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Treating Traumatized Children: Risk, Resilience, and Recovery

Danny Brom, Ph.D.Director

Best Practices In Disaster Mental Health and Resilience: What Is, What Could Be!

New Orleans, March 19, 2009

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Objectives of the lecture

1 .Get acquainted with an integrative model of intervention to protect children in the face of war and disaster2. Understand the organizational and communal resources needed for community wide implementation of resilience programs.3. Share some thoughts about how to bring new models of care into the system

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What do we know about the influence of trauma on children?

When she hears the alarm again everything freezes. She regressed back to behaving like a baby, bedwetting and asking for a bottle, or pacifier.

At first he was very afraid of the Kassams and the sounds. Slowly a new process begun, I think- repression. When a Kassam falls he opens the door and runs out to see where it fell, and what is happening, he became very involved with all this, like Wow- great a Kassam fell, fascinating. He is not afraid any more.

I prefer to decide what to do with my life and not let them decide for me… (when asked why he took risks)

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What we also know

- The literature on traumatized children is far behind the literature on traumatized adults

- Traumatized children hardly show up for services

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From: Sent: Wednesday, July 16, 2008 5:18 PM

To: rgill@herzoghospital.orgSubject: Israel Center for the Treatment of Psychotrauma - Ask The Expert

ר:שם פרטי: ג:שם משפחה

:הודעה!שלום רב

הוא לא מפסיק לדבר על נסראלה. במלחמה הוא היה רק בן שנתיים, אבל הוא זוכר את הכול. מאז . שנים4-הבעיה שלי היא עם בני בן ה, ילדים4- נשואה ואמא ל34שמי ר אני בת 4המלחמה אני לא יכולה לצאת לעבוד ולא לעזוב אותו בכלל. הילד רואה את נסראלה בחדשות הוא מתעצבן ומרביץ לטלויזיה. אם אנחנו קונים לו משחקים שמתאימים לילד בן

הוא לא נוגע בהם, הוא רוצה רק חרבות ונשקים. כשהוא יושב לצייר הוא מצייר קטיושות או פצצות ארוכות שיגיעו לנסראלה. אני לא יודעת למי ליפנות אני מבקשת את עזרתכם .אני לא רוצה שהילד יגדל עם כל כך הרבה שנאה ויהפוך להיות אלים

בברכה ותודה ר

I am 34, married, and a mother of 4 children. My problem relates to my 4 year old son. He does not stop talking about Nasrallah. During the war he was only two years old but he remembers everything. Since the war, I can not go to work nor leave him alone. When he sees Nasrallah on TV he becomes angry and hits the TV. When we buy him age appropriate toys he refuses to play with them and is interested only in weapons and swords. When he draws, he draws only Katyushas or bombs and says he wants them to reach Nasrallah. I do not know who to contact and I am asking for your help. I am afraid he will grow up with so much hatred and may become a violent person.

Thank you in advance, R.

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What is resilience?

Individual Resilience is the ability of the organism to adapt positively in the context of past or present adversity.

Questions:What is positive adaptation?Are we talking about “ability”?What kind of adversity..?

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What is societal Resilience

Societal resilience is the ability of society to adapt positively to adversity and keep society functional, supportive and open.

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What are the challenges for society after massive trauma?

1. Survival mode (focus on short term immediate solutions)

2. Patterns of Traumatic Bonding 3. Coping with feelings of

helplessness4. Isolation of victim groups 5. Sensation seeking6. disregulation

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1. Survival mode

Focus on Preparedness (preparing for the past)

Focus on prevention, often to the exclusion of the curative approach

Neglect of long-term planning

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2. Patterns of Traumatic Bonding

1. Strong bonding in peak periods (in-group)

2. Wild growth of volunteer organizations, often competing fiercely.

3. Neglect (and often isolation) of groups that are seen as “guilty”, or as “not coping”.

4. Strong rejection of out-group

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Traumatic bonding long-term: an example from Israel

Life in Israel has grown cheap. In place of asociety of mutual cohesiveness and genuinesolidarity, we have alienation, and peoplemerely pay lip service to the grief of others.This is an inevitable development: the worsethe armed struggle ... , themore Israel's citizens are concerned with theirown well-being and repress the significance ofthe ever-increasing bereavement.

U. Benziman, Haaretz 26/10/03

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A New Orleans example

01/08/2009 Katrina's Hidden Race War

Repost from The Nation; an investigative report supported by the Nation Institute. In Algiers Point, white vigilantes shot African Americans with impunity in the days following Hurricane Katrina.

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3. Feelings of helplessness

Strong emphasis on doing and helping

Emphasis on heroism Depression and fatalism Continuous search for

protection/new solutions Ongoing grief and Death Imprint

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3. Feelings of helplessness

Multi-layered traumatic memories are based in personal, familial, cultural experiences

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4. Isolation of victim groups

Estrangement between victims and non-victims is a two-way process

Society creates special status for victims

Victims feels alone:

1. “No one under-stands me”

2. Need for recognition (narcissistic phase)

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5. Isolation of victim groups(cont..)

