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Best Practices in Mental Health Emergency Recovery in Schools

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Title: Best Practices in Mental Health Emergency Recovery in Schools


1
Best Practices in Mental Health Emergency
Recovery in Schools
  • Jackie Kibler, Ph.D.
  • Department of Psychology, University of Montana
  • jackie.kibler_at_umontana.edu
  • Matt Taylor, M.A.
  • Associate Director
  • Institute of Educational Research Service
  • The Montana Safe Schools Center
  • matt.taylor_at_umontana.edu
  • Scott Poland, Ed.D.
  • Coordinator of the Suicide Violence Prevention
    Office
  • Center for Psychological Studies, Nova
    Southeastern University
  • spoland_at_nova.edu

2
  • Presenter Disclosures
  • 2010 NASP Annual Convention
  • There are no financial interests to disclose, no
    honorarium provided for this presentation, and no
    funding by any publishing company.
  • One intervention which is the focus of this
    presentation, CBITS, is a commercially
    distributed product, however the presenters have
    no monetary or direct research interest in this
    products distribution. PFA is in the public
    domain.
  • Attendance at this conference was supported in
    part by a by Grant awarded by the U.S. Substance
    Abuse and Mental Health Services Administration
    (SAMHSA) as part of the National Child Traumatic
    Stress Network. The opinions contained herein
    are those of the author(s) and do not necessarily
    represent the official position or policies of
    SAMHSA, The University of Montana or NOVA
    Southeastern University.
  • References to specific companies, products, or
    services should not be considered an endorsement
    by the author(s) or SAMHSA.

3
The Emergency Management Cycle
Plan for a rapid, coordinated, effective response
Decrease the need for response
Restore the learning environment Monitor and
assist the healing
Execute the plan
4
What is NIMS and ICS?
  • NIMS stands for the National Incident Management
    System now being put into operation across the
    country, in part as a result of the events of
    September 11, 2001.
  • NIMS is intended to create a consistent
    nationwide approach for federal, state, tribal,
    and local governments
  • The Incident Command System (ICS) is the key
    component of the National Incident Management
    System (NIMS) that is most relevant for schools.

5
EMERGENCY MANAGEMENT LAW ENFORCEMENT FIRE
DEPARTMENTS EMERGENCY MEDICAL SERVICES

ICS
SCHOOLS
6
4 Main Goals of ICS and the ICS Organizational
Structure
  • 1. Maintain a manageable span of control
  • 2. Establish predetermined incident locations
    and facilities
  • 3. Implement resource management
  • 4. Ensure integrated communication

7
Expanded Sample School Based ICS Example
Incident Commander
Liaison Officer
Public Information Officer
Safety Officer
Operations Section Chief
Planning Section Chief
Logistics Section Chief
Finance Admin S. Chief
Student Supervision
Documentation/Recorder
Staffing
Insurance Claims
Transportation
Facility and Materials
Food Services
Personnel
Site/facility Security
Communications
Student Reunification Group Supervisor
Health Services Group Supervisor
Psychological First Aid Team Leader
Note vertical reporting lines below Section
Chiefs only for space saving illustration,
Supervisors report directly to Chiefs, Team
leaders to supervisors etc,.
Medical Triage Team Leader
8
What Are the Key Components of Recovery?
  • Physical/Structural Recovery
  • Business/Fiscal Recovery
  • Academic Recovery
  • Psychological/Emotional Recovery

9
Recovery
  • Strive to return to teaching and
    learning as quickly as possible.
  • Recovery will not happen quickly.
  • Recovery involves medical, psychological,
    infrastructure, legal, insurance, and
    documentation issues.
  • Reduce fear, facilitate grieving, promote
    education.
  • Conduct after action reviews with staff and first
    responders.

