic stress

  • Persistent stress

  • PTSD

    Macy, 2006


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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


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Disaster Trauma:Affected PopulationsEvans, 2003

Victims, eyewitnesses


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Disaster Trauma:Affected PopulationsEvans, 2003

Victims, eyewitnesses

Victims’ families & close friends


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Disaster Trauma:Affected PopulationsEvans, 2003

Victims, eyewitnesses

Victims’ families & close friends

Emergency responders


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Disaster Trauma:Affected PopulationsEvans, 2003

Victims, eyewitnesses

Victims’ families & close friends

Emergency responders

Vulnerable people, teachers, neighbors


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Disaster Trauma:Affected PopulationsEvans, 2003

Victims, eyewitnesses

Other children & parents

Victims’ families & close friends

Emergency responders

Vulnerable people


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Disaster Trauma:Affected PopulationsEvans, 2003

Victims, eyewitnesses

Other children & parents

Victims’ families & close friends

Emergency responders

Vulnerable people

Entire population


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


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Disaster Stages

Before

Preparedness

During

Acute/

Intermediate

After

Recovery


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Other Players in Crisis Response

Public Safety

Public Health

Behavioral Health


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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


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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


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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


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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


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Tasks of Trauma Response Team


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Tasks of Trauma Response Team


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Tasks of Trauma Response Team


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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


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COMMUNITY STRESS PREVENTION CENTER

GEOGRAPHICAL

PROXIMITY

POPULATION

AT RISK

PSYCHOSOCIAL

PROXIMITY

CIRCLES OF VULNERABILITY

MAPPING BY THREE DIMENSIONS


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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


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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


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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.


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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.


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Thank you

THE COMMUNITY STRESS PREVENTION CENTER

For further information please contact

[email protected]

www.icspc.org


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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


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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


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Psychological First Aid Goal: To increase coping skills and restore functioning

  • Establish safety

  • Provide comfort

  • Work toward stabilization

  • Provide clarifying information

  • Identify support systems


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Psychological First Aid Is Not

  • Psychotherapy

  • Research

  • An emergency response

  • A long-term intervention

  • A “stand-alone” intervention

  • A chance to identify future clients


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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


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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


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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


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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


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Traumatic Stress ResponseTime Lines: 0 - 72 Hours

  • Fight & flight & appraisal systems

  • Freeze systems

  • The “crying curve”

  • Temporary cognitive distortions

  • Temporary performance interruptions

    Macy, 2006


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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


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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


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Types of Interventions

Provided in school, in shelters, community

settings

  • Orientation groups

  • Stabilization groups

  • Coping groups

  • Individual stabilization and referral


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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


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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


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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


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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


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    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


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    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


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    Traditional Role

    Office-based treatment

    Multiple treatment sessions

    Therapeutic relationship

    Client comes to you

    Spectrum of disorders

    Main contact = provider

    New Role

    School/community-based treatment

    Brief intervention, focus on here and now

    Psychological first aid

    You go to client

    Focus on recovery

    Community Team = multiple people involved

    Change in Roles


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    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.


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    victims/concerned

    community

    administration

    neighbourhood

    classroom teacher

    teachers

    family,

    friends

    classmates

    fellow students

    principal

    relatives

    the whole school

    schools in the neighbourhood

    Circles of Vulnerability

    Community Stress Prevention Centre, Kyriat Shmonah, Israel

    )


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    victims/concerned

    helpers/supporters

    community

    administration

    social workers

    The media

    external counselors

    neighbourhood

    classroom teacher

    churches, priests

    teachers

    family,

    friends

    classmates

    principal

    internal counselors

    fellow students

    relatives

    community members

    the whole school

    psychologists

    schools in the neighbourhood

    Circles of Support

    Community Stress Prevention Centre, Kyriat Shmonah, Israel


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    FOOLS RUSH IN!!!


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    • 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.


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    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


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    Afterwards: Recovery Phase

    What does the Trauma Response Team

    do?

    • Check-ins

    • Routines and rituals

    • Debriefing—what did we learn from this experience?


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