Care of victims may perpetuate their special (i.e. isolated) status

Professionals sometimes are unable to hear their traumatized clients (Danieli) (Counter transference in the best case)

“Blaming the victim” serves to reduce anxiety

Children Grief

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5. Sensation seeking

Keeping up alertness Addiction to alertness (adrenaline) Risk-taking behavior

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6. Disregulation

Exhaustion Disregulation of anger Perception of time Memory for immediate past

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So, what can we do when massive trauma hits?

- Prevention/building resilience ?- Early detection ?- Therapy ?

How do we build all of this into one integrated system?

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Third Generation Trauma Services

First Generation = Trauma – Pathology - Treatment

Second Generation = Prevention Programs

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Five Main Fields of Services

• Building Resilience

• Immediate Intervention

• Detection of disorders

• Treatment

• Training

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Parent Groups

Care giversGroups

Groupfacilitatortraining

“How do we cope?Community Resilience”

Ecological – systemic intervention

Community intervention

Empowerment and assistance on the individual and community level

Therapeutic intervention

4 treatment modules

Therapists training

Treatment

FirstPhase

Second Phase

Interviewers training

Identifying toddlers and parents in distress

Screening process

Integrative intervention for protecting children:Community and Clinical Intervention Model

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Parent Groups

Care giversGroups

Ecological – systemic intervention

Community intervention

Assistance on the individual and community level

Therapeutic intervention

4 treatment modules

FirstPhase

Second Phase

Screening process

Direct care for children:Community and Clinical Intervention Model

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Groupfacilitatortraining

“How do we cope?Community Resilience”

Ecological – systemic intervention

Community intervention

Empowerment and assistance on the individual and community level

Therapeutic intervention

Therapists training

Increasing capacity

Interviewers training

Identifying toddlers and parents in distress

Screening process

Capacity building for trauma care:Community and Clinical Intervention Model

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Parent Groups

Care giversGroups

Groupfacilitatortraining

“How do we cope?Community Resilience”

Ecological – systemic intervention

Community intervention

Empowerment and assistance on the individual and community level

Therapeutic intervention

4 treatment modules

Therapists training

Treatment

FirstPhase

Second Phase

Interviewers training

Identifying toddlers and parents in distress

Screening process

Integrative intervention for protecting children:Community and Clinical Intervention Model

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Continuum of Services

Community

Target group Content Agency

Event

Immediate Care

Pre-event

Long- term

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Example of school intervention

Discussion with principal and leading team Workshop for school staff Parent meeting Information and consent regarding screening Screening - administration of self report questionnaires by

teachers and research assistants in the classroom Classroom debriefing with teacher and research assistant Feedback of results to school counselors Counselor interview to validate screening results Meeting with parents and identified child for decision making

and referral to school or community based services Start a whole school resiliency program More specialized school based programs after follow- up

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Research Team

Community Team

Treatment Team

New- York Team

Dr. Ruth Pat-Horenczyk

Osnat Peled

Michal Achituv

Alon Weltman

Dr. Daniel Brom

Nira Kaplansky

Dalia Yosef

Prof. Mooli Lahad

Ornit Rosenblat

Zvi Fajerman

Dr. Claude Chemtob

Shelley Horwitz, UJA Federation of NY

Israel Center for the Treatment of Psychotrauma, Herzog Hospital, Jerusalem,

Israel

Mashabim, Kiryat Shmona, Israel

Mount Sinai School of Medicine, New York,

NY

Psychological Services, Shaar Hanegev, Israel

An example: Living Under Threat of Missiles:

Toddler-Parents Resilience Project in Sderot – Israel

The study has been supported by UJA-Federation of New York through a grant from The Picower Foundation

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Community Intervention

• Enhancing Parental Resiliency

• Psycho education

• Learning to Play Again

• Identify Coping Resources

• Enhancing community support

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Organizational demands Sound organizational thinking Learn from mistakes Multi-level involvement Buy-in from highest level Psycho-education and training as

organizational tools

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Conclusions1. When trauma is a massive presence in

society, we need to think systemically and get away from our “one-on-one” orientation to therapy.

2. Active screening and outreach to children at risk are highly effective for all ages

3. The big challenge for the science of traumatology is to see if “resilience” can be built or strengthened.

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Conclusions (cont…)4. Understanding and utilizing human need

to help and to bond in ongoing trauma can enhance social resilience

5. Long-term planning and inter-agency collaboration are indicated

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So what am I saying?1. We need to open our minds to broader

concepts than PTSD.2. There are natural tendencies of society

that counteract the planning of services in the midst of ongoing trauma

3. Mental health workers can be most effective in a post-disaster or post-war environment if they transcend their clinical role.

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For more information:

www.traumaweb.org

Thank you !!