10
Key Issues in the Recovery Phase School
Psychologists as Crisis Intervention Team Members
  • How to structure recovery section of emergency
    management plan (EMP)
  • Opening or closing schools after an event occurs
  • Public, staff and student communications
  • Memorials after a student or staff death
  • How to handle key dates

11
Crisis Intervention Planning Preparing in Advance
for Recovery
  • Outline service delivery systems (MOUs/MAAs)
  • Template letters
  • Accepting donations
  • Empty chairs
  • Memorials and anniversaries
  • Thresholds and responsibility for closing
    reopening
  • Training
  • National Organization for Victim Assistance
    (NOVA)
  • National Association of School Psychologists
  • National Child Traumatic Stress Network
  • U.S. Department of Education

12
Crisis Intervention Working with the Media
  • Have media policies and procedures already in
    place that set limits and keep media away from
    staff and students.
  • Caution staff and students about speaking with
    media
  • Designated spokesperson should prepare written
    statements and rehearse sound bites for
    television that include mental health and safety
    recommendations

13
School Psychologists Promote the Mental Health of
Students Considerations for Emotional Recovery
  • Purpose To promote coping and resiliency for
    students, staff, and their families following an
    emergency or crisis
  • Key components
  • Recovery/mental health services that are
    available and acceptable in your district
    internal and external resources
  • Psychoeducation
  • Psychological first aid
  • Intervention strategies models
  • Long-term considerations (school board approval),
    recovery funding such as Project SERV and SAMHSA
    Crisis Counseling Grants

14
Crisis Intervention Tips for Helping Students
  • Share information in developmentally
    appropriate ways.
  • No one should be lied to or misled about
    the circumstances.
    Recognize all the
    connections around the school system.
  • Students need to hear sad or tragic news from
    trusted adults and should be able to ask
    questions.
  • Turn off TVs and gather students in a circle and
    talk about the event and their perceptions,
    safety concerns and sources of help.
  • Help everyone identify previous and current
    sources of support.

15
Crisis Intervention Creating a Caring Climate
  • Know that the crisis becomes the curriculum for a
    few days.
  • Provide guidance about when to resume the
    curriculum and when its okay to resume testing.
  • K-12 schools should stay open as source of
    support and consistent routine after tragedies.
  • Provide guidance about homework/tests, certain
    rules and expectations may need to be relaxed.
  • Re-establishing routines is helpful to all.

16
Traumatic Stress
  • Traumatic stress is an acute distress response
    that is experienced after exposure to a
    catastrophic event
  • Traumatic stress occurs because the event poses
    a serious threat to
  • The individual's life or physical integrity
  • The life of a family member or close friend
  • One's surrounding environment
  • Individuals who have witnessed injury or death
    are also at risk to develop a trauma stress
    response.
  • 1 in 4 (61 Northern Plains Indians, in one
    IERS/NNCTC study 100 PTSD)

17
Developmental Reactions to Traumatic Stress
  • Preschoolers
  • Regressive behaviors
  • Reenacting traumatic events through play
  • Sleep disturbances
  • Anxious attachment
  • Elementary School Children
  • Same as preschoolers, plus
  • Trouble concentrating
  • Physical symptoms (e.g., stomach aches,
    headaches, etc.)
  • Disruptive behaviors
  • Withdraw from others

Importance of caretaker/adult reactions
18
Developmental Reactions to Traumatic Stress
  • Adolescents
  • Regression
  • Anger
  • Avoid reminders of traumatic event
  • Loss of hope
  • Guilt
  • Withdrawal
  • Flashbacks
  • Eating problems
  • Sleeping problems (e.g., nightmares)

19
Responding to Traumatic Stress
  • Lets shift gears. . .

20
Multi-Level Trauma Intervention Options
  • Tier 1 General School-Based
  • Psychoeducation, triage and assessment
  • Supportive environment
  • Tier 2 School-Based, Student/Group/Staff
    Specific
  • Trauma and grief - Focused counseling
  • Short-term group or individual counseling
  • Tier 3 Specialized Community-Based
  • Referral to on or off-site mental health services

21
Cognitive Behavioral Intervention for Trauma in
Schools (CBITS) Lisa Jaycox, Ph.D (2004)
  • Developed to work with inner-city children who
    experience trauma symptoms from exposure to
    violence.

22
Basic Categories of Responses to Threats which
CBITS addresses
  • Shattered assumptions
  • I am in control (My parents are in control)
  • I am safe (My parents will keep me safe)
  • Bad things happen to other people, bad things
    cant happen to me. (My parents wont let bad
    things happen to me)
  • I am worthy and life has meaning
  • Re-experiencing the event and intrusive thoughts
    and images.
  • Hyperarousal
  • Avoidance and numbing
  • Sense of a foreshortened future

23
Treating Childhood Traumatic Stress in Schools
Summary of CBITS
  • Cognitive Behavioral Intervention for Trauma in
    Schools (CBITS)
  • Based upon Cognitive Behavioral Therapy
    components
  • Evidence based
  • 10 session group counseling protocol
  • Each session builds upon the previous session and
    allows for practice
  • One to three individual sessions
  • Parent and teacher education sessions
  • Ages 11-15

24
CBITS Screening and Intervention time line
Clinical Interview
Pre-group Assessment
Screening
Group not needed Group not appropriate Refer out
CBITS Group (10 weeks) Self-assessments
Post-group Assessment
Allow tracking of outcomes.
25
Special Considerations for CBITS Group Selection
  • CBITS is not for sexual abuse if the only trauma
  • The traumatic event should be at least one month
    old (otherwise, consider Psychological First Aid)
  • Refer children with very severe symptoms
  • Identify group dynamics before choosing group
  • Use co-facilitators if possible
  • CBITS manual is written for professionals with
    mental health intervention experience
  • Danger to self? Others? Cognitive impairments?
  • Does child need Tier III treatment?

26
Seeking, Supporting and Celebrating the
Resiliency in Our Students and Colleagues.
27
Trauma-Informed Intervention Examples
  • Psychological First Aid PFA (Brymer et al., 2005)
    PFA for schools forthcoming
  • Cognitive Behavioral Intervention for Trauma in
    Schools (CBITS) (Stein et al., 2003)
  • Support for Students Exposed to Trauma (SSET)
    (Jaycox, 2006)
  • Trauma-Focused Cognitive Behavioral Therapy
    (TF-CBT) (Cohen, Mannarino, Deblinger, 2006)
  • Traumatic Grief Component Therapy for Adolescents
    (TGCT-A) (Saltzman et al., 2006)
  • Child Development-Community Policing Program
    (CD-CP) (Maranas, Murphy, Berkowitz, 2002)

28
Considerations for Emotional Recovery Short-Term
  • Emotional Triage
  • What is the history of the community?
  • What is the trauma, support network and
    risk-taking history of the individual?
  • Psychological First Aid (PFA-S / Listen, Protect,
    Connect)
  • Initiate Group Crisis Interventions (GCI)
  • Be cautious about Critical Incident Stress
    Debriefing (CISD/CISM) because of the potential
    to re-traumatize some individuals
  • Educator and Provider Self Care!!
  • Consider utilization of services for staff
    through district Employee Assistance Programs
    (EAPs)

29
Emotional Triage Circles of Vulnerability
Geographical Proximity
Population at Risk
Psychosocial Proximity
30
Considerations for Emotional Recovery
Psychological First Aid
  • Psychological First Aid (PFA) is an
    evidence-informed modular approach for assisting
    children, adolescents, adults, and families in
    the immediate aftermath of disaster and terrorism
  • Designed to
  • reduce the initial distress
  • foster short- and long-term adaptive functioning
  • PFA meets four basic standards
  • Consistent with research evidence on risk and
    resilience following trauma
  • Applicable practical in field/school settings
  • Developmentally appropriate across the lifespan
  • Culturally informed and adaptable

Source National Child Traumatic Stress Network
and National Center for PTSD, Psychological First
Aid Field Operations Guide, September, 2005
31
Psychological First Aid 8 Core Actions
  • Initiate contact and engagement
  • Ensure safety and comfort
  • Stabilization
  • Gather information on current needs and concerns
  • Provide practical assistance
  • Connect with social supports
  • Provide information on coping
  • Link with collaborative services

Source National Child Traumatic Stress Network
and National Center for PTSD, Psychological First
Aid Field Operations Guide, September, 2005
32
Core Action 1 Contact and Engagement
  • Coordinated within ICS - particularly teacher,
    team leader or principal (introductions)
  • Be identifiable as an approved provider
  • Non-intrusive, compassionate, helpful
  • Quick, as many contacts as possible
  • Do not interrupt, does not need to be verbal,
    dont assume.
  • Culturally and developmentally appropriate
  • Is there a problem that needs immediate
    attention?

33
  • Core Action 2 Safety and Comfort
  • Engage in active, practical, familiar tasks to
    increase sense of control
  • Make the environment safe
  • Provide direction
  • Shield students from highly distressed
    individuals and from reporters
  • Recommend avoidance of repeated viewing in
    media

34
  • Core Action 3 Stabilization
  • Avoid adding to cognitive/emotional overload
  • Focus on adults calming children
  • Address primary, immediate concerns
  • Help students and teachers understand what to
    expect in terms of emotional responses
  • Steer adolescents away from impulsive reactions
  • Encourage grounding activities

35
  • Core Action 4 Information Gathering
  • The nature/ severity of experience
  • Death of family member, separation from loved one
    or other losses, other siblings in school
  • Concerns about ongoing threat
  • Physical Illness, medications, substance use
  • Guilt / shame
  • History of psychological problems or exposure to
    trauma and loss

36
Core Action 5 Practical Assistance
  • Identify / re-clarify most immediate needs
  • Discuss and action plan
  • Act to address the need to the degree possible
  • Focus on realistic options/solutions
  • Focus on empowerment
  • Help students and staff meet their own needs so
    that they feel more control in an out of control
    situation

37
Core Action 6 Connecting with Social Supports
  • Discuss support-seeking and giving
  • Provide comments that are
  • 1) reflective
  • 2) supportive
  • 3) empowering
  • Understand individuals may be reluctant to seek
    support, as appropriate, seek to understand why
    this is
  • Issues related to separation, loss, and
    displacement.
  • When working with young children, it is important
    to focus on the child in the context of the
    relationship.
  • When working with adolescents, remember the
    importance of peer relationships.
  • Utilize teachers who serve as primary caregivers
    for students

38
Core Action 7 Information on Coping
  • Basic information on stress reactions
  • Review common psychological reactions
  • Provide examples of positive coping actions
  • Provide examples of negative coping actions
  • Explain possible developmental delays/disruptions
    to parents and caregivers
  • Provide teachers and staff with information about
    students as well as about self care and stress
    reactions in adults

39
Core Action 8 Linkage with Collaborative
Services
  • Provide direct links to additional needed
    services
  • Promote continuity in helping relationships
  • Work closely with school / community mental
    health providers and document referral
    suggestions

40
Discussion of Recovery Scenario
  • Charleston Public Schools (fictitious)
  • 2,800 students
  • Scenario
  • Its early morning, December 18.
  • School has just begun for the day.
  • A full school bus is late arriving due to ice on
    the roads.

41
Discussion of Recovery Scenario
  • The bus has 22 students from the MS/HS on board
    (ages 10 17)
  • As the bus arrives to the middle school,
    approaching at an unusually high speed, the
    driver is unable to stop the bus.
  • The bus skids and then crashes through the
    heavily windowed wall of the music room and into
    a room pillar.
  • After a very brief period and a section of the
    roof, the pillar and 2 walls collapse onto the
    bus and the classroom.
  • There are 25 students in the music room7 students
    are killed and 32 students are injured four of
    them severely
  • The bus driver was found to be intoxicated
  • The school psychologist is out of the country
  • Your district has Mutual Aid Agreements with
    Valley Community Mental Health Agency
  • The Superintendant, Mayor and School Board call
    for a community ceremony within 3 days.

42
Discussion Questions
  • What are the first five steps you would take to
    activate the schools Mental Health Recovery
    Plan?
  • How do you identify the students and staff that
    are at different levels of risk?
  • How to you initiate, organize and manage the
    PFA-S process?